Reinventing wheels etc

In the BMJ of 23rd April are listed the finalists for the BMJ Neurology team of the year awards, which include the Multiple Sclerosis team of UCLH for its integrated service.

Reinvention of the wheel? Failure of institutional memory? Left hand not knowing what right hand is doing?  All three possibilities come to mind when I read the nomination which “to everyone’s surprise” showed that urinary infections were the commonest cause of admission in patients with MS.

I am certainly surprised it was a surprise.  Indeed when I read this I was almost speechless.  I have known, and taught this for nearly 30 years.  I took over a Young Disabled Unit in 1985.  Over the next ten years I and my multidisciplinary team turned it from a long-stay unit with 15 residents to a dynamic rehabilitation unit with some 300 clients, the majority of whom had MS.  We provided a regular inpatient respite service, a helpline and regular outpatient review, which was supplemented in later years with bladder ultrasound.  The superb nursing staff were also alert to admissions of our clients to acute beds, from which they would be extracted as soon as possible – or at the very least they would make a trip to the acute ward to advise.  I taught all the trainee doctors that patients presenting to A&E with a sudden deterioration in their MS had an infection (usually urinary, but sometimes chest) until proved otherwise.  While deterioration was rapid, so was recovery if effective treatment was instituted rapidly.  I might add that, as a clinical point that will save some lives if anyone reads this, some patients with an acute infection regularly developed severe hyponatraemia which we attributed to acute adrenal insufficiency, and recovered with hypertonic saline and hydrocortisone; whether this phenomenon was related to previous high dose steroid treatment for relapses we never did determine.

We also provided an effective pressure sore service. Regular physiotherapy helped prevent contractures and maintain mobility.  Occupational therapy home visits were a sine qua non. Our service was entirely integrated.  Our local district nurses involved in home care regularly exchanged information.  If a patient “went off” suddenly then infection testing was arranged at home.  Not infrequently I would write the antibiotic prescription.  Unit emergency admissions were organised not by GPs but by family or the district nurses by direct contact.  In this way we actually kept MS patients out of acute hospital beds.  All of this was done without any input from neurologists.

To return to my opening paragraph it appears to me that the UCLH team have reinvented the wheel.  I regret that my teaching in a suburban district general hospital never permeated to the centre to provide a lasting institutional memory, but perhaps the most damning indictment is that, until relatively recently, it was rehabilitationists who dealt with long-term MS patients and not neurologists, who concentrated on diagnosis (once made, there was little treatment, so many, though not all, lost interest). So the crossover of information from left to right hand was as limited as in a patient whose corpus callosum has been transected.  It is thus encouraging to see the growing interest and enthusiasm of neurologists in integrated long-term management.

Though our model was highly effective, and much appreciated by patients and their families, it was expensive.  The Unit kept afloat as much through my political lobbying as through its care success. Within a year of my retirement it had been closed down.

If you make a diagnosis and administer the treatment, and the treatment fails to work, it’s the diagnosis that’s wrong.

I once had a 17 year old patient with low back pain referred after the GP had become exasperated by his failure to improve – oh, and by the way, his ESR was 57 (for the non-medical reader, a high ESR is indicative of inflammation, infection or malignancy).

He was very stiff so I made a confident diagnosis of ankylosing spondylitis, not least because his SI joints looked fuzzy on the X-ray.

After two trials of different non-steroidals for a month each I put him on phenylbutazone. This didn’t work either. It now became apparent that his pain w as quite localised to the L2 region – which was just off the top of his original pelvic X-ray – and further investigation confirmed that he had osteomyelitis in L2 and L3 presumably from the discitis between. Common? No.

Corollary: if a physical sign doesn’t fit the diagnosis, reconsider the diagnosis.

An Indian gentleman in his 70s presented with typical symptoms of polymyalgia (pain and early morning stiffness across the neck and shoulders) and a high ESR. His son said he had just returned from India and had been investigated for an intermittent fever, but his malaria tests had proved negative.

I gave him some steroids (prednisolone-EC 10mg daily) for a fortnight; he did not improve at all. I assumed I had not started him on a high enough dose, and doubled it for another fortnight. Nothing.

So I followed the corollary and wondered whether this was some sort of malignancy (myeloma and prostate cancer can both masquerade as PMR) and did some further tests – bloods and a bone scan. I was inspecting the latter when a message came round from A&E that he had been admitted with a paraparesis; he had lost power and sensation in both legs..

Have you remembered the fever?

The liver tests were right up the Swanee and the scan showed a hot spot at T3. Osteomyelitis (probably tuberculosis) was the diagnosis on biopsy at the neurosurgical centre.

Patients with polymyalgia respond dramatically to steroids and the ESR comes shooting down; if this does not happen, then either we have some other unrelated pathology (as above) or we are dealing with some other sort of inflammatory joint disease. Medicine is like buses, not trams. You need to be able to make detours when things are not right, not just grind to a halt.

While this is a rather medical post, I am prompted to add it having just read “The Monogram Murders” by Sophie Hannah – it’s a Hercule Poirot story in the spirit of Agatha Christie.  Poirot tries to make the nice-bit-dim policeman, Catchpool, do some thinking for himself, pointing out repeatedly that facts are facts and you cannot ignore them when they don’t fit the theory.  You must make the analysis fit the facts, not the other way about.  In both these above cases I failed to do that.  As a corollary to that I estimate that every doctor will make at least two mistakes a year that result, or might have resulted, in serious harm to the patient.  I have.