Sunday, February 22, 2009

Proper Use of the Emergency Room

I had a patient the other day who came in to the emergency room (the ED) at the suggestion of his primary care doctor. He had extremely high blood pressure at his doctor's office, but by the time he came into the ED, he had taken the blood pressure meds he was supposed to take, and his blood pressure had dropped significantly - almost normal! In addition, even though he had extremely high blood pressure, he never had any symptoms from it, and so although we might take steps to lower it in the ED, we likely would not admit him, especially now that his blood pressure had come down to almost normal after taking his blood pressure medications, which is how it should be.

The patient was livid. He had paid his $50 to get evaluated in the emergency room and demanded that he be admitted. He claimed his doctor had promised him an admission, which was not true, as we talked to that doctor ourselves.

Although not great, I use this as an example of how people misuse the ED and have the wrong preconceptions about it. Some people I understand - they don't have insurance, so they basically use the ED as their primary care. I don't like it, and I think there are better ways to deal with this or solve this problem (a whole topic in itself), but I understand. What I don't understand is why some people come into the ED at all when they have good primary care or have non-urgent problems.

The Emergency Room is supposed to be for EMERGENCIES. It is for people who can barely breath from pneumonia, not for people suffering from run-of-the-mill colds. It is for people who have broken bones and fractures, not for people who have had lower back pain for the last 6 months. It is for people who are vomiting so much or have so much diarrhea that they are seriously dehydrated, not for people who may have one episode of vomiting or diarrhea but are still able to eat and drink just fine. It is for people who are having a heart attack, not for people who have had "chest pain" that has been proven to be not related to their heart for the 10th time.

Not only is it a huge waste of public and hospital funds, but I don't understand why people would want to spend hours and hours in the uncomfortable waiting room of an emergency room when they can make an appointment with their primary care provider. In fact, when it gets super super busy, and people stay outside in the waiting room for hours and hours waiting to get seen, you can actually see people start to leave. In my opinion, if they weren't sick enough to stay and wait, they shouldn't have been there in the first place.

Thursday, February 19, 2009

When things don't go as planned...

Several months ago, I met a patient who had already been in and out of the hospital for months. He already had had many complications and was pretty sick. This guy had bladder cancer and had to have his bladder taken out. His ureters - the tubes that carry urine from your kidneys to your bladder - were instead fused to a part of his colon so that urine was diverted to his colon instead of his bladder. Immediately after the surgery, he had a heart attack, which is not common, but can happen because surgery takes such a big toll on your body, including your heart. He recovered well from this, and went home. Unfortunately, two days later he came back to the emergency room looking incredibly sick. It turns out that his wound had started to come apart, which is a potential complication of any surgery. His ureters were de-attaching from his colon, leaking urine into his abdomen, and he possibly had an infection within his abdomen. They had to open him back up and fix everything. In the end, it was all still leaking, so they had to place stents within his kidneys that led outside his body to drain the urine instead. He was discharged to rehab.

One week later, he was having his stents changed, and he suddenly became very very sick - he had a fever, the chills, and looked really sick. That's when I saw him. He had developed a very serious infection called sepsis where the infection is basically all throughout your blood. His blood pressure started becoming way too low and he had to eventually be transferred to the ICU where they could start him on special medications to keep your blood pressure up and your heart pumping. It turned out he had multiple types of bacteria growing in his urine, as well as fungus growing in his blood! That's pretty rare, but he had many potential sources of infection - not only did he have the normal sources that every else has (lungs that can develop pneumonia, urine that can develop urinary tract infections, and blood that with even just a blood draw can potentially develop bacteremia or sepsis), he had stents in his kidneys as well as an ostomy (his colon came to his skin and his stool came out through a bag) that were at high risk for infection. Moreover, he was a pretty sick guy, and he'd been in the hospital quite a lot over the last few months, so he was immunocompromised and at higher risk for infections, including hospital-acquired infections. Eventually, he was discharged about two weeks later to yet another rehab facility after being treated with multiple antibiotics.

Two weeks later he came back again. Actually, he had two emergency room visits in between as well. This time, he had developed serious bleeding from his gastrointestinal tract, requiring many blood and platelet transfusions. Over the next 6 weeks, he developed sepsis again and multiple infections, and also developed respiratory failure requiring intubation to help him breathe. Although after several weeks we were able to take the tube out and he could breathe on his own, he was still incredibly sick and his prognosis was very very poor. After many discussions and having dealt with this for nearly 6 months, his wife decided to make him DNR. After 6 more weeks in the hospital and the ICU, he eventually died.

I tell this story because sometimes, it can be amazing what a relatively simple procedure can lead to. I would not call a bladder removal a simple procedure, but I'm pretty sure this patient and his wife went into the operation with an optimistic attitude. He had bladder cancer, but it would be removed, and he would have to pee in a bag for the rest of his life. Traumatic, perhaps, but something you could live with. Instead, he had 6 months of increasing medical complications that eventually led to his death. I don't think the doctors did anything wrong at all, or could have done anything differently - sometimes it's just bad luck and unfortunately, patients and their families are often not prepared for things like this.

Tuesday, February 10, 2009

Wednesday, February 4, 2009

A Universal Electronic Medical Record System

I have an ongoing discussion with my husband about this - the need for a universal electronic medical record system. I don't think anyone really disputes the benefit we would have from such a system. The only thing I could think of is that it may be easier to access the system and there may be more breaches of individual privacy.
The potential benefits are enormous. I can't count the number of times patients come into the hospital or the emergency room with inadequate histories of their own medical care, or without a list of their medications. With a universal electronic system, there would be improved continuity of care, resulting (hopefully) in improved medical care. Not only would we have all their lab and imaging results at our fingertips, but we could get in touch with all the primary care doctors and specialists much more easily for additional information. This can be especially difficult to do if you are trying to contact a doctor at a different hospital or clinic after hours. Secondly, there would be a huge savings in health care costs. More often than not, laboratory and imaging tests are repeated unnecessarily because we don't have the results from another hospital or clinical setting or are unable to personally view imaging ourselves, such as chest x-rays or cat scans. This isn't good for the patient either, as multiple blood draws can introduce more infection or deplete already sick patients of their blood, and expose patients to more radiation than necessary.
Unfortunately, the costs to implement such a system are also enormous. The majority of hospitals still run on a paper system and of the hospitals that are on an electronic system, very few of them are 100% paperless. Moreover, these hospitals all run on separate systems. To get all hospitals on the same electronic system would be incredibly time-consuming, logistically a nightmare, and costly beyond belief. During the transition, there would probably be many records lost, confusion regarding how to access records or results and much worse and slower health care. The hospitals themselves probably all have their own systems in place already and would be reluctant to switch to yet another system, especially if they just spent all this time, effort and money to implement their own electronic system. Many hospitals would probably just want to make their system compatible with whatever universal system is being implemented, which is not ideal. And who would pay for this? The government?

Despite all the roadblocks, I still think it's a worthwhile investment, and hopefully the eventual benefits would outweigh the costs and the inconveniences and temporary lapses in health care.