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On Tuesday I went without any attempt at a nap. I saw a financial advisor for about 2 hours in the afternoon to try to put some of our financial house in order and hung out with Geoff watching the first year of Breaking Bad. Pain remains about the same.
Reflections on Internship
I managed to spend 6 months of my internship working in the emergency room. In 1969 there were very few emergency room "specialists." The American Board of Emergency Medicine was not created until 1976. I don't believe that there were any training programs for Emergency Medicine in 1970. In teaching hospitals, emergency rooms were likely to be well-staffed and the point of triage for urgent illnesses. The emergency room was a large source of the "cases" used in teaching. In hospitals without training programs, the medical staff generally made arrangements to take turns providing staffing. This was much more likely to be hit or miss depending on the particular skills of the doctor assigned to the call.
The patterns of health care delivery were changing rapidly in the United States in the 1960s. People were more mobile than ever before. There was a decline in the number of general practitioners as young physicians increasingly gravitated to careers as specialists. This meant that fewer people had a long term relationship with a family doctor. It was more and more likely that the emergency room would be used for those problems previously handled by general practitioners.
The truth is that a large percentage of medical complaints are self-limited. Take, for example, the way in which influenza might be treated in the emergency room as opposed to treatment from the family doctor. Arrival in the emergency room with the sudden onset of a fever and cough, is very likely to result in a lab study, the complete blood count, and possibly, a chest x-ray. The visit to family doctor is more likely to result in a physical examination, no blood or x-ray evaluations, and the admonition to go home, get rest and drink plenty of fluids.
Why are these situations so different? I think the driving force is the tolerance (or lack of tolerance) for uncertainty . One morning in 1970 I cared for a man who had driven himself to the emergency room after experiencing a shaking chill that lasted for several minutes. Maybe his name was Joe. He was in his thirties, previously healthy and had a temperature of about 103. There were no physical findings except a runny nose. I spent the next few hours getting common blood tests as well as tests for uncommon infectious diseases. I ordered X-rays. I made sure that there was no evidence of an infection in his urine. I drew blood cultures so that we would have more data should he still be ill in a few days, and I also drew a tube of "acute serum" to be frozen for a couple of weeks so that a comparison could be made if a rare germ were suspected. Several hundred 1969 dollars later I called the chief medical resident and asked him to look at the patient. The resident was Donald Wood, M.D., a remarkable physician who would go on to found a cardiology center in Salisbury, Maryland. After examining the patient and looking at the lab data, Dr. Wood called me into the little conference room adjacent to the emergency room. In his usual jovial fashion, he said: "Dr. Sohr, your patient will be happy to know that he almost certainly has the flu--after all we are in the middle of a mini-epidemic. I'm sure that will put his mind at rest. But, I don't think that Joe will be so happy that you have taken a thousand dollars out of his wallet to impart that information to him."
Let's see how an older, wiser Dr. Sohr might have handled that situation in his family practice office in Worden, MT in 1980. Joe arrives after experiencing shaking chills. The older Dr. Sohr has seen this condition, called "rigor" on several occasions. Joe's examination reveals a runny nose but his chest is clear. In formulating the diagnosis and plan, Sohr says: "Joe, I can't be a hundred percent sure of what is going on right now, but I think it is very likely to be the flu. I don't think that a lot of testing will clarify the picture for us but things should come into focus in the next 72 hours. I think you should go home and take it easy for the next few days...." A general discussion of flu symptoms would follow.
For my patients dealing with uncertainty I was pretty concrete. For suspected flu I might have said: "Things can get better, worse, or stay the same. I expect that you will have the usual flu symptoms--here is a handout for symptoms and their management. If things get worse, such as pain when you breathe, producing heavy sputum, or inability to keep fluids, down, I'll want you to see you again--that day. The office will make sure that you can get in. If things haven't changed in 72 hours, call me back."
The other means of for dealing with uncertainty in my own practices was to permit walk-ins beginning late in the day until everyone had been seen who wanted to be seen. I was a solo family doctor for most of my work life. Everyone in my practice knew they could be seen on any day. Late afternoon walk-ins reduced my need for coming back to the office later in the evening and reduced late night telephone calls. I believed that access to care was an essential service. Assurance of access makes uncertainty more tolerable.
When the patient knows that he can always reach help, it makes it easier to live with the earliest stages of an illness. This is one of the most important economic advantages of an established doctor-patient relationship. For the relationship to work effectively, there must be a level of trust on both sides. The doctor must be able to depend on the patient to make reasonable decisions, i.e. to call when things are not going well, and the patient must believe that he can be seen in rapid fashion when he requests the physician's help.
This kind of relationship is generally lacking in the emergency room. Neither party has a long history of successful interaction and problem solving. There is more pressure on the physician to "prove that the patient is not seriously physically ill." The price of such proof is additional expense for lab, x-rays, and other services. At least that's my take on it.
No Room At the Inn
During my months in the emergency room as an intern, there was generally a shortage of beds. The rule at our hospital was that the last two medical and surgical beds could only be filled by direct orders from the chief residents of those services. Our hospital had both private and public wards. In those days, before the advent of more rigorous utilization review, it might be economically advantageous for a physician to be less efficient to the point that additional hospital days might be required. Generally the doctor made rounds on the patients in the hospital daily and charged a fee for each visit.
When hospital beds were tight, the private physician was less likely to be firm with a patient or patient's family who wanted immediate hospital care. Consequently, the chief residents were given control over the last few beds. As beds tightened up, the pressure on the emergency room doctor increased proportionately. Whereas the previous week a patient might have been admitted for an evaluation and treatment of an early pneumonia, this changed when beds were not available. A more extensive evaluation had to be done in the E.R. and a much greater effort was devoted to finding a way to treat the patient out of hospital. Sometimes this is a good thing and results in an overall reduction in the cost of care.
A factor that we seldom consider is the risk of hospitalization itself. If you want to find a killer germ that does not respond to common antibiotics, look for it in a hospital. The error rate for medication administration is not trivial among hospitalized patients. I have seen estimates of thousands of deaths a year. The risk involved in the provision of medical care was euphemistically called "Diseases of Medical Progress" in 1970 when I first became interested in them. Their formal moniker is Iatrogenic Illness (Greek-- meaning coming from a physician).
Mr. R
Mr. R was in his early 80s and he had an enlarged prostate (Benign Prostatic Hypertrophy--BPH) that compressed his urethra to the point that normal urination was affected. He was seeing Dr. U, the urologist, the last visit being the prior day when Dr. U passed a straight catheter, drained the bladder, and sent Mr. R home.
While the drainage the previous day was relieved, Mr. R's kidneys were still working normally and his bladder was filling up and there was no place for the urine to go. As the bladder distended, Mr. R became more and more miserable. He lived with his son, Bob, who had seen his father's struggle for the past few weeks. Rather than go back to Dr. U, Bob decided that his dad really needed to be admitted to the hospital to have the problem fixed once and for all. Consequently Bob brought Mr. R to the emergency room with his suitcase. (This is known to all emergency room workers as the 'positive suitcase sign'--the patient expects admission to the hospital.)
Mr. R arrived at the emergency room at about 1 PM on one of those days where there were only 1 or 2 beds. It wouldn't matter what Bob, or Mr. R, or Dr U wanted to do--only the surgical resident would be able to honor this plea for admission.
Since Dr. U was on the staff at South Baltimore Hospital, I was required to assess the patient and give him a call. Sometimes doctors preferred to come to the emergency room to see their patients in person. Dr. U was busy in his office at the time and asked that I insert a Foley catheter and send Mr. R home to be followed up in the office the next day.
I did as requested. A Foley catheter has a balloon on the end that is inserted into the bladder through the urethra. Once the catheter is in the bladder, the balloon is inflated with sterile saline or water to about the size of cherry. This makes it more difficult for the catheter to slide out or to be pulled out by the patient.
During this whole process, Mr. R was lucid, could describe his discomfort, and was able to cooperate with the procedures. Perhaps we drained about a pint and a half from his bladder and he was immediately more comfortable. I relayed Dr. U's instructions--to go home and to the office the next day but Bob was having none of it. He said that it wasn't right to treat his father this way and to require that Mr. R be transported to some facility on a daily basis in order to empty his bladder.
I called Dr. U and told him that the family was refusing to budge. Dr. U talked with Bob for a while and then Bob handed the phone back to me. Dr. U told me to call the surgical resident and have Mr. R evaluated and to then call back.
It was a busy day and the surgical resident didn't get to the emergency room until about 4:30. The resident examined Mr. R, noted that the bladder was no longer distended and that urine was flowing from the catheter normally. He reported back to Dr. U. who then called me and told me to assure the family that surgery was being arranged. I was told to discharge the patient with the same instructions.
I talked to Bob. I told him that there was nothing I could do to help at this point. I did not have the power to admit patients to the hospital, that the hospital was full anyway, and that Dr. U was promising definitive treatment within the next weeks. It was now well after 5 PM. Bob asked me to call an ambulance for his father. I told Bob that I could not do that but that he could. He said he would. Mr. R was now sleeping peacefully.
The emergency room was very busy. There were only 7 treatment gurneys and all were filled. Mr. R was taking up one of them and he was not receiving treatment, only waiting for transport. I really needed that stretcher. I asked Bob about the ambulance. He said they were still working on it, trying to get the volunteer company from their community. It was about 6:30 and I was scheduled to leave at 7:00. Dr. X, my replacement would be there shortly to make rounds and to sign me out.
I turned to Bob and said: "Look...I can carry your Dad out to your car if you like. Then, perhaps you can get a neighbor at the other end to get him into the house." Bob agreed and went to get the car. A few minutes later, he reappeared and said that the auto was next to the ambulance bay.
I was young and strong and the old man weighed perhaps a hundred and thirty pounds. I carried him in my arms with his head and neck lying on my left biceps. He was very light but I noticed that he didn't wake up when I picked him up. As I began walking toward the E.R. door I noticed that his breathing was no longer regular. It was Cheyne-Stokes...Mr. R has probably had a stroke was likely to die in the next few minutes to hours. I was now at the car. Bob was behind the wheel. His wife was holding open the passenger door. They were expecting that I would Mr. R him in the middle of the front bench seat with Bob and his wife adjacent and wedging him in.
My face and ears felt extremely warm. I'm sure that they were as red as a beet. I swear the devil was actually telling me..."Sohr. He'll be fine wedged in there. They'll get home before they notice something is really wrong. By then, you'll be off the shift and heading home and Dr. X will have to deal with it." I'm sad to admit that I thought about it for a moment.
I said to the family, "Look...something bad has happened here. Why don't you park the car and come back in."
I turned around and carried him back into the emergency room. But when I tried to put him back on the gurney, I saw that it had already been filled. The only vacant spot was an ancient wheelchair sitting in the corner of the E.R., something that FDR might have used. I sat him there and strapped him in so that he wouldn't fall. I told the nurses that he had not really been discharged and remained an active patient.
It was now about 7 PM and Dr. X was awaiting impatiently. We started with the patients on gurneys. I presented them and informed him about where they were in the evaluation process. Dr. X saw Mr. R out of the corner of his eye and pointed to him, "Sohr, that man gonna die." Dr. X quickly went on the next patient.
I had to talk to Mr. R's family. Of course they were upset. Bob said: "Perhaps you guys won't be so certain next time."
This was such a sickening experience. When I debriefed it with others, I didn't see anything more that I could have done. I couldn't be sure that lifting him had not been some final insult to an ancient vascular or skeletal system but I didn't blame myself for that.
It brought home the ugly situation in which I was working. I promised myself to try to avoid the practice of medicine where the hospital was not available to help me manage the evaluation of a patient. I wanted, to the greatest extent possible, to avoid a medical career where I was pressed into service to prove that someone was not sick enough for hospitalization.
For the most part I managed to keep that promise to myself.
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