"I think I have the swine flu, " I told the admitting nurse in the emergency room of a Las Vegas hospital two weekends ago.
The nurse stuck a thermometer under my tongue and clamped down my left arm with a blood pressure monitor strap.
"It is painful when I breathe," I said.
"Where do you feel the pain?" she asked. I told her it's right in the middle of my chest. "The pain traveled from the top right side of my ribcage," I told her, "and on my back directly behind it, until it traveled to the center of my chest. Then the pain in the other places was gone."
The nurse hurriedly wheeled me into one of the emergency rooms and then I saw Nurse Ratched of "One Flew Over the Cuckoo's Nest" masquerading as a doctor. "You don't have swine flu," she sternly corrected me, "you don't even have a fever."
She ordered an ECG (electrocardiogram) on me and soon a young Filipina technician was wheeling in an ECG machine and fitting me with its wiring. A phlebotomist came in to stick a needle in me, then I was rushed to the x-ray department, which I had all to myself - there were no other patients there at 4:30 in the morning.
About half an hour later, Doctor Nurse Ratched came back and told me I was not having a heart attack - all the tests were negative.
I could have told you that, I thought. Who said anything about a heart attack? "I have all the symptoms of swine flu, including the diarrhea - except for the fever," I told the doctor. "It never felt like I was having a heart attack," I said in triumph.
I thought I would put the doctor slightly to shame. Instead, she said: "We'll admit you anyway for a one-day stay just to be sure. We also want to do a nuclear stress test on you this morning."
The controlling Dr. Nurse Ratched was at it again. Was she being cavalier with the people's money, knowing that Medicare had my back?
I was brought into a private room on one of the higher floors, given a tranquilizer and was out till about eleven.
I was released that day with the doctors knowing that I did not have a heart attack. They still did not know what was wrong with me. They suggested I should see my primary care physician right away.
As I should have expected, my primary care physician was on vacation, so his assistant - a physician's assistant (PA), not a doctor - saw me. She recognized right away that I had had an asthma attack and I was still having one right there at her office.
Asthma was my second choice, after swine flu. After all, I had taken my wife Paulita and Paul to Zion National Park in Utah, where there were a lot of trees and strange high-desert plants. I must have picked up some strange allergens in Utah, I told my PA, whom I actually liked. She's a very likable person. She has a ready smile, in sharp contrast to my primary care doctor who has personally seen me only twice since I moved my family to Las Vegas two years ago. Both times, he saw me for two minutes - including the time he spent writing my prescriptions.
I filled my asthma prescriptions at my favorite Walgreens and went to work. I started taking the Prednisone pills, started using the Advair inhaler, and every time I felt tightness in the chest I puffed in a couple of Albuterol inhaler puffs.
I noticed that I had begun to have occasional skipped heart beats, but I was not worried because my medication, Sotalol, had reliably been my ally every time I had those occasional missed heartbeats.
Four days later I was in the emergency room again, this time at the St. Rose Hospital. I didn't want to go back to the first hospital to be treated by Dr. Nurse Ratched again, with a full-blown atrial fibrillation episode. For those who are not familiar with atrial fibrillation, it is when you feel there is a tiny mouse that is going around and around in your heart. The upper portion of your heart is out of rhythm with the lower portion because that upper portion is beating faster than the lower portion.
I was not scared because I'd had those episodes before and I always came out of those like I had just gone ten rounds with Mike Tyson, but having already taken a four-hour nap. No big deal, just an honest day's work at the office.
I am not telling you this for your sympathy - though that might be unavoidable - but to illustrate to you what is wrong with the American health care system.
The doctors at the first hospital that admitted me, knowing that I was not having a heart attack, should have tried to reach a correct diagnosis. They didn't. They had already done all those expensive procedures on me so they knew the hospital and the doctors, lab technicians, x-ray technicians, etc., were going to be paid. Plus they had their behinds covered. I could not later come back and sue them for not being thorough.
Our health care system compensates doctors and hospitals and laboratories for procedures done, not for actually having cured or helped the patients. It's like we all went to school and got A's for effort, not for having actually demonstrated that we had learned anything.
I don't usually agree with former President George Bush, but I like his tort reform idea. I think there should be a limit to jury awards and settlements in medical malpractice cases. The main reason doctors order many unnecessary tests is to protect themselves from malpractice lawsuits. Some doctors have had to pay tens of millions. The limit should only be $1 million for the most serious malpractice cases.
If I were President Obama, I would suggest however that a special court shall be set up to try cases where there is evidence of gross misconduct to determine what the proper compensation to the victim or the victim's family should be. But those cases should be the rare exceptions.
The physician's assistant who prescribed all those asthma medications, which were all steroids, should have known that deep in my medical history was evidence that steroids had caused irregular heartbeats that progressed to a full-blown atrial fibrillation.
If as President Obama has suggested medical records in this country had been computerized and available on the Internet - but only to authorized persons - my physician's assistant would have known that there was a better than even chance that my heart would go into a full-blown A-Fib condition with the use of the asthma drugs. Perhaps, my PA would have temporarily increased the dosage for my maintenance medication for irregular heartbeats. Or, she might have changed my medication to something stronger to counteract the asthma steroid medications.
Or, sensing the very real danger, she might have given me a different set of asthma medications - ones that may not be as powerful, but are not based on steroids.
The doctors in New Jersey, where I spent 30 years of my life, all knew my special sensitivity to steroids, but because medical records are not computerized, there was no way my PA or my doctor could have known that. I guess I should have told them, but it did not occur to me to tell them because I wanted the asthma drugs and was willing to take a chance.
I was happy with the treatment that I got at St. Rose Hospital, especially since I was assigned a cardiac nurse who not only knew what she was doing but had cardiac issues herself and was clearly empathetic.
I had some anxious moments, but on reflection the doctor at St. Rose did all the right things and controlled costs by not ordering unnecessary procedures that would just increase the cost to U.S. taxpayers without adding to the treatment. The St. Rose doctor waited till my blood pressure sufficiently rose (it had been very low throughout) before giving me a brand-new medication (Metoprolol Tartrate) to put my heartbeat back in rhythm. She also gave me a Xanax to put me to sleep.
When I awoke a couple of hours later, my heart was in sinus (normal) rhythm.
Must have been quite scary; it's really bad when you are ill and have no confidence in those looking after you.
ReplyDeleteYouhave eoncuntered an interesting phenomena :"It's not my patch" medicine, which occurs because of over- specialization. The cardiac team realised you did not have a heart problem, so they were no longer interested in you. Everyone forgot that you had trouble breathing; if you had been sent to a respiratory unit, they would have found your problem, but its a bit like gambling in Las Vegas - you may be lucky or you may not. There is a specialty called "general medicine" (known as internist in the US)which looks at every system and at the whole person, but there are not many of them around.I do not want to be wise after the event, but your presenting complaint was not dealt with despite an overnight admission.
IN Australia we are undergoing the biggest health care reform in our history and on the agenda is computerised records available to your caregivers, as well as national control and funding of all hospitals. Generalized computer access to hospital records is already available within our Area Health service (geograhical region) at any hospital.
Try to keep as well as you can,
Tony
Hi Tony,
ReplyDeleteMy primary care physician is an internist. The problem is, the guy is never around. He has two locations and merely functions as the CEO/COO of his combined operations. The Physicians Assistants are the ones who actually see the patients. My doctor has no bedside manners. He seems annoyed that you have to see him and add to his ever-growing schedule of appointments with patients.
Medicare Advantage, which is costing the government an additional $60 billion a year, has made it more difficult for patients to look for the best doctors. Since Medicare Advantage is an HMO, only those doctors in the network can be seen by patients. Obama wants to abolish Medicare Advantage and save $600 billion over ten years. That would take care of 60 percent of the cost of health care reform as projected by the Congressional Budget Office.
The other 40% will come from other cost savings and an increase in the tax rate to 40% for the highest earners in the U.S.
For me and a lot of seniors, Obama's reform plan will mean better doctors at less cost. I know I haven't explained this last part, I will do so in a memo to everyone.
My friend, Dr. Gene Pulmano, has been kind enough to critique this last post. He has very valuable insights that I find useful and others may find valuable. Since his comments are quite lengthy, I will post them here in installments.
ReplyDeleteFrom my blog: "I think I have the swine flu, " I told the admitting nurse in the emergency room of a Las Vegas hospital two weekends ago.
Dr. Pulmano's comment: I would have asked you: What made you think so? What symptoms do you have? If you did not have fever, sore throat, some cough, stuffy nose, muscle aches or pain, malaise or significant fatigue, or nausea, vomiting and diarrhea--it's very unlikely that you have a swine flu, or any viral upper respiratory tract infection for that matter; there are plenty of other viruses that can cause URTI.
From my blog: The nurse stuck a thermometer under my tongue and clamped down my left arm with a blood pressure monitor strap.
Dr. Pulmano's comment: She did the right thing. For one, you believed that you had swine flu. That she put an automatic blood pressure cuff on you was also the right thing to do. However, I would have taken your BP, at least initially, manually. Automatic BP machines are prone to errors for so many reasons which I need not go into. I would have gone further: taken your pulse rate, respiratory rate. BP, PR, RR are called Vital Signs and they are a must, especially in an ER setting. They are called Vital Signs for a very good reason; they could tell the doctors or nurses if you are in trouble and serve as baseline info, so that when your condition changes, your doctors or nurses have objective parameters for comparison.
From my blog: "It is painful when I breathe," I said.
"Where do you feel the pain?" she asked. I told her it's right in the middle of my chest. "The pain traveled from the top right side of my ribcage," I told her, "and on my back directly behind it, until it traveled to the center of my chest. Then the pain in the other places was gone."
Dr. Pulmano's comment: There is a useful tool that doctors utilize given a patient's complaint/symptom or set of symptoms. I refer to the concept of differential diagnosis. Differential diagnosis is a set of probable diagnoses, that range from the most probable to least probable, or in certain setting such as an emergency room and given your (our) age, from the most serious to the least serious. This serves as a guide to one's further interview of the patient to arrive at the most likely diagnosis. This mental list also assures the doctor that he's not missing anything important. It's much like a checklist, but more than a list, that pilots employ before they take off. Further, the differential diagnosis will serve to clarify some of the patients symptoms. Not going thru this process leads to jumping to conclusions that could mislead a doctor to making the wrong diagnosis.
Formulating a differential diagnosis is akin to generating a set of hypotheses, and one pick's the hypothesis that best accommodates or explains the facts or "facts" (or factoid, because a lot to soc-called facts are not empirical facts but subjective info). It Involves the back and forth interplay of inductive and deductive reasoning. In this sense, it's very much like along the lines of the scientific method.
(continued on next comment)
Continued from last comment:
ReplyDeleteDr. Pulmano's comment: In your particular case, it's valid to consider a heart attack, and to do the pertinent lab studies and procedures such as EKG. However, given the description of your symptom, one has to consider other things, such as a pulmonary embolism (lung blood clot), dissecting aortic aneurysm (tearing of the wall of the main chest artery, the aorta), peneumothorax(leakage of air from the lung into the chest cavity), pleuritis (inflammation of the lining of the lung), costochondritis (inflammation of the joint of the hard and soft bones of the rib, about 2 inches off the edge of the breast bone of the chest), and plain muscle strain; there are other conditions, but quite far off and one has to delineate the boundaries of one's differential diagnosis. If the patient's condition proves difficult, one can then extend the set of differential diagnosis.
All these considerations can be clarified with more questioning and a good physical exam and ancillary tests and procedures.
I just want to interject that when one deals with chest pain, especially in our age group, one has to be more careful in assessing it and ascertain, as much as possible, the nature of the chest pain. There are chest pains and there are chest pains. You'd be surprised how chest pain could mean different things to different people. Some people who could not breath would call their symptom chest pain; others would describe their chest pain as a feeling of pressure, tightness , dull ache or sharp pain, etc; a true heartburn could be interpreted by the patient as chest pain and vice versa. It's all very subjective. A chest pain, properly defined, could be a key to the diagnosis; in other situations, in and by itself, may not mean anything unless considered in the context of other symptoms, what I call a "constellation of symptoms" and in the light of other variables, such as age, gender, past medical history, lifestyle, medications, etc. This is where your one's depth and breadth of knowledge of medicine, experience and judgement come in.
From my blog: I could have told you that, I thought. Who said anything about a heart attack? "I have all the symptoms of swine flu, including the diarrhea - except for the fever," I told the doctor. "It never felt like I was having a heart attack," I said in triumph.
Dr. Gene Pulmano's comment: Diarrhea per se, without the other symptoms of flu, is really uncommon as a manifestation of a flu (common cold). I think her comment that you did not have a heart attack was only meant to reassure you and herself, for that matter, that you did not have something serious.
From my blog: I thought I would put the doctor slightly to shame. Instead, she said: "We'll admit you anyway for a one-day stay just to be sure. We also want to do a nuclear stress test on you this morning."
Dr. Pulmano's comment: This is a judgement call. It's not out of line. There is a dictum that I normally follow: When in doubt (and there are many instances in medicine, especially in ER setting) resolve the doubt in the patient's favor.
(to be continued in the next comment)