Can’t Touch This…

Actual Patient Conversation:

“Man, that Dilaudid didn’t even touch my pain.”

“Uh, Okay.  Your CT was negative so you’re fine to go home.  I’ll ask your nurse to come discharge you.  Come back if you get light headed or start to vomit but otherwise, just take Motrin for your headache and you should be fine.”

“Can you give me a prescription for Vicodins.”

“No.  If the Dilaudid didn’t even touch your pain then this must be the kind of pain that doesn’t respond to narcotics and a couple of Vicodin would be useless…I mean Dilaudid is one of the most powerful narcotics we have and it didn’t do a thing.  Stick to the Motrin.

“How about some Demerol.”

“No.”

Another Actual Patient Conversation:

“Vicodin doesn’t even touch  my pain.”

“I’m sorry.  That’s all I’m going to prescribe.”

“Can you give me a ‘scrip for my Methadone?”

“No.”

“Well, how ’bout a shot of somethin’ before I go?”

“No.”

“Aw, man.  Fuck you.  I want to speak to the manager.”

“Sir, this is not the International House of Pancakes.”

Darn You, Manny Rivers!

More than the usual number of incredibly sick, incredibly old, incredibly senile, incredibly decrepit, and incredibly still alive patients today.  There must have been a convention because for the first half of my shift the average age of my patients was around 86 and between the eight of them they had 112 distinct medical problems, 38 doctors, 26 artificial joints, six pacemakers, 18 coronary artery stents, and, as three of them had ileostomies, only five functioning rectums.  The presenting complaint for seven was some variation of decreased mental status and one had stroke-like symptoms consisting of a slight facial droop although it was later confirmed that this was an old finding, first observed during the Clinton Administration.

A couple of the families were reasonable and declined any further medical care except hospice but the rest wanted “everything done” and committed us to expensive and extremely futile workups and admissions; three of the patients in particular went to the Intensive Care Unit where they are even now laying insensate and demented in their cocoon of medical equipment, either spending their grandchildren’s money or screwing our Chinese and Arab creditors depending on how likely you think it is that we can ever pay back all of the pretend money we are printing to pay for this insanity.

A day in the ICU costs Medicare approximately $4000 once all the costs are factored in.   A week or two and we’re talking serious money, much of it totally wasted in the sense that many of the patients on whom it is spent have almost no chance of ever leaving the ICU and, if they do, will be essentially vegetative until they finally die.   ICU charges under Medicare are in the Neighborhood of 40 billion dollars per year and rising.  Medicare itself spends around 300 billion per year, almost half of that for hospitalizations of all kinds.

I blame Manny Rivers and his surviving sepsis campaign.  Sepsis is an infection that leads to shock  and, until very recently, was largely fatal especially in the elderly who regularly succumbed to septic shock from bad urinary tract infections or pneumonia (so much so that pneumonia was once know as the “Old Man’s Friend” as it regularly relieved the suffering of the senile and bed-bound).  Dr. River’s great gift to medicine was what now seems like a simple method to aggressively treat sepsis that has significantly decreased mortality, extending the lives of many patients who would have otherwise been almost untreatable.  The foundation of his method is a five or six liters of inexpensive Normal Saline and, stripping away all of the fancy equipment and the flashing lights, that’s pretty much it.

While generally a good thing, especially as I have seen many elderly septic patients returned to the full enjoyment of their glorious old age, just because we can do something doesn’t mean we need to do it all the time.  I don’t always know when care is futile and I am not so arrogant to think I can judge the worth of anybody’s quality of life but there are some cases that are so obviously futile, that for example of a nonagenarian  whose every bodily function comes through and out of a tube and who hasn’t so much as moved purposely in a couple of years, that what we do is not only insanity from an economic point of view but also from a human decency one as well.  We do what the families want, however, rational or not.  First because we are conditioned to never give up.  Second because we have surrendered a great deal of medical decision making to the patients and their families even if they are not qualified to make the decisions and, more importantly, as they are not paying for any of their treatment have no skin in the game.  Third because we are afraid of the legal implications of withdrawing care, so much so that hospitals have ethics committees for the rare occasion when enough is enough whose principle purpose is to spread the liability.

And fourth, as there is a lot of money changing hands there is little incentive for hospitals not to aggressively treat everybody who comes in.  It’s either that or have ICU beds sitting idle generating no revenue whatsoever.

But the madness needs to stop.  What we need is a Futility Scoring System, perhaps a simple sum of points given for co-morbid conditions and age above which only comfort care or home hospice will be reimbursed by Medicare.   And it needs to become the standard of care.

Now if we could only find someone to put the bell on that damn cat.

Can’t Touch This…

1001 Ways to Die

1001 Ways to Die

There has got to be a better way to die and surely the patient at the center of our frantic activity couldn’t have wanted this one.  I arrived at his room with a code in progress although, as the patient was still alert, most of the activity involved throwing towels on the floor to soak up the large quantities of ink-colored blood pouring from his mouth, his nose, and the edges of his adult diaper.  The patient was obviously in severe respiratory distress and one of our junior residents who was running the code prepared to intubate, securing the patient’s airway and providing ventilatory support being the first most reasonable step to…well…I don’t know what except that the family wanted everything done even though no power on earth could reverse what was ordained by cruel nature and metastatic cancer.

As the patient opened his eyes for the last time, gaping in horror as he drowned in his own blood, I’m sure he saw gibbering death slouch into the room, leer at the nurses, and settle into the shadows with a smirk on his face to enjoy the end of the show.

Then, as suddenly as turning off a switch the patient was gone which naturally didn’t stop us from ineffectively performing half an hour of violent maneuvers on his body and throwing all manners of potent but useless medications into it before the family, huddling in terror just outside the door, were convinced and asked us to stop.  We slid a breathing tube into his trachea, rammed a  big intravenous line into his femoral artery, crammed him full of fluid, ran electricity through his heart, and bounced him around his stool and blood-soaked bedding; only pausing to look hopefully at the monitor for cardiac activity even though he was glassy-eyed and had that dead look about him.  Our junior resident even optimistically ordered some O-negative blood (which is what you give if you don’t know the blood type) from the blood bank but we weren’t exactly holding our breath for it to arrive from the deep basement labyrinth of the hospital.

If you can believe it, the desperate struggle against failing organs now at an end, he looked better dead than alive but then, as I first saw him crouching on a bedside commode moaning in terror,  I didn’t exactly catch him at his best.

Eternal God Whose great mercy endures forever. Spare me, Your devout but occasionally wayward servant, from this kind of death and grant that I may die peacefully in my bed.

Why People Love Complementary and Alternative Medicine

I had a patient the other day with some very mild conjunctivitis (“pink eye”) which, in otherwise healthy adults is almost always-and I mean the planets align when it’s not-viral or from some other cause that is untreatable except for symptomatic relief.  After checking her visual acuity, verifying that her pupils were normally reactive (to exclude iritis which is a big deal), and even doing a completely unnecessary slit-lamp examination of her cornea I was able to give her the good news that her condition was benign, required nothing but symptomatic relief, and would almost certainly resolve completely in the next one to two weeks without the need for topical antibiotics (which we often prescribe even though the evidence for their effectiveness even in the case of mild bacterial conjunctivitis is less than compelling) but only some mild analgesic eye drops.

The patient balked at the thought of one to two weeks, “Won’t the medications you’re giving me make it heal faster?”

“No,” I explained.  The eye drops just offer relief of symptoms but nothing we can do will shorten the duration of your conjunctivitis. It’s very mild, we don’t really know what’s causing it, and you should be fine.  If it gets worse you can see an ophthalmologist or even come back here.”

“Can’t you give me something to make it heal faster?”

“No,” I explained.  The eye drops will just offer relief of symptoms but nothing we can do will shorten the duration of your conjunctivitis. It’s very mild, we don’t really know what’s causing it, and you should be fine.  If it gets worse you can see an ophthalmologist or even come back here.”

And so it went for five minutes after which, not convinced, the patient allowed that she would be paying a visit to a well known local Wellness Center, a shameless emporium of every form of snake oil I have ever heard of, where no doubt the magician on duty will provide some magical potion or Eastern herb that will miraculously cure her conjunctivitis in from one to two weeks.

And yes, Gentle readers, there are people in our sad and rapidly deteriorating country who will come to the Emergency Department at two in the morning for mild, and I mean mild, “pink eye.”

1001 Ways to Die

Some Simple Math and other Random Thoughts from a Harmless Asian Bear-Mammal

I’m Better, Thanks

Like I said, it’s only in residency training where one could be happy to be sick while on vacation. I am just getting over a bout of what was probably the flu and as there is no practical way to take any time off as a resident, about the only time we can lay in bed or otherwise rest is either on vacation or when our day’s off correspond to our illness. They make a big deal about cautioning us not to work when we are sick for the sake of patient safety, of course. That’s all some of our patients need, to be exposed to their doctor’s gastroenteritis or other noxious infections but realistically, what are we supposed to do? In a pinch we can usually take one or two days off but as this involves screwing over the person assigned to back-up call, there is a tremendous reluctance to do this among residents. In other words, most of us would have to be spitting up blood or passing large chunks of our large intestine in our stool before we’ll call in sick. Still, there is nothing worse than having to work three fourteen-hour shifts in a row while running to the crapper every hour. Far better to be at home on vacation where you can at least relax between bouts and get some rest. Not to mention that my empathy for the typical 3AM vague-abdominal-pain-and-oh-by-the-way-can-I-have-a-sandwich patient, never very strong, is non-existent which is probably unfair to the patient (but if the shoe fits…).

Some residency programs are so small that they really have no backup for their residents at all and calling in sick in that situation will cause a major panic as well as instantly refuting the assertion made by shifty hospital bureaucrats that residents don’t contribute to the running of the hospital and are a burden to the put-upon institution. If this were really the case then the hospital would be delighted if we took a generous helping of sick days as this could only improve their bottom line. As is, however, when a resident unit goes down the service into which it had been installed goes into a major panic mode complete with sobbing and pleas for help. The sad thing is that a lot of residents buy into the notion that they are a liability to their program and act accordingly. Yes, I will grant you that a brand-new intern may appear to be good for nothing but he is actually many times more savvy than, for example, a brand-new PA who is actually paid real money, not to mention that the intern can make medical decisions limited only by his self-awareness of his limitations and his own personal comfort level. And by the time he gets a little experience the intern is a definite asset, many times for all practical purposes running the service at night. Good residents are completely trusted to handle routine admissions as well as routine emergencies and while I have never had an attending physician give me any grief whatsoever for calling him in the middle of the night for advice or to run a difficult patient by him, the expectation is that we should be able to handle most things and maybe the call for a patient admitted at 2AM can wait until 0730.

But most of us, like in any other non-government job, work when we are sick.  What choice do we have?

Some Simple Math To Illustrate Where the Money Goes

“But Panda,” many of my regular readers write, “Surely you are exaggerating the cost of futile care. Is this not a red herring, merely a symptom of your dislike of dealing with living cadavers more than a real problem?”

Let me address this question by making three points. First of all, I am not against providing expensive, high tech medical care to the elderly. How could I be? Not only are the elderly the majority of my patients but most of them are completely lucid, healthy enough to enjoy whatever it is the elderly do for fun in their secret recreational vehicle conclaves, and benefit mightily from the installation of the occasional artificial joint or the correction of a once lethal medical condition or two. While it is true that from a purely economic point of view, it would be better if we all died the day after we retire or from the first major medical problem that blindsides us (whichever came first), we are not pure economic creatures and that two-trillion bucks we’re spending should at least do some good.

Second, while there are gray areas in determining when care is futile, I know real futile care when I see it. The patients I often describe, the ones who are older than dirt, not nearly as responsive, and collections of every major pathology you can imagine but who yet manage to cling to some strict constructionist version of life are distressingly common, so common that I probably see and admit at least one or two of them a week to the ICU. (This is not even considering the patients that are post-arrest or on the losing side of a major cerebral vascular accident accident and who are, in fact, dead except for the polite fiction of ongoing organ perfusion.) Suppose that each of these breathing cadavers is admitted to the ICU and stays for a week before either subverting our best efforts and dying or pulling through and being sent back to their pre-death warehouse until the next time. Suppose also that I work fifty weeks a year and see a hundred of these patients in that time. A week in the ICU probably costs close to twenty thousand dollars, maybe more, maybe less, but probably around that if we add the cost of their passage through the Emergency Department.

Folks, that means that about two million dollars of futile, almost entirely wasted medical spending passes through my humble resident hands every year. There are about 5000 Emergency Medicine residents working at any given time in the United States and through our combined hands, assuming that they all see the same patient mix, must thus pass around 10 billion dollars. And that’s only hospitals with residency programs and not even counting direct admissions to the ICU. Assuming that a year of comprehensive medical insurance (not that I’m into that sort of thing, you understand) costs $12,000-or-so a year for a typical family; that’s about 80,000 families worth of medical insurance. Consider also that only one-fifth of the major hospitals in the United States have residency programs of any kind but most still have the usual ICU facilities and it is not hard to see that the bill for futile, end-of-life care siphons off enough money to pay for all of the medical care for about half a million families (again, not that I think we should do this kind of thing). And that’s just direct hospital costs. We probably spend twice as much in non-critical and non-emergent care in the last long, slow, tango with the reaper.

My third point is that there is no incentive at any level of the medical industry to use a little common sense. At the high end, physicians risk severe legal consequences for not doing exactly what the family wants no matter how unrealistic. So dangerous is the legal terrain in this area of medicine that most hospitals have an ethics committee part of whose purpose is to spread legal responsibility. In many cases, however, there is no financial incentive to withdraw care as Medicare makes no distinction between the living and the living dead. At the patient end, the families have no financial stake in any of the decisions they make. If we but charged the families a small fraction of the cost for futile care or, more diabolically, had payment garnished from the patient’s estate upon their death, the families would be looking for the plug, especially in the cases where the ICU serves as an expensive funeral home where families can meet to see the body. If the family ever says, “We want to keep Uncle Joe on the ventilator until the rest of the family can fly in from Seattle,” they should be responsible for the full cost of the additional stay.

Some Simple Math and other Random Thoughts from a Harmless Asian Bear-Mammal

Putting Granny Down and Other Health Care Conundrums

(I hesitate to present this article because everything in it is so indisputable to those who work in health care that I might be accused of belaboring the obvious. With this in mind I ask for the indulgence of you, oh my regular readers, who may skip this article entirely as nothing new will be covered. I submit this article in the hope that random internet passers-by, people who have no idea how health care is delivered, will find something interesting in it and that it may give them a different perspective from their usual desire to pay as little as possible for a service that they think comes as easily as turning a tap provides water. I also want to give a hat-tip to the Happy Hospitalist for his excellent series of articles laying out some of the facts of life about health care and its cost.-PB)

Bread and Circuses

This is not a political blog and I like to avoid discussing politics as much as possible for not the least of which reasons that civil debate is impossible even with many who consider themselves well-informed and open-minded. You can, for example, have what you believe to be a reasonable conversation with what you take to be a rational person when something inside them snaps and they start foaming at the mouth about the CIA plot to topple the World Trade Towers, blame the Muslims, and allow President Bush to assume dictatorial powers. This sort of thing used to be confined to the lunatic fringe but now even otherwise respectable political candidates, sensing that kookery has become more prevalent, will cater to these kinds of impulses. This is not to say that we don’t have long history of colorful politics in our country but only that we have not advanced much in our political discourse in the last 231 years. The mob gets an idea in its head, placed there or at least reinforced by its political leaders, and the thing is obliged to run its course no matter how destructive or ridiculous.

The latest idee fixe of the mob is that Health Care is a right and sensing the political winds, even some of the Republican candidates in the impending presidential election, ostensibly from a party that traditionally serves as a check to some of the more destructive initiatives coming from the left, have embraced the notion. What the left means, of course, by declaring medical care to be a right is that someone else needs to provide it regardless of the effort required. The Holy Grail of the left, after all, is the quest to have someone else take care of all of their basic human needs leaving them free to work at some meaningless public service job from which they can never be fired and which shelters them from the productive sector. (College professors, who strive mightily for tenure and the shelter from the world that it provides, perfectly epitomize the desire of many to fall into the comforting bosom of the nanny state.) As it has never been hard to convince people that things should be free, in this particular lying season the race is on to see who can give away as much of other people’s time and effort as possible. Some political candidates will be more overt taking the more obvious socialistic route while others will be more circumspect, inventing ingenious formulas to prove that we can pay for all the health care everybody needs without spending every dollar of tax revenue doing it and without comprimising any of the other legitimate functions of government. We have but to fix the health care system and everything is going to fall into place.

The premise of the health care debate is wrong, however. The health care system in this country is not broken. It is a beautifully evolved creature, functioning perfectly, and exquisitely adpated to the political, legal, and economic environment in which it operates. In other words, every initiative to fix health care wil be useless, as ineffectual as rearranging the china while the bull still rampages, unless the underlying conditions that dictate the current system are addessed and there are very few political candidates with the political courage or even the understanding of the problem to do it.

Consider first the legal environment in which we operate. It has been correctly pointed out that awarded damages and even malpractice insurance costs account for a relatively small fraction of total health care expenses. This fact is used by plaintiff’s attorneys to justify their depredation on physicians and hospitals, tacitly admitting that while they may be somewhat overzealous as they chase ambulances, their activities amount to very minor parasitism and should be ignored. It cannot be denied, however, by anyone who has been less than a quarter of a mile from a real patient that a large portion of a physician’s work, and by extension the support staff’s and the hospital’s, is devoted to keeping the lawyers at bay. What is most paperwork, after all, but an attempt to cover oneself legally against every possible bad outcome, even those that are an inevitable result of either the patient’s own incredibly bad health or equally incredible irresponsibility. On the witness stand, unfortunately, every patient is a sympathetic figure who has been harmed by an incompetent doctor from whom not only absolute perfection but absloute omniscience is expected.

It is no wonder then that much of a physician’s time is spent wrestling increasingly detailed paperwork designed to automatically protect against legal jeopardy. Little of this time has anything to do with patient care and yet oppressive paperwork is so indispensable in modern medicine that it would be no exagerration to say that most of every physician’s time is spent typing at a computer or writing notes even though it is common knowledge that from a purely medical point of view, everything pertinent about most patients most of the time could be written in big letters on one side of an index card. Who is seeing patients, the real deluge of which is looming and has yet to hit the system as the baby-boomers discover that their coronary arteries are no different from their parent’s, when the doctor is trying to devise medicolegal documentation to dissuade the lawyers?

No one. They tell me that we have a physician shortage and yet the paperwork burden on physicians keeps increasing as even the very hospitals which should be lobbying against this kind of thing invent even more complex paperwork systems to ensure that if anyone should step out of line, the trail of plausible deniability is intact and somebody else, the physician who never completed his JHACO certification in hand washing for example, is the culpable party. It is this lack of trust, this hopeless desire to avoid legal risk, that adds an incredibly expensive burden on our health care system.

In addition to the paperwork requirements, the wasteful and futile effort to prevent the legal profession from finding chinks in our professional armor, the threat of litigation forces the physician to ignore good medical practices and common sense in how health care resources are spent. There is, it seems, no complaint too trivial or no presentation of a chronic condition that does not require a physician, if he wishes to avoid placing his career and property in jeopardy, to order every test and study under the sun on a fishing expedition to avoid the possiblilty of a missed diagnosis. Thus do many patients with vague abdominal pain and unimpressive physical exam findings receive a healthy volley of testing and imaging, the exact extent of which is often dependent on how often or if the physician has ever been sued for a missed diagnosis.

The point here is that some conditions will be missed. If you want to minimize this probability, already vanishingly small just using the traditional skills of history and physical exam, it is going to cost money, a lot of money, as we are well within the realm of diminshing marginal returns and playing the zero-defect game, while it may pick up the rare silent presentation of a deadly disease, results in a huge number of expensive, low probability studies which only confirm what we already know, namely that the patient is not sick. You cannot have it both ways, on one hand opining that health care is expensive but on the other insisting that expensive technology should always trump medical judgement. The current system is adpated to allow physicians to survive both the onslaugt of the legal profession and the often unreasonable expectaions of patients who are conditioned to expect a test or a study and won’t believe a doctor unless they see the labs.

Things Cost What They Cost

I had a patient several months ago, a very pleasant, otherwise healthy middle-aged gentleman who looked fit and had obviously spent his life taking care of his health. He stated that he was an avid runner and he looked the part, several orders of magnitude fitter than most of my patients that day who were half his age. His presenting complaint was a vague, intermittant sensation of chest pressure which had started several months before and which he had been ignoring until his equally fit, highly intelligent wife had finally ordered him to come to the Emergency Department. He was without symptoms at presentation with a completely normal EKG and, other than his age, had absolutely no risk factors for coronary artery disease. As he had a very good cardiac story, we began our standard cardiac workup (that we actually do even if the story is not so good), fully expecting that all of his laboratory studies would be negative and he would be admitted for a routine exercise stress test which would probably be negative after which he would be easily discharged with the usual boiler-plate discharge instruction for chest pain of an unknown origin.

Twenty minutes after I first saw him he developed a mild, constant nagging ache in his chest which was initially relieved by subligual nitroglycerine. A repeat EKG showed what are known as ST-segment depressions (indicators of ongoing ischemia) in the lateral leads. This was followed shortly by an unequivocally positive Troponin, one of the standard cardiac markers. Clearly there was something going on and our disposition plans changed accordingly to an immediate cardiology consult for an as yet urgent (but non-emergent, you understand) coronary artery catheterization. He was definitely “ruling in” as we say.

Shortly after our call to cardiology the patient develop more severe chest pain which could only briefly be managed with a nitroglycerin drip and morphine before it became excruciating, doubling the patient over with pain and nausea. Another EKG now showed pronounced ST-segment elevations, the harbinger of ongoing myocardial infarction, in the inferior leads. The patient was now having a massive heart attack, all in the space of less than an hour from a standing start of a normal EKG and no symptoms. He was taken to the cath lab for an immediate catheterization which showed an almost complete occlusion of his entire right coronary artery, not quite as bad as an occulsion of the Left Anterior Descending Artery (also known as the widow-maker) but bad enough and certainly a life-threatening or life-ending event all the same.

He walked out of the hospital two days later “feeling great” with plans to contnue his healthy lifestyle.

Fifty years ago this gentleman would have either died in the Emergency Department or shortly thereafter. At the very least he would have left the hospital after a several week stay so debilitated that a normal life would have been impossible and probably would have continued to have heart attacks and arrythmias until one or the other finally killed him, probably fairly soon. Although he may have had an extensive hospital stay, he would not have received forty thousand dollars worth of life-saving medical interventions and the health care system would be spared the inevitable expense of the complications that would have developed as my patient aged and, despite his healthy lifestyle, reached and passed his pre-programmed genetic obsolescence.

This is one patient. A guy who is doing everything he’s supposed to and yet I have no doubt that the cost of his health care will eventually run into the millions of dollars as greater and greater efforts are made to save his life. Now consider that most of my chronically sick patients are in no way making even the slightest effort to take care of their health and, where my otherwise healthy patient had an isolated cardiac event which should be relatively easy to manage, these patients each have several to a dozen deadly medical problems which are only prevented from killing them by the expenditure of vast sums of health care dollars. Fifty years ago they would not have survived the intial heart attack or the the failure of their kidneys. Their kindly country doctor would have arrived at the house with his well-worn doctor’s bag, examined the patient, looked appropriately grave and directed the family to call their priest and the funeral home. The total cost to the health care system would have been whatever the doctor charged for his visit and the patient’s family themselves would have paid the bill.

It is therefore senseless to complain about the cost of health care and long for the fairly recent days when providing medical care did not suck up a fifth of our gross domestic product. Times have changed. Medical care today is expensive because it is a sophisticated enterprise employing some of the highest-skilled and most intelligent people in our society. Fifty years ago, while doctors were equally intelligent and trained to be superlative diagnosticians, the treatment options for serious medical conditions were severely limited and the deteriorating course of a cancer patient, for example, was followed more for the intellectual exercise than for the ability to intervene. There was no Golden Age of medicine when doctors were more caring and provided effective and economical treatments. Doctors may have been more caring fifty years ago but thats’ all they had to offer. It was just play-acting which is not very expensive.

You then, who complain about the cost of medical care should look to yourselves and your own families. Keeping your aged grandmother alive is expensive. The majority of all health care expenditures for a typical pateint are incurred towards the end of their life. As their medical problems accumulate their care becomes a constant battle, waged with expensive specialists and procedures, to briefly stave off the inevitable and ends up costing the health care system thousands of dollars for every month added to the life of the elderly and multiply comorbid. Whether this is a good or a bad use of resources is the subject for another debate. But you can’t have it both ways, on one hand expecting that no expense will be spared squeezing the last dregs of life out of you and your family while at the same time acting shocked, yes shocked, that your health insurance premiums are so high. As the Happy Hospitalist notes, you can’t insure a burning house. The amount of money required to keep your aged gandmother alive at the twiglight of her life far exceeds any health insurance premiums, either to private insurance of Medicare, that she has paid in her life. The money has to come from somewhere. To demand that expenses be reduced is the same as asking that care be withdrawn from somebody else’s grandmother, something that sounds reasonable as long as it is done to somebody else.

Throwing Good Money After Bad

I see the same patient, it seems, several times a day: An octogenerian, severely demented nursing home resident who spends their day laying in their own feces and urine except when they are sent to the Emergency Department by the nervous staff for an exacerabation of one of their many comorbidities. The EMS report usually states that the patient, a person who has not stood upright or talked to anyone since the Clinton administration, has had an alteration in their mental status, a brief interval of decreased oxygen saturation in the setting of severe emphysema, or an irregular heart rate which did not resove under the automatic ministrations of their second Automated Implantable Cardioverter Defibrillator. They are usually found to be septic from one source or another and are often admitted to the ICU for a week or two of highly expensive critical care to stabilize them enough so they may be returned to their warehouse until the next time. This little drama is repeated many times until finally we reach the limit of our ability to cheat the reaper and the patient finally dies in the ICU, usually after one more round of expensive interventions demanded by the family who want no expense spared in the effort to squeeze out one more week of life for the patient..

For perspective, maintaining an ICU bed costs a hospital several thousand dollars per day which someone, somehow, has to pay. Medicare and insurance companies can low-ball doctors with impunity but as the cost of a physician’s services are a relatively small portion of the total cost of running the ICU, an enterprise that involves many highly trained nurses and the latest equipment, there is no way to realistically decrease the expense of taking care of a critical patient.

My European friends, some of them physicians, are amazed at the measures we take to keep patients alive who have absoutely no quality of life and no chance of recovery. The Europeans may have cradle-to-grave socialism but they have a fairly well-defined idea of when to let the patient go to their grave. In the United States it seems sometimes that we want to follow the patient into the mausoleum, trying to the very last to get one more day or even one more hour of life for the patient regardless of cost. This is a mindset that is built into our system, evolving as it has from the egalitarian and extremely misguided notion that the patient or their family should be an equal partner in medical decision making. I say misguided because putting the patient or their family in charge of health care without at the same time making them responsible for their decisions is a formula guaranteed to lead to excessive spending. It is easy to say, “We want everything done,” if someone else is footing the bill. If we but required families of terminally ill patients for whom all care is futile to pay even a fraction of the cost for their care there would be a mad scramble for the proverbial plug.

Whether it is good or bad that patient’s families have so much say in the decision to continue futile care is also the subject for another debate. But as long as there is no disincentive for the families and no ability for the physician to finally throw in the towel, our system is going to be ridiculously expensive at the terminal end and there is no way this will ever change until a political candidate has the guts to say, clearly, that to save money it may be necessary to put your granny down.

Putting Granny Down and Other Health Care Conundrums

Obels for Charon

Futility

On the last day of her life, your mother went on a spending spree. I intubated her at around 9AM and for the rest of the day we threw money at her, successfully keeping her alive until about dinner-time when her liver cancer finally had enough, gave us the finger, and showed us who was really in charge. It was not a pretty death, but then I knew it wasn’t going to be when I only just managed to jam the breathing tube through her vocal chords before they were obscured by blood and other unwholesome-looking fluids. Still, over the course of a very interesting day she got an expensive bronchoscopy , five or six lab draws, a central line, an arterial line, three units of blood, a chest x-ray, continuous nursing, pumps, fluids, two consults, monitors, blinking lights, and the usual buzzes and beeps.

We did everything but put a coin under her tongue for the Ferryman which, considering the outcome, would have been just as cost-effective.

The next time, please pay attention to what we have to say when we have “The Talk” like we did two weeks ago to tell you that your mother had passed beyond the limits of our abilities and all we could really hope to do was to ease her suffering as she died. Unfortunately, as we live in an egalitarian age which worships your autonomy, when you seemingly ignored our advice and said, “Do whatever it takes,” our hands were tied and we committed ourselves to two weeks of slowly torturing a dying woman. I understand how you feel about your mother. I have a mother too but you can’t have really wanted this. We coded and shocked her, what? three times in the last eight hours? It had to have hurt her the first time when there was actually something of your mother to bring back. After that, well, I just don’t know.

Not all life is priceless. Not even your mothers. When you said, “Do whatever it takes,” what you really meant was, “Do whatever it takes as long as I’m not paying for it.” But there are very real costs associated with medical care and somebody is paying them. I don’t mean to lay this burden on you but since you want the autonomy to make medical decisions, you need to have all of the facts. Would you have ignored our advice if you had to mortgage your house to pay for your mother’s last two weeks of futile care?

Medical care, like most resources, is scarce and there’s never going to be enough to go around. Somebody has to decide how it’s going to be allocated and for better of worse we seem to have elected you even though you seemingly have no interest or incentive in the matter.

I don’t think you made a good choice here. That’s all. Medical care is for the living. Your mother needed hospice and maybe to die at home peacefully.

This doesn’t mean I don’t think we should spend money on the critically ill. I don’t know how much a year or two of life is worth and we certainly get sick but otherwise highly functional patients who we can return to a happy and meaningful life. I’d hate to make that kind of decision based on simple economics, assessing the value of a year with actuarial exactitude and making decisions accordingly. On the other hand there is a difference between critical care and futile care. Maybe I can’t define the exact line separating the two but I know the difference when I see it. Perhaps you were too emotionally involved to make the distinction and it was unfair to leave it up to you. It’s hard to let go, especially as the popular culture has conditioned us to expect medical miracles although I don’t know what you were expecting with your mother. The eventual outcome had never really been in doubt and you knew perfectly well that you mother was not going to be leaving the hospital this time.

When I pronounced you mother and closed her eyes for the last time, the ancient stillness of the tomb was deafening.

Obels for Charon

Apropos of Nothing

1100 Bucks a Month

Just from the outset, let me say that poor 70-year-old Mr. Neely was definitely being neglected and possibly being abused by his son. The first thing they told me was that his hair was so dirty and unkempt that it was like one single dreadlock. The nurses had to cut off the worst of it to wash his hair, possibly for the first time in ten years. His nails were filthy and three inches long. Other than his obvious expressive aphasia and severe peripheral vascular disease, he had no medical history that his son could recall and had not been seen by a doctor (or anyone else, possibly) for the entire twelve years he had lived with him. His right leg has been amputated below the knee at some unknown time and the remaining foot was so swollen that the tissue ballooned out from around the elastic of his feces-encrusted sock. His shin was covered with black, gangrenous eschar and his toes were rotting off.

The son displayed a strange lack of concern about his father’s deplorable state and his medical problems, especially his expressive aphasia which is a symptom of a stroke in the speech centers in the dominant hemisphere of the brain (usually the left). All Mr. Neely could say was, “Wonderful…no…no…wonderful,” which he repeated continuously whenever he was alert.

“When did you first notice his speech change?” I asked, which is a reasonable and an important question when treating victims of strokes.

“About four years ago.” A complete lack of concern from the son.

Jesus.

“Didn’t you think about taking him to the doctor when it happened?”

“Well, it didn’t get any worse so I figured it would get better.” He might have been talking about what he had for lunch.

“When can he come home?” was his next question.

“I think he needs to be in a nursing home. You’re obviously not taking very good care of him,” I said, not trying to be non-judgmental, “What on earth is going through your head when you see him like this?”

Poor Mr. Neely. Trapped in his own private hell surrounded by neighbors who probably didn’t even know he existed. His son had probably gotten used to living off of his social security check in a house whose mortgage had been paid since the time when his parents still had hopes that he would amount to something. He might have died like that except the fear of losing the social security check had finally made his son risk bringing him to the Emergency Department.

What does this have to do with anything? Nothing really. No big lessons or morals to be teased out here except that maybe there aren’t two sides to every problem. Some things are obvious. Mr. Neely’s son was obviously a scumbag and was obviously neglecting his father. Evil obviously moves in the shadows of our world even if it is sometimes understated and bent on nothing more than a pitifully small government check.

Apropos of Nothing

Dawn of the Dead

Loaves and Fishes

The body of Mr. Dubois recedes into the shadows as the nurse turns down the lights. His family wants some time with him before he is taken wherever it is we take the bodies of those who finally exhaust our ability to reanimate them. Mr. Dubois did not go quickly or easily. His death has spanned months, if not years. The massive stroke which finally finished him off was just the last in a series of insults, all of which steadily whittled away at his intellect, his quality of life, but never the conviction of his family that he needed to be kept alive at all costs.

The details of Mr. Dubois’ decline are familiar to anyone who has worked in an intensive care unit. Already in poor health from numerous chronic medical problems as well as mildly demented, he suffered a minor stroke and became bed-ridden. His wife, in poor health herself, was unable to transfer him from his bed to a bedside commode and his children eventually moved him to a nursing home where, with the exception of dialysis three times a week, he spent his days laying in his own urine. Over the course of a year he made several visits to the ICU where he was treated for pneumonia and sepsis, urinary tract infection and sepsis, sacral decubitus ulcers and sepsis, and finally a COPD exacerbation with pneumonia and sepsis. This lead to the final, massive stroke which should have finished him off except that after years of neglect, his family was still not ready to let him go.

They were perfectly willing to park him in a nursing home, you understand, as long as they didn’t have to think about him. I’m sure they visited even if the visits eventually tapered off to a hurried fifteen minutes every other week, visits more to demonstrate that they still cared than to look after Mr. Dubois who lay in his bed literally rotting away both mentally and physically.

At the end the family didn’t want Mr. Dubois to suffer, at least not while they were around. I’m sure they didn’t lose sleep over the suffering he endured as an immobile piece of bodily-fluid producing meat in his fly-blown nursing home. But in the hospital, with the doctor and skilled ICU nurses it was all sanctimony and reverence.

The contracted, slack-jawed body of Mr. Dubois continued its leisurely spiral towards death as we used every expensive weapon in our arsenal and spent tens of thousands of somebody else’s dollars in our absolutely inexplicable desire to play along with the family’s delusions.

The family’s delusions, like most, grew in isolation of the basic facts. I suppose if his family had taken care of him at their home as was the case for almost all of human history the story might be different. If they were the ones cleaning his bowel movements, spooning soft food into his mouth, or living with the rotten smell of ulcerating bed sores, one of which had eroded down to his sacral bones, they might have been relieved at his death, both for their own sake and his.

Nor did they give a thought to the cost of his many hospital stays, the total amount of which is almost impossible to calculate. Somebody else will pay, they always do. He’s paid taxes his whole life, goes the mantra, so let Medicare handle it despite the fact that one week in the ICU probably ate Mr. Dubois’ entire lifetime contribution to the system.

A day in the ICU costs several thousand dollars with only a minimal level of care. Then there are the many paid specialists continually consulted to tell us what we already know, namely that Mr. Dubois is dying. The nephrologists shakes his head sorrowfully over his kidneys. The cardiologist writes notes and orders expensive studies which reveal that his heart is bad. The gastroenterologist fails to discover the source of his frequent melanotic stools and the hematologist advises that even though his leukemia is going to kill him in a few weeks (guaranteed) we should go ahead and transfuse four units.

The vascular surgeon, the only realist in the bunch, when consulted for a possible repair of Mr. Dubois’ dangerously bulging abdominal aortic aneurysm says, “Are you fucking kidding me?”

Too bad he can’t write that in his consult note. The dry precision of medical prose gives the illusion that we are in control of Mr. Dubois and could turn him around with a little coordination between the medical specialties. The family certainly buys into this notion. Aren’t all of his medical problems being managed? Don’t doctors have all the answers with their extensive education and big words? Surely all of those monitors, pumps, and flashing lights must be doing something. We’re not asking for loaves and fishes here, doc. Just keep his heart beating.

So that’s what we do. In the end all we are really doing is giving the house staff valuable experience running ACLS codes. We get a carotid pulse back and beam with pleasure at the good thing we have done despite the fact that it is taking three different pressors to keep his blood pressure compatible with life and to remove any one of them will be the end of Mr. Dubois. What we’ve really done is paint ourselves into a corner. He is never coming off the pressors. In about a day, if he lives that long, Mr. Dubois’ toes and fingers are going to start rotting off.

Perhaps then we can withdraw support, if it’s all right with the family that is.

Dawn of the Dead

Pulmonary Consult

Breathe

“I’m a difficult patient,” declaims Mrs. Olafsen proudly around a mouthful of Whopper with cheese. “Nobody knows what’s wrong with me.”

“Really? It certainly looks like that from your chart.” Mrs. Olafsen is gigantic. It took four nurses to get her from the stretcher to her bed. Her legs, like two scaly tree-trunks, encircle a greasy fast food sack which was supplied by one of her skinny daughters.

“I’m Dr. Bear, one of the Emergency Medicine residents working with the pulmonary service. Your doctor asked us to come take a look at you.”

There is a lot of Mrs. Olafsen to look at.

“They tell me you had some trouble breathing.”

“Oh yeah.” She carefully shifts her enormous body and gestures for her daughter to hand her the vat of soda resting on the night stand. “I couldn’t hardly breath when I came in. Isn’t that right?”

Her daughters nods furiously.

The chart does not do Mrs. Olafsen justice. Asthma, COPD (Chronic Obstructive Pulmonary Disease), CHF (Congestive Heart Failure), NIDDM (Non-Inuslin Dependent Diabetes mellitus), PVD (Peripheral Vascular Disease)…all the usual abbreviations. Everything about her is larger than life. She actually looks and sounds pretty good, all things considered.

“I’ve had the flu or something for the last two weeks. I just couldn’t breath at all this morning and my daughter called the ambulance.” She roots in the bag for the greasy debris and finishes her drink with an exuberant slurp.

No kidding. She presented a few hours earlier in Status Asthmaticus, a sometimes fatal exacerbation of asthma which is refractory to the usual treatments. Imagine every small airway in your lungs clamping down tight. I read with interest on her chart that the use of heliox (a low-density mixture of oxygen and helium that results in less airway resistance) was contemplated but not used because she got better.

The oxygen going to her small tracheostomy hisses and bubbles in the humidifier. I see that she is at her baseline oxygen requirement and is “satting” in the upper nineties. Vitals suprisingly good. Her blood pressure is better than mine and she is the most alert and engaged patient I have seen all day.

Mrs. Olafson. Viking fertility godess surrounded by her pretty, reverential daughters. Nothing much to do, really, except write the usual admission orders and the standard prose on the admission HPI. (“46-year-old woman with a history of asthma presented to the Emergency Department in staus asthmaticus…etc. etc.”) However, If there’s one thing I’ve learned this month it’s that everybody can have a pulmonary embolus and Mrs. Olafson is a set-up for one. The D-dimer was equivocal so I order a doppler ultrasound of her massive lower extremities.

The ultrasound lab pages me an hour later.

“You’ve got to be kidding.”, says the tech, “It’ll take three of us just to lift her pannus out of the way.”

“Just do the best you can. I don’t think she’ll fit in the CT scanner.” I know it’s asthma but we’ve had a bad experience recently with a pulmonary embolus (PE) so the service is a little spooked. I examine my logic for ordering the ultrasound. A negative scan, by itself, does not rule out a pulmonary embolus which can only be confirmed or excluded by a CT 0f the pulmonary artery and it’s branches. A low D-dimer would have done it but it is high…but not that high. Why not just skip the ultrasound? We’re going to start DVT prophylaxis anyways.

“When will I get a bed,” asks Mrs. Olafson clearly tired of repeating her story to another guy in a white coat.”

“I don’t know. But we’ll get you upstairs eventually.” The moon will not set before I see Mrs. Olafson safely transferred and slumbering in semi-upright splendor. She seems melted in the flickering light of the television.

The Fresh Prince of Bel Air. I swear, it’s the only thing on at 3 AM.

Mr. Bomagard has died. An hour ago, the ICU informs me.

“Who?” I’ve never heard of him. I’m cross-covering.

“You know, the guy we coded for half an hour yesterday.”

Oh. That guy. I was at the code but it was very well-attended so I didn’t do much. An elderly and demented gentleman who checked out several months ago but whose body had been preserved as a museum to our arrogance and folly.

Mr. Bomagard actually died yesterday. He was in asystole for close to ten minutes before his heart was coaxed back into sputtering life. That was the best CPR I have ever seen. His arterial line measured optimistically normal blood pressure during compressions but trickled away to nothing when they were stopped. And he had the oxygen saturation of a teenager. He came back in stages. From asystole to ventricular-fibrillation at which point he was shocked, the response becoming more dramatic as the current was dialed up. He was finally stabilized in a tenuous sinus rythm on a continuous infusion of amiodarone. And three different pressors to keep his blood pressure up.

What were we doing to you, Mr. Bomagard? You have been in a nursing home for the last three years and haven’t spoken or moved in nine months. This was your fourth ICU visit in the last year. Maybe when you’re being fed through a tube, breathe through a tube, defecate and urinate through a tube…maybe it’s time to let you go. It’s not even a question of your dignity because we’ve taken that away from you. Your shrivelled naked body bounced to the rythms of chest compressions under the bright flourescent lights for ten minutes while your children looked on from just outside the door. Another minute and we would have called it off.

We should have let him go a year ago but families lie. The patient always perks up for them. He knows they’re in the room. It’s not much of a quality of life but we’ll take it. Please don’t let him die. We still see the man we knew in the contracted husk with the tubes and wires sticking out of him. You didn’t see him when he held his first grandchild or on our honeymoon before he shipped out for the Pacific. He’s still in there, somewhere.

He has to be.

“It’s not like they held a gun to my head and made me smoke,” says Mrs. Needlebacker between coughs. “I knew it was bad but I still did it.”

“Don’t beat yourself up, Mary,” I say, “We all have bad habits.”

“Do you, young man?”

“Well, I used to drink but my wife made me quit.”

Mrs. Needlbacker laughs then coughs. I didn’t really drink that much but what can I say? She is 65-years-old and lung cancer has got her in its death grip. When, in her 150 pack-year history of smoking did she realize it was kiling her? When she became short of breath working at her job as a cashier? When her need for supplemental oxygen finally overlapped into her entire day?

She has been coughing up blood. I write “hemoptysis” on my daily note.

“Can I do anything for you, Mary?”

“Yeah, let me out to smoke.” She laughs but she’s serious.

“You’re on oxygen. Your hair might explode.” If it was in my power I’d wheel her downstairs myself and let her smoke as much as she could stand. “Besides, those things will kill you.”

More laughter, more coughing. “No, you’re killing me.” We make the same jokes every day.

I will be off the service on Monday. We are transferring her to hospice in the morning.

Pulmonary Consult

ICU

Waiting for a Miracle

“You understand that if your father’s heart stops we’re going to be pounding on his chest and shocking him to try to get it started,” I say to the family of Mr. Green, “There will many people in the room who you have never met inserting lines in his veins and arteries, drawing blood, giving him fluids, and it will be controlled chaos. If we get him back he will just be even more critically ill than he is now and the next time his heart stops we will repeat the same routine.”

Mr. Green is eaten up by cancer which has metastasized everywhere including his brain. It seems difficult for the family to understand the connection with this and the large fungiating, bloody melanoma on his right big toe. (“Can’t you just amputate his toe?”) He is on the ventilator and is also on a pressor drip (levophed, or epinephrine) to maintain his blood pressure. To say he is not doing well would be an understatement.

“We understand that, Doctor, but we’re praying for a miracle.”

This is by far the worst part of this ICU rotation. Everybody likes to deliver good news but in the ICU it is often necessary to concede defeat. Resident or not, whatever your level of experience you become the point-man of the whole medical profession and it is your job to explain that whatever propaganda the family may have heard, there is no cure for death and when it’s time to go, it’s time to go.

“I’m a religious man myself,” I begin, carefully choosing my words, “And I believe that God watches over all of us and will not abandon us in our time of need. But I also know that any further treatment for your father is only going to put off the inevitable. I can’t tell you how long he has. It may be twenty minutes, it may be a week. I don’t know. But I can say with certainty that we have come to the limits of our ability to do anything but briefly prolong his and your suffering.”

Distressed look from the family.

“So I believe that the best thing to do is to keep him comfortable,” I continue, again choosing my words very carefully, “Trying our best to preserve his peace and dignity.”

“Do we have to decide right away?” asks Mr. Green’s oldest daughter, “We would like to get more of the family involved.”

“Please, take all the time you need. Have the nurse page me when you come to a decision.”

The decision is to change his code status from “full code,” meaning that every effort will be taken to restart his heart and support his breathing, to “Do Not Intubate/Do Not Resuscitate (DNI/DNR).” A simple decision from the point of view of the physician and nurses but incredibly painful for the family who have a lifetime of history with Mr. Green.

A critical care physician once related to me the story of a patient of his who at the age of 82 and after a lifetime of diabetes had developed renal failure requiring dialysis three times a week. He was completely blind, a triple amputee, unable to speak as a result of throat cancer, and had right-sided heart failure from COPD. He had recently undergone a partial colectomy for ischemic bowel and had a colostomy. He was fed via a PEG tube (Percutaneous Endoscopic Gastrostomy) and breathed through a tracheostomy on supplemental oxygen. As one last insult he had recently suffered an MI which burned out a significant portion of his left ventricle dropping his ejection fraction, already low from the right sided heart failure (which drops cardiac output by decreasing amount of blood to the left side of the heart) to something barely compatible with life. But he clung to life and communicated that he wanted every measure taken to keep him alive.

“You know,” The physician said to me, “In Europe they would have let this guy go five years ago. There’s no way they would expend the kind of resources we have to keep him alive.”

“What do you think about it?” I asked.

“I think it’s a tremendous testament of the will of the human spirit to live and I’ll do everything I can for the guy.”

So there’s the problem. When do you keep a patient alive even when treatment appears to be futile? In the case of a patient who can make his own decisions the answer is clear. You do what he asks. When the family acts as a surrogate the decision is a lot more complex. In the case of Mr. Green, the oldest daughter took me aside and confided to me that her brother and her father had had a falling out several years before and had never patched things up. The brother was the strongest advocate for taking all possible measures to keep his father alive.

It would not be too much of a stretch to believe that guilt played some role in the son’s attitude towards his father whose death would leave a lot of important things unsaid, perhaps an apology and a reconciliation.

But that’s how it goes in the ICU. Some patients get better. Some get worse and die despite your best efforts. And some come in and make you wonder why they were admitted because nothing can be done beyond comfort measure.. The ICU shouldn’t be a place for hospice or palliative care but it is sometimes used for this purpose.

ICU