Saturday, April 23, 2011

A Fantasy



George, a man of 75 in good general health, felt sudden pain in his upper abdomen and went to see his family doctor, Dr. West. After talking to George and examining his abdomen Dr. West sent George to Mercy Hospital, where he was immediately admitted to the Med-Surg floor. Upon arrival his nurse, Nurse North, took down all his vital information, put the orders as written by Dr. West in the computer. Lab personnel appeared within ten minutes and drew the ordered CBC, CMP, amylase and lipase levels. Five minutes later the patient was taken to X-ray where an upright Chest X-Ray and Abdominal X-Rays were performed.



When George arrived back in his room he was seen by Dr. South, a surgeon, who talked to George and examined him. Dr. South learned that George had suffered from Peptic Ulcer disease for years and had stopped taking his medication six months before because he felt fine and he didn’t think he needed it anymore. When Dr. South examined George’s abdomen there was rigidity and diffuse tenderness, suggestive of generalized peritonitis. Dr. South then reviewed the labs, which were on the front of the patients chart and revealed a White Blood Cell Count of 18,000 and hemoglobin level of 12. The chemistries revealed a slightly decreased bicarbonate level of 21.



Dr. South then went to the X-Ray department where George’s films were being examined by Dr. East, the Radiologist. They examined the X-Rays together and both immediately commented on the presence of free intra-peritoneal air under George’s right hemidiaphragm.



With all this information, Dr. South diagnosed a perforated peptic ulcer and George was scheduled for immediate surgery. He was in the Operating Room within the hour, after he had received preoperative IV fluids and antibiotics. The operation went smoothly and George returned to his room, where Nurse North received him. She checked his vital signs every hour for the first six hours and checked on him frequently, inquiring if he had any pain, checking the urine output and his dressing. Dr. West and Dr. South came by in the evening to check on George and be sure he was stable after surgery and that nothing unexpected was happening.



On the first day after surgery, Nurse North helped George out of bed and he walked in the halls. His urinary catheter was removed and he seemed to be progressing through his post-operative course uneventfully. He was able to start eating on the second day after surgery when he was also walking independently.



However, that night, he developed pain in his left chest. Dr. West and Dr. South were called. They examined George at his bedside, and evaluated the EKG and Chest X-Ray that had been obtained while they were on their way to the hospital. Dr. West noticed an abnormality of the left lung suggestive of atelectasis. He consulted Dr. Central, the Pulmonologist, who came to see the patient, despite the late hour, who concurred with Dr. West’s diagnosis. Respiratory therapy was ordered and the remainder of the post operative course was smooth. George was discharged home on the fifth post-operative day and was back to normal within a few weeks.



Wouldn’t this fantasy be nice? Could a world where hospitals were allowed to efficiently care for their patients; where family doctors attended to their patients in the hospital; where consultants responded quickly and instituted therapy expeditiously, where nurses were given the means to spend time with their patients, possibly exist?



Conspicuously absent from this scenario are case managers, hospitalists, insurance companies, CT Scans, admitting personnel, and LTAC’s. Also missing is SCIP, core measures, endless forms, and mountains of paper that nobody but the hospital billing department ever examines.



Medical specialization has increased to the point where there are surgeons who describe themselves as foregut specialists. Family doctors are given disincentives to attend to their own patients in the hospital, even though nobody knows their patients better.


Medicine has become complex over the last decade and our diagnostic and therapeutic skills have soared on the wings of new technology. Patient care has improved with the superior diagnostic accuracy and complex procedures are often performed in less invasive ways.



But, has something been lost?