Coordination of Care Requires Patient Input

As a general internist with a small concierge practice I have tried to coordinate my patients’ care and dealings within a complex, bureaucratic and dysfunctional health system. Patients have access to me 24 hours a day, seven days per week by telephone, cell phone, email and text messaging.  I do not have an answering service so all after-hours calls are forwarded directly to me.   During the initial patient orientation visit we discuss the need to keep me abreast of their health concerns and problems so I can bring the big picture to their immediate and localized health concern or problem.  Similar information goes out in my quarterly newsletter and is on my web site. I am trying to reach the technologically sophisticated patients as well as the technologically challenged.

I was somewhat surprised to receive a late Friday night call from the local ER to tell me one of my 86 year old cognitively impaired individuals was being evaluated. When I spoke to the charge nurse I found that the patient was brought by the paramedics for intractable nausea and vomiting.   This particularly charming, mild to moderately cognitively impaired, woman had moved with her 90 year old husband from her private residence to a senior facility on my suggestion so that care was available for her as she deteriorated and required more hands-on attention. They were thrilled with the new apartment as well as the care and concern provided by the staff.  I had seen the patient six weeks ago and she was doing fine. There was no mention of problems.

Since her last visit she had developed a dental problem. Unknown to me, her dentist extracted all her left lower jaw teeth and made arrangements for a periodontist to perform three dental implants.  The periodontist pre-medicated her, one hour before surgery, with 1 gram of the antibiotic amoxicillin because seven years ago she had a surgical knee replacement.  She then had the surgery and was sent home on Tylenol and codeine for pain.

She took her second Tylenol with codeine at home, went down to the community dining room, ate some chicken soup, felt ill and vomited several times.  The dining room staff just called 911 and transported her to the local ER.  I was called by the ER doctor after his evaluation to say he believes that between the large dose of oral antibiotic and the codeine, the patient became nauseated and vomited. He was prepared to give her some intravenous fluids and send her home.  After completing the IV fluids she got up to go home, became lightheaded and had another bout of emesis.   I was called back at about midnight and went in to evaluate her.  She looked fine but a bit dehydrated so I decided to observe her overnight while administering fluids and anti-emetics if she needed them.

I had no previous knowledge that this cognitively impaired woman with a limited future lifespan was having such extensive dental surgery.  There is much controversy about whether an individual with a prosthetic knee replacement even needs antibiotic prophylaxis with an antibiotic notorious for causing GI distress.  There were additionally concerns on my part about the choice of a codeine based narcotic for pain control based on her existing medication list.

Had the husband, patient or dentist called in advance to discuss this we could have come up with alternatives that may have prevented this hospitalization.  If the primary care physician is not included in the care plan and kept current, how can one be expected to coordinate care?

After evaluating the patient and making the arrangements for her to stay overnight, I expressed my disappointment to the patient’s spouse about not being informed of the impending dental procedures of this magnitude in advance.  He apologized profusely for not thinking to call me or asking the dentist to call me. He asked me to write about it in my blog to let the other patients know why they need to keep their doctor informed of all their health care comings and goings.

Diagnostic X-rays: A Source of Potential Danger?

Last week a patient of mine complaining of cold like symptoms demanded a CT scan of the sinuses. She had been caring for her preschool age grandchild who attended day care and was now experiencing her fifth upper respiratory tract infection in the last 12 months. Her nasal congestion, sore throat, minimally productive cough, aches and pains and overall malaise were typical of the common cold caused by a host of viral agents seen frequently in crowded daycare center classes.  She had no tooth, jaw or facial pain.  We discussed why she did not need an antibiotic at this point and why exposing her to ionizing x- irradiation made no sense.

“How much radiation is safe to receive?” she asked.  According to most experts, there is no safe level of radiation to receive. Different tissues take up and store different amounts of radiation and it all depends on the size of the dose, the distance from the source of radiation and the time of exposure. Most expert panels suggest that we do not receive more than 0.05 mSv per year above our normal annual exposure.  Yes we do receive about 3 mSv per year from naturally occurring sources including cosmic radiation from outer space and radon in the ground and basement of our homes.  People living at higher altitudes receive even more annual natural exposure, with those living in the plateaus of Colorado and New Mexico getting 1.5 mSv more per year than those at sea level. As our radiation exposure increases, the chance of ill effects and ultimate malignancy increase as well.

Recent research data shows that the number of diagnostic and surveillance medical x-rays including CT scans has increased dramatically in the last decade especially in the pediatric age group which is very susceptible to the cumulative radiation doses. A simple chest x-ray exposes you to 0.1 mSv of radiation which is comparable to the natural exposure we receive from 10 days of exposure in our natural surroundings.  Compare that with a chest CT scan which provides 7 mSV of exposure or the equivalent of 2 years worth of natural exposure.  A CT scan of the head, done routinely in ER visits for minor head trauma, fainting or severe headache provides 4 mSv or 16 months worth of natural radiation exposure and is considered a “ low” risk of causing fatal cancer.   The patient who shows up in the ER with lower abdominal pain and gets a CT scan of the abdomen and pelvis with and without contrast receives up to 30 mSv of radiation which is comparable to 10 years of natural exposure.  Now think of the type of exposure cancer victims are receiving routinely to monitor the effectiveness of their treatment and disease progress.

In the hands of skilled technicians and experienced radiologists, obtaining medically necessary studies remains safe.  What may be needed is a realization by all involved that the more exposure we have the more risk we experience. For this reason, I will be giving my patients a radiation exposure history tracking card for their wallets. Each time they have a medical x- ray I will be asking them to record the date and type of procedure.  This will include dental x-rays (0.005mSv or 1 day’s natural exposure level) and all other procedures so we can track annual exposure and consider alternative diagnostic options in those with large exposure numbers.

As the country considers the new health care reform proposals and opponents speak about rationing to save money and “death panels”, remember that some of the reductions proposed are designed to spare us excessive and unnecessary ionizing radiation exposure.

For more information about radiation, visit the web sites listed below.

American College of Radiology – http://www.acr.org/

Radiology Info – http://www.radiologyinfo.org/

Effective Radiation Dose / Exposure – Chart