By now I’m sure Dr. Casey has already told you he asked me to take over this case. I’ve reviewed the work you and your colleagues have done so far. This is a quite a first case for a new resident. I wish my first case had been this interesting!
As I was reviewing everything Dr. Casey sent me on the patient, I realized there is one thing that is going to make treatment even more difficult. Mr. McGrath’s cirrhosis is going to limit the treatment options available to him. I wanted to make sure you’re clear on what’s happening here.
Treating Hepatitis C
Hepatitis C is a treatable condition. Normally patients are given a combination of two drugs, interferon and ribavirin to help rid their bodies of the Hepatitis C virus. Once the hepatitis is no longer attacking a patient’s liver, that liver can begin to heal itself.
Unfortunately, Mr. McGrath’s liver damage is severe. In fact, Hepatitis C caused his liver to become cirrhotic. It’s almost like the cirrhosis started a chain reaction of problems. Cirrhosis of the liver means Mr. McGrath has significant liver damage and the blood is not flowing correctly through the liver. This restricted blood flow caused Mr. McGrath’s spleen to become enlarged, which resulted in a low platelet count. As I mentioned, Hepatitis C is a treatable condition, but interferon can’t be given to a patient with a low platelet count.
So now we’re stuck. We can’t treat his condition until his liver is healthy, but his own liver is seriously diseased. So it seems our only option is to get him a liver transplant and then, once he has a healthy liver, we can treat the Hepatitis C. (Remember a transplant will give Mr. McGrath a healthy liver, but it will not cure the Hepatitis C.)
Calculating the MELD Score
UNOS, the United Network of Organ Sharing, was established to help fairly facilitate every organ transplant performed in the United States—not an easy process. One of its primary roles is to manage the waiting list for those who need organs. The key to doing this is to give organs to patients according to priority, based on the severity of their condition (and not based on fame or fortune!).
In the case of liver transplants, UNOS measures this priority using something called a MELD score (MELD stands for “Model End-stage Liver Disease”). In order to get Mr. McGrath’s name added to the UNOS list, we first need a MELD score. Even though we still need to test Mr. McGrath's fitness for surgery it is important to get him on the UNOS list right away. I’d like you to calculate a MELD score for Mr. McGrath using the attached test results.
Surgical Fitness
A liver transplant is a major surgery and we need to make sure Mr. McGrath is physically able to handle it. Two important things that help determine surgical fitness are nutritional status and muscle mass. I saw Mr. McGrath briefly to introduce myself and, given my clinical experience, he appears to be strong enough for surgery. Of course, there are other important factors we need to look at, like how healthy his heart is. Obviously, I can’t look at him and know if his heart is healthy. I mean I’m good, but not that good!
So I’d like Mr. McGrath to have each of the following tests:
- EKG to test for cardiac health at rest
- Cardiac stress test to check the heart under stressful condition
- Chest X-ray to see if his lungs are functioning properly
- HIV--we can’t perform a major surgery on a patient who is compromised by infection
Informed Consent
In order to proceed with these tests, Mr. McGrath must first give us his consent. Informed Consent means patients are fully informed about their conditions and treatment options, and can participate in making decisions about their care.
Explaining the Diagnosis and the Tests for Surgical Fitness
I think the McGraths will feel more comfortable getting this news from a hepatologist, instead of a resident, so I’ll talk to them. However, I want you to prepare a document they can refer back to, in case they have questions after I speak with them. Given Mr. McGrath’s mental status changes and his wife’s deep concern about him, I think this document is really important. I have attached our Patient Consent Template to help your organize your report for Mr. McGrath.
Based on the work you’ve already done, write up a detailed explanation of Mr. McGrath’s diagnosis. Specifically you should:
- Explain why Hepatitis C is causing Mr. McGrath’s liver cirrhosis.
- Describe why he is experiencing each of the three symptoms (jaundice, ascites and mental status changes).
- Explain that Mr. McGrath will still have Hepatitis C after the surgery.
Then help Mr. McGrath understand why he must have each of the four tests I mentioned above. Specifically, make sure he understands the following points:
- What the test is, how it is performed, how Mr. McGrath will prepare for it.
- The rationale for ordering the test. What questions you trying to answer with this test and how will it help determine if Mr. McGrath is fit for surgery.
- Any potential risks or side effects.
Finally, when you are explaining diagnoses to patients, you have to keep in mind that even though they are pretty sick, they may not expect their condition to be so serious. Few people anticipate having to undergo an organ transplant and it can be very scary. Be clear and empathetic in your description, but convince Mr. McGrath that he must consent to further tests.
Thanks,
Dr. Laura Schaffer, M.D.
Attending Physician
Division of Hepatology
Lincoln Regional Medical Center
