A slip in time — a simple injury and relearning the medical system
July 2nd, 2021, a day which will live in annoyancy, I slipped on a slightly sloped wet boulder along the Kangaroo Creek trail in Royal National Park.
From that brief moment of clumsiness, I would struggle to walk normally for six weeks.
Trigger warning: If you have issues reading a long-winded lack-of-conscience account of a minor medical issue turning into weeks of wasted time, skip this and watch the Kenneth Branagh version of Much Ado About Nothing.
My back hit the rock underneath me, but the large internal-frame pack protected me. But my shins had cracked into the edge of the rock in front of me. Pain. Blood. The right shin was much worse — an open wound. In a John Rambo moment, I doused it with hand sanitiser and grimaced. Leigh gave me a plaster, I applied it, and wrapped a handkerchief around it.
We kept going on but lost the trail and had to circle back, escaping the park 4 hours later, just after the sun had set. We exited the trail exhausted, and went home to clean and wrap the wound.
Hospital Visit 1: This is simple
I have a decent first aid setup at home, so I thought there wasn’t much chance of infection, but Monday I stopped by the GP and she sent me straight to the emergency room. My right leg was red and swollen. At the St. Vincent’s ER, where the wound was cleaned, the docs diagnosed me with cellulitis, gave me IV antibiotics, and they released me with 5 days of antibiotics. I felt pretty poor about my wound cleaning skills.
Hospital Visit 2:
On a follow up with the GP four days later, she felt that the leg was getting worse. Back to St. Vincent’s Emergency! Under the cautious eye of an infectious disease specialist, they didn’t think it was that severe. “A few more days of antibiotics should do the trick.” When all you have is an antibiotic hammer…
Hospital Visit 3:
A week after, the would was looking good, but my ankle had swollen up and explosive to walk on at night. A scheduled phone check-up with the infectious disease specialist over the phone, they told me to go into the ER and ask for Ortho to check for a septic joint. Turns out that is unrelated to a septic tank.
Hours after being admitting, the on-call Ortho specialist at St. Vincent’s arrives, clearly having a bad day where it’s been back to back trauma so I’m a mild case of the yawns. When she hears that the infectious diseases specialist told me to ask for Ortho, I am rewarded with an eye roll, and she guides a shaky med student into sticking a needle deep into my ankle joint to draw fluid. Note: this is called ‘aspiration,’ but a better name might be “Excruciation”.
Because doctors consider “being admitted” as a huge overhead, they kept me overnight to await the test results, which no one expected to show anything. This was clearly a case of “let’s do tests to eliminate an unlikely case, but actively treat the patient like it is the worst case.” The test came back negative for any scary stuff, they did another round of IV drugs just in case, and declared this as “reactive arthritis”, a highly unlikely diagnosis, which turned out to be close to the right diagnosis but far enough away that it then cost me another week in the hospital.
My Nephrologist steps in
I had been keeping my nephrologist in the loop as the case went on, and after 72 hours of staying completely off the foot, with no improvement, she decided to take action: she ordered a gallium bone scan! This was my first “nuclear medicine” test, but I received absolutely no superpowers whatsoever. Meh.
The day the results came back coincided with a return to the St. Vincents fracture clinic (where the orthos hang out). The young intern read the report, seemed confused, and told me, “It’s arthritis” despite the clear recommendation of additional tests in the bone scan report. My nephrologist’s patience was exhausted, and she had me admitted to Royal North Shore.
Hospital Visit 4: Futility
As much as St. Vincents was plagued by delays, Royal North Shore crawled at a geriatric turtle’s pace (which matched my current walking speed). The only reason I was admitted was to get an MRI, which I did not receive until 48 hours later. Neither hospital was handling COVID cases at this point so that wasn’t the reason.
During those two wasted days, I gave blood, and answered a barrage of routine questions like, “Have you opened your bowels?” Personally, I would want to know if you’ve closed them. That seems much more important.
My roommates were a pensioner dealing with brutal side effects from radiation targeting his prostate cancer, a nonagenarian toe amputee yelling “help me” at the top of his lungs to have the nursing staff lower his bed in the middle of the night, and a half-sane man who would yell at his wife, hang up, and then call her back to apologise. Who needs Netflix or the Olympics?
Any questions I asked caused mass confusion. Normally I’ve always been told not to have contrast during scans because of my kidney history. Asking about this delayed the MRI further — but eventually I spent 75 minutes in the hammering cylinder. All to have the MRI come back without any additional information — we knew it was not a fracture, we knew it was not osteomyelitis. Again, all we did during those two days is eliminate all the scary stuff. All of this could have been done as an outpatient.
Eventually, a rheumatologist said he was firmly convinced that it was a reaction to the infection, but not reactive arthritis, which only comes from specific infections like Chlamydia (for which I tested negative — I had not been intimate with any Koala’s in the last 45 days).
The next three weeks, the ankle slowly returned to normal, and I rode my bike on the trainer the second week of August, and managed my first run during the third week. Six weeks without being able to walk normally had progressed, and most of my medical “treatment” had not contributed to any of that progress.
What did I learn?
Medical staff are challenged during COVID, be sympathetic to them
First and foremost, any complaints I have are more about the system than the individuals. Nurses, techs, and doctors all wanted to help, but were either too swamped with cases, handcuffed by the system, or following the procedure dictated to them even though they knew it was sub-optimal for the patient. With the rise of COVID, it’s even worse. Medical personnel are under more regulations, stress, and case loads. Of course, the best thing you can do for the medical staff (and other patients) wherever you live is to get vaccinated and help reduce the case burden!
GPs are more of a referral engine than a care coordinator
Friends of mine in the medical profession have talked about the decline in diagnostic skills by GPs. It’s much easier to forward you on to the ER or a specialist than work on the diagnosis yourself — and often the patient is left coordinating their care without an understanding of the system.
There are exceptions — A close friend of mine remarked of her GP, “He’s broken through deadlines and has had amazing referrals twice. Calls me to check in when I haven’t booked in.” We need more GPs like this.
Australia is missing internal medicine in hospitals
In many hospitals in the US, when you are admitted, you have a doctor in internal medicine coordinating your case, who understand how to work the system, how to get all the right specialists involved and react to their input, how to get your tests back quickly, to minimise your stay in the hospital. Much of the use of internists was driven by economic reasons but it also generates better outcomes for patients. Whoever owned my case in each of my Australian hospital visits just didn’t have the time or the breadth of knowledge to coordinate my care (or even to just make the hard call to dismiss me early and do it all as an outpatient).
The system cannot handle “half-serious” cases
If you’re seriously ill, hospitals are optimised for you. If you’re not, they just don’t work well. Heart attack? Hospital is the place for you. Trauma? Head to the ER. Something you need removed from an orifice before your kids get home? They have gloves and lube at the ready. Non-urgent, complex medical issue which will take some time to sort out? Good luck in a hospital. Of course it completely makes sense to prioritise the critical cases, but it means if you’re not critical, you should seriously re-think whether being in hospital is for you.
A novel program, “Hospital-in-Home” at St. Vincents — designed to make sure people could progress their medical treatment as an outpatient, is fantastic in theory but an absolute fiasco in my experience. The small crammed hallway they operate out of shows their importance to the hospital, and their complete lack of record keeping is abysmal (they told me to show up, then had no record of me, the doctor who I had spoken to didn’t remember me, then after two hours of waiting they announced that they could not provide the treatment they said they could and I had to be admitted). Hopefully they can pay some attention to this program because it could drastically save time and reduce the need for overnight stays for non-critical patients.
They call it practising medicine for a reason
The number of mis-diagnoses (or lack of a diagnosis) is staggering. The inability to explain things to the patient is perhaps the largest crime. The younger doctors were 10x better at explaining things (usually I find in life, the more recent you learned something, the better you are at explaining it). Unless I interrogated the doctor, the current situation, the next steps, and the reasons for those next steps, would rarely be communicated.
The myth of a medical test providing a clear diagnosis exists in our heads from too many medical TV dramas. The TV doctor runs a test, gets the diagnosis, and then they apply the treatment. Almost every test I took “mostly” ruled out something, but were never conclusive. Even the tests for uric acid crystals could not be relied on for gout (20% of the time, a negative result can still mean you have gout).
Perhaps the most frustrating is the misunderstanding of time — I spent two days waiting for an MRI which eliminated osteomyelitis (which the bone scan should have eliminated). They did x-rays but always said the x-ray doesn’t show everything. This all could have been done as an outpatient — but the hospital staff just accepts the delays as part of the system rather than thinking of the system more broadly, and looking for other options (like outpatient treatment) as a solution.
And yet, no bill…
There’s a wonder to the Australian medical system, in that I never had to trade off the financial cost (the cost of time was the issue for me) or even consider it. I never saw a bill the entire time I was in hospital. One financial coordinator came to me during one visit to make sure I understood that any additional costs would be covered by my supplemental insurance, but that even it was unlikely to be used given the coverage by medicare. We pay a decent chunk of taxes for medicare, but even with all of the problems I experienced, it’s worth it.