5 ms·

I’m sorry to hear this and of the incredible suffering your mother and her loved ones have had to go through. I am quite aware that there is a significant numbe

I’m sorry to hear this and of the incredible suffering your mother and her loved ones have had to go through. I am quite aware that there is a significant number of physicians who are careless, apathetic, rushed, eager to get home after long working hours. Many are incompetent but I would venture to say that a larger number is plenty competent. It’s just gotten to a point in their career where they are “burnt out” for whatever reason and they are aiming for speed. It becomes another consumer transaction and as the patient load increases during the night, the clinician just tries to simplify things as much as possible, taking shortcuts, working under weighty incorrect initial diagnoses. Once you’re seen by that first doctor who makes what should be a tentative diagnosis, that opinion carries a great deal of psychological force. Of course this depends on the docs seniority. In your mom’s specific case, it is inconceivable to me that any trained physician would see her post-surgical history and subsequent development of an abdominal mass and not think immediately of a hernia and possible strangulation as it grew. A first-year medical student can palpate the abdomen and readily tell there is herniation through the abdominal wall. Is it reducible or not? An abdominal CT scan should be reflexive. It’s even more maddening when more than one physician misses the obvious or at least the way it sounds to me given the information you’ve provided. Physician burnout is a real alarming phenomenon with emergency room doctors having one of the highest rates. This was already an issue pre-COVID-19. I can’t help but worry about how worse it may get.

danachow 4y ago
From my reading of that story what was interesting was that shit hit the fan with a post-op infection after the hernia repair. A reducible hernia isn't an automatic indication for surgery these days - and post-op risks outweighing benefits is one of the reasons why. It's also weird why the "time left untreated" would have any bearing on the repair and risk of complications - people go through life with uncomplicated hernias for years - if they're complicated they declare themselves pretty rapidly. There are many other reasons I can think of that would increase risk though. When I hear a story like this it is very hard for me to believe the entire pertinent medical history is being conveyed.
- haldujai 4y ago
  I concur. I often work as a radiologist in the ED setting, while this is anecdotal I can’t imagine that anyone with history of recent hernia repair, purulent discharge, and chills would not get a CT scan at an academic centre in the US (OP stated residents were present. I can only speak to the centre I’ve worked/rotated at but this seems inconceivable based on the requisitions I get in my career. We do a lot more for a lot less. The only point I would disagree on is that “time left untreated” can increase complication rate. If this a partially strangulated hernia and there was a microperforation (quite common and often missed) or bacterial translocation in the hernia sac mesh would almost certainly get infected. Even if not strangulated/perforated at time of surgery, if there are dense adhesions from recurrent/intermittent obstructions that may also increase operative complexity and a lysis of adhesions may contaminate the field. That said you could also just not use mesh.
  - vo2maxer 4y ago
    Remember that in the chronology, the infection occurs after the second surgery, the hernia repair. The mass develops after the first surgery. I agree with you otherwise. Internal Medicine here.
    - haldujai 4y ago
      Yes exactly, perhaps I was unclear. In my description, it is conceivable that due to chronicity the field was contaminated at the time of second OR and/or a lysis of adhesions resulted in a contaminated field. If the surgeon implanted mesh in a contaminated field this would be seeded and inevitably get infected. This is not uncommon and why surgeons often don’t implant mesh in complex LOA or possibly dirty fields. I’m not saying this is what happened, but delayed diagnosis of a complicated hernia can increase the risk of complications from repair.
      - cameronh90 4y ago
        It's not clear to me exactly why the wound got infected, as currently all the parties involved are blaming each other. The surgeon who performed the mesh repair did clearly state it was a possibility, but the hernia wasn't suitable for non-mesh repair, which would have been his preference. There was no indication of infection or contamination at the time of the hernia repair, and the surgeon who performed the mesh believes the infection was most likely caused by poor aftercare, which was handled by the local hospital due to covid travel difficulties. Of course, he could just be saying that to cover his ass.

danachow 4y ago

From my reading of that story what was interesting was that shit hit the fan with a post-op infection after the hernia repair. A reducible hernia isn't an automatic indication for surgery these days - and post-op risks outweighing benefits is one of the reasons why. It's also weird why the "time left untreated" would have any bearing on the repair and risk of complications - people go through life with uncomplicated hernias for years - if they're complicated they declare themselves pretty rapidly. There are many other reasons I can think of that would increase risk though. When I hear a story like this it is very hard for me to believe the entire pertinent medical history is being conveyed.

haldujai 4y ago
I concur. I often work as a radiologist in the ED setting, while this is anecdotal I can’t imagine that anyone with history of recent hernia repair, purulent discharge, and chills would not get a CT scan at an academic centre in the US (OP stated residents were present. I can only speak to the centre I’ve worked/rotated at but this seems inconceivable based on the requisitions I get in my career. We do a lot more for a lot less. The only point I would disagree on is that “time left untreated” can increase complication rate. If this a partially strangulated hernia and there was a microperforation (quite common and often missed) or bacterial translocation in the hernia sac mesh would almost certainly get infected. Even if not strangulated/perforated at time of surgery, if there are dense adhesions from recurrent/intermittent obstructions that may also increase operative complexity and a lysis of adhesions may contaminate the field. That said you could also just not use mesh.
- vo2maxer 4y ago
  Remember that in the chronology, the infection occurs after the second surgery, the hernia repair. The mass develops after the first surgery. I agree with you otherwise. Internal Medicine here.
  - haldujai 4y ago
    Yes exactly, perhaps I was unclear. In my description, it is conceivable that due to chronicity the field was contaminated at the time of second OR and/or a lysis of adhesions resulted in a contaminated field. If the surgeon implanted mesh in a contaminated field this would be seeded and inevitably get infected. This is not uncommon and why surgeons often don’t implant mesh in complex LOA or possibly dirty fields. I’m not saying this is what happened, but delayed diagnosis of a complicated hernia can increase the risk of complications from repair.
    - cameronh90 4y ago
      It's not clear to me exactly why the wound got infected, as currently all the parties involved are blaming each other. The surgeon who performed the mesh repair did clearly state it was a possibility, but the hernia wasn't suitable for non-mesh repair, which would have been his preference. There was no indication of infection or contamination at the time of the hernia repair, and the surgeon who performed the mesh believes the infection was most likely caused by poor aftercare, which was handled by the local hospital due to covid travel difficulties. Of course, he could just be saying that to cover his ass.