Saturday, 27 July 2019

A "House" in Singapore?

I'm a fan of the TV series (ended), "House", which is about a genius doctor, Gregory House, who leads a team of diagnosticians to solve medical mysteries - basically patients who present with complicated, unusual, or non-responsive symptoms.

I am reminded of the show because of this news article by a doctor in private practice.

He diagnosed a rare illness, vasculitis in one of his patients.

Which is one of the rare diseases that House's team often come up with.

Which prompted this query/comment:
"... is there a need for a Diagnostic Unit like in "House" in Singapore?"
Intriguing question.

Short answer: no one will set up such a unit.

The case in question developed much like how a story would unfold in an episode of House (extract from the news article):
K is 20 years old and has no past medical history. Two weeks before he came to see me, he had a fever and a sore throat. He went to Hospital A, where a chest X-ray did not find anything wrong and he was discharged with some medications.
A week later, while his fever had subsided, he started having severe abdominal pain and was admitted to Hospital B.
There, an endoscopy was done which showed ulcers in the duodenum, which is the first part of the small intestines. He was prescribed gastric medication. A computed tomography (CT) scan was said to have found nothing abnormal.
After discharge, his pain worsened and he finally came to see me.
K was in distress and begged for the strongest painkillers. K’s abdomen was tender. A CT scan showed nothing life-threatening or urgent, but his jejunum, which is part of his small intestines, was swollen at some part.
Laboratory tests showed elevated C-reactive protein (CRP) at about 100mg/L, which was way above the normal range of 10mg/L.
CRP is a marker for infection or inflammation. It signified that K’s condition was serious.
I treated K as a case of infective jejunitis (food poisoning) with antibiotics, hydration, and painkillers.
But K did not respond as expected. His pain remained severe, requiring regular doses of narcotics injection. His CRP dropped slightly to 73mgL, but it was still very high.
I was puzzled and asked K’s parents to show me his CT images and all laboratory reports from Hospital B for comparison.
At Hospital B, K’s CRP was also elevated at about 100mg/L. And his jejunum was already slightly swollen. This confirmed my suspicion that his serious condition had happened a week ago at Hospital B.
On the fourth day of his admission under my care, K developed a rash on both his lower limbs. This was a sign of an uncommon disease called vasculitis.
In an episode of House, patients were usually referred to the Diagnostic Team after hospitals and doctors have treated for all the usual or common diseases suggested by the presenting symptoms.

BUT the patient would have not responded to the treatment, or in some cases gotten worse or developed other new symptoms that are contraindicated or atypical.

So reading the above extract, I could imagine the scenario and how House's team would have toss about suggestions and diagnoses to fit the symptoms, and predict possible outcomes of treatment options.

So wouldn't it be useful to have such a diagnostic team to focus on unusual or rare diseases so as to help patients faster. After all, in this case the "abdominal pain that was so bad, [the patient] said that he wanted to “kill himself to stop the pain”."

That is needless suffering, if the diagnosis had been speedy and accurate in the first place, right?

Well, no.

In many episodes of House, the patient very often get worse before the team gets their diagnosis right. Part of this is for the narrative structure of a TV episode, of course. It is a one hour show, and if they get the diagnosis right in 10 minutes, what are they going to do for the next 50 minutes?

The other reason is medical reality. In the above case,
On the fourth day of his admission under my care, K developed a rash on both his lower limbs. This was a sign of an uncommon disease called vasculitis... 
We cannot blame doctors at either Hospital A or B for not thinking about vasculitis when K was first presented with fever and abdominal pain.
I was able to make the correct diagnosis only when his rash appeared. His rash is called a purpuric rash, which is very typical of vasculitis. Without this rash and its biopsy, it would be almost impossible to make a diagnosis of vasculitis.
The conclusive symptom (purpuric rash) only appeared after the 4th day after his admission, and more than two weeks after he first sought treatment at Hospital A, and about 10 days after he presented with fever and severe abdominal pain at Hospital B.

However, the characteristic rash only appeared after 10 days, and without that rash, it would have been foolish and impossible to make a diagnosis of vasculitis.

In other words, his suffering was... unavoidable.

One possible critique of "House" the TV series is that given the hit-and-miss, trial-and-error the team seem to approach their work of diagnosing patients with rare and unusual disease is that they never get sued. And in litigious USA, it is unrealistic. Considering how frequently the patient-of-the-day (or episode) often experience a roller-coaster of treatment outcomes, it is unreal how passive and even stoic House patients are.

Very often, they get a lot worse before the team eventually figure out the correct diagnosis and treatment.

Yes, the suffering in many cases were inevitable, unavoidable, and the mistaken diagnosis were very defensible based on the presenting symptoms. But if this were real life, for every one patient they cured, they would spend 6 months in litigation. If not longer.

The net result would be a team that is more caught up in lawsuit than diagnosis.

I believe the same would happen in Singapore. Maybe we are less litigious. But we are aware of our options:
"K’s parents thought of filing complaints against hospital A and B initially, but they aborted the idea after hearing my explanation. I am glad K’s parents are understanding."
Nice save.

But this is one reasonable patient.

There are unreasonable ones. And if there were a unit that focused solely on rare and uncommon diseases, they would be deemed experts and patients would expect them to work miracles.

And sue them when the miracles take a little longer to work out.

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