Tuesday, July 24, 2012

Protocol


                            


Standardization of our educational systems is apt to stamp out individualism and defeat the very ends of education by leveling the product down rather than up.- Harvey Cushing


In the not so distant future:

Dr Intensivist stared into the room where Miss P. lay on her hospital bed, the only noises were the steady rhythm of the ventilator and the beeps of the EKG. Dr. Hospitalist stood nearby.

“Miss P. doesn’t look too good,” Dr. Intensivist remarked.

“I know,” replied Dr. Hospitalist. “Her blood pressures been trending down and she’s only making miniscule amounts of urine; white counts up to 30 thousand, too”

“What did the CT Scan of her belly show?”

“Nothing much, just the colon was a little dilated, otherwise it was normal.”

“Well, something’s not right. Her bicarb is 15, lactate is 12.”

“Do you think it’s in her belly?”

“The CAT Scan didn’t show anything.”

“Good point. Maybe we should call Dr. Cut?”

“But, the CAT Scan is normal. We don’t need a surgeon”

“I guess we’ll just continue to support her, It’s a shame really, she’s only 65.”

“We’ve followed the protocol to the letter, so we’ll be safe.”

They both stared at Miss P. from the doorway and shook their heads, almost simultaneously.

“We should check the protocol again. Let’s see, Sepsis, abdominal pain, acidosis, high WBC, hypotension, unremarkable CAT Scan. There’s a space here for physical exam. Did you examine her?”

“I did when she came in; she was soft, very minimal tenderness, nothing much.”

“Let’s see, comorbidities. End Stage Renal disease, Insulin Dependent Diabetes, Aortic Stenosis. The Protocol says probable pneumonia with Congestive Heart Failure. Treatment recommendation is dialysis and antibiotics. Well, Dr. Nephron dialysed her yesterday and her blood pressure is only 80; I don’t think she’ll tolerate another dialysis.”

“Protocol says start pressors…she’s already on Levophed and Vasopressin. Protocol says prognosis is hopeless.”

“Well, if she’s not better by tomorrow, we’ll need to do something.”

An impossible scenario, couldn’t happen, one may think. Think again. A similar case played out about a week ago. The only difference was the patient was 88 with fewer comorbities. The patient was admitted to the ICU and seen by the Intensivist, Hospitatist and Nephrologist. She was clearly septic and was on Levophed and Vasopressin, but not improving, On the second hospital day and Infectious Disease Specialist was consulted. He came in the early evening, the patient now in the hospital for twenty four hours. Despite the CT Scan that revealed only a dilated colon his abdominal exam suggested she had peritonitis.

He consulted General Surgery, me, and I saw her almost immediately. As reported, the CT Scan revealed very little. She was intubated and being mechanically ventilated, but she was alert. I asked her if her belly hurt and she nodded in the affirmative. I lightly tapped on her abdomen and she winced in pain.

She was taken to surgery in short order with a preop diagnosis of ischemic or gangrenous bowel and underwent a subtotal colectomy ( and a splenectomy, incidentally, nobody’s perfect) for gangrenous colon. She is now recovering, slowly. Looking back through the chart, the only physician that noted an abnormal abdominal exam was the ID consultant. It is possible that she did not manifest the obvious signs of  peritonitis earlier in her hospital course.

 I do know that as more and more “protocols” are developed, which is a major goal of the Affordable Care Act (Obamacare), this scenario will be played out on a regular basis as standardization of care leads to consistent levels of mediocrity. Is that to be the future of Medicine?