<p>I guess I missed the part where it was stated that the doctors/nurses at HUP failed to recommend that she follow up?</p>
<p>Thanks for the clarification Galwaymom—the key diagnostic tool in a meningitis work up is analysis of the spinal fluid in the ER and then if found to be negative then the patient is given instructions on signs and symptoms that should lead them to seek further medical attention</p>
<p>galwaymom: Are you saying that Tom Clark, a CDC epidemiologist and expert on meningitis is wrong?</p>
<p>That’s right, Momof2, unless of course other worrisome findings on exam, or blood tests warrant admission for other reasons (e.g. low blood pressure, a very high white count in the blood and evidence of another source of bacterial infection, abnormal chemistries, etc. etc. etc.).</p>
<p>Unfortunately, sonssecty, you are not understanding me or what the epidemiologist is saying (we are saying exactly the same thing), and I don’t think I can make this clearer for you. Sorry.</p>
<p>I had decided I was done posting on this thread, but here are a few facts.</p>
<p>Neiserria meningitidis is a bacteria that can be present in the normal bacterial flora of the nasopharynx. It had been determined that 5% of children up to the age of 15 carry the bacteria in their flora, and 25-35% of youngs adults 15-25 are carriers. (Neiserria may sound familiar. Neiserria gonorrhea is a cousin. However, it is never a “normal flora” bacteria.) It is far more common to be present in the nasopharynx of this age group than even MRSA (methacillin resistant staph aureus.)</p>
<p>One can become ill with a viral syndrome, even a viral meningitis (for which there is no treatment other than supportive care). This weakens the immune system, allowing the N. meningitidis to grow, invade (the meningeal covering of the brain is ridiculously close to the nasal passages) and cause an infection. One can read about the interesting epidemics in the meningitis belt of the Sahara dessert, flamed by the dry winds inflaming nasopharyges of its inhabitants. </p>
<p>Medicine is not black and white. </p>
<p>Black: Some one screwed up, made an error in not diagnosing and treating this patient and she died. </p>
<p>White: Someone presents to the ER, has a viral syndrome and is treated and released. But, this person is one of the 25-35% who has N. meningitidis living in their nose/throat. They get sicker, their immune system is stressed, the bacteria gets past the blood brain barrier and causes now a bacterial meningitis. The lumbar puncture done on initial evaluation is normal-normal glucose, normal protein, normal gram stain, negative PCR DNA testing for N. meningitidis, negative antigen testing. normal WBC’s. Because there was no meningitis on initial presentation.</p>
<p>Most cases are shades of gray and lie somewhere in between, as this case most certainly does. </p>
<p>It used to be said that 10% of all cases of meningiococcal meningitis were fatal, and even more if it was meningiococcal sepsis. It is a disease that kills people. </p>
<p>Every one of those deaths are tragic. Having a lawyer involved so immediately after a meningiococcal death, perhaps even more tragic. Trying to decide on a board like this, and getting all worked up about it back and forth… with multiple quotes taken out of context from sites like Merck at Home about how the case "should have been treated…a good reason for applications for med school to be down. </p>
<p>And there are CDC experts on both sides of the law, some who testify for the defense, and some who testify for the plantiff. CDC experts can be hired guns, just like any other expert. For each one who a lawyer can get to say one thing, another lawyer can find two who will go on record saying the opposite, with plenty of publshed cases and hard science to support either side.</p>
<p>Lots of shades of gray.</p>
<p>
</p>
<p>You don’t keep patients in the hospital for observation for fevers! REPORTEDLY, she had a completely negative LP, are those supposed to keep her overnight for observation??? Student Health might do that in some places if the student is sufficently miserable, but not a busy city hospital which I presume UPenn hospital still is - certainly was when I interviewed there many moons ago.
I hesitate to bring this up because Sonssecty will make a crusade of it, but chances are the child’s insurance wouldn’t pay for the observation admission anyway - in this instance it might have saved her life (or not, remember none of us have read the medical record), and the family would have never known and fussed because they got a big bill.
Several years ago we had a young man, 19, who had a severe reaction to having his blood drawn. Feeling faint during a stick is a common event for us, but this kid scared me to death, and I called the code team because he was turning blue and making seizure like motions. He started breathing again, and was taken to the ER for a short observation, still groggy. He had picked up his 10 year old brother from school and swung by the hospital to get his blood work drawn, so the ER called his Mom, asking her to come pick the boys up after this episode, they were concerned about his ability to drive. Mom is irate that she has to come get son, then a few weeks later she calls the hospital, ****ed, because she got a $200 bill for an hour of ER time and monitoring to be sure it was safe for her son to be discharged.
Don’t talk to me about doctors and hospitals helping people in need! We are human, we make mistakes, and hospitals often come off as uncaring, but the vast majority of us are doing the very best we can working in a system with tremendous constraints, working for people who expect perfection from very unperfect systems.</p>
<p>galwaymom: I truly want to understand this and I do appreciate your input. I have re-read the quote from Tom Clark and it does not sound like you are saying the same exact thing at all. Sorry.</p>
<p>cangel: ummm, she didn’t just have a fever. Perhaps it would be good to re-read previous posts. I won’t make a crusade about it, but who cares about the insurance thing? We’re talking about a person’s life.</p>
<p>…a good reason for applications for med school to be down. </p>
<p>I was seriously thinking of linking this thread to one of those "wow-you-can make-a-lot of money-as-an-MD pre-med threads. Maybe that’s where this thread can serve it’s best purpose.</p>
<p>Let me try one more time to clarify where you may be hung up, sonssecty:
In any suspected case of meningitis, the spinal fluid lab results are analyzed in the ER. In any form of meningitis, they are abnormal. The reference by the epidemiologist to the early tests being inconclusive means that one cannot distinguish between viral and bacterial meningitis by those early tests, and so the MD starts antibiotics immediately until the definitive tests are back.</p>
<p>SS- You HAVE to consider the insurance aspect. It is always factored in. Of course hindsight is 20/20 etc., but it appears to me that a reasonable decision was made to let her go home. If insurance were never an issue, I’m sure we would all move into the hospital with our asthma attacks and bronchitis. Get real.</p>
<p>Okay. So you are saying with 100% certainty that if the LP is normal, even early on, that the person does not have meningitis?</p>
<p>MOWC: “move into the hospital?” Come on.</p>
<p>100% normal LP= no meningitis</p>
<p>"I was seriously thinking of linking this thread to one of those “wow-you-can make-a-lot of money-as-an-MD pre-med threads. Maybe that’s where this thread can serve it’s best purpose.”</p>
<p>Shrinkrap, please do so! Some of these kids need a healthy dose of realism. My friend “makes a lot of money as an MD”, but she pays half of it to her malpractice insurance company and prays every night that she has never been involved a lawsuit.</p>
<p>BB.</p>
<p>New York Magazine has been running a periodic series called diagnosis about patients with mysterious symptoms and how what’s wrong with them actually gets found. It’s a bit scary how often it’s luck that solves the problem, or inexperience means that a young doctor looks into things that the older doctor knows are highly unlikely, or my favorite example, only the old doctor recognizes a case of scurvy because no one has a seen a case in 30 years or more.</p>
<p>Malpractice is a burden at best, but worrying that a wrong decision could contribute to a death is worse. Sometimes no amount of money is worth that responsibility.I am not suggesting mistakes be ignored, it’s just important that future doctors understand what living with that feels like. Being judged by people who don’t understand makes it harder.</p>
<p>I’m certainly no medical expert, but as a medical student, perhaps I can talk a little about the psychology – I’m just gearing up for the responsibilities, and starting to feel very overwhelmed by the impossibility of the profession.</p>
<hr>
<p>1.) Physicians are **never, ever certain **of a diagnosis. Tests have aspects which are referred to as “sensitivity” and “specificity” – that is, sometimes a test will miss a diagnosis, or will incorrectly make one. These numbers are never, ever 100%.</p>
<p>1b.) Patients often have **different symptoms **with the same disease, or the same symptoms with a different disease. Meningitis is supposed to present with heache, neck stiffness, fever, and altered mental status. Apparently, 17% of meningitis patients don’t have neck stiffness. 13% of meningitis patients don’t even have a headache. All told, 56% of patients present “wrong”. “Patients,” my professor told us just this morning, “don’t read the textbooks.”</p>
<p>1c.) I could be walking around with pancreatic cancer right now. Some pancreatic cancers are asymptomatic, because some of any disease is asymptomatic. Some pancreatic cancers will be missed by diagnostic scans, because some of any disease is missed by diagnostic scans. (Besides, I haven’t been scanned anyway.) Some pancreatic cancers won’t turn up in blood tests, because some of any disease doesn’t turn up in blood tests. (Besides, I haven’t been tested.) Should I start up on chemotherapy and radiation?</p>
<p>Of course that’s a more extreme example, since the young lady in question had some symptoms. But the most common symptom in meningitis is headaches. If we’re going to prophylactically treat every headache for meningitis, we should also treat them for brain tumors and strokes while we’re at it.</p>
<hr>
<p>2.) Every treatment has side effects. There’s nothing you can do that might not, even if you’re right, come back to harm the patient. Antibiotics are no exception, although many people (adults in particular) still seem to remember penicillin as a miracle drug.</p>
<p>We do, after all, have trillions of bacteria in our body at any given time. Disrupting these can alter intestinal balance, leading to vomiting and (more commonly) diarrhea. These can both potentially have serious consequences.</p>
<p>Second, disrupting normal bacteria can alter the balance within bacterial populations, since not all bacteria respond equally to all antibiotics. Killing off normal bacteria is much like the Cultural Revolution experiment of killing off all the birds in China: all of a sudden, you have locusts eating your crops. Similarly, antibiotics might simply have led to this girl’s infection with a more dangerous bacterium. (This has been explained above.)</p>
<p>Third, treating everybody with prophylactic antibiotics can simply lead to **resistant organisms **-- killing more people down the line.</p>
<p>Fourth, many antibiotics have intrinsic side effects. I don’t know what would have been used in such a case, but we’ve been learning a great deal about just how dangerous these drugs are. **Kidney failure and ototoxicity <a href=“killing%20ear%20cells”>/B</a> are apparently two of the most important complications.</p>
<p>Fifth, sometimes even specifically attacking the right bacteria can lead to undesired consequences, depending on what and where it is. Many of the most dangerous toxins of bacteria are actually contained within the bacterium itself. Drugs which result in bacterial death and (ultimately) break them open can sometimes be more dangerous because it actually releases the bacterial toxins. I’ve never heard of this as a complication in meningitis – we were taught it in the context of intestinal disease – but it serves to illustrate the point that treatments can sometimes do more harm than good.</p>
<p>Sixth, don’t forget allergies. You don’t want your patient developing or experiencing drug allergies.</p>
<p>2b.) Here’s a big one. Meningitis patients apparently improve when you put them on steroids. Steroids, though, are ugly drugs. Dramatic weight gain is the least of the side effects, compared to bone weakening and suppression of your immune system. If you give steroids to a girl, she’s in for a world of hurt – whether she needs them or not.</p>
<p>2c.) The standard in criminal law is “beyond a reasonable doubt.” They can do that because our system believes that it’s far better to presume on the side of innocence.</p>
<p>In medicine, there’s no presumption. That’s not a luxury doctors can afford. Because every treatment has side effects, you have to make your decisions based on benefit/harm beliefs based on the best information you have to go by. You can’t treat every patient based on the worst case scenario – you’ll get sued that way, too, and this time the plaintiff will be right.</p>
<hr>
<p>3.) Even tests are not safe! Lumbar punctures can alter the pressure of the spinal compartment, ultimately resulting in the patient’s brain being squeezed through the bottom of their skull <a href=“%22brain%20herniation%22”>B</a>**. This is, I hope it goes without saying, fatal. If an LP isn’t safe, then many patients are referred to CT scanning. A CT scan, of course, is a massive series of x-rays – so many that a computer can reconstruct them at any angle into a three-dimensional picture. Is the **radiation **safe? Do we want to risk it on an eighteen-year-old?</p>
<p>Sometimes diagnostic scans use “contrast” in order to be worthwhile – otherwise, you can’t see anything you need to see. Sometimes people die from contrast injections, whether in **allergies **or kidney failure.</p>
<p>I know this isn’t relevant to the case in question, since she seems to have had an LP done without herniating her brain, but it (again) serves to illustrate the point. Sometimes wanting to be certain of a diagnosis is what’s going to kill your patient.</p>
<hr>
<p>4.) The CDC expert’s language was, I think, ambiguous. It could be interpreted in one of two ways.</p>
<p>a.) “Even if rapid analysis is negative for meningitis, you should treat it as if she has meningitis until actual cultures come back.”</p>
<p>b.) “Rapid analysis may say she’s positive, but there’s a very good chance it’s wrong. (In other words, the test has low “specificity.”) Regardless of that chance, however, you should still treat her as if she has meningitis until actual cultures come back.”</p>
<p>The first statement strikes me as being inconsistent with the way I’m being trained right now. If you’re going to behave exactly the same way, regardless of what the rapid analysis shows, we’re taught *very clearly *not to bother with such a test.</p>
<hr>
<p>5.) Is the CDC **more reliable **than HUP? I wouldn’t be willing to stake my life on it.</p>
<hr>
<p>A story from yesterday. We’re working up an exercise with a hypothetical patient with chest pain. Two things immediately rise to the top of our “differential diagnosis.”</p>
<p>A **differential diagnosis **is the list of all the possible things this patient could have. Our differential for chest pain, by the way, includes easily twenty items and there’s no responsible way to work all of them up.</p>
<p>Right at the top of the differential, however, are **myocardial infarction <a href=“heart%20attack”>/B</a>, and **aortic dissection <a href=“the%20walls%20of%20your%20biggest%20blood%20vessel%20are%20coming%20apart”>/B</a>.</p>
<p>The two diseases have opposite treatments. In an MI, you want to find a way to make sure the heart muscle itself is getting enough blood to stay alive. Since MI’s are thrombotic events (caused by a clot), one approach is to give the patient a clot-busting drug like tPA. This is a responsible approach in some situations.</p>
<p>However, an aortic dissection means you’re pooling blood in spaces where you don’t want it. Clots might be the only thing keeping you from hemorrhaging completely. tPA, in this situation, would worsen the bleeding and almost certainly kill your patient.</p>
<p>And yet you don’t have the luxury of waiting. Heart muscle is dying as we speak in an MI, or the dissection is probably peeling away moment-by-moment in an AD. (As second-year students, we have not yet learned what we actually do. Only how to compose the differential.)</p>
<p>So apparently there’s a test you can run for an MI, and that’s how you decide to treat it. (CPK-MB/Myoglobin/Troponin, I think.) If it’s an MI, you might give tPA. If it’s an AD, you rush to surgery.</p>
<p>Simple? Well, the tests can be wrong. And if they’re wrong, you run the very serious risk of killing your patient.</p>
<p>Now, let’s add in one more complication. Sometimes, an AD can cause an MI, if the lining of the aorta has peeled back so far that it blocks off the blood vessels feeding the heart itself (the coronary arteries).</p>
<p>In that case, you have an AD, but the MI tests will come back positive. So you give tPA, the clots which are the last line of defense against a total hemorrhage bursts, and in just a few moments you’ve killed a patient. Not your first, probably, and probably not your last, either.</p>
<p>“Wow,” I asked my preceptor. “How would you ever catch that?” She looked at me and shook her head quietly.</p>
<p>My interpretation: “You have to get lucky.”</p>
<p>Very interesting and informative post. Thanks, Mike.</p>