CodeBlueBlog: CSI MEDBLOGS: THE TAKING OF CLINTON 1..2..3. The Docs at Columbia Drop The Ball?

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CSI MEDBLOGS: THE TAKING OF CLINTON 1..2..3. The Docs at Columbia Drop The Ball?

Am I Conspirational or Observant?

I've taken a lot of heat for making observations and asking questions. Isn't this what people want from the Blogosphere? Kevin M.D. does a much better job analyzing the news and staying current; Chris Rangel has a keener eye and more passion for the policy issues; Dr. Charles and The Madhouse Madman (congrats bud) explore the literary and humanistic aspects of their jobs. None of that is what I do here. I look at the nonsense that passes for medical news and ask questions whenever that news does not make sense to me, which is just about always.

What really is offensive is when I ask questions and OTHERS say I am claiming cover-up or conspiracy. I am doing neither of those things. Nothing I say cannot be traced along a logical thought-line with documentation both in the literature and by my extensive training and experience. That's part of what I offer. Let me also say here, publicly, what I wrote to one of my commentators, previously.

... it is my opinion that the BEST physicians reach out with their imaginations in their diagnoses.

I don't chase zebras*, but I always wait for them. And I've caught a herd of them in the last 20 years-- because I'm not afraid to question someone's established order of case presentation and history.

I still get thank-you cards and letters from patients who were zebras when I found them in some physician's barn of horses. In medicine there is a saying: you can't find something if you don't know what you are looking for. It sounds trite, but it holds a lot of import. Just because I ask COULD this unusual circumstance have an unusual diagnosis doesn't mean I am going to kidnap Bill Clinton and treat him with chemotherapy but if you don't think about those possibilities, you will never make those diagnoses.

--- NOW LET ME TELL YOU WHY I AM RIGHT ABOUT THIS CASE--

The Most Dangerous Game

Yesterday, the physicians at Columbia Presbyterian admitted that one of my three possible scenarios was indeed, correct. They missed his complicated pleural effusion for five months.

As I said two days ago:

either they failed to do appropriate follow-up and MISSED it for six months (unlikely); or, they have been hiding his problem while they exhaust all nonsurgical treatment options; OR ... Bill Clinton's exudative pleural effusion is from something else.

Yesterday, as reported in The Times, they physicians at Columbia made several points:

#1. Clinton's pleural abnormality was undetected until one month ago

#2. It is their contention that this abnormality has been present since the bypass surgery and is a direct complication of that surgery

#3. The presence of a chronic complicated loculated pleural collection after bypass surgery causing pleural thickening, inelasticity, and lung collapse (traction atelectasis) is very rare. How rare? REALLY rare. Said Dr. Craig Smith, Clinton's surgeon:

This is a very rare complication

(I've seen it) only a handful of times in 6,000 surgeries.

Say Aaahhhhh

So, some of the best doctors in the world did a procedure (bilateral mammary artery harvests) that has a high risk of post operative occurrence of complicated effusions, then missed that effusion when it occurred (in their most famous patient ever), then failed to follow up that patient until he came back to them with chest pain and shortness of breath.

The panel of Presbyterian physicians made a major point of insisting that a persistent complicated pleural effusion causing pleural fibrosis and lung collapse is a rare complication -- and indeed it is.

HOWEVER, what they didn't say was that if they had detected the relatively commonly occurring complicated effusion immediately post-op then maybe this rare sequelae could have been avoided. This rare complication is actually probably the natural history of an undetected, untreated,complicated postoperative effusion.

So, cut the BS guys.

Here's how rare the effusions are according to the Archives of Internal Medicine:

All patientsunderwent internal mammary artery grafting. Early effusions(<30 days after CABG) occurred in 45 patients (63%) and lateeffusions (30 days after CABG) developed in 26 (37%).

So, his doctors knew that Clinton had a really good chance of developing an effusion with this procedure. So how did they miss it??

Rara Avis: We Try Harder

Most of the letters I've received have made the point that Clinton was likely noncompliant; however, given the frequency of complicated pleural effusions after bypass with the mammary arteries, the docs should have been hard on the case.

Surely Bill Clinton has had a chest X-ray abnormality for MONTHS; and surely he has had unequal basilar breath sounds for a similar period of time.

Did Clinton not EVER see an internist after his bypass? Does the former president NOT have a personal physician? Did that personal physician NOT listen to Bill's lungs? Would he not have noticed a DRAMATIC asymmetry in breath sounds between the right an dd left lower lobes?

I WAS RIGHT TO BE SKEPTICAL

Because I gave the benefit of the doubt to the surgeons and physicians taking care of Clinton, I almost completely dismissed the possibility that they would have MISSED this relatively common sequela of mammary artery harvesting.

I therefore had to question whether or not there was some other reason for a complicated pleural effusion, and any doctor worth his mojo would immediately think of cancer. Period.

I tell you what. I'm still skeptical that they actually missed this bad problem and I wouldn't be at all surprised if, later today, they tell us that Bill Clinton's pleura is SOCKED IN with tumor.

Let me say something else. EVERYONE is downplaying the severity of this procedure (thoracocoscopy / thoracotomy). Hilliary Clinton, displaying naivete and lack of any medical insight at all said yesterday:

"It is a routine procedure although it is an uncommon complication,"

Since when is a thoracotomy routine? I mean what is the definition of routine? Clinton is undergoing general anesthesia for a VATS with likely conversion to a thoracotomy (you know, widen the incision, spread the ribs and violate the thorax?). They will be performing a therapeutic pneumothorax with the risk of persistent pneumothorax, bronchopleural fistula, infection, stroke...I could go on ... Here's one reference to decortication:

Postoperative complications included 8.7% wound infections and 1.2% recurring empyema. Operative mortality was 1.2%. The indication for decortication to improve pulmonary function alone is questionable. As a rule it is based upon 2 factors--both elimination of infectious foci and improving function.

So stop foisting this on us as routine. A rectal exam is routine. This is major surgery.

Good luck to you Bill. I hope I am wrong. And I wish you well.

*There is a maxim in medicine that says: when you hear hoofbeats, think horses not zebras. The idea is that common things are common and a goodphysician should not be confabulatng wild explanations for situations that probably have a routine cause.

However, GOOD physicians understand that the statistical distribution of diagnostic possibilities fall under a probabilistic curve that includes many rare and unusual entities. Thus, although one should not CHASE zebras, it is my cntention that neither will a good physicians fail to CATCH a zebra should one run by.

Posted by Doctor CBB on March 10, 2005 at 11:10 AM | Permalink

Comments

Thirteen years ago, this week, I was diagnosed with myasthenia gravis. A resident caught it after several doctors had failed to.

When the diagnosis was confirmed with the tensilon test (the attending called it a 'gross success') the attending asked the resident how he'd managed to properly diagnose TWO cases of Myasthenia Gravis in just 2 months. His response "I was too tired to think horses when I heard the hoofbeats, all I could think was zebra."

Since then, he's diagnosed four more cases of MG. More than most doctors (non neurologists) see in their lifetime, much less diagnose!

Since the MG diagnosis, the other added diagnosis' of lupus, elhers-danlos type 3, insulin resistance, have not been as hard to get. But before that? Finding out what was wrong? Seemed like it was never going to happen. No one thought MG, stress, depression, post partum depression, MS, chronic fatigue syndrome, diabetes, thyroid disorder, were all investigated ... when none of those came back ...they went back to stress ... then they decided it was physical and decided again it was chronic fatigue syndrome.

Then a tired resident caught the zebra.

Posted by: Peggikaye | March 10, 2005 at 09:31 PM

Your take on Clinton's appearance has been confirmed by Howard Fineman at MSNBC: "White House aides say that, behind closed doors and up close, he looked hale enough the other day, his color good and his steps sure. Maybe so, but I saw him at the same distance a few weeks ago at an event in the Capitol, and he looked awful: Lincoln-thin, his big hands hanging limp at his sides, his face a pallid mask. A man who, for better or worse, was the very definition of unbridled vigor has been humbled." from http://www.msnbc.msn.com/id/7138932/site/newsweek/
Sounds like he is worse than the media is saying.

Posted by: Garrett | March 11, 2005 at 12:51 AM

I've been reading your thoughts on this since Amba put up a link. Fascinating.

Posted by: Emily | March 11, 2005 at 08:00 AM

I heard on the radio that the docs were going to keep him in the hospital for at least 10 days. Doesn't sound too routine to me.

Posted by: DrTony | March 11, 2005 at 12:28 PM

Note that Clinton was the only president in recent memory to refuse to release the results of his regular medical exams. The press protected him, of course, but it sure smacks of something hidden. Hmmmmmm......

Posted by: jack caffey | March 11, 2005 at 11:36 PM

first of all i'd like to say that you excel in the aforementioned niche that is the code blue blog. i think my favorite posts were during the yuschenko days of wonder. as you normally do, i think it may disarm certain readers if you continue to present your ideas as speculations, investigations, and informed deductions rather than assertions of fact. I'll keep coming back for the no-spin health-related news!
all this on clinton makes sense the way you've presented it.

Posted by: charles | March 12, 2005 at 12:14 AM

Dr. Tony, I remember that. I was so sure they were hiding something when he was in office. At the time, I was sure it was Myasthenia Gravis ...the drooping eye lids, the horse voice, the falling down the stairs in the middle of the night. The fatigue he seemed to suffer ... I was sure he was going to get out of office and we were going to be told he had some chronic illness. Either AIDS or Autoimmune disorder ... then his wife ran for office and I knew we'd never hear if it was true or not.
Since, I've learned I have lupus and my horse voice probably has more to do with lupus than MG so that blows my whole theory of Clinton having MG anyway ... but hey! It sounded good at the time!

Posted by: Peggikaye | March 12, 2005 at 07:45 PM

First of all Thank you.

Second, great take on Clinton case. I've been way too busy to notice but finally got back to blogging. As always, love reading yours although it usually makes me feel like a bad physician because I'm always thinking "How come I didn't catch that?"

I agree with your hypothesis, something is rotten in denmark.

Posted by: Mad House Madman | March 14, 2005 at 05:22 PM

I heard Clinton was back home today.

Posted by: marty salo | March 14, 2005 at 09:06 PM

Fantastic Post!!! I knew something was wrong with him, and I knew it was being covered up. I fail to understand why it's so important that it be kept secret, unless the media is worried about a HIPAA lawsuit. You make a very strong case for a cover-up. Tell us why it's so important that it be kept secret!

Posted by: James Travis | March 17, 2005 at 12:36 AM

Thank you! As it took seeing dozens of doctors who insisted that my symptoms were caused by the horse of "hysteria" (even when they knew about my syrinx but just deemed it irrelevant) before finding the ones who caught the zebra family of syringomyelia, Chiari, EDS, and some bonus freak osseous masses on C-1 and C-2, I am so grateful every time I see someone who gets it. "Although one should not CHASE zebras, it is my contention that neither will a good physician fail to CATCH a zebra should one run by" explains it perfectly. [How I'd love to write that at the top of my surgical reports and send copies to all of my fired doctors]. Thank you for getting it: your colleagues and patients are lucky to have you.

Posted by: Eliza | March 21, 2005 at 08:04 AM

Is he going to get a bit of honesty? or is that too much for a liberal politician to handle?

Posted by: trembling timberdoodle | April 04, 2005 at 10:55 PM

Last night Brian Williams was interviewing President Clinton on the NBC Nightly News. I almost went into shock at how terribly ill the Big Dog looks and sounds. I know that he went on the South Beach Diet quite awhile ago with Hillary but what I saw was shocking. He appears to be scaringly ill as in dying.

I would hope that he has gotten second and third opinions from outstanding diagnosticians. I truly do not understand exactly what is a pleural effusion but from what I have read on this blog is appears to be a structural problem that makes breathing difficult.

When he spoke last night he looked and sounded like a shell of himself. Sharp and alert and on top of his game yet at the same time, terribly pale, voice quite weak; skin pulled so tight on his face a bulging vein was noticeable on the left side of his head by the hairline parallel to his eye.

So the bastards didn't assassinated him with bullets but by bullying, lies, and ostracizing him, they destroyed him. Maybe not death in a plane wreck as they did the Wellstone's but nonetheless the Big Dog looks like he is truly on his last leg. We need to help him now, but how?

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