Sometimes, when I see what the mainstream media is talking about, I get physically nauseated. Probably 80% of the time, we are focused on nothing. Whether it is Britney Spears or Reverend Wright or, currently, a pay freeze for all federal employees, we continue to miss the big picture. Freezing pay for federal employees will not solve the deficit. It won’t even come close. It is an excellent example of a stupid policy.
Back to healthcare. About 18 months ago, I sat down to write a book on healthcare. I thought I knew a little bit about healthcare. I’ve been a trauma surgeon for over 15 years. My father, whom I used to help in his office, was a family practitioner. So I’ve been around healthcare for more than 30 years. I have seen something as simple as an examination table cost more than $1000. In the course of my health care research, though, I became overwhelmed by the amount of data and the simple size of the task. Healthcare is a vast monstrosity. It is extremely difficult to get your arms around the whole problem. Therefore, it makes sense to me that we need to examine this problem in small pieces. Let’s look at the intensive care unit. In the intensive care unit, physicians practice some of the most advanced medicine that can be found anywhere in the world. Although I do not like to use case reports (anecdotes) as inspiration for action, they can illustrate a larger point.
Case 1: a 90-year-old gentleman was driving a golf cart on the road when he swerved to miss a car. The golf cart rolled down an embankment and the gentleman was thrown from a golf cart and hit his head on a rock. A witness saw this crash and called for an ambulance. The patient was awake and alert when the ambulance arrived and he was taken to the trauma hospital. The patient arrived at the trauma center complaining of a headache. The CT scan of his head revealed a small subdural hematoma (a collection of blood between the skull and the brain) near the temporal lobe. There was a small contusion (bruise) of the temporal lobe. The rest of the CT scan was perfectly normal for a 90-year-old gentleman. (This subdural hematoma does not require neurosurgical intervention.) At this time, the patient began having some language difficulties, was becoming a little confused and was admitted to the intensive care unit. Interestingly, the patient’s son was a pathologist. He was informed of his father’s condition. The next morning, per protocol, the patient had a repeat CT scan of his head. It was completely unchanged. Approximately four hours later, the patient’s mental status began to deteriorate. He was now having severe difficulty finding the correct words to express himself and was becoming agitated. At this time, the patient’s son came by for visitation. The son, extremely alarmed at the deterioration of his father, demanded that something be done. He informed the critical care physician that this patient lived independently was highly functional. The pathologist wanted a repeat CT scan. The critical care physician asked a few questions – what if the CT scan was worse? Did he want his father to undergo a neurosurgical procedure/surgery if necessary? How aggressive did he think they should be with a 90-year-old gentleman who was previously healthy? The pathologist, a physician, was unable to answer any of these questions. (Please remember that none of the patients presented here are real, but are presented to illustrate a point.)
What do you think should be done? Should we get a repeat CT scan emergently? Should we just keep the patient in the ICU (at a cost of $1000 – $1500/day) and watch him closely with continued IV fluids and supportive care? Should we transfer this patient out of the ICU to a regular room and institute “comfort measures?” (Case 2 tomorrow.)
Update: To continue with this case, the patient did undergo a repeat CT scan at the request of the family. The repeat CT scan was unchanged. Neurology was consulted. They came by and explained to the family that the patient’s symptoms were due to the bruise in his temporal lobe. It was unclear if these symptoms would resolve themselves or not. Over the next 24 hours, the patient’s symptoms improved and the patient was transferred out of the intensive care unit to a regular room. Over the next 48 hours, the patient continued to improve and was back to baseline. (He was walking, talking and eating without difficulty.)
I posted this case not as some sort of “miracle,” but as an exercise in thinking about end-of-life issues. How can a physician whose father is 90 years old not have some sort of plan with regard to end-of-life issues? If a physician cannot have a plan then what chance do the rest of us have?
Finally, I would like to address a sentiment that I noticed over at the Daily Kos (I posted this case there also) and also here on my blog, “hurry up and die.” If you read this case and you feel that the medical team was trying to push this 90-year-old man into the grave, you’re sadly mistaken. Instead, all medical teams should be weighing the risk versus the benefit of all therapies. A craniotomy in a 90-year-old has a survival rate of less than 5%. On the other hand, watching, waiting and evaluating turned out to be the right thing to do. By making sure that the patient’s blood pressure was adequate, giving the patient an adequate supply of oxygen and providing appropriate nutrition, the medical team put this patient in a position in which he could heal himself. What was the risk of a repeat CT scan? Not much. That’s why the medical team thought it was okay to order repeat scan. Yes, there was added expense, but it also put the family’s mind at ease. This is also important.