July 14th, 2007 by Dr. Val Jones in True Stories
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This story is from my intern year diary. It’s a quick snapshot of a patient who had overdosed on heroine, coded, and was resuscitated. I think about him sometimes… especially when I read about the rampant drug abuse problem in the US.
—————
I poked my head into the 4-bed communal room on the sixth
floor. The nurse had called to say that
one of the patients was agitated and required restraints. I was asked to assess the situation.
It was immediately clear to me which of the four patients required
my attention. In the far, right corner
was a pale young man, stark naked and thrashing about in his bed. He was babbling something about Ireland and how
he needed to get home. I had gathered
from a quick review of his chart that he had overdosed on heroine, was
resuscitated after coding in the E.R. and transferred to the floor for
observation as he detoxed from the overdose.
I approached the flailing body tentatively. “Hello.
I’m Dr. Jones. You appear to
be quite distressed. What seems to be
the matter?” I said as I pulled a sheet up from the bottom of his bed and
placed it over his genitals.
The young man, barely in his twenties, lay very still as I
spoke to him. He stared at my face with
bulging eyes, speechless for a full 10 seconds.
“Are you alright?” I asked.
“Where am I?” asked the man in a quiet voice.
“Where do you think you are?” I asked, using the opportunity
to assess his mental status.
“I’m somewhere in Ireland,” he said, head turned
towards the window with a view of the Chrysler building.
Seeing that his reasoning was not intact, I replied kindly,
“Well, actually you’re in a hospital in New
York City. You
took an overdose of heroine and your heart stopped…”
“Wow, that sucks,” said the man, sincerely surprised by the
news.
“We were able to resuscitate you in the emergency room,” I
added.
“Cool,” he said, as if the event had transpired in another
person’s life.
“So right now you still have a lot of drugs in your system
which is why you feel confused,” I said, “I think it will take several days
until you return to your normal state of health.”
“Sounds good,” nodded the man.
“Do you know where you are right now?” I asked, suspecting
that his short-term memory had been completely lost.
“I’m in Amsterdam,”
he said, undisturbed by his delirium.
I sighed as I realized that nothing I said to him would
register for longer than a second or two.
“Such a young person, what a waste,” I thought.
The man started to thrash about in his bed again.
“What are you doing?” I asked.
“The back stroke,” he said, surprised that I didn’t know.
I glanced at the man in the bed nearby. He was watching our interaction with some
amusement. He had been reading the New
York Times with a book light. He was a
private patient on a heparin drip for a deep venous thrombosis behind his right
knee. I nodded at him and shook my
head.
Weeks later I heard that the young man’s thoughts were no clearer than they were that night, and that he was transferred to a nursing home for long term care. The brain damage that he suffered from his drug use (and lack of oxygen during his cardiac arrest) had caused permanent, irreparable damage. Another tragic victim of a brain on drugs.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
July 9th, 2007 by Dr. Val Jones in Opinion
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One of my colleagues just forwarded me a NY Times article by Jerome Groopman. The article begins with the issue of inexperienced interns – how newly minted MDs begin clinical care for patients in July of each year, and how these rookies can make harmful mistakes.
He goes on to explain that doctors aren’t trained to think well about the diagnostic process (the thesis of his recent book) and that we’d all benefit from studying cognitive psychology.
Dr. Groopman makes some interesting points in this article, but I was most struck by his flippancy regarding the dangers of getting treatment in July. He simply says, “Today, most hospitals closely watch over interns.”
I personally think the issue is more sinister than that – there are many ways that an intern can make mistakes, without ordering a single test or procedure, and under the full scrutiny of red tape regulations and documentation practices.
When an intern fails to recognize a life threatening condition and chooses to do nothing, or to let the patient wait for an extended period of time before alerting his or her team to the issue, serious harm can befall that patient. And that harm is not caused by inexperienced procedural technique, or ordering the wrong medicine – it’s caused by doing nothing. This “doing nothing” is the most insidious of intern errors – and it is not remedied by any form of hospital quality improvement initiatives. It is the risk that a hospital takes by having inexperienced physicians in the position of first responders. Interns gather large amounts of information about patients and then create a summary report for their supervisors. The supervisors (more senior residents) don’t have time to fact check every single case, and must rely on the intern’s priority hierarchy for delivering care.
But many hours pass between the time an intern examines a patient and when a supervising physician checks back in with that patient. And within that period of time, many conditions can deteriorate substantially, resulting in the loss of precious intervention time.
Dr. Groopman describes an experience from his own life in which a surgical intern (in July) correctly diagnosed his son with an intussusception (twisted bowel) but then incorrectly determined that the baby could wait to go to the O.R. Of course, untreated intussusceptions are nearly always fatal, and each minute that passes without intervention can increase the risk of death.
And so, in my opinion, it is in fact more dangerous to be admitted to a teaching hospital in July, but not necessarily for the reasons that people assume (procedures performed by inexperienced physicians or drug errors – though those mistakes can be made as well). Rather, it is because interns don’t have the clinical experience to know how to prioritize their to-do lists or when to notify a superior about a patient’s health issue. Timing is critically important in quality care delivery – and that variable is not controlled by our current intern oversight system.
Now that I’ve completely terrified you – I will offer you a word of advice: designate a patient advocate for your loved one (or yourself) if you have to be in the hospital as an inpatient (especially in July). If you can, find someone who is knowledgeable about medicine – and who knows how to navigate the hospital system. A nurse, social worker, or physician are great choices. That person will help you ensure that concerns are prioritized appropriately when your intern doesn’t yet fully appreciate the dangers behind certain signs symptoms. If you have no advocate, then befriend staff members who are particularly caring and experienced. Be very nice to them – but don’t be afraid to insist on being examined by the intern’s supervisor if you really are concerned. Unfair as it may seem, sometimes the most vocal patients get the best care.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
July 1st, 2007 by Dr. Val Jones in Health Policy, Opinion
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There were a series of amusing anecdotes presented at the
very beginning of Sicko. Various people
were denied coverage by health plans for things that didn’t have the right
coding or were submitted incorrectly.
One woman received a message that her ambulance transportation to the
hospital from the scene of a car accident (where she was knocked unconscious)
was not covered by her health insurance because she did not obtain pre-approval
for the ambulance ride. She asks, “When
could I have called for pre-approval?
It’s hard to get permission when you’re unconscious.”
Another person was declined coverage because he was too thin
(he was six feet tall and only 130 pounds), and one young woman was
denied because she was overweight (5’1” and 175 pounds).
While these denials are laughable, they are ridiculous
specifically because they are decisions that appear to be made by a computer –
or perhaps by applying inflexible rules to real life scenarios without the
benefit of human interpretation. [See my cartoon on the subject.]
And as we consider Mr. Moore’s proposed solution to the apparent
capriciousness of health insurance company coverage policies – we see that his
single-payer solution is really no different.
He is trading one impersonal decision maker for another. Big government is no more capable of
delivering personally relevant care than is the health insurance industry. The problem with both is that they take
decision-making away from the patient and those closest to their situation – the providers who have a
much better sense of what is needed and appropriate.
As a physician it really upsets me when a third party payer denies coverage of an important treatment to my patient. I understand that we have to have some broad, population-based rules for medical coverage as a means for cost containment – but a one-size-fits-all system will always fail some people. We physicians are regularly on the phone on their behalf, explaining to appeals associates why our patient needs X, Y, or Z… and then have to re-explain the medical necessity up the chain of command until a Medical Director is finally reached, who then has no incentive (other than basic human decency) to give in to the pleading physician’s request on behalf of her patient. We (and our staff) spend uncompensated hours upon hours doing this every week.
And Medicare creates rules to deny coverage to people too (and it probably doesn’t save on administrative costs over health insurance plans anyway, notes Charlie Baker at Harvard Pilgrim Healthcare, Inc.). So from a physician’s perspective it feels as if we’ve had our clinical judgment usurped by bureaucracy and for-profit health insurance companies. We have been reduced to claims advocates rather than clinicians. It is exhausting and infuriating – and I don’t see this improving any time soon (and neither does Paul Levy at Harvard).
Healthcare is not free, as Dr. Leap points out, and unfortunately it’s also not personal. And that’s what I am lamenting – the depersonalization of medical care. My patients will not be able to make a full range of informed choices with my help – they will be given a very limited menu of options from their third party payer – who will argue that they are not limiting care because the patient can always pay out-of-pocket for anything their physician believes is necessary, but is not covered under their plan. And so where does that leave the patient on a modest income? Effectively, they are indeed limited to the options covered by their third-party payer. And this is so ironic, given the new push for personalized medicine (optimizing individual treatment via genetic testing, etc.) In the end it seems that we’re aiming for personalized medicine and an impersonal healthcare system. And maybe that’s part of what’s “sicko” about all of this.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
June 29th, 2007 by Dr. Val Jones in News
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Well, having grown up on a yogurt farm – nothing delights me more than scientific evidence that this fine dairy treat is good for your health. Hats off to my friends at the Imperial College, London who just published a study showing that elderly, hospitalized individuals may use yogurt to avert nasty bacterial infections that cause explosive diarrhea.
Yes, it’s the battle of the bugs at its best – the most common yogurt bacteria: Lactobacillus casei, L. bulgaricus, and Streptococcus thermophilus work together as pretty effective colonic bouncers for enemy bug C. difficile. In this study, elderly patients (n=57) at risk for hospital acquired diarrhea (due to antibiotic use) were given 2 small active culture yogurt drinks/day during the time they received antibiotics and for one week afterwards. Another group (n=56) was given similar drinks, but the yogurt cultures had been sterilized with heat (so there were no actual live bacteria in the yogurt).
And guess what? None of the patients who drank the live yogurt got C. difficile infections, while 9 in the other group did! That means that for every 5 elderly people in the hospital (and taking antibiotics) you could potentially save one from getting a painful gut infection.
So if grandma’s in the hospital on antibiotics, you might want to ask her doctor if she can eat yogurt. It may make the difference between a short stay and a long and unpleasant healthcare experience.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
June 28th, 2007 by Dr. Val Jones in Uncategorized
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I’ve been expressing my concerns over the recent quality control issues in China – first the melamine in pet food, then the contaminated medicines, next the anti-freeze in toothpaste. The New York Times has an interesting piece on the toothpaste scandal. But they miss an interesting issue at play: cost cutting is the underlying cause of all this.
Antifreeze (diethylene glycol) is less expensive and mimicks the flavor of mouthwash. Melamine (the poison recently found in pet food ingredients) is a cheap filler product that increases the apparent protein content of pet food.
So China was putting these cheaper imitation ingredients into their products to improve their bottom line, not because they were particularly interested in causing the death of people and pets.
And before we point a finger at them… let’s think about why the toxic toothpaste got into our hospital and prison systems: because the administrators were trying to buy the cheapest possible products to save on costs. And the least expensive items are often from China. This is a good example of how cost cutting can endanger lives – with both the US and ChinaThis post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
