Occupational Health - Second opinions or Glimpses of the Obvious

Last week I saw three patients in rapid succession whose NHS doctors had made the wrong diagnosis, missed the diagnosis and ignored the diagnosis.

Occupational Health is about getting the patient back to work, and if that involves sending the patient back to their NHS doctors, I do what it takes.



Person 1 injured his hip four months ago and has been off work for four months.
He complained to me of hip pain, he complained to his physiotherapist of hip pain, he complained to his General Practitioner of hip pain, he complained to his Orthopaedic consultant of hip pain. As far as I could tell, I was the first person to examine his hip since his initial visit to Accident and Emergency, where he was Xrayed

He gave a story of a "dislocated hip". This is unlikely - First, dislocating a hip takes a massive amount of force (FTR - hip replacements dislocate easily). Second, it takes a full general anaesthetic and a lot of effort to put them back.

However! - he did this during a Rugby game - and the "other buggers were big" - and he was immediately treated by an experienced physiotherapist who manipulated his hip and it then felt a lot better. But he still couldn't walk. He has not walked properly since.

His back did not show much wrong when I examined it, but when I examined his hip by feeling in his groin, which is where the hip joint can be felt - he hit the roof with pain. And this guy is a tough cookie. I have sent him back to his GP with a letter, and not back to work.

Person 2 has had funny turns for the last four years. He has extensive investigations for heart disease even to the point of having a stent put in. However his "funny turns" persist and to his mind he is worse than he was when he first went to see his doctor.

He is short of breath, he can't comfortably lie flat, he has episodes largely at night of feeling strange, even as though he has been stabbed in the chest and is about to die. The last doctor he saw almost got the diagnosis. But they sent him for a scan, and four days later the scan was normal. He also goes on long coach trips.

This is a classic story of recurrent pulmonary emboli - and the cardiologist put in a stent because he is fat geezer with slightly narrowed arteries to his heart.
I put him off work and wrote a note to his doctor, asking him to arrange for him to be investigated for pulmonary emboli and raised blood pressure in his lungs.

Person 3 also had dizzy spells, but of a different type perhaps more related to long term night shifts. But a twenty four hour ECG has shown his pulse slowing to 33 beats per minute.

He was told by his consultant that this was normal for a fit person. He is over 50 and even Rebecca Adlington's pulse rate never gets that low. He needs a pacemaker.

The morale of these stories, is that the diagnosis comes from understanding the patient. All three had been seen by consultants in major teaching hospitals. A consultant appointment was once a gold standard.

The difference between consultants and an occupational health physician is not so much one of skill but of time. All three diagnoses were in the history. "Investigations" can be wrong, Person 2's scan was done too late and in any case would not show up small clots on the lung (pulmonary emboli). They look at the wrong part - Person 1's MRI scan looked at his back not his hip. "Investigations" can be right and be ignored, as was the case with Person 3.

I would like to think that even ten or twelve years ago, I would not have found so many diagnoses. Roughly one in ten of the people I see, have the wrong diagnosis. Nothing, even in this high tech world beats a good history and examination. People matter, and cannot not be fobbed off with a few high tech tests, when they need a proper medical opinion.

Once upon a time, I thought tests were better and more reliable than doctors. Whether a Masserati is a better car than a Ford depends on more than the technology under the bonnet. If a blind person is driving the Masserati, you are safer in the Ford driven by someone who first finds out where you want to go.


Copyright Dr Liz Miller, Well and Working Ltd

www.lizmiller.co.uk
www.moodmapping.com

Occupational Health - more second opinions - Tragic and Trivial

Occupational health is a window on the world, I cannot prescribe drugs, nor order any tests but from my crow's nest I see life. Sometimes what I see in Occupational health goes beyond description for a twentieth first century civilised nation



45 year man blind from an avoidable and treatable complications of cataract surgery.

Refuse Collector - Essential manual worker



Aged 45, rapidly progressive cataracts and hypertension. Waits eighteen months for surgery "to get his blood pressure under control". Operations 4 and 6 months ago. Not back at work, sent for Occupational Health referral.



On examination, Light and Dark perception only.



Likely diagnosis - Bilateral detached retinas, occuring a few days after surgery.



Complications - no post operative check, not when the man goes for surgery on his second eye



Prognosis - Grim



The trivial.



Technician (aka Mechanic) for top car manufacturere

Non essential Manual worker



Pains in wrist, not severe, just aches occasionally.



Third visit to private specialists - and private physiotherapists, following checks for Hand and Arm Vibration Syndrome and Carpal Tunnel Surgery



Unknown fact - this employee races 1,000 cc bikes at the weekend, which puts his wrists into extension and this, combined with the vibration and weight of the bike, is hurting his wrist.



Complications - at risk of private surgery for Carpal Tunnel Syndrome



Prognosis - excellent if he changes the bars on his bike
www.lizmiller.co.uk
www.moodmapping.com

Occupational Health - more second opinions - Glimpses of the Obvious

Occupational health is an unlikely place to make a diagnosis. On the other hand, there are a lot of people not working because they have not had proper treatment

I have seen two people recently who have been treated for the wrong diagnosis.

The first was a woman on a large number of painkillers, and had recently started antidepressants, for piercing chest pain. Every orifice had been penetrated by medical instruments. However what made her different, was her habit of drinking a cup of scalding tea every hour. Was there a connection between pouring near boiling liquid down your throat and severe pain? Almost certainly! We negotiated a deal - she would carry on drinking tea, but cool it down first.

The second had injured his finger. His work involved typing and the pain he still had, three months after the injury prevented him working. A quick examination showed that he had also injured his nerve. In the hand and fingers, tendon and nerve injuries often occur together - the nerves and tendons are close together. When I was a medical student, our teachers drilled us to look for a nerve injury where there is a tendon injury, and to look for a tendon injury, where there is a nerve injury. This young man had a partially severed nerve, that had not been treated, was causing severe pain, and making it impossible for him to do his job.

I probably see one case a month where poor medical treatment of minor injuries leads to a person losing their job. A woman who does not have an X-ray to check their fracture has healed, until the fracture has past the point of healing. Nowadays no one seems to get physiotherapy after a knee replacement. The result is that he cannot climb stairs, not because the operation was not a success but because no one showed him how to climb stairs after surgery.

These injuries and omissions are not audited. No one checks that a doctor has asked about hot tea drinking or that someone can climb stairs after a knee replacement. Yet they reflect the underlying quality of a service. The everyday touches that make up good care.

What is the remedy? Nothing short of personal vigilance. If it does not feel right, it probably is not. Learn to be your own doctor, and save up and get private medical care.

Private doctors tend to care more about their patients. Private patients are valuable, because they pay directly for their treatment. Private doctors depend on their reputations for referrals. State doctors do a job, with too few resources and as long as they get their targets, tick the bureaucratic boxes, no one is the wiser as to whether they include the everyday touches of good medical care.

www.lizmiller.co.uk
www.moodmapping.com

Diagnosis - find out everything about the problem

Just as you expect your garage mechanic to fix your car, people expect the doctor to fix them

And in many ways the process is similar!

I saw a young lad in the clinic two days ago. a 24 year old security guard, with a pain in the knee. He had been off work for a month and he could barely walk. He had seen his GP, been referred to a specialist and was seeing a physiotherapist with a diagnosis of "Patellar misalignment"

Except it didn't add up. I don't like the diagnosis "Patellar misalignment". The patella is a bone that sits in the quadruceps tendon. It is not a bone like the femur or thigh bone, it is a "sesamoid" bone. The patella sits in the quadruceps or thigh muscle where the muscle crosses the knee joint. If the patella is "misaligned", the muscle not the patella has a problem. Nonetheless, surgeons get so excited by the diagnosis of "patella misalignment that they even remove the patella.

The typical patient with patella misalignment is a teenage girl, not a fit young man

I looked at his knee, not swollen and full movement but he had an acutely painful spot where the muscle joined the top of the patella. Nonetheless, his legs did not look right and he did not look right. He was zipped up in a jacket even though he was in the clinic. My attennae were burning.

The penny finally dropped. "Do you do weight training?" "Yes" "Take your top off"

Once the jacket was off, there was the incredible hulk. Massive pects, and taut abdominals and tiny spindly legs. I got the full story. He weight trained in the gym but he only did his torso because that was the bit people saw first. Until May of last year, he had trained as a boxer but he had stopped the boxing training and within a month the pain had started in his knee.

I know I was the not the first person to tell him about the dangers of concentrating on a few muscle groups in the gym rather than whole body training. He had a boxing trainer but he did the weights on his own

The diagnosis - "patellar misalignment" - but anyone who builds up part of their body and neglects the rest is building a maching with a lever partly made of reinforced steel - the massive pects and taut abdominals and partly twigs - the puny legs and knees.

The lad's twig legs were having trouble holding up the steel girder, causing Pain in his knees.

The remedy - weight training with a professional trainer and all round training such as boxing. This would help his body to come back into balance and help him lose the hulk on matchsticks profile.