“Dave” showed up at my office last week with neck pain, worsening weakness in his arms and legs, and changes in his bladder control. All signs pointed to something gone bad in his neck.
His internist had already thought of this, because he’d ordered the appropriate MRIs. And they’d all been read as normal, leaving me without a cause.
Here is where the problem began. Everything about Dave’s exam and story pointed to something serious in his neck. But the tests were normal.
There are a lot of MRI places out there. Some of them have good quality machines, while others haven’t updated their machines, or software, in a long time. In addition to this, some places use specially trained neuroradiologists to read MRIs, while others use general radiologists. So there’s a different quality of reader, too.
This isn’t meant as a slap against general radiologists. As a general neurologist, I don’t claim to be exceptionally good at various subdivisions of my field, either. No one is good at everything, and recognizing our limitations is part of the job.
As a result, we have a short list of MRI places I use, where I trust both the equipment and radiologists.
But your average internist doesn’t usually know the difference, as they’re too busy with the insanity of a general medical practice. Most of the time the decision is made by a scheduling person, based on the patient’s insurance, when the next available opening is, and maybe even what place brought them lunch. And Dave, unfortunately, had his studies done at Poor MRI, Inc.
So I called Poor MRI, Inc., and asked for the films, which came the next day. The image quality wasterrible,and Dave moved during the study. From what I could see, the films were unreadable.
But I’m not much of a radiologist, let alone a neuroradiologist. So I dragged the films to someone I trust. She agreed. They were unreadable and worthless.
Now, it might have been a tolerable situation if the reading doctor had dictated something about the films being useless, and recommended they be repeated with sedation, or on a different machine. But instead he dictated them as normal.
So I needed another MRI, done on a decent machine, with sedation, and read by a neuroradiologist. Easier said than done.
I ordered the study. His insurance denied it, on the grounds that he just had an MRI last week, and so they wouldn’t pay for another.
I appealed it, and personally called their physician reviewer. I told him the patient had something serious going wrong in his neck. I told him the previous films were worthless. I even offered to send him the films to look at himself.
He told me that I’d have to live with them, and it wasn’t his fault that the ordering doctor had chosen that facility. So I was stuck. And Dave was getting worse. What could I do?
I had only one option.
I admitted Dave to the hospital. It was a gamble. Once I had him in I could do whatever tests I wanted, but if I were wrong, it would be a nightmare to justify the admit to his insurance.
While I was working at my desk, Dave was rolling into the hospital’s MRI. Within an hour the neuroradiologist called me. Dave had a huge herniated disk in his neck, crushing his spinal cord. I called a neurosurgeon immediately, and 2 hours later Dave was having the disk, and it’s threat of landing him in a wheelchair, taken out.
Dave did fine.
But the case is still pretty damn scary when you think about what might have been.
Doctor Grumpy is a neurologist who blogs at Doctor Grumpy in the House.
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