Monday, September 22, 2014

When the Patient Becomes a Specimen

He lay in the hospital bed, belly-up, staring at the ceiling. We knocked as we entered and asked the patient a barrage of questions. How was he feeling? What doctors had he seen in the past? What other medical conditions did he have? When did he first start to notice uncontrolled nosebleeds? What other symptoms did he notice? An endless series of questions for a patient already overwhelmed with newly diagnosed leukemia, a cancer of white blood cells. As these cells proliferate uncontrollably due to bone marrow dysfunction, they crowd out other cells in the blood. Platelets, for example, which create clots to stop bleeding, decrease in number leading to spontaneous bleeding. White cells malfunction, allowing bacteria, fungi, and viruses to slip past the body’s floundering immune system. Patients with certain types of leukemia also develop an enlarged spleen, called splenomegaly. This occurs because the body looks for places other than the bone marrow to produce blood products. The spleen and liver are two organs capable of producing red blood cells (or once were during embryonic development). They enlarge in their attempts to compensate for bone-marrow failure.

Red blood cells.
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“Come over here and feel this,” the attending physician said to the three of us, all medical students, after interviewing the patient and performing a physical exam. “Is it alright if they feel for your spleen?” he asked. After the patient assented, the three of us, one by one, began to poke on the left side of his abdomen, palpating up and down and subsequently tapping and listening for when our taps became dull or tympanic. We searched for where the spleen began and ended. And there it was, a large, blown-up balloon inside the patient’s belly, squirming around as we attempted to assess its size through palpation. We stood in line, each excitedly repeating what the previous student had done. It was, after all, the first time any of us had ever felt splenomegaly. In this particular interaction we converted this human being into a test tube by observing, exploring, feeling, and assessing, detached from the reality of the patient’s experience.

We do this regularly during our third year of medical school — we violate patients’ privacy for the sake of our education. Part excited, part nervous, part sheepish, we come when called by our teachers to listen to lung sounds and heart sounds; to inspect wounds and infections; to feel for various organs, tendons, and muscles in living human bodies. Though this experience feels new and uncomfortable for us, it is worth noting that medical students have learned in this way — with a lot less regard for the patient — for quite some time.

In a 1946 issue of Now, a political and literary journal, George Orwell published an essay entitled “How the Poor Die.” In this essay we accompany Orwell, who in 1929 experienced a bout of severe pneumonia, through a frightening, dark, and even humorous tour of a French hospital he simply calls the Hôpital X.

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Orwell describes the admissions process: “I was kept answering questions for some twenty minutes before they would let me in.... At my back a resigned little knot of patients, carrying bundles done up in coloured handkerchiefs, waited their turn to be questioned.” From here, with a 103 degree fever, Orwell disrobed, put on a short hospital dressing gown and walked, without shoes, 200 yards outside on a February evening to his hospital ward. Unfortunately, his quarters were no better than the journey to them. There was a “foul smell, faecal and yet sweetish,” [my comments on hospital smells are here] and the room contained three rows of beds “surprisingly close together.” It seems, from Orwell’s description, to have been more of a mess hall than a hospital floor.

In the bed across from him, Orwell witnessed a patient undergoing a medical procedure: “a doctor and a student performed some strange operation on him. First the doctor produced from his black bag a dozen small glasses like wine glasses, then the student burned a match inside each glass to exhaust the air, then the glass was popped on to the man’s back or chest and the vacuum drew up a huge yellow blister.... It was something called cupping, a treatment which you can read about in old medical text-books but which till then I had vaguely thought of as one of those things they do to horses.” (A recent review of the efficacy of this treatment has shown the evidence for it to be largely inconclusive.)

Subsequently, Orwell, who ostensibly also required cupping for his illness, joined in the medical education as “the doctor and the student came across to my bed, hoisted me upright and without a word began applying the same set of glasses, which had not been sterilized in any way. A few feeble protests that I uttered got no more response than if I had been an animal.” And in his classically dark humor, Orwell notes, “I was very much impressed by the impersonal way in which the two men started on me.... It was my first experience of doctors who handle you without speaking to you or, in a human sense, taking any notice of you.”

On a daily basis, nurses woke the patients at five in the morning and measured their temperatures but never washed them. Orwell remarks, “if you were well enough you washed yourself, otherwise you depended on the kindness of some walking patient.” The doctor typically dropped by later with interns and medical students and “there were many beds past which he walked day after day, sometimes followed by imploring cries.” Only if there was a patient with some interesting medical illness or presentation would the doctors attend to them. The attention they paid Orwell was almost too much for him, with “a dozen students queuing up to listen” to his chest.

It was a very queer feeling — queer, I mean, because of their intense interest in learning their job, together with a seeming lack of any perception that the patients were human beings. It is strange to relate, but sometimes as some young student stepped forward to take his turn at manipulating you he would be actually tremulous with excitement, like a boy who has at last got his hands on some expensive piece of machinery.... You were primarily a specimen, a thing I did not resent but could never quite get used to.

Orwell proceeds to describe in great detail the other patients in the hospital, a potpourri of characters. We read about an older man who cannot urinate, and about a veteran of the Franco-Prussian War of 1870, dying as female relatives look on, “obviously scheming for some pitiful legacy.”

Then Orwell discovered a patient with cirrhosis of the liver due to alcoholism (a surprisingly common type of patient in hospitals these days, too). “About a dozen beds away from me was Numéro 57 — I think that was his number — a cirrhosis-of-the-liver case.” This patient’s liver was so enlarged that he was “a regular exhibit at lectures.” The physician lectured to the medical students on 57, describing the particular physical findings of someone with chronic alcoholism and an enlarged liver. The doctor felt for the patient’s liver and showed his students what it was like. “Utterly uninterested in what was said about him, [the patient] would lie with his colourless eyes gazing at nothing, while the doctor showed him off like a piece of antique china.”

Numéro 57 died in the middle of the night, although no one knew it until the morning. “This poor old wretch who had just flickered out like a candle-end was not even important enough to have anyone watching by his deathbed. He was merely a number, then a ‘subject’ for the students’ scalpels.” Orwell, as soon as he had gained enough strength, fled the hospital: “it was a hospital in which not the methods, perhaps, but something of the atmosphere of the nineteenth century had managed to survive, and therein lay its peculiar interest.”

Finally, Orwell offers an incisive comment on hospital medical care: “Whatever the legal position may be, it is unquestionable that you have far less control over your own treatment, far less certainty that frivolous experiments will not be tried on you, when it is a case of ‘accept the discipline or get out.’” Orwell directs his social critique at hospitals which treated and took advantage of the poor — forcing them into crowded quarters, ignoring their cries for help and even operating on them without anesthetic.

Despite the comparative pleasantness of my own experience in my medical studies, whenever I read this essay I wince at Orwell’s descriptions because of how familiar they are to me. The instances of the patient as a kind of specimen resemble in some remarkable ways the example I gave at the beginning. To be sure, we always thank a patient, ask if we can perform the appropriate physical exam maneuver, and acknowledge the patient’s right to refuse an exam. Nevertheless, we treat the patient as a test subject, which, however unfortunate, is necessary for our future profession. As patients we must ask ourselves whether we want to be treated by physicians who have never heard wheezes on a physical exam or never felt for an enlarged liver. Patients at teaching hospitals indeed make sacrifices for our education and for the welfare of our future patients.

Orwell also points out the patients’ abdication of privacy in the hospital. Unquestionably, this is accurate even today. When patients arrive, they put on a hospital gown, or uniform, depending on how you look at it. The gown is, humiliatingly, almost completely open in the back except for a meager string that, even after being tied, barely holds the back together. With the uniform on, they become hospital patients under the supervision and care of the nursing staff and doctors. Each patient has the same gown with the same color scheme. Each patient is similarly under our watch.

When we enter a patient’s room, the knock at the door is more of an announcement than a question. Overnight, patients are poked and prodded for their blood samples. How strange that even their blood seems to be property of the physicians, nurses, and lab technicians. Many patients are attached to an IV pole which holds bags of fluids and medications being pumped into their veins. And thus, they cannot get up without dragging hospital property along with them. Of course, the staff does not usually treat patients like hospital property; of course, patients can choose to leave at any time; and of course, patients are there so they can get better. Regardless, the situation is one in which a patient submits himself or herself to the hospital so completely that, inevitably, some aspect of the patient’s sense of privacy, independence, and humanness is lost.

Even taking all these similarities into account, Orwell's hospital experience is more of a nightmare from our perspective. But the parallels should give us pause. Has something of the atmosphere of the nineteenth century managed to survive even in the latest and best conditions? Must it?

Friday, September 5, 2014

The Costly Complications of Emergency Medical Care

During one Emergency Department (ED) shift, EMTs brought in an older woman to the hospital. She had called emergency medical services (EMS) and explained that she had low blood sugar, or hypoglycemia. Hypoglycemia can lead to coma, brain damage, and death as well as other more minor symptoms such as tremors and sweats. But when the EMTs arrived to pick this woman up, her blood sugar levels were normal — there was no emergency at all. In fact, as she admitted once she was in the back of the ambulance, she only called EMS because she had run out of glucose strips, which diabetic patients use to monitor their blood sugar. A family medicine doctor can easily procure these for a patient, and running out of these strips in no way constitutes a medical emergency. Once this woman got to the ED, the physicians drew her blood for labs, examined her, and measured her blood sugar again in order to make sure there was no emergency.

In another instance of misused resources, a middle-aged gentleman called an ambulance because, supposedly, he could not walk. However, the patient was able to get himself up from the stretcher and climb onto the ambulance, which his daughter said was normal behavior for him. He received a full workup in the ED with labs and x-rays. Similarly, a mother brought her son into the ED because he needed a full physical before playing sports. The ED physicians spent time speaking to the patient, doing a physical exam and drawing basic labs to look at his blood.

These kinds of situations occur daily — we squander emergency medical resources on non-acute medical conditions. Sadly, emergency physicians and EMTs do not have a choice in the matter, which can be disheartening in a system where resources are precious. And while there are many factors affecting inefficient emergency medical care, we have a law to blame for at least some of the daily inefficiencies — EMTALA (the Emergency Medical Treatment and Labor Act).
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Congress passed EMTALA in 1986 with Ronald Reagan’s signature, ensuring, among other things, that patients requesting emergency medical care receive it regardless of their ability to pay. In a 2001 article published in the Baylor University Medical Center Proceedings journal, Dr. Joseph Zibulewsky puts the law in perspective. In 1986 and 1987, case studies from Cook County Hospital in Chicago described how other hospitals transferred patients to Cook County because the patients could not pay for their care, a practice known as “patient dumping.” The studies concluded, as Dr. Zibulewsky writes, that “this practice was done primarily for financial reasons.” In fact, “the reason given for the transfer by the sending institution was lack of insurance in 87% of the cases.” Moreover, the patients who were transferred were twice as likely to die as those who were not transferred. Nor were these isolated events: “This practice was not limited to Chicago but occurred in most large cities with public hospitals. In Dallas, such transfers increased from 70 per month in 1982 to more than 200 per month in 1983.” As a result of widespread patient dumping, EMTALA was signed into law.

EMTALA consists of three basic tenets all of which must be followed regardless of a patient’s insurance or financial status. First, any person who presents to the hospital for medical care must receive a medical screening examination (MSE) to ensure that there is no emergency medical problem. As the law reads:

if any individual (whether or not eligible for benefits under this subchapter) comes to the emergency department and a request is made on the individual's behalf for examination or treatment for a medical condition, the hospital must provide for an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition...exists.

As the examples at the beginning of this post illustrate, no matter what a patient comes in with, an emergency medical condition must be ruled out, so a medical workup must be performed. Additionally, the ED must “provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility.” In other words, the patient’s condition must be stabilized before discharge. If the hospital is not equipped to care for a particular medical condition, the hospital must transfer the patient to another hospital capable of providing the needed care.

And all this does not just apply to ED physicians. Any specialist consulted by the ED (in fields like neurology or psychiatry) must see the patient within 30 to 60 minutes of being called. EMTs are also beholden to this law. As Zibulewsky explains, an “appeals ruling in Hawaii has extended this [EMTALA] to virtually any ambulance, even those run by city or county services.” Thus, once a patient is in an ambulance, he or she “can be considered to have come to the ED.”

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Hospitals and physicians face stiff consequences for failing to abide by EMTALA. The law applies only to those hospitals and physicians who participate in Medicare, which nearly all of them do. And if the hospital violates EMTALA, reimbursements can be taken away. On an individual level, physicians can be responsible for up to $50,000 in civil court if they violate the law. Given how many hospitals and doctors receive reimbursements from Medicare and how much money hospitals receive from Medicare (hundreds of billions of dollars), it behooves institutions to follow EMTALA as best they can.

Unfortunately, the law is incredibly problematic for many reasons. In the first place, vagueness abounds: what counts as a medical screening examination? Is it just a physical exam? Is it just a history of the patient’s present illness? Must a CT scan be included? This is completely nebulous. Also, what counts as stabilized? If a person is bleeding to death with a broken leg and a physician stops the bleeding and casts the leg, can the patient be discharged without a follow-up appointment with a physician? If the trauma has left someone severely debilitated and is surviving only on a ventilator, is it now the hospital’s responsibility to find an acute care nursing home and continuous care for this patient? Does the hospital keep the patient in the ICU and eat the cost indefinitely?

Furthermore, the law adds population burden and financial cost to a floundering medical system. A 2008 article by Dr. Damon Dietrich and Dr. Michael Crapanzano concluded that while “EMTALA was intended to provide all patients the right of medical care in the ED regardless of ability to pay, a cost: benefit analysis performed by Duke University...suggests it did just the opposite.” Moreover, “EMTALA actually impedes access for an EMC [emergency medical condition] by overwhelming resource capacity.” Many people who come to the ED actually need emergency medical care, not just glucose strips. And putting time and resources into non-emergency care takes away resources and time from emergency care. Also, because care is “free” in the ED, patients have no qualms about coming in whether their problems are or are not acute. In turn, this leads to overcrowding. Some statistics, though not proven to be a direct consequence of EMTALA, demonstrate the severity of the problem. In 2001, “two out of every three hospitals reported diverting ambulances to other hospitals” due to ED overcrowding. Additionally, “ED visits in 2003 rose to 114 million, up from 97 million in 1997.” This overcrowding with uninsured patients costs the hospitals and its patients tremendous amounts of money. As a result, emergency rooms close, further exacerbating the problem of ED overcrowding. Between 1988 and 1998, 1,128 EDs closed, leading to dramatic increases in patient volumes and waiting times at other EDs.

Then, of course, there is the financial burden. An ambulance ride itself can cost over a thousand dollars. Also, the authors of the Duke study estimated that EMTALA has a net cost on hospitals, government agencies, and social welfare that runs in the billions of dollars. We thus have good reason to think that EMTALA places financial strain on our medical system as well.

But it’s not just patient care and hospital emergency rooms that are negatively affected by this law. According to the American College of Emergency Physicians, ED doctors “on average provide $138,300 of EMTALA-related charity care each year, and one-third of emergency physicians provide more than 30 hours of EMTALA-related care each week.” Unfortunately, ED physicians have no say in the matter — the federal government mandates that they donate their time and money. Some physicians are rightfully upset that they are not receiving compensation for the work that they have no choice but to do.

And yet, I support the idea of EMTALA. It would be callous to kick patients in need of emergency care to the curb simply because they can’t pay. As Avik Roy, health care policy expert and Opinion Editor at Forbes, has written in National Affairs, “There are some instances in which we should obviously consider more than economics: Certainly no wealthy nation should allow a destitute woman who has been hit by a car to die in the street. Likewise, in a pressing emergency, catastrophic care should be provided to those who need it, and the costs can be sorted out later.” Absolutely.

However, this law, a classic example of unintended consequences, is not the way to assure that care. It increases the cost, time, and population burden on the ED and also mandates that physicians give up their time and money to treat patients whether or not those patients need emergency medical care. And this is not just a partisan fight: political and healthcare activists of all stripes find this law deleterious and inadequate and have called for its repeal. But repeal of EMTALA seems distant as we try to sort out the effects of the Affordable Care Act. Nevertheless, if we cannot repeal it, we must improve upon it and rectify its effects as best we can to ameliorate patient care in the emergency room.

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Incidentally, the problems arising from this law also illustrate an important point about medicine and politics. Politics is not some drama playing out on a distant stage and leaving most of us unaffected; it affects physicians and patients — so at some point all of us — every day in very practical, tangible ways. Whether EDs or hospitals face overcrowding, closures, or mandated care, all roads lead through the workings of politics, a topic which we can’t ignore if we want to understand medical practice. As John Adams famously wrote in a letter to Abigail Adams, “I must study Politicks and War that my sons may have liberty to study Painting and Poetry Mathematicks and Philosophy.” Adams’s point, though meant for his generation, holds true for all of us. We must familiarize ourselves with politics and ideas — these affect every interest and every profession as all are confined and freed by law. Medicine is no exception.