“They are telling us he needs emergency surgery. What should we do?”
The woman was clearly frightened. The night before her husband had suddenly developed the signs of a stroke. His facial muscles had gone limp and his speech was slurred. In a panic they had hurried to the closest emergency room, a local hospital where I did not have privileges. Several hours, many tests and multiple vials of blood later the diagnosis of a stroke was confirmed and he was admitted to the hospital.
The following morning a doctor came in and told them the reason for the stroke. One of his internal carotid arteries, the major supplier of blood to the brain, was severely narrowed. So narrowed, the doctor told them, that urgent surgery was required to open the vessel and prevent a further stroke. The family was caught completely off guard, for the morning had brought profound improvement in his condition. His speech had normalized and his facial muscles had improved. They wondered why the surgery was so urgent. Unsure of what to do or how to proceed, they called me.
They told me that the doctor was insistent that he needed urgent treatment. They then asked me if they could transfer to another hospital where I had privileges and could assume his care. While this was possible I had a number of questions I needed to answer before I could say "Yes.". Foremost among them was why the doctor was recommending urgent surgery in the first place. There very few circumstances in which the surgery needs to be performed urgently, but I wanted to be sure he was not one of those rare patients. At the same time in the majority of cases performing urgent surgery dramatically increases the risk of complications so I did needed to get all of the information I could before making a recommendation.
The next 24 hours consisted of me doing online research and making multiple phone calls to specialists to review his case. Each article and conversation confirmed my initial suspicions. Urgent surgery was absolutely not indicated. There was no reason for him to remain in the hospital. I called the family and shared my recommendations with them. Emboldened with the information I had given they declined the surgery. Angry, the doctor that night wrote transfer orders without discussing the case with me, a significant breech in protocol. Transfers are not possible without doctor to doctor conversation so he remained in the hospital overnight.
I spoke with the doctor the next morning. I asked him about the patient’s status and X-ray results and why the surgery was deemed urgently necessary, “He could have another stroke!” was his reply. I shared with him that I had reviewed the literature and discussed the indications for surgery with three different specialists and that I could not see any medical reason why the surgery needed to be done right away. He got angry and started to attack me personally. I stuck to my guns and suggested that it seemed that the patient was stable enough to be discharged from the hospital and that he could see a surgeon in a few days. He finally relented and within a few few hours the patient was safe at home. The risky and unnecessary surgery was avoided.
I was deeply troubled and emotionally shaken by what had transpired. The patient had come dangerously close to needlessly undergoing a risky surgery. I was grateful for the opportunity to help but I wondered how many other patients had not been as fortunate over the years. Second opinions are important!
Follow me on Twitter @bartbarrettmd, or subscribe by clicking the button on the page. Questions and comments are welcome!