April 8th, 2008 by Dr. Val Jones in True Stories
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I was working in the ER late one night when I was asked to see an elderly woman with the chief complaint of “I almost fainted.” This complaint carries with it one of the broadest differential diagnoses known to man. What could be the cause of a near fainting episode in an elderly woman? It could be anything from dehydration, to an irregular heart beat, to anemia, to malnutrition, to a urinary tract infection or pneumonia. Pretty much anything could make one swoon when you come to think of it.
And so I met the lady, perched atop a stretcher in one of the ER bays. She was chipper and friendly with a shock of curly white hair. She was sitting up, conversing comfortably with no pain or any bodily complaints whatsoever. She was absolutely charming, taking the time to notice my own disheveled condition and inquiring as to when I’d had my last meal.
Her blood pressure was a little bit low, but she had no fever, or heart rate abnormalities. She was not over or underweight, she was well-groomed and alert. I really doubted that there was anything wrong with the woman, frankly, and was kind of assuming that she had stood up too quickly and had a vasovagal episode.
But out of habit I began my physical exam, from head to toe – methodically looking for abnormalities of the head, eyes, ears, nose, throat, cranial nerves, chest, lungs, back, skin, range of motion of arms, strength, sensation, heart sounds, and then the abdomen. As I placed my cold hand nonchalantly on her belly, my arm instinctively jerked away almost before my cerebral cortex was able to interpret the input. Oh my gosh, there was a pulsatile abdominal mass, clear as the nose on her face!
I was barely able to compose myself and asked her to excuse me. I bolted straight for the attending’s desk, and white as a sheet with wide eyes I stammered: “the lady in bed 3 has a pulsatile abdominal mass!”
The attending stood up immediately and followed me to the lady’s room and confirmed my diagnosis. She had a dissecting abdominal aortic aneurysm. We called the trauma surgery team and she was taken to the OR minutes later. The dear lady survived the surgery and was discharged home in her usual state of pleasantness. I’ll never forget that physical exam finding, and how taking the time to place my hand on her belly was all that was needed to save her life. If I had gone with my suspicion prior to the exam (that she was fine but maybe had a UTI) I may have wasted the precious few minutes she had (before her artery ruptured) on getting a urine sample!
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For other surprising physical exam findings, check out part 1 and part 2.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
February 1st, 2008 by Dr. Val Jones in True Stories
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For various reasons, our healthcare system has become very fragmented. Physicians are under financial incentives to do tests and procedures (rather than counsel patients), to become specialists instead of generalists, and to diagnose and treat large volumes of people at 5-10 minute intervals. Gone are the days when primary care physicians took care of 3 generations of family members, watching them grow, understanding their mental and physical health intimately, and helping them to get the right care at the right time. Doctors are rarely part of the family anymore, they’re robots on a really fast treadmill, doling out test results and prescribing procedures based on population based protocols deemed maximally efficient at treating disease at minimal cost.
Does this transition from trusted friend to mechanical puppet matter in terms of health outcomes? The argument is that using lab tests and evidence-based protocols substantially improve health – which is why government initiatives like Pay for Performance are pressuring physicians to treat you from a common diagnostic cookbook. But when we lose the human element in medicine, the long term relationships (aka “continuity of care”), we may misdiagnose people and prescribe inappropriate treatments. Working at lightning speed adds fuel to this dangerous fire. Perhaps a true life example will crystallize my arguments:
Frannie Miller was a thin 86 year old woman living independently with her husband. Although she was slightly forgetful, she managed to do all the cooking, cleaning, and general home upkeep. One day she slipped on the stairs entering her house and fell on the cement. She fractured two of her vertebrae and spent some time in the hospital to manage her pain. Upon discharge she decided to stay with her son’s family since she wasn’t able to return to her usual independent regimen. Her son, dutiful as he was, carefully recorded all of the medications that she had in her pill bottles, and set up a daily schedule to administer them to her. What her son didn’t realize, however, is that Frannie had been prescribed these medications by three different physicians operating independently of one another.
Frannie had mild heart failure with a tendency to retain some fluid around her ankles, so she was prescribed a low dose diuretic by a certain physician. Of course, Frannie didn’t think she really needed the medicine, and never took it. On a follow up visit with another physician, Frannie was noted to have the same mild ankle swelling, and (assuming that she was taking her medicine as directed) the new doctor believed that she needed a higher dose of the medicine and prescribed her a new bottle (which of course, Frannie never took). About 6 months later at a follow up appointment, a third physician met Fannie and further increased her diuretic dose.
So when Frannie arrived in a weakened state at her son’s house, and he decided to give her all the prescribed medications, she received a massive dose of diuretics for the first time. Several days after convalescing at home, Frannie became delirious (from severe dehydration) and not knowing why her mental status had changed, her son took her to the nearest hospital.
Of course, no one knew Frannie at the hospital and had no records or knowledge of her health history or her baseline mental status. She was admitted to a very busy general medicine floor where (after being examined only very briefly) she was believed to have advanced senile dementia and hospice care was recommended for her. Her son was told that she probably wouldn’t live beyond a few weeks and that he should take her home to die. A visiting nurse service was set up and Frannie was discharged home.
How is it that a fully functional 86 year old woman was sentenced to death? It was because of a lack of continuity of care (a shared online medical record could have helped) with doctors moving so quickly that no one took the time to sort out her real problem. Are diuretics appropriate treatment for heart failure? Yes. Did any one doctor violate Pay for Performance rules for heart failure? No. Did the population based protocols work for Frannie? Heck no.
There are so many Frannies out there in our healthcare system today. How can we measure the harm done to patients by the fragmentation of care? Who will collect that data and show the collateral damage of the death of primary care?
This particular cloud – thankfully – has a silver lining. A physician friend of Frannie’s son happened to inquire about her health. The son explained that she was dying, and the physician rightly pointed out that there was no real medical reason for her to be that ill. The friend asked to see her medication list, and knowing that Frannie weighed about 80 pounds was shocked to see a daily dose of 120mg of lasix. Slowly the diuretic SNAFU became clear and the family friend asked that Frannie be immediately rehydrated. She perked up like a wilted flower and returned to her usual state of health within days. Frannie was cured.
I believe that we must find a way to get shared medical records online for all Americans. Having scads of frantic specialists operating independent of one another for the wellbeing of the same patient, yet without being able to share a common record, is endangering an untold number of lives. Not having continuity of care – a primary care physician for each American – is also endangering lives and reducing quality of care. If we could get these two fixes in place, I believe we’d have revolutionized this country’s healthcare system.
What do you think?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
December 15th, 2007 by Dr. Val Jones in Health Policy, Opinion
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More healthcare dollars are spent on end-of-life measures than perhaps any other single expense. About 25% of Medicare’s 2.8 trillion dollar budget is spent on care for people in the final year of life. That works out to be about $2500/person/year that we spend on government funded end-of-life care. Medicare spending overall is closer to $10k/person/year in this country… and given that the average household pays $6K in taxes/year… you can see that we’re in a real pickle when it comes to healthcare spending (and that’s just for Medicare).
In a recent blog post, PandaBearMD suggests that it’s time to “put granny down.” This gallows humor speaks to what the medical community has been been discussing in more academic terms. Here are some interesting sound bites (click on links for full references):
Terminally ill patients should be treated outside of acute care facilities. …Acute care hospitals are, by definition, set up for handling acute conditions – trauma, childbirth, orthopedics, heart attacks, etc. Terminal illnesses are not acute conditions, and therefore should be treated in a facility or setting that is chronic-care oriented.
The technological advances that medicine has witnessed in the last few decades are no more apparent than in the ICU. Yet when used inappropriately, this technology may not save lives nor improve the quality of a life, but rather transform death into a prolonged, miserable, and undignified process.
Hospice care can reduce the cost of end-of-life care by 30% or more (though this is debated).
“We don’t operate in a closed health care system, where there is a fixed number of dollars for health care, and thus the need to choose how to allocate those dollars,” said Dr. Weissman. “Our health care system is open-ended, which is why the cost of health care goes up every year. So we’re not making a tradeoff of spending more on the elderly and thus not using those resources on children’s care.
While it is fairly obvious that we deliver a lot of unnecessary, costly, and heroic medical care at the end of life, determining how to ration this care is fraught with moral and ethical dilemmas.
What sort of population-based rules should we institute to govern access to acute care services at the highest level? Would limiting care to people based on age or comorbidities sit well with Americans? Imagine that you’re 65 – just entering retirement and expecting to enjoy another 20 years of life – and you’re disqualified from top tier medical treatments because of your age. Who has the right to judge your worthiness of top medical technology?
I know of an elderly woman who accidentally took too many diuretics over the period of two weeks. She became delirious and was admitted to a hospital where the doctors assumed she had end stage Alzheimer’s disease and sent her home with hospice care. Another doctor later discovered the error, rehydrated her and she returned to her usual state of health. It was a close call for that “granny.”
My parents are in their late 70’s and in excellent health, enjoying book writing and traveling. I asked them to read PandaBear’s analysis of end-of-life care in the United States – and how billions of dollars are spent on heroic measures for the frail elderly.
My mother said tersely, “I hope I die in Europe.”
My father replied, “Whether you’re old or young, it’s nice to be alive.”
But I can’t help but think of that patient who was sent home with hospice care for delirium caused by severe dehydration. Will we turn our backs on the elderly and not carefully consider their differential diagnoses simply because of their age? As long time tax payers, are they not the most deserving of access to top technologies if so desired?
This is one tough dilemma – and the best I can advise is that we each create living wills, and save our own money for that rainy day when we need critical care, but are ineligible based on some future population-based rule to save money on futile care. In that case, the wealthy would always maintain access to the best care available.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
November 14th, 2007 by Dr. Val Jones in News, Opinion
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“Grow old along with me! The best is yet to be, the last of life, for which the first was made.”
— Robert Browning
As a rehabilitation medicine specialist I do a lot of work with cognitively impaired men and women. The brain is a fragile and fascinating organ, and perhaps the most perplexing one to treat. Alzheimer’s disease, of course, has no known cure – and those who contract it meander through a frustrating cognitive web towards a final common pathway of dementia, dependence and eventually death.
Former Chief Justice Sandra Day O’Connor has been in the news lately because her husband, an Alzheimer’s patient who requires nursing home assistance for activities of daily living, has forgotten who she is. But even more emotionally difficult is the fact that he has fallen in love with a fellow nursing home resident, and has been behaving like a love-sick teen – holding hands, staring into her eyes and kissing her tenderly.
The New York Times reports that Ms. O’Connor is “happy for her husband” that he has found joy in the midst of his cognitive decline. I wonder if there truly isn’t part of her that mourns the loss of those kisses that were once for her.
My fondest hope is that I can grow old with my husband, and that we will enjoy our final years together, in possession of all our faculties. I hope that Robert Browning’s poem will ring true at the end, and that I never have to watch my husband forget who I am. Sadly, since my grandmother passed away from Alzheimer’s – I wonder if it will be my husband, and not me, who watches the other decline?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
July 31st, 2007 by Dr. Val Jones in Health Policy, News
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Two sad cases were reported lately – one by Medgadget in which a young child with Treacher Collins syndrome was denied a special bone-implanted hearing aid. Children with this genetic syndrome usually have normal intelligence, though their appearance reflects underdeveloped facial bones. Apparently her insurance company would pay for the procedure to install the hearing aid, but the $15K device was not covered in her parents’ insurance policy. Her parents could not afford the device, and the child has little hope of developing the ability to speak normally without the aid.
The second case was of Britain’s most elderly woman – a 108 year old who was told that she’d need to wait 18 months to receive a hearing aid from the National Health Service. Mrs. Beal is wheelchair bound, and unable to communicate without a hearing aid. Her favorite hobby is listening to music. Doctors say that she is unlikely to live long enough to receive the new hearing aid.
These two cases demonstrate that care is rationed in both a free market healthcare system, and a government run single payer system – and that rationing affects the disabled and the elderly first. This is the sad inevitability of limited resources, with only the independently wealthy enjoying the best of what healthcare can offer. Perhaps charity alone will hear the cries of these hearing impaired individuals?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
