Tuesday, July 7, 2015

Is Our US Healthcare System Broken?

     Major Question: Is our healthcare system broken?

     This post really has very little if anything to do with Obamacare, unless someone can somehow blame the current care provided on various unintended consequences of that omnibus law, passed without anyone even reading it in its entirety.
     As a retired internal medicine doctor, a couple months ago I had medical needs and made a decision to seek care at a local emergency room. I woke up one morning with nausea and vomiting. It continued throughout the day and in spite of putting myself on a complete liquid diet, I still could not retain anything I drank. At about 8 PM that evening my husband said (in typical logical husbandly manner) "Wife, (his romantic endearing name for me), you had better make a decision if you want me to take you to the emergency room. It's either now or wait until tomorrow morning. Don't plan on waking me at 2 AM to take you." So I tried to drink a little more room temperature soda and it came right back up. Off we went to the ER.

      Everything started out fine. When I arrived the place seemed pretty quiet, no one in the waiting room, and they took me right back to an exam room. Soon two nurses were in the room having me get undressed, and taking a brief history from me. They accessed my records on the computer and asked me a few questions about my medications, my diabetes, what my blood sugar had been running, etc. All well and good, I thought. One of the nurses took my blood pressure and pulse and temperature, and another checked my blood sugar again. An IV was started to give me some fluids as I knew I was terribly dehydrated. The nurse that started my IV had a little difficulty finding a vein, and finally had to use one in my right antecubital area (inside of the elbow) where there is normally good sized veins.  Blood was drawn for lab tests as well from that IV. Then the nurses left. After 15 or 20 minutes, a young woman in a white lab coat came in and introduced herself as the PA (Physician's Assistant). She took a very brief history as well, with only a couple more questions than the nurse had asked. She asked me if I had any abdominal pain. I told her, "No, but there is a lot of gurgling and activity there." She did NOT examine me in any way, my mouth, my chest, and most of all, not my abdomen. She never placed a hand or a stethoscope on my body, and soon left the room saying the Doctor would be in shortly.

     After perhaps another half hour, my husband commented that he had forgotten to take his evening medications and perhaps he would drive back home to do that and then presumably come back to pick me up after I had received some IV's and hopefully felt better. As he was leaving the exam room, he said, "I don't think your IV is running at all." I couldn't see it as it was hung up behind me. I just knew that I was still rather nauseous and my mouth felt like the Sahara Desert. Apparently he went and told the nurses before he left that the IV was not working so soon the male nurse that had started my IV came in and said, "I hear your IV is not running." As he checked it, he said, "Oh, my bad! I forgot to turn it on." Supposedly he turned it on and got it running again. And he did at this point, give me an injection of Zofran to treat the nausea. About 15 minutes later, a different nurse came in and said the doctor had ordered a CT scan of the abdomen and pelvis. I made a questioning "Huh?" sound and said "Was my white count up?", and the nurse said, "Ya, I was surprised at that order also. Let me look at your lab work." After looking at the computer, she said, "Oh, my, your white blood count is 17,890 with a left shift." For the lay people among my readers, that is in the range of "appendicitis or pneumonia" level, definitely seeming to indicate other than just a viral gastroenteritis. Hence the CT scan order. I still had not seen a doctor at all and no one had examined my belly or my lungs, nothing. As the nurse was leaving my exam room, the transporter for Xray came in to take me on the gurney for my CT. The nurse said, your IV isn't running very well but we'll have to disconnect it now for you to go to the CT scan. So off the transporter went with me.

     In the CT room, the tech had to give me an injection of contrast for the CT but she noted that the IV seemed to be plugged. The injected medication didn't want to go in. She untaped the IV needle and moved it around a little bit and then felt that it was running OK. Being the doctor I am, I asked her to try a bolus of saline first to make sure. I really didn't want all of the Xray contrast media to infiltrate the tissues of my arm because the IV was blocked. She told me she was convinced it was working and she gave me the contrast through the IV. The remainder of the CT procedure went fine. I did notice that the machine didn't take long at all. The only CT I had ever had before was of the Head and that was a much slower machine. Back to the exam room in the ER. A nurse came in after a while and, hooked up my IV again and told me they were waiting on the CT results, did I need anything. I told him that my mouth was still very very dry, could I have a moist swab to moisten my mouth and lips with. I knew that kind of medical supply used to be available. The nurse thought a minute and then pulled out something all sealed in a cellophane wrapper and handed it to me. He left the room. I opened the package and there was a swab all right but it was dry, not moist. I didn't know what good that was going to do me.

     Another 45 minutes to an hour passed. I guessed my IV was working now, because I felt a little better. Finally another nurse came in and brought along a cup of ice water. She said, "Your CT is normal, just some diverticulosis but no diverticulitis." I know what this meant. There was no riproaring infection in my belly. Apparently I just was so dehydrated that my white blood cell count was elevated due to that. The nurse said, "I guess if you can drink some of this water and keep it down, you can go home. I have called your husband and he said he would come to get you." I did drink some fluid, kept it down, and I was released to go home.

     At no time did I see a doctor through this entire ER visit with only a nurse and a PA taking a brief history. At no time did anyone, nurse, PA, or doctor touch me in any fashion in the way of examining me. Yes, the elevated WBC did earn me a CT of the abdomen and pelvis. I thought: "I wonder if there is an outcome study that says it is no longer of any value nor is it worth the time and money, and training required to actually examine a sick patient in the ER. Maybe such an outcome study says that you just send everyone for at CT scan. I was in the ER (and CT suite) for a total of about 3 1/2 hours. I think I got about 45 minutes of fast running IV fluids during that time. I did get an injection that stopped my nausea. I did get a CT which provided me with a lot of other negative information such as no cancer, no blockage of bowel, no appendicitis, etc. And I took home a prescription of anti nausea pills in case the nausea came back. (It didn't.) I was lucky! There was nothing seriously wrong with me, probably just a severe gastritis virus that caused severe dehydration.

     I have repeated this story to doctor friends of mine who work at this hospital. I told a retired doc in my luncheon group who was a surgeon. I told my son the professor of Surgery at Indiana, and he commented that I probably should not have been sent for the CT with contrast before I received any IV fluids, because I am a diabetic on a drug called metformin which in combination with dehydration and the CT contrast can cause kidney failure. If my white blood cell count was so elevated just from dehydration, I could have been at such risk. Well, that didn't happen. I had my kidney blood work checked 2 days later before restarting my diabetes medicine and it was normal. Again I was lucky. But none of these doctors can believe my story, especially the fact that I was in the ER for a total of 3 1/2 hours when it was not overly busy, and I never saw a doctor. Now I know that the doctor was probably involved behind the scenes somewhere. But his name was listed on the bill for services performed. I also felt I would like to send for a copy of the records of  my visit and read the notes where someone wrote: "Exam of the abdomen is benign, shows no tenderness, and no masses. Bowel sounds are normal."  Because no one laid a hand on my belly. But to get paid for such a visit, one must document certain bullet items and one big item is an examination of the parts of the body affected by the illness.

     By the way, I did tell the male nurse that I was a retired internal medicine doctor and where I had worked just 7 years ago, telling him after I thought he had gotten the IV going. So it should have been known there that I knew what to expect in the ER when it comes to care. One friend said maybe I intimidated the whole bunch and they stayed away from me for that reason. I thought about that but I don't think I am intimidating, and I never complained to anyone about any of these oversights. I thanked the Xray tech profusely for getting my IV going.

     I related this story to some of my lady friends. Of course, everyone comes forth with a similar tale about mistreatment, mistaken diagnosis, and other tales from treatment in ERs, hospitals, and clinics. I normally ignore these tales because I have known for years that patient expectations are way out of balance and are subject to misinterpretation due to lack of medical knowledge. But one friend told me her experience where she had taken her father into an ER. He was told in the ER after a CT scan of the abdomen, and without much interaction previously with the ER doctor, that he had colon cancer with metastases to the liver and that he didn't have long to live. After admission to the hospital, his own doctor told him he had diverticulitis ( a bowel infection that can swell and look something like cancer) and he had a couple benign cysts in his liver. A couple weeks later I read a personal essay written by a medical student in one of our medical journals describing exactly the same occurrence to the student's relative: diagnosed with terminal cancer in the ER, this time a hematological malignancy much like leukemia. This student's relative only had an elevated white count like I had due to reversible illness or infection. All of these tales are leading me to wonder where our healthcare system is going? Have the time pressures that even I was subject to in my practice finally caused a breakdown in the care given. Are ER' understaffed so that there is no time for caretakers to deal with the patient face to face? Where does an ER doctor almost unknown to the patient deliver what he/she thinks are the correct diagnoses when it might be a terminal diagnosis? Does this speak to the training of the doctor? Does it speak to a lack of caring communication? As I said, I was lucky. But what if I had a pneumonia causing my elevated WBC? No one listened to my lungs. What if the CT with contrast given to me on top of severe dehydration and metformin had caused kidney failure? At the very least I would have been sickened further and hospitalized.

     My advice to all: When you seek care for being very very sick in an unknown way, take an advocate with you, preferably someone who has at least some degree of knowledge about medical care and is not afraid to speak up in your behalf.

     Here is an op-ed piece from the latest JAMA (Journal of the American Medical Association) which decries much of the same phenomenon, but this time from the voice of a radiologist, someone who would even gain financially from the overuse of CT scans. He is complaining about over-utilization.


     Now combine this overuse of tests and imaging to try to achieve certainty with a tendency to not even talk with or examine the patient, but just to enter test orders, you have a big reason for why our healthcare dollars spent are skyrocketing. Surprisingly it doesn't cost very much to have a doctor or PA place their hands and stethoscope on a patient.