05 January 2010

You can lead a horse to water

America does have very good medical care, all the grandstanding and political rhetoric notwithstanding.  It's imperfect and expensive, but it's still great care, and the despite the crisis of the uninsured, care is generally accessible for most, and for nearly all of those with life-threatening conditions.  Which is why it's so mind boggling when you see a patient in the ER who clearly has a terrible disease, has access to care, and simply fails to avail him or herself of it.

For example, I saw a patient with a craniofacial tumor.  At least, that's what I figured out it was.  She didn't come riht out and tell me that she had been previously diagnosed with a malignancy; her chief complaint was that she had been having double vision for "months" and that now she had totally lost the vision in her right eye.  It was obvious on first glance that there was something wrong with the orbit as the right eye was massively anteriorly and laterally displaced.  She looked as disfigured as some renditions of Quasimodo's face -- truly horrible.  Her pupil was nonreactive on that side and she had just about no light perception.  I was kind of mystified, and more perplexed at how long she had let it go before getting it checked out.    Here's her CT:


You can imagine the tension.pressure on the optic nerve!  Here's an annotated version for the non-radiologists:

proptosis note

You don't see the other eyeball because the head is rotated a bit.

It didn't make sense, and I noted that she had decent insurance.  I looked her up in the hospital computer, and found that she in fact had a lot of records in the oncology database -- including missed appointments for surgery and radiation oncology procedures and a final sad note that she had been "lost to follow-up."  She never got her tissue biopsy, and just stopped showing up after that, refused phone calls and ignored letters.  Wild.  She had, of course, failed to mention this to me in her medical history.  Sheesh.

I think it was a case of denial, severe depression/apathy, combined with social isolation that made this possible.  There wasn't much for me to do in the ER -- the eyeball was clearly a lost cause, and she was admitted with a slew of consults.  Sad case.  I never found out what it was that she had, which is also a pity.  I would have been interested.


  1. I can tell you what she had... denial. I think that this 'it will go away if I ignore it' is much more common that I thought before entering medicine!

  2. a bit off topic, but:
    why did she get admitted? is there any concern these admissions won't be paid for by insurance?
    i can see why you wanted her admitted - clearly best for her given her history of failed outpatient management (for any reason)...but i wonder if the insurance won't see it that way.

  3. The other end on the scale of balance of when to worry about ones health. Hipocondria (I have cancer! I just know it, I can feel it!), normal concern ( WTF is this pain?), and denial (this patient).

  4. I remember a busy night in our casualty.I was trying to sort out the emrgent from the non-emergent patient. I was sifting through the thirty odd files of patients that were waiting to be seen , to see if i could send some home and came across this triage nurse note: 'Man with 6 month history , difficulty seeing'. I grabbed the file and thought'HA' this is not a casaulty patient. I triumphantly walked up to the seated gentleman ready to throw him out. Just before i turfed him I asked him to fold back the rediculously looking bandage that he had swathed over his head and right eye. Only to reveal a similar sized cranio-pharyngeal tumour. Eye bulging, rotten ball, orbit disrupted, a mess. dejectedly I told him he could take a seat again and I called the surgical team. I expect this in my african context- to see it in your context is a big surprise.(and she had health insurance)


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