American ER Doc Gone Walkabout Episode 021
Some of you just might be young enough that you never assisted in the performance of an open cholecystectomy. Especially, an open cholecystectomy on an inflamed, nasty, oedematous gallbladder. Everything oozed, tissue planes for dissection were hard to find and stay with, the tissue was friable and easily torn — leading to more oozing and worsening visibility. It was a bloody mess (the American literal terminology, as well as the Ozzie expletive). It led to conversations such as: “Is that the cystic artery? “I think so, it’s heading in the direction of that big red bag — formerly the gall bladder.” “Shall I put a tie on it?” (this was in the days before clips). “Are you sure it’s not the right hepatic artery?” “Well, we can tie it off and see if most of the liver turns black.”
The decision to undertake cholecystectomy, in the days before laparoscopy, was a bit tougher than in the current keyhole era. The right subcostal incision had a lot of morbidity — dividing the rectus muscle guaranteed a lot of postoperative pain, more atelectasis and pneumonia post operatively, at least a couple of days in hospital, at least a month out of work — longer if you were a manual laborer. You certainly didn’t want to rush into the surgery to prevent just an occasional bout of biliary colic. On the other hand, you didn’t want to delay, if true cholecystitis was present, and force the above scenario upon yourself as operating surgeon.(Back then, people didn’t rush into the ER after 18 seconds of pain, as they do now. We often faced the badly inflamed scenario because the person with abdominal pain had tried to tough it out at home for a few days before presenting to “A&E”.)
Things changed with laparoscopy. Inpatient stays were short, pulmonary complications rare, postoperative disability measured in days rather than weeks. So, most gallstone-containing symptomatic gallbladders were going to come out sooner rather than later. If you operated urgently, and it wasn’t an inflamed gallbladder, you hadn’t set the patient up for a surgical procedure, with major morbidity and long recovery, that wasn’t yet absolutely necessary.
It made it so much easier to just operate early on, before things got inflamed. The morbidity was less for the patient. Even if it wasn’t destined to progress to a badly inflamed gallbladder, he was going to have the surgery soon anyway. And, the likelihood of a nice, clean operative field for the surgeon was increased, and was potentially attractive to the surgeon.But, like much in medicine, it isn’t just medicine.
Since the dawning of the age of laparoscopy, I’ve worked in a couple of postal codes.
One postal code was rich, with a lot of economic competition among surgeons — a bit like a scrum with a patient thrown into the middle. If a patient presents to ED with biliary disease, even if there is no formal sign of cholecystitis, and he/she becomes pain free, but that patient goes home, she might choose a different surgeon for her elective cholecystectomy and the duty surgeon loses a source of revenue. The decision is easy: admit the patient, and the gallbladder will be a pathology specimen in a matter of hours and all is well for both patient and doctor.
One postal code, on an American Indian Reservation, was poor. But, the surgeons were not paid by the case, so the procedure didn’t provide direct income augmentation. But, the patient wasn’t likely to go elsewhere if we treated him unpleasantly — so, the surgeon wasn’t likely to escape doing the case. But, if we delayed, we increased the likelihood of an inflammatory mess that made the case difficult, made the surgeon sweat, and in the worst case resulted in conversion to an open cholecystectomy — as well as complications, sepsis, death and other unpleasantness. A call to the surgeon, with any hint of cholecystitis, resulted in admission and early operative intervention. If you accept the proposition that operative intervention is the proper treatment for cholecystitis, this seems a good option.
In Tassie, where the economic milieu was similar, but operative loads on the house staff were greater, there was a greater motivation to push simple biliary colic down the road a bit, onto the elective list, but there wasn’t very much motivation to try to delay surgery for minimal reason. So, we didn’t really need a flagrantly awful cholecystitis before a call to the surgeons resulted in admission and operation.(Do you have a hint of where I’m headed here?)
In case you Aussies have been misinformed and perhaps believe that the US has a functioning government, the news of recent weeks should have disabused you of that notion. However, even before the Americans (may God have mercy upon the black souls of her politicians) voluntarily put themselves in the position of having to close large parts of our government, we’ve had a pilot project of a dysfunctional medical care system.(One interesting sidelight for me: next week, I’ll be hiking into the Grand Canyon with a group of Brits. In order to save money, the US government is planning on shutting off both the flow of water down the Colorado River through the canyon, and turning off gravity to the canyon. The scenic values may be somewhat less, but the hike back out should be a breeze. I digress. Sorry.)
The really medically dysfunctional postal codes of large parts of the US are where much of the population is poor and uninsured (recall that in the US, the minimum wage is $7.25, even a single person can’t live on that — compared to $16 in Oz — even folks in the US with full time jobs may be far below the poverty line). In such areas, every operation is a money loser for the surgeon and the hospital (and, as I learned in MBA school, if you have a net loss per unit sold, you can’t make a profit based on volume.) So, if you use every possible means to discharge a patient with biliary pain.(Doctor, after ketorolac, diazepam, and 40 mg of morphine, he seems quite comfortable – and even breathes occasionally. I think we can discharge him to follow up with his GP, though non-existent, in 3-4 weeks, during which time he suffers 8-10 more attacks of colic. The GP can then try to find a surgeon who will put him on the elective list for intervention in another couple of months or more. If we’re lucky, the patient will move to Biloxi, where a different surgeon can do the procedure or he’ll get an attack of severe cholecystitis while on the bus to his job across town, and some other surgeon can fight through the edema and hyperemia that I could be avoiding right now by operating, instead of carrying on this conversation.)
OK, I admit the surgeons aren’t that flagrant. But, our EM residents get to hear the mantra: he’s not sick enough, the GB wall isn’t thick enough, the WBC isn’t 20,000 — let’s send him home. Eventually, we learn to not bother with the consult. If there isn’t clear evidence of cholecystitis, send the patient home without consultation — that only wastes time and prolongs the ED stay. And, then the envelope for discharge starts a very subtle expansion, and more patients are discharged even though they have had prolonged pain prior to ED presentation, or aren’t really completely pain free, or the WBC is slightly elevated……
But, that behavior puts the patient at risk of going on to have severe cholecystitis, with all the potential for a worse outcome, and puts the surgeon in the position of doing a more technically challenging procedure.
I’ve had a couple cases in recent months where the resident was ready to send home a patient, because all the labs were normal, and the pain was “almost” gone after large doses of analgesics, but who had been continuously symptomatic for days. The resident was surprised that, when I insisted upon surgical consultation, the surgeons whisked the patient off to theatre with the commentary that any further delayed would make the whole thing a bloody (both US and Australian usage) mess.
One other technical comment: While in Launceston, I learned the value of using CRP in addition to WBC as an aid in decision making. Seems strongly supported in the literature, and widely used in much of the world, but nearly unheard of in the US, so I’ve been trying to add it to our decision process in beautiful Colorado — take note CU residents reading this!What do I conclude with this?
There are differences from place to place in how low the bar is set for taking a person to theatre promptly for biliary disease. The level of the bar is often set by economic factors, but is often within a range justifiable on clinical grounds. It is, however, possible, if we’re not careful, to let one’s bar get pushed to a level where few can jump it. The decision is easy if there is associated pancreatitis, other sonographic or lab signs of common duct stone, or flagrant signs of cholecystitis. But, if we ignore signs of mild cholecystitis, we do neither our patients nor our surgical colleagues a favor — and saddle them with more difficult operative conditions, more likelihood to face the challenges and morbidity of conversion to an open procedure, and more postoperative morbidity. Before discharge we should be searching hard for the subtle markers of inflammation: mild WBC elevations, elevated CRP, prolonged pain. And, the patient should be pain free — not better, not nearly, but zero, nada, not even a little bit — after most opioid effects have abated. If not, get the consult.
Later, mates.Next time: Lies, Damned Lies and Monitors
American ER doc