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?
My thoughts on the encroaching communist menace that is Nobamacare.
ReplyDeleteappellatesky.blogspot.com/2012/07/prying-my-insurance-card-from-my-cold.html
I do not think you "know" any such thing. You project, and not even based on fact, but on fear. I find it very hard to believe that most physicians, or even most patients, would settle for that sort of paint-by-numbers "medicine" — and it's notable that the sort of hyper-specialization you describe had already been underway long before this legislation was enacted. I do not claim the ACA is a perfect piece of law; but it was by far the lesser of two evils. "Communist menace" comments only show a complete failure to understand the extent to which our existing healthcare service was placing Americans into, well, a state of feudal serfdom pretty much sums it up, given that utilizing healthcare in our former set-up has been more or less a ticket to eternal destitution, debt, and servitude.
ReplyDeleteIf your fictional patient were among the uninsured, would she be getting ANY care, even lousy care? Probably not; she would more likely stay away from medical practitioners in the hope that her belly ache subsided on its own, and would only show up at the ER when the problem became acute (and probably irresolvable). Assuming she survived, she would likely be unable to pay the bill, and costs to those who have insurance would rise by 28% the following year as BCBS sought to pass along the increased charges submitted by hospitals and specialists to its clients—such increases being the only way said hospitals and specialists can receive fair remuneration for services a patient cannot afford (not blaming the MDs, mind you... our system is totally whacked).
It seems as though many, many people have little appreciation for the cost of medical care UNLESS they are uninsured. Certainly that was the case for me. I had insurance once, and the most I ever put out of my pocket was a $30 copay. Without it, even a simple visit to my kids' pediatrician runs me $150. My younger child's diabetes diagnosis practically bankrupted me: we're talking ~$24,000.00 a year in maintenance costs, not including emergency visits (which, as hard as we try to avoid them, are inevitable in a diabetic preschooler). How is anyone supposed to afford that on a typical American household income? Given the impossibility of that, is the "solution" to allow those with lesser resources to simply die young because they cannot afford to "pay for play" on the medical merry-go-round? I'm sure you'll understand why I find that unconscionable.
I hope your commenter above, who talks about his insurance card, has a deeply rooted appreciation for how lucky he is to HAVE an insurance card. Most of us who don't, would gladly donate a kidney in return for the assurance that health coverage is ours for the asking.
Truthfully, the physicians should get out of the doorway, washed their hands,and examine the lady abdomen again today. I did it yesterday is very funny.
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