Throw technology at the problem because maybe patients know best

X-rays, as well as blood tests, scans and other investigations, have magic healing powers and are the envy of all Healthcare Professionals worldwide. I have sent many limping half-dead patients hobbling down the corridor to X-ray, to find them 20 minutes later, fully restored, bright as a button, by a quick and painless normal X-ray.

This case concerns a young man of 25years of age who twisted his ankle whilst running wearing a large backpack. He was fit and not one to make a fuss. Rather than bother the doctor, he rested his ankle up overnight. The following day, it was no better so he went to his local Accident & Emergency. They referred him to an onsite GP, who referred him back to A&E for an X-ray of his seriously swollen ankle. The X-ray was normal but because he could not walk, he was given a large plastic boot,  a pair of crutches and an appointment to come back in two weeks. Two weeks later, the swelling was gone, the ankle still tender but he could just abot walk. The boot and crutches were removed and two weeks later he began physiotherapy. Six months later he was more or back less back to his usual self.

Over the next couple of years, he twisted his ankle several more times, playing football, climbing, fell walking and finally walking on an uneven pavement.  His ankle was now a chronic problem. The orthopaedic surgeon wondered whether the ankle was unstable and X-rays showed early arthritis. The patient no longer plays football nor take any kind of exercise.

The patient now can’t run, has intermittent pain in his ankle and over time he may need an ankle fusion and he is already looking at a downhild spiral of western disease: diabetes, obesity, widespread arthritis, high blood pressure and heart disease. He might need joint replacements and even spinal surgery to keep him upright on his legs.

How could this have been done differently? Could we not, in the middle of the twenty-first century AD, have prevented this man’s spiral down a helter skelter of preventable diseases?

Definitely

First, early definitive investigations. It was twenty-four hours before he had an X-ray to rule out a broken ankle He had injured his ankle quite badly, so if not a broken bone, what was the likely injury. Answer: either a damaged ankle ligament or a torn Achilles tendon.

Second, this was a severe sprain – he couldn’t walk. Something was definitely wrong. So if not a broken bone, what was the likely injury? Answer: either a damaged ankle ligament or a torn Achilles tendon.

Answer: Either a damaged ankle ligament or a torn Achilles tendon.

Ligaments are the strapping that keep the bones on the straight and narrow, stronger than nylon and steel they hold the bones in place. If they are damaged, or torn then the joint starts to become unstable and this damages it.  With damage to the surface of the joint comes pain, loss of movement and arthritis. Further medical treatment includes painkillers, naproxen, steroid injections and eventually an operation to fuse the joint or replace it.  The pills damage the stomach, further pills stop the stomach producing acid, this affects digestion and so the steady decline begins.

Ligaments do heal – but they need to be held supported and immobile for three months or more. If very badly torn, they may need an operation. These treatments need to be done sooner rather than later, to prevent the joint surfaces being damaged.

Xrays show bones, MRI scans show ligaments. Xrays cost approximately £80 –  £100, MRI scans maybe up to £300.  A normal X-ray could lead to an MRI scan, which together with nurse time might cost £500. The correct diagnosis – either a mild sprain or a torn ligament means our young friend has the correct treatment, his ankle is secured for the correct amount of time in his airboot, Indeed his ligament injury might even need a surgical repair. He then has the right physiotherapy, at the right time and after six months he is all but good as new, without a permanently weakened ankle and the incipient time bomb hidden within it.

This approach means ‘Throw technology at the patients’. Do a £300 MRI scan early, make the right diagnosis, give him the right treatment and start to close the health gap. Because this level of care is available if you are rich and desirable. Yet a £300 MRI scan at the time of injury saves the £10,000s in the patient’s later lifetime.  As it is, he will die younger and at a significantly greater cost than his richer cousin.

Patients are right to have faith in their X-rays, blood tests, scans and other investigations. The key to a successful outcome is in making the correct diagnosis before you start treatment. In this case, it seems highly likely that the patient had torn their ankle ligaments when they first injured their ankle. The best outcome, following from this diagnosis would have been to immobilise his ankle for eight weeks. Once the ligaments have healed, active physiotherapy gets him moving and restores his muscle power.

A normal X-ray could have been followed by a MRI, which would have shown whether the ligaments were torn, or just sprained.

The present system is messy, inadequate and unreliable. The first stop has to be the laboratory- get your results then choose your doctor/nurse or physiotherapist for your treatment. The State, aka the NHS, does not know best, You the patient should know what is in your best interest because it is your body and you are charged with its care.

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