im not sure where to go..

[Guest soulamongststars]

im not sure where to go to ask about this, but if anyone here could help me i would be so grateful. a close friend of mine has been very ill and the doctors havent really been able too indentify what is wrong..right now they believe she has IBS, and they really dont know how too treat it..if you could be of any help it would be greatly appreciated...please, anything you know, anything you can add at all, that could help, please respond here or send an email too orionsghost@yahoo.com..thanku so much for your time..here are her symptoms..

 

diarrhea

constipation

cramping/bloating

sharp pains in the stomach/sides/back/neck

Headache

light bleeding(like menstural,but not when menstural cycle is going)

rectal bleeding

nausea

fatigue

tiredness

gas

heartburn

indegestion

upset stomach

[Guest therealcrackers]

Bunch of questions to ask first before we get into the whole diagnosis over the internet thing.

 

Pain: Onset?

Place/Positioning?

Quality? (stabbing, burning, shooting, etc.)

Radiates? (does it go anywhere else)

Severity? (0-10, 0 nothing, 10 worst EVER)

Timing? (before/after meals, morning, night)

What makes it worse/better?

 

When did all this start, how long, how frequently, how bad.

 

What's the worst thing about it?

 

Any imaging done?

 

If a lot of docs have tried, a well-meaning bunch of medical students is going to be stumped too.

[Guest DrSahsi]

I'd suggest stopping before anyone starts, and before I get going about the appropriateness (as well as the medicolegal implications) of informal diagnosic attempts over an internet web forum.

 

I sympathize with the plight of soulamongststars. Dealing with the vagaries of an uncertain diagnosis can be harrowing enough as it is. It's even more difficult when there's the impression that treatment is out of your (or your close friend's) grasp. I think it's important for your friend to communicate her concerns with her physician(s) directly. They're the ones who are in the better position to put together the whole picture from history to physical examination to investigations, and so forth.

 

Your friend is very lucky to have your concern, and your friendship. Best of luck to you both.

 

- Rupinder

[Guest UWOMED2005]

I couldn't agree with Dr. Sahsi more - I was thinking of saying something myself to the same effect.

 

Besides the more serious inherent medicolegal issues asking non-physicians (with the exception of Dr. Sahsi and those moderators who are now residents) a question like this, the internet is not a very good forum for establishing a diagnosis. The history is shaky, and there is absolutely no chance for a physical exam, not to mention any labs or radiology that would be needed.

 

(partly to stimulate discussion) Just look at what is happening with Ontario Telehealth. For those not familiar with the program, it was started by the Ontario government with the idea of relieving the burden on Emergency departments by having nurses assess and triage patients over the phone, and hopefully avoid emerg. Most of the emerg docs I've worked with think it has had the opposite effect (Dr. Sahsi or someone else with more experience than I please feel free to comment.) The problem is that the telehealth employees have no ability to properly assess a patient (as the encounter is over the phone,) and the last thing the government would want is for telehealth to underdiagnose something resulting in something serious. Patient calls with a headache? Could be a subarrachnoid hemorrhage. Stomach ache and nausea? Can't rule out early stages of bowel obstruction. Child with a fever? Could be early meningitis. People are encouraged to call telehealth about anything, and might call telehealth for something they would have handled at home with gravol and tylenol. But since telehealth can't do a proper assessment and rule out something serious, someone who might not gone to emerg is now directed there.

 

Good luck to you and your friend.

[Guest DrSahsi]

UWOMED2005: Some of us are staff now. 8o

 

The Telehealth system is a valiant effort gone horribly wrong. There is hard statistical data that shows that visits to the ED have actually increased since Telehealth was instituted in the province of Ontario (mind you, there are potential confounds in that study, but that's another issue).

 

It's hard enough to do telephone triage as it is (as we had to do in family medicine), since you don't have the full set of data that you'd normally have in the office or ED to help make decisions. It's even harder when you have a computer telling you what to do.

 

The big problem with Telehealth in practice is that the nurses who answer the telephone are not allowed to exercise their professional judgement. They're not allowed to think. The questions and answers are all based on a computer model, which has been designed from the ground up to be paranoid. It has to be. I've seen the sore throat pathway, and it can get downright scary in sections. But there's no choice. When in doubt, you have to default to the presumption that you're dealing with an emergency... and should be seen by a physician ASAP. The examples cited by UWOMEDS2005 are right on the money.

 

The other problem too is that of referral bias. We as ER physicians see all the Telehealth referrals, appropriate or not, while what we *DON'T* see are the ones that Telehealth actually tells to stay home. There are a couple of studies I"m aware of looking at Telehealth's efficacy in a more objective manner. I'm looking forward to seeing those results.

 

- Rupinder

[Guest UWOMED2005]

Thanks Dr. Sahsi, you've pretty much confirmed what I thought and had heard of telehealth. As always, your opinion is much appreciated.

 

Congrats on becoming staff. I thought you'd be done by now. Are you praciticing in Hamilton?

[Guest DrSahsi]

UWOMEDS2005: Practicing on a part time/casual basis in Hamilton, looking at other sites as well. I still have an exam in September, so I'm trying to study with my new found scheduling flexibility... but the urge to pretend I have a life again is pretty overwhelming.

 

Glad I could help address some of the issues around Telehealth Ontario. Overall I think it's a great idea, just bogged down in the details of how its deployed.

[Guest shrinkage]

...but I think it is spectacular. I'm not sure what goes on behind the scenes with the whole "computerized question model", but I've called it 3 times (once for a sport injury for myself, and twice for my wife, for her SLE-related complications) and never got the impression that the nurses where so "electronically hamstrung."

 

We were saved three visits to the ER (one of them was converted into a visit to a walk-in clinic).

 

I believe that the nurses (at least some of them) ARE using their own judgement...they also seem to have access to previous Telehealth call transcripts in order to establish a sort of limited history.

 

If my presumption is correct...I believe that the verbal ability of people calling the service plays a great role in its effectiveness. People who are better able to describe their mechanism of injury / antecedents of illness onset...and can accurately and anatomically describe their symptoms are (in my opinion) going to get far better telephone consultation treatment.

 

I hope this movement does not lose its momentum...I believe that once "video telephones" become mainstream (probably 10 - 20 years away still), the value of these types of services will be increased even further.

 

I am obviously no medical expert (although I'm happy to say that I will beginning my med. studies at UWO this fall)...I just thought I'd present another side to the story.

 

Good luck to the person described at the beginning of this thread...