The Truth... What is it?



  1. home:

    After an uneventful 3rd pregnancy, a 25 y/o white female had labor and delivery induced at 41 weeks (a week past her due date), productive of an 8 lb, 11 oz girl with excellent Apgar score of 9/9. Cord-blood bilirubin level was significantly elevated at 12; cord blood type was B+ and mother was O+....."ABO-incompatible hemolytic disease of the newborn", a usually mild problem, was diagnosed. Baby was placed under bili-light to aid in reducing the elevation. 48 hours after birth, on Friday, an apparently well baby and mother were discharged home, a baby's blood sample drawn for the discharge base-line record. Totally unexpectedly, the blood count showed the platelets (tiny blood components which prevent bleeding) to be only 50% of normal levels....a potential sign of potentially fatal bacterial sepsis (blood poisoning); the blood WBC absolute neutrophile count was never higher than 7000. A family member pathologist reviewed the blood smear as well as having previously processed the baby's placenta (after birth) to be sure all was normal. The on-call pediatrician was able to quickly check the baby to be sure the spleen was not enlarged, to be sure the baby didn't seem toxic, to repeat the lab tests (which duplicated the earlier values), and to receive assurance from the pathologist that the blood smear did not look septic and that the placenta was definitely negative for ANY evidence of a hidden infection. Antibiotic treatment was with-held, and the baby was allowed to return home Friday afternoon and was monitored without any treatment... all values returning toward normal by Monday. 10% of placentas from apparently normal deliveries like this have evidence of a hidden infection....usually not making itself known or being a problem. What if your newborn turns sick in the 1st 48 hours...wouldn't you like for the doctors to know what the placenta has to tell?

  2. Thank goodness our lab processed the Pap smear, too:

    We received a hysterectomy specimen on a 40 y/o female with a history of "abnormal Paps". Our routine gross (with the naked eye) exam was negative for anything unusual; so, routine slices of the uterus and cervix were taken for microscopic exam. When our pathologist viewed the slides the next day, they were all perfectly normal. And the abnormal history was initially unexplained. But the most recent Pap smear had been diagnosed in our lab due to the fact that the physician office was now owned by our hospital; and our hospital policy was that all surgical and cytology (anatomic pathology) specimens were to be "tested" by the fully credentialed, fully-in-compliance with State Board of Medical Examiners (state licensing Board) pathology group members based at the Lexington Med. Ctr. hospital. The pathologist reviewed the abnormal Pap slides and determined that a significant, as-yet-unexplained abnormality was present. As a consequence of the fact that these pathology services were being done at "the point of service," the discordance between the history and the uterus findings became obvious and compelling. The pathologist returned to the uterus specimen container and re-examined the specimen...once more it appeared unremarkable to the naked eye. Our pathologist, predicting the likely site of abnormality, sliced in all of that area of the uterus for microscopic exam. The next day, the slides came out and showed a small and dangerous cancer. The pathologist contacted the gynecologist who noted that the patient, years ago, had a series of abnormal Pap smears which were followed for several years by "normal" Paps in a commercial lab. Immediately upon getting the abnormal diagnosis on the most recent Pap, the patient was called in and was resistant to a strong (because of the recurrence of Pap abnormalities) recommendation for hysterectomy. Fortunately, the gynecologist prevailed; and the hysterectomy was performed. Fortunately, the doctors office, hospital, and pathology group were in a system of "point of service pathology". Fortunately, the gynecologist and pathologist were "good doctors"...citizens actively participating in, living in, and devoted to their local communities. They went the extra mile. They did what was right (not what might have been viewed by medical businesses as cost effective). And the patient received the subsequent "icing on the cake" of the additional therapeutic measure of radiation therapy. She is cured!!! Outside of a smoothly functioning "point of service" pathology coverage, she might not have even been diagnosed! Guess what...had a disastrous false negative diagnosis (missed diagnosis) occurred, it would have not made even a "blip" in so-called quality assurance monitors of the Wall Street type medical business world.

  3. The right hand didn't know what the left hand was doing:

    A 63 y/o man, father of a long-time official in a local hospital obtained his usual care from his family doctor on the other side of a metropolitan city. At one point, that doctor ordered a CT scan of the man's abdomen at a down-town, commercial image center whose reports did not reside in any of the hospital computer information systems. He developed back pain and was seen at another area...the largest (medical-school associated) Studies showed bone "lesions", one being of the breast bone. A biopsy was done and the lesion was simply diagnosed as a "metastatic malignant tumor". He was referred for radiation therapy at the local hospital of his child. In order to better plan therapy, the radiation oncologist needed information about the tumor (the above was a "cost-effective", minimalist diagnosis). It was shocking to the local pathologist at the radiation therapist's hospital to see that no more had been determined. The story had been obtained "by word of mouth" (since the report was not available in the information system) that CT scans looking for an original (primary) tumor were negative. Slides were borrowed (taking almost a week). It was seen that special stains would be needed from an expert pathology group on the opposite side of the USA. More slides had to be requested and then forwarded to the distant group. The studies highly suggested that the tumor came from the patient's liver. The radiation oncologist, a "good doctor", investigated much harder and was able to track down the studies at the commercial imaging center. In fact, the CT studies had been highly abnormal, demonstrating cirrhosis of the liver and ascites...a setting risky for the growth of a primary liver cancer. A blood test was positive and added confirmatory evidence. Now the case made sense and proper radiation treatment was executed.

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(case #1 posted 3 Aug. 1998; #2 posted 17 Aug. 1999; #3 posted 17 Aug. 1999.)