Sue Ieraci: Testing risk

I RECENTLY returned from a wonderful trip with an even more wonderful woman who just turned 80.

With her permission, I want to tell you about recent encounters she has had with the health system and what we can learn from them. We might get some clues about cost drivers and priorities, and how to redirect them. I will call her Mrs E.

Late last year, Mrs E was waiting for a bus, having refused a lift home. Bored with waiting, she started to walk to the next stop. Seeing the bus approaching, she made a run for it, tripped on her shoe heel, and fell onto the footpath, hitting the back of her head.

She was not knocked out but had a bleeding laceration on the back of her head and was taken by ambulance to a major teaching hospital, where she was seen by the trauma team. Scans of her head and neck were both normal and she was kept overnight for observation.

Mrs E mentioned to a nurse that there was blood on her pillow. The pillowslip was changed.

Later, she was discharged home, with a mess of coagulated blood and hair on the back of her head —– and no sutures.

A healthy older woman, not taking anticoagulants, who had a mechanical fall and the only injury she sustained wasn’t treated.

Fast forward to the second episode. Mrs E’s younger sister has recently had a stroke. Mrs E develops pain in her neck and is worried she may also be having a stroke. She can’t get in to see her usual GP, so goes to a medical centre.

The doctor orders a neck computed tomography (CT) scan, which shows a goitre, provoking a thyroid scan, which leads to a biopsy. The referring doctor does not know that she previously had radioactive iodine for hyperthyroidism, that is now resolved.

A few tests, time, expense and anxiety, and she is also OK.

The third episode occurs on a holiday Monday, when Mrs E decides to treat herself to a movie. She eats takeaway salad and starts to feel sick while in the movie. By that night, she has vomiting, diarrhoea and severe abdominal pain, leading to another ambulance trip to a teaching hospital emergency department.

Someone thinks she may have cholecystitis, so she is admitted and given antibiotics. She rapidly improves clinically, but her liver function tests are abnormal. Her biliary ultrasound is normal, but more consultations and tests ensue.

The CT cholangiogram shows a possible filling defect. Her history and tests are all consistent with bacterial food poisoning (most likely salmonella), and she is almost back to normal, but a cholecystectomy is discussed even though she has never had biliary colic before or since.

Thankfully, her family encourage the hospital team to leave her alone and let her go. She is back to her normal self in no time, and gets to enjoy an overseas holiday, with fantastic food, symptom-free.

So, what is it that makes clinicians treat the test results and not the patient? Are we so afraid of missing a diagnosis that we miss the patient entirely? Why can’t we investigate sequentially, rather than by a scattergun approach? Are we too pressured to move patients along an assembly line, or have we just lost the skill to manage people as individuals?

This wonderful woman has maintained her good health. She is active, social, watches her diet and has a positive attitude to life.

When she has a symptom, a concern or a problem, what she needs is for the people involved in her medical care to listen, understand and take a patient-based approach — not just conduct a battery of tests. And we need to look closely at her — look at the person she is, not just at her results.

It is part of human dignity to accept risk. Mrs E is not risk-averse, so why are we?

Dr Sue Ieraci is a specialist emergency physician with 30 years’ experience in the public hospital system. Her particular interests include policy development and health system design, and she has held roles in medical regulation and management.