US Edition
Two years on from the death of 13-year-old Martha Mills from septicaemia, the Government recently endorsed “Martha’s rule”. This would give families the right to insist on a second opinion if concerned, as her parents were, that medical treatment is inadequate. The prospects for the implementation of this eminently reasonable rule seem very favourable.
It has however, if inevitably, focussed attention on the fresh perspective of a second opinion in the much more common circumstances when advised, for example, of the necessity for a major operation or alternatively that “there is nothing to be done” about some grievous illness. This is far from straightforward as it entails first being referred back to the family doctor who must then be persuaded to arrange a further appointment with a different specialist – making it clear a second opinion is being requested.
A daunting prospect not for the faint hearted but persistence may well be rewarded – as it was for an acquaintance diagnosed with a rectal tumour and initially informed he would require a lengthy surgical procedure and a permanent colostomy. Not so, according to the second surgeon he consulted – a straightforward excision would suffice together with “watchful waiting” for any signs of recurrence.
A reader whose mother’s deteriorating mental state was attributed to a series of “mini strokes” tells a similar story. After being told it would be best to place her in a nursing home and that he “should get on with the rest of his life”, he eventually managed to persuade her family doctor to refer her to a specialist psychogeriatrician. He promptly diagnosed a rare if treatable form of dementia – the vital clue, previously overlooked, being that a year earlier his mother’s walking had become “uncertain” together with her being incontinent of urine.
Abnormalities of gait and incontinence followed by mental decline are typical of only one condition, “normal pressure hydrocephalus”, caused by an excess of the fluid surrounding the brain. The insertion of a stent to drain it off allowed the tissues of the brain to recover as indeed did his mother’s mental state.
When blood pressure drugs don’t work
It is now almost 20 years since the usually cheerful practice nurse found my blood pressure to be alarmingly high (180/115) with the near certainty of my experiencing a heart attack or stroke. The avoidance of this fate by the simple expedient of taking pills to lower it ranks amongst the most significant of medical achievements – for which, of course, I am immensely grateful.
It is sufficient for most, myself included, to “just keep taking the pills”. But the few whose blood pressure remains high despite taking a combination of three or more drugs warrant further investigations in anticipation of finding an underlying, and potentially curable, cause.
Dr Lesley Charles of the University of Alberta has recently reviewed two important forms of this “treatment-resistant hypertension”. The first of these is renal artery stenosis, a narrowing of the major artery to one or other of the kidneys, with high blood pressure signalled by the presence of a bruit (the rumbling noise of blood passing through the narrowing) heard through the stethoscope. In some, if not all, a procedure to widen or bypass the artery will restore the blood pressure to normal.
The further possibility is overactivity of the adrenal glands perched on top of the kidneys, the source of the hormone aldosterone that regulates the volume of blood in the circulation. This, being more readily diagnosed than in the past, is now, Dr Charles observes, the commonest cause of treatment-resistant hypertension. In almost two thirds of patients drugs that block the action of aldosterone or surgical removal of the gland are curative.
Pushing for a second medical opinion could make all the difference
A new rule would give families the right to insist on a second opinion if concerned that medical treatment is inadequate