“Nothing Acute”

Travis no longer had the severe belly pain he went to the emergency room for last month. He was just in for a routine physical. He seemed healthy enough, but as we talked, I saw that the ER note in my EMR made reference to a CT scan that we never got a copy of. The ER report just said that the scan showed nothing acute.

The pain he had experienced was excruciating and lasted a few hours. It made him vomit and it was right in the epigastrium, just under his breastbone. It went away as suddenly as it had appeared.

I logged in to Maine Health InfoNet and located his CT report. It contained two abnormalities.

First, there was “streaking” around the gallbladder and sludge or small stones. I showed the report on the screen of my laptop and explained that very small gallstones can pass down the bile ducts into the small intestine. When they do, the pain is just like the one he had. If they get stuck, the pain doesn’t go away like his did, you get jaundiced and need to get an ERCP hundreds of miles away to relieve the obstruction.

“You need a gallbladder ultrasound”, I told him. “Believe it or not, ultrasound is better than CT at showing stones and sludge in the gallbladder. If you have lots of little stones there, you’d be better off having your gallbladder removed in order to prevent a disaster later on.”

The second abnormality was an unusual appearance of the bones in his pelvis, possibly a bone cancer, but statistically more likely to be completely benign. But the report recommended additional X-rays of his pelvis.

“Why didn’t they tell me all this?” He seemed incredulous.

“This happens all the time”, I explained. “They may only have a preliminary report from a teleradiologist in a different time zone, stating just ‘nothing acute’, or they may rely on making a blanket recommendation to ‘follow up with your PCP’ even if you feel well.”

“They did say that”, he admitted. “But I felt fine.”

“Their job is to decide if a patient needs emergency procedures”, I went on. “Their system would be completely bogged down if they had to arrange followups for what we jokingly call incidentalomas, things that may or may not be signs of disease. Many people think primary care doctors go through outside reports in great detail as they come in, but there is no time in our schedules to do this when we see patients all day long. Thinking we can do all that on the fly or in our spare time is a flawed business model. So the safest and most practical way to handle things is to have a followup visit after an emergency room workup has taken place.”

“Boy, I’m glad I happened to have this appointment”, he said.

“Like I said, this is so common. A couple of years ago I saw a young man like you for something routine and he had been to the ER, too, at a different hospital. When I went over his CT report, it turned out he had a small kidney cancer. He had surgery and is fine now. But I possibly saved his life. And I have many other stories like that.”

I have written about this kind of situation many times. It is an important reason to have a primary care doctor, a medical home. The bureaucrats have created many models and “workflows” for following up on emergency room visits, but as they rely on non-physicians, they risk adding fluff without medical insight.

“Follow up with your doctor” is a safer bet, because as much as I would like every doctor’s motto to be “If you find it, you own it”, that is not the way things work in healthcare these days.