Monday, September 2, 2013

The Anatomy Of A Hospital Admission

If Hattie had but one flaw, it was that she held her doctors in too high esteem. It was not unusual for an eighty year old woman of her culture to want to please her cardiologist. So when her blood pressure came up a little high, she was too embarrassed to admit that she had forgotten to pick up the toprol and hadn't taken it in over a week. The cardiologist hemmed and hawed, he buried his head in the computer, and eventually wrote for norvasc, a new blood pressure medication. What he didn't do was ask about whether she had regularly taken her pills. He also forgot to tell her that leg swelling is a side effect of the medication

But Hattie wanted to be a good patient. She squinted her eyes tightly and bowed her torso respectfully.

So you want me to take both the toprol and norvasc?

The cardiologist shook his head vigorously in affirmation as he reached for the door knob. He looked back, half his body already out of the room, and asked if there was anything else. By the time Hattie tried to lift her voice to answer, he was long gone. The waiting room was full and surely he didn't have time to stay around for her.

The next week, Hattie arrived at her primary care doctor's office for a diabetes check. After arriving thirty minutes late, he reviewed her chart. Although he read the cardiologist's note, the eleven page novel was so dense that he missed the part about the new prescription. He spent the majority of the visit clicking away at his computer, and making sure Hattie was up to date with her Hgb a1c and lipid monitoring. When he was about to zoom on to his next patient, she leaped up to catch his attention.

But the swelling in my feet, what is causing the swelling in my feet?

Befuddled by his computer, rushing to get to the next patient, and thoroughly annoyed by trying to address an issue other than diabetes, he sat back down and scrathced his forehead. The blood pressure was low and the legs were indeed swollen. Under intense pressure, he quickly reasoned that this must be an exacerbation of her congestive heart failure. He looked up at the clock and then down at the patient. He didn't re review the patient's medications. He didn't get on the phone and call Hattie's cardiologist. These precautions would have taken too much time. Instead he wrote her for a prescription of lasix ( a diuretic which would lower her blood pressure further) and ordered an echocardiogram.

Two days later, Hattie showed up to the emergency room dizzy and short of breath after lifting heavy boxes in ninety degree weather. She was dehydrated and had low blood pressure. This is exactly what would be expected to happen to an elderly woman who:

1.Inappropriately was put on an extra blood pressure pill because her cardiologist was too busy to ask about whether she was compliant with her medications.
2.Inappropriately was diagnosed with congestive heart failure instead of norvasc induced lower extremity edema because her primary care physician failed to illicit the history of a new medication or call her cardiologist.
3. Was exposed to high ambient temperatures.

And what happened in the emergency room? The ER doc read the history in the electronic medical record of congestive heart failure, examined the patient and saw the lower extremity edema, and incorrectly gave Hattie IV diuretic.

It was only hours later, when the hospitalist sat down at Hattie's bedside, that the tale of her woes came clearly to light. He ordered IV hydration, stopped the lasix and norvasc, and restarted the toprol the next day when the blood pressure came back up. Then he sent her home.

Now you may read this diatribe and think that my point is to trump the benefits of hospitalists or talk about the terrible diagnostic abilities of outpatient physicians.

But what I really want to say is that good doctoring takes time and concentration.

Both are commodities that most well intentioned clinicians caught in the dictates of our flawed healthcare system,

no longer have the luxury of.


rxgl said...

Well written. I wish I could say this doesn't occur very often but unfortunately,it does. Certainly, patients do bear some responsibility in communicating openly regarding what they are (or aren't) doing with their meds but most won't let you know until you directly ask them. This is a large part of my daily work with EVERY patient that walks into my office. From that, I would surmise that 7 out of 10 are NOT doing something we assume they are.

Anonymous said...

I agree too. I don't think the problem was going to be that the docs are bad and hospitalists are good. I have seen personally that there is a lack of education among docs (unless it presents in one or two typical ways, they can't figure it out), unwillingness to research (even if you give it to them, they ignore it), inability to use common sense, and lack of communication between all the groups of docs. The bigger problem I have had, unlike what rxgl said above, is that even when you put it out in black and white with peer reviewed medical research, they still can't figure it out or don't want to be bothered.

james gaulte said...

Well at least we can be confident that sorta thing will not happen when patients are all safely ensconced in medical homes and Accountable Care Organizations.

Dr. Archer, the internist with doubts said...

If I had a nickel for every time I had witnessed something like this, I'd be as wealthy as the hospital administrator who sucked all the money away that the physician staff produced for him.