NOTE SIZE OF LESION, RAISED EDGES, REDNESS AROUND THE WOUND. Clinical Diagnosis: malignant ulcer, basal cell or squamous cell carcinoma with evidence of superficial inflammation and possible superficial cellulitis (infection). Home remedies have failed and the lesion is rapidly deteriorating.
After several weeks of unnecessary delays (patient responsibility), we (with the family and family physician), after much coaxing, were able to get the owner of the lesion to a proper dermatologist with whom the patient was familiar and comfortable. A biopsy was done in the dermatologist’s office and the following week, the microscopic evaluation of the pathology confirmed a diagnosis of Squamous Cell Carcinoma.
Lesion after biopsy
Although the patient wanted to continue to experiment with topical therapies, surgery was the only option. Mohs surgery (http://en.wikipedia.org/wiki/Mohs_surgery) was recommended as were some local surgeons.
However, the patient did not want to go to any of the recommended surgeons due to their hospital affiliations. His preference was to go in the direction of another hospital. So, a “suitable” plastic surgeon was found who was associated with the preferred hospital. Approximately 6 weeks later, during a visit with plastic surgeon number 1, the need for Mohs surgery was confirmed, but due to constraints in his practice, the patient was referred to a dermatologic surgeon who was capable of doing the necessary surgery. So, after one false start and several weeks, the surgery was done as an outpatient. Mohs surgery with porcine skin graft.
Lesion nearly healed about 10 weeks after proper Medical Diagnosis and Surgical Treatment (Mohs Surgery)
Lesion today (3/26/2014) approximately 17 weeks after proper surgical excision and porcine skin graft. Note minimal vertical scar is about 5mm wide and healing is nearly complete. Post inflammatory hyperpigmentation is decreased. There is a 2mm vertical interruption in skin surface under which new epidermis is growing in. The wound is closed. Treatment is limited to daily application of generic petroleum jelly.
Commentary and Review Through the B2 Lens
Many things could have been done better, but the patient was resistant to definitive diagnosis and treatment. Family engagement enabled proper diagnosis and treatment over the long haul. Delays in definitive treatment could have resulted in life threatening complications such as thromboembolism and infection. The risk of metastatic disease was extremely low and this was not a major consideration. Cost of care could probably have been reduced by preventing the lesion in the first place, but those calculations and all costs and charges calculations have not yet been completed. Early treatment could have reduced the chance of complications. We are unable to measure the cost, or impact of the actual delays in treatment caused by the patient’s resistance to definitive care. We do know, however, that the cost of care to patient, family and the third parties could have been markedly reduced by early diagnosis and definitive treatment.
OVERALL B SQUARED (B2) Score = (BEST MEASURED PROCESS SCORE X BEST OBSERVED OUTCOME SCORE) =
4 x 10 = 40/100
This low B2 Score reflects the low process score.
PROCESS SCORE: 4/10
This low score is higher than it should be by default, but it still reflects several process failures.
Family Engagement = 1/1
Optimal Patient Care = 0/1
General Prophylaxis failure = 0/1 (Squamous cell carcinoma could probably have been prevented with use of sunscreen, or reduced sun exposure)
Organ Specific Prophylaxis = 0/1
EMR = 0/1 NA?
QIPI = 1/1 = NA
Staffing = 1/1 NA
Physician Time Use = 0/1 ?
Surge Capacity = 1/1 NA
Overall Process = 0 /1
Cost = 0/1
OUTCOME SCORE: 10 /10
This high outcome score was better than expected.
The bottom line is this. The outcome in this case was good and the process could have been markedly improved. These sorts of patient factors often interfere with optimal care. Barriers to optimal care interfere with BEST CARE and must be reduced by making our healing places more appealing to patients.
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