Appendicitis is often missed because physicians don’t think of it
“Diagnostic algorithms tend not to be very helpful for appendicitis because the clinical signs and tests are so variable. By keeping in mind common cognitive errors, unusual presentations, and the predictive value of tests, a physician may recognize an atypical case of appendicitis that would otherwise be missed . . .
. . . The freezing effect occurs when a physician latches onto a positive finding and loses sight of the bigger picture. This occurred in the case of a 29-year-old woman who came in with right lower quadrant pain and a temperature. She had a normal pelvic exam, but an ultrasound showed an ovarian cyst. She was sent home with a diagnosis of an ovarian cyst, and later came back with a ruptured appendix. Just because a diagnostic test is positive doesn’t mean it has pinpointed the cause of the patient’s complaint, he cautioned.
The availability error means judging a case too quickly based on how readily a diagnosis comes to mind. Dr. Rose offered the example of a 55-year-old woman who came in with gastric pain and vomiting. Her belly exam was normal, and family members had just had stomach flu. She was diagnosed with viral gastroenteritis, despite not having any diarrhea. Hers turned out to be an atypical presentation of a myocardial infarction.”
In this day and age, one has to rule out diseases that can kill the patient first, and then work down to less serious diseases. The days where one can diagnose clinically alone are gone. It will be atypical presentations of serious diseases that will get you.
For someone with right lower quadrant pain, the diseases that you don’t want to miss are appendicitis, pelvic inflammatory disease (in females), or bowel perforation. Hanging your hat on an ovarian cyst without adequately ruling out the diseases above (especially appendicitis), or excluding appendicitis based on a normal WBC, is inviting trouble.
Bottom line: Practive defensively, CT everyone, and keep yourself out of trouble.
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- Using CT scans to diagnose chest pain in the ER
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{ 14 comments }
“…and keep yourself out of trouble.” How about: keep your patients out of trouble?
Uuuhh… because the one being kept out of trouble with that strategy is the doctor? And most certainly not the patient?
If the chances of having appendicits with a completely normal exam, completely normal labs and a vague history are say 1 in 10,000 , you’ll have to expose 9,999 patients to x rays before you catch the one patient who really has it.
And that one patient, in an earlier, more sensible time, would have been caught anyway once the symptom profile evolved. In the best work ever written on appendicitis and the acute abdomen, Dr. Cope wrote of how poor surgeons rush patients for exploratory laparotomy who did not have any physical problem, simply because they had no clinical skill to tell the difference. The best therapy more often than not is observation of the patient, and the tincture of time.
But not in today’s world. Today, if you tell the patient there is absolutely nothing wrong that is detectable by reasonable diagnostic methods, but come back immediately if anything changes, and that 1 in 10,000 case comes back when it does change and you successfully treat her, you’ve just handed yourself a lawsuit. (In an earlier, wiser time, you’d have gotten thanks – not just from the one you saved, but from the other 9,999 that you spared from needless harm).
The question becomes where you lay geniuses who tell your doctors how to practice medicine will stop. If you have a little difficulty breathing, intermittently, you may not have anything worse than a cold – but you also have maybe a 1 in 20 million chance of having a brain tumor sitting at the back of your brain.
So lets “protect” all the patients, shall we? Everyone a little breathless now and then gets a CT brain, MRI brain, heck, throw in a PET scan. Geniuses.
Defensive medicine solely benefits the doctor – there is no benefit to the patient.
That is why I purposely leave out any reference to the patient when writing these little quips about defensive medicine.
Ordering unnecessary tests and X-rays expose patients to unneeded radiation, procedures, and cost. Doctors can provide exceptional care without these unnecessary tests. The unfortunate point of defensive medicine is that doctors now are forced to order more tests to cover their ass – thus “keeping ourselves out of trouble”.
Dear Genius MD at 6:21:
The object of your professional activities is to keep your patients out of trouble, and by doing so you keep your own sorry behind out of trouble. But I guess you missed that day in med school. Or maybe it’s so blindingly obvious that no one should have to say it to you.
Kevin says: “Defensive medicine solely benefits the doctor – there is no benefit to the patient. . . Ordering UNNECESSARY tests and X-rays expose patients to unneeded radiation, procedures, and cost. Doctors can provide exceptional care without these UNNECESSARY tests…[CAPS ADDED].”
But what is ‘unnecessary’? When appendicitis is a possibility, are these tests unnecessary? When there is a notoriously obscure condition which is potentially lethal and not uncommon, how is it ‘unnecessary’ to conduct tests to rule it out? Unnecessary tests are those which do not provide a significant added value to the diagnostic process. The linked story makes clear the diagnostic usefulness of certain tests in pursuing possible appendicitis and the relative uselessness of others like WBC count.
The point of the linked story is that a doctor should not jump to conclusions, and it gently admonishes the doctor not to be misled by easy answers [diagnosing flu instead of an MI because family members have had flu]: “In this day and age, one has to rule out diseases that can kill the patient first, and then work down to less serious diseases…The days where one can diagnose clinically alone are gone. . . Hanging your hat on an ovarian cyst without . . . excluding appendicitis . . . is inviting trouble.”
A brain scan to rule out appendicitis would be unnecessary. An abdominal CT would not be, because there is a reasonable relationship to ruling out a potentially lethal condition based on the symptoms.
The days of a defensible, solely clinical diagnosis of appendicitis are past, because we’re not casting knuckle bones anymore. Use the technology, don’t resent it. Why would you do anything else is beyond me.
If the only thing keeping doctors from failing to run reasonable diagnostic tests is the fear of getting sued, then let’s keep the medmal system exactly like it is.
Anon,
I am happy that you are participating in this thread, because your opinion represents the folly of defensive medicine.
“Unnecessary” testing is certainly a debatable point – where do you draw the line?
Would you obtain an MRI for every back pain? A head CT for every headache? A stress test for every chest pain?
Because, there is always a chance that the back pain can be a meningeal abscess, the headache a brain tumor, and the chest pain angina. Anything is possible in medicine.
However, who pays for all this testing? MRIs and CT scans aren’t cheap. If every symptom was worked up to the max, health care costs will balloon through the roof.
With defensive medicine and doctors’ CYA mentality, this is happening already.
Remember, more tests does not equal better care.
Thanks,
Kevin
Defensive medicine is often about irrational fear and a hope that practicing in this way will prevent a lawsuit. Working on the recommendations in the article “10 things to guarantee a lawsuit” will do a lot more in reducing risk than defensive medicine.
Kevin,
I think you’re missing the point of the linked story. It doesn’t say test everything all the time to the max — it says not to jump to conclusions because it’s easy and quick [see also a recent post on your site from a neurologist about speed not being the essence of diagnosis], but to consider what might be missed and needs to be tested for. The plea in the story is to utilize diagnostic tests (and not just clinical diagnoses) when there is a good chance a potentially lethal condition could be missed and the diagnostic tests are of high sensitivity and specificity and readily available; appendicitis and MI are used as examples.
While that may end up being ‘defensive’ medicine, it is first and foremost GOOD medicine — to not leap to an easy conclusion or be seduced by first impressions. If you don’t utilize the diagnostic tests available in such situations, you may then wish you had — and then it becomes in hindsight ‘defensive’ medicine.
You jump immediately to the extreme position of “No matter what we do it will not be enough! Who will pay for it when we do all the testing for all diseases! We’ll be doing MRIs for hangnails! Therefore we should revert to making clinical diagnoses alone, and prevent people from suing us.”
There is a middle ground, but you’re not seeing it. No, the middle ground has no hard and fast boundary, because there’s no such thing. The linked article has a really good point that you are missing, and I don’t know why you won’t see it. It says don’t be so cocky that you miss a blown appendix because you think CTs are stupid and the patient must have the flu. There is a lot of space between “Who’s going to pay for all this! I won’t do it!” and considering the risks when sending home a hot appendix to return to you ruptured or dead.
It’s not intended to be an offense to your abilities — the linked article is encouraging you and all docs to keep an open mind and employ diagnostics where the risks of error to the patient (not the doctor) are catastrophic and the prevention would be significantly less so.
This still involves judgment calls; if you don’t want to be making them, then maybe medicine isn’t a good place for you. The point of the linked article (let me say it again) is to be more balanced in how you approach diagnosis. It’s a good article, calm and wise. Please read it again.
“Genius MD” says, “The best therapy more often than not is observation of the patient, and the tincture of time.” Nice onomatopaeia, but when the risk of a ruptured appendix is stacked against a CT, why not do the CT? First you have to decide that it possibly IS appendicitis, and the linked article is encouraging you to keep an open mind and not dismiss the possibility out of hand. It’s a matter of a more mature approach to practice.
Genius the MD also says, “Cope wrote of how poor surgeons rush patients for exploratory laparotomy who did not have any physical problem, simply because they had no clinical skill to tell the difference.” What a load of value judgments in THAT sentence. In this ‘earlier, more sensible time’ that Genius harkens back to, there weren’t CTs, and all that was possible WAS deployment of clinical skills. And mistakes got made, and people got operated on who shouldn’t have, and others who should have didn’t (and often died as a result). But now that you have CTs etc., why not use the technology to narrow the margin of error instead of Genius turning it into an ego thing to brag that he has such superior clinical skills that he doesn’t need those silly CTs. That is the very definition of arrogance and won’t look good on the witness stand. Pity that the patient may well be dead at that point.
Keeping the PATIENT out of trouble will keep the DOCTOR out of trouble, DR GENIUS.
Have you tried a diagnosis decision support system called Isabel? It can give you a differential list to work from to help you avoid missing something important and keep an objective view. Some of the best children’s hospitals are now using it. It was written up recently in the Wall Street Journal.You can try it out with a 30 day free trial at http://www.isabelhealthcare.com
From a patient’s perspective…
I went to our physician because I was having a persistent problem with cold feet. They felt cold, and they in fact were cold. I often turn on the heating pad when I go to bed in order to warm my feet. I figured he would say something about circulation, or vitamins. No, his first thought was, “Well, it could be syphilis.” I pointed out that I had been married a good many years and my wife and I were devoted to each other, but he insisted on a blood test. It was negative, as I knew it would be. My wife thought this was hilarious. The physician lost interest in my cold feet.
A year later I stuck the back of my hand with a large cholla pad, and reacted badly, with swollen joints. The good doctor looked at my hand and said, “Well, it could be gonorhea.”
Now I realize that having a physician who thinks of all the possibilities is a good thing, but there is also Occam’s razor, dealing with the simplest solution. I mean, if the patient just had an encounter with a cactus, one really should consider the cactus stickers as the most likely suspects.
Final straw: I was having symptoms of an elephant sitting on my chest, for months. When we went to Ouray, Colorado on vacation, elevations up to 11,000 feet, the elephant vanished. The instant I returned to the desert, the elephant was back. The doctor sent me next door to the emergency room and they performed all sorts of tests, including a stress test on a treadmill. Nothing.
Before you read further, your diagnosis would be…
A year later we had a new HMO and were able to go back to a wonderful physician, the finest we’ve ever met. He is an absolute whiz at diagnosis. I described my symptoms and he immediately said, “You have GERD.”
And he was right. Prilosec removed the elephant.
Almost 40 years ago, shortly before we married, my (1st) husband experienced abdominal pain, nausea and vomiting, accompanied by a fever. He left the college dormitory to spend a few days in his parents’ care; consensus was that he had the flu. He mentioned several times, however, that he suspected appendicitis.
Fast forward 4 months: We had married and just moved out of state. On our first weekend in our new home, he experienced serious abdominal pain in the LUQ–or ULQ–whichever. We were new in town, but knew a few people, one of whom worked in a clinic and recommended her doctor. He arranged for us to meet a surgeon at the ER. WBC was normal, but the doc said he wouldn’t be surprised if it were appendicitis, especially after hearing about the earlier episode. We went home. Another episode occurred a few months later, with pain in the LLQ, after which our internist said my husband was going to give him and the surgeon coronaries. Appendicitis was still the primary suspect.
About a year after the first episode, my husband went to bed complaining of severe pain in the RLQ. He woke me up at 4 a.m. and told me to call the doc. This time the WBC was abnormal.
Surgery was supposed to take about an hour, so I ran home for a couple of his things and got back in about that time. Doc was still in surgery. When he came out, he told me it had taken him an hour to chisel through the hardened poison that had collected around the appendix. He said the thing had been seeping for about a year, and the reason the WBCs had been normal was that Art had previously waited a coupld of days to call the doc.
This is my entry in the “atypical appendicitis” contest.
“I’m a Doctor, I have appendicitis”. That’s what I told the ER doc when I strolled in with RLQ pain. It was my great misfortune that they believed me. And took out a normal appendix. Had they done the usual diagnostic tests, they would have found TNTC RBC in my urine consistent with the renal colic I had.
For almost 3 years my husband has suffered from anemia. Tests were run many times and it is the consinsus of all that he just needs blood periodically. How can we just go to the hospital and have these unnecessary tests done and just get the blood periodically? They start the tests and then if you complain the doctors get mad and write untrue things in the chart. Then say you can check out AMA and your insurance will not pay. They insist on keeping you 2 weeks and doing their unnecessary tests. Then say you will just have to have blood periodically.
I agree that you should not close the door to possibilities without being 100% sure.
My 8 yo son came home from school doubled over in pain, said he had been to the school nurse 3 times that day and she sent him back to class because his temp was only 100.2. I immediately took his temp still 100.2 and went straight to the ER, the doctor there did the usual tests Blood work normal UA normal CT was nopt showing anything, the doctor came into the room told me his labs looked good and the CT didnt show anything but that he was really not comfortable sending him home with the pain and fever that he wanted to do an MRI I knew when they called the radiologist in the room that the found something. They rushed him stright from there into surgey only stopping for a moment to explain that they could not do surgery lap. that they had to cut him open because it was retrocecal and very enlarged. The surgeon came out of surgery said everything was fine and that my son had the largest appendix he had ever seen, he was glad they caught it in time. The ER doctor came by to see how he was doing and told me he was really glad he went with his gut instinct and ordered that test.
Vicitm
I was recently cut open to have about a foot of my intestine removed when “OOPS” it was appendicitis., I was being told for weeks it was Crohn’s disease. I was hacked open when no medicine worked for what they thought was my illness. I am hurt, and mad as hell how do you butcher someone and say, well at least we accidently found it. I should have had a simple surgery to remove my appendix, instead I have to go through weeks and months of healing and baby food because they made a mistake!! You don’t care about the lives you hurt a doctor cares about a pay check!!
Sincerly,
Vicitm
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