Tuesday, May 05, 2009

The Good Old Days of American Medicine

The 'good old days' for doctors in America were the seventies. But let's talk about the 'good old days' for patients in America. They are right now and they are about to end. 

The good old days for patients have been at the expense of American doctors and nurses and paramedics for thirty years now, and because of EMTALA, Medicare, and gutless politicians and physicians. Group politics, super. See ya later individuality and achievement.

After Obama 'fixes' medicine my life will be easier and I will make more money for less work and with capped liability to boot! I will take some pleasure in pointing this out to all of you muddle headed liberal do-gooders and earth mothers out there, but not too much, because I will pull out a lot more 'pronouncment of death' forms. These patient encounters are easy and there's no risk and I get paid, so cool. You just have to make sure the patient is really dead, and this is only occasionally difficult. Here's a story about what will not happen anymore. 

You will not be an 80 year old smoker who has been struggling to breathe for two days and when you call 911 they will not get there right away. You will not be rushed to the hospital with lights and sirens blaring and you will not be thrust in front of me at 4am with a heart rate of 220, curiously the same as your systolic blood pressure, and I will not, then, do the following...

I will not run into the waiting room to find your family (after shouting out, IV, nitro drip, cardiazem 25 IV, morphine 4 IV, set up RSI, pacer pads!) to find out if you have a living will (you are too far gone to do more than scream and breathe).

Through their tears they will not tell me to 'do everything'.

I will not then run back into your room, pulling a few techs and nurses with me and do the following...

I will not give you 20mg of etomidate followed by 25mg of succinlycholine and slide an 8.0 tube into your trachea and hook you up to a vent.

I will not then push about 50mg of propofol on you before shocking you with 100 Joules of synchronized electricity to get you out of your atrial flutter with aberrancy, and will not rush you to the scanner to make sure you are not dissecting a thoracic aortic aneurysm or pushing against a massive pulmonary embolus.

I will not, after you come back from scan, have a brief moment to look in your eyes (as the propofol has been momentarily stopped), and apologize to you for intubating you (as it seemed like you didn't want me to do it, but I could not trust you (at the brink of death and without documentation) to make a good decision), and have you nod your head to me and try to thank me. 

I will not then send you to the ICU where, in spite of your continued smoking habit and lack of insurance or money, some of the finest critical care physicians I have known will, in all likelihood, succeed in getting you out of the hospital, back home, and comfortably smoking. They will lose money in the endeavor (and sleep and time away from family), but that's what they do now.

Instead, when you call 911, you will get a recording or be put on hold. If you make it past the call screener you will be rushed to the hospice where you will die in a haze of morphine. But, and here's the good part, it WILL be 'free' (and I will be free to take a nice nap on the overnight shift).


  1. Liz, Hospice RN2:28 AM, May 06, 2009

    Ya know, dying in a pleasant morphine haze sounds a whole lot better than all the panic, screaming and anxiety that accompanies trips to the ER and ending up on a vent.

    I'm not saying I'm pro rationing, but I don't see how we can avoid it. It's simply not possible to give every single person every single intervention indefinitely.

    The hardest part about dying is being ok with it.

    Love the blog!

  2. dear liz,
    first thanks for what you do. i think hospices are wonderful and am not of the mind that if someone is ready to quit the medical fight that they should be cajoled into futile care. not at all. but i do disagree that rationing is inevitable. it is inevitable only if you accept the premise that everyone has a right to the best health care that money can buy, including people that are in the country illegally and people that do have money but do not budget for insurance. if everyone who rode and ambulance had to pay even five dollars and everyone who checked in to the ER had to pay five dollars up front we would not need to ration. if market forces were allowed back into medicine we would not need to ration because people would choose. the same people who now budget for cell phones and cigarettes but not health insurance would not get the best medical care available anywhere but would go to the city hospital and get pretty good care. those with insurance would get the best care. i don't know why this is not fair. as it will be EVERYONE is going to be equally miserable and equally underserved, which seems to be the liberal answer to everything. why punish the responsible and decrease the quality across the board. why?

  3. ah, and one more thing liz, if i save my money and want to live to be 100 and can pay for my care who is anyone to deny me that? doesn't it scare you to death that this is exatly what is going to happen? logan's run stuff right under our noses.

  4. 9-11,
    Do you really shout "SET UP RSI!!!"???? no offense, but that's a little Gay..and thats comin from a guy who knows every line from "Top Gun" so I'm an authority. Kudos on the italics.. Don't give up so fast, as long as there are Goodfellas out makin a buck there'll be a need for a Doc who's handy with the suturin and doesn't bother with no stinkin Insurance cards or pre-authorizations... my Uncle Paulie can always use another good Soldier,

  5. Let me disagree with you for once here, 911.

    I don't believe nationalized healthcare(at least in the British sense of Doctors as employees) is coming for one simple reason, Lawyers.

    Trial lawyers, one of the key groups that fund the Democratic Party(them and teachers), just won't allow Doctors to be immune from their lawsuits. They don't want to give up one of their many cash cows.

    The more likely thing to happen is the government will expand schip, medicare, and medicaid to try to cover everyone while paying less and less each year. This, of course, causes a natural rationing of care due to the lower pay and finally(and almost immediately) giving rise to secondary private insurance. Thus we'll end up with public(mainly teaching) hospitals that accept government insurance and have very long queues and private hospitals(which will pretty much be like our current ones, just without the uninsured/government insured) where they only accept private insurance.

    But don't expect a Canadian one tiered system. Lawyers still want to sue doctors after all and you need private money going into healthcare for lawyers to do that.

  6. Roman,

    I never thought I would hold out hope on the account of trial lawyers.

    But thank you, you do make sense, I'm 22, have private insurance (not provided through work) and although I hope I don't ever need a brilliant medical intervention, if what you're saying works out, I'll stroll into a nice private hospital, gently place my insurance card on the table and say thank you, trial lawyers.

  7. If that's me they bring in, make sure to check my right front pocket. I'll have cash in there. Just between you and me.

  8. Why does this 80 yr old not have Medicare? Would it make a difference if they did?

    There are a lot of people out there who smoke, or drink excessively, or are way too fat, or abuse drugs. They will be transported under flashing lights to the nearest ER (ED) when these lifetime choices cause them to crash in the last months of their lives. This is a given.

    To claim that Obama will divert all of these people to the Happy Place to Die, as a direct result of changes to the way health care is paid for, just doesn't follow. But perhaps it should. Perhaps there should be an automatic permission given, when an unhelmeted motorcyclist leaves the top of his skull on the expressway, to harvest organs, too.

  9. Matt M,
    Yeah,Matt that Medicare's really great, gets you front of the line privleges and a happy ending in the Executive Lounge... you're right about those fat slobs who drink too much,smoke, and use Drugs, but leave Ted Kennedy out of this, OK??
    Where do you think they get 90% of the organs for transplants?? 20 Year Olds on Katanas. Funny how no one bitches about the billions spent on HIV meds for those other thoughtless unhelmeted bastards...


  10. matt, he did have medicare, that's why i said he didn't have insurance.

    any move away from personal choice of the means of one's ulitmate end-of life medical treatment is a step towards hell.

    interesting point about the lawyers. hope you are right, but right now they can't sue military or VA docs or docs that work for certain 'city hospitals' so i'm not sure you are right.

    matt, wish i could agree with you on the motorcyclists but i don't. i support every american's right to take risks with their own lives in the pursuit of chicks. it's what made us great.

  11. 911,

    Well, in those cases the Docs are employees of the government(or a government) hence the immunity. The trial lawyers will probably give everyone national health insurance without actually making physicians employees of any government entity. This will probably have the effect of private physicians dropping government insurance.

    Basically, I don't think most democratic members of congress are willing to piss off the trial lawyers by stealing one of their cash cows. Most need the money that lawyers funnel to them(not to mention that about a third of the members of congress are lawyers as well).

    So I'm confident that "private"(or as private as you can get now) medicine will survive due to the greed of trial lawyers. Remember, the democrats merely want the feather of bringing universal healthcare to the people. Doesn't matter to them if the people can actually get REAL healthcare, just as long as they have "access" to it. However, the democrats still need the money they get from trial lawyers to actually win elections therefore they'll never do anything to harm their lawyer friends.

  12. anon 1036,
    please don't get me wrong. i don't give a rats ass if the patient in front of me has money or not or has just smoked a fat rock or even killed someone, i do what i do. the point about money is that, and here's an idea that used to be accepted as gospel, because, well, it is... the most efficient and beneficial way to distribute resources including medical care is the free market. the end. if you are someone who has been educated in modern day america you probably missed this whole bit of truth but this can be easily remedied by reading thomas sowell's 'basic economics'... a few hundred pages, brilliant, edifying, and the guy's black so you will be doing your part for diversity too. i am not dogging you at all, i just don't want to come off as someone who, given the opportunity, would let someone die in front of me if they didn't have money. i'm talking about the whole enchilada, not the child of God in front of me.

  13. I can second 911 on Sowell's "Basic Economics", not so much because I've read that certain work of Sowell's(I havn't) but because I know Sowell is a good writer and knows his stuff.

    He's also probably the best conservative public intellectual currently alive as well(Milton Friedman without a doubt held that title before Sowell, but he died a few years back).

  14. I've just spent a week at my 87-year old grandfather's side, watching him cling to life beyond the point where "life" has any meaning.

    The doctors "saved his life," when by all accounts it should have ended, both to save him the continued suffering he faces and that his wife faces in caring for him.

    Taxpayers will foot the ENTIRE bill for his care. For the week+ that he was in the ICU and the weeks he is facing in transitional care with occupational and physical therapy, and all of his care afterwards. While his wife is tied to the slowly rotting, half-senile pre-corpse that used to be her husband.

    Seems to me that we're not doing ENOUGH rationing as it is. I'd sure as hell prefer that our government paid out the cash to give basic care to 1000 younger, healthier citizens than to keep the shell of one elderly man breathing past the point of having any quality of life.

    The system is fucked up, yes. But the idea that a future socialized care system will somehow give slightly less care than our current socialized care system seems to be less of a problem than you present it to be.

  15. Dear Annonymous,
    You'll save us all alot of money if you just shoot yourself in the Head, make that mouth, pointed up at 45 degree angle so you get the Brain Stem and don't end up in a PVS. Be sure and use a round with at least 1,5000 ft-lbs of energy at the muzzle, jacketed hollow point, so you don't endanger any healthy neighbors, and if you call 911 10 minutes or so ahead of time, they might still be able to use your heart and kidneys...

    Frank, M.D.

  16. I lurve all the hysteria. Nothing gets me hotter than a flappy-armed man in a white coat and stethoscope.

    I wish you did house calls.

  17. frank,
    thanks for the set up punch. perhaps it was the k.o.

    dear anonymous,
    let me point out a few things to you. first of all, i think it's about 50-50 that you are lying because it's very easy to cease and desist all heroic interventions at the end of life and if your grandfather or grandmother wanted the tubes and IV sticks to stop hospice would have been readily and easily available. so his doctors save his life because someone in the room, your grandfather, your grandmother, or you, did not have the nuts to say, 'that's enough', the taxpayer foots the bill, and you use this as an argument FOR rationing? FOR socialized medicine? incredible. you should try being a magician.

    but more worrisomely, you seem to be a real idiot, assuming, since you are young and healthy, that you are somehow more deserving of health care than your grandfather. what have you done to deserve the kind of care he got? and who are you to write off senior citizens with chronic illnesses as deserving anything less than the best we can.

    if it is true that his life has been extended beyond anyone's wishes (his especially) then you have a lawsuit! if his 'life was saved when it should have ended' and this was not your grandfather's wish then he is to blame for not making these wishes known to his physicians and putting them in writing.

    you would have been a great nazi or maoist. you think that you and your generation are special and deserving because you are young and educated beyond your IQ.

  18. Dear Anon,

    You call it hysteria, and then add that you wish we did house calls.

    You really should think before you post. What do you think led to the decrease and near extinction of the house call in modern American medicine?

    Though certainly multi-factorial, you can directly plot the decline in a linear fashion from 1965 (Medicare).

    At that time, many "flappy armed" men with stethoscopes spread the word that governmental intervention would forever change the landscape of American medicine. Looks like they were right.

    Maybe if people like you had heeded the warnings instead of ignoring it and labeling it "hysteria", the house call would still be a viable patient care option.

    In fact, many of the greatest problems (including the cost) in American medicine today are directly related to Government involvement. These subjects have been covered over and over on this blog (with numerous excellent references which I encourage you to read).

    Our contention has always been that LESS, not MORE government involvement is the only way to fix the problem.

  19. Hah!

    ...and oh dear.

    The reference to the house call was made in the most strictly non-clinical sense of the phrase.

  20. Hah, Hah!

    I was well aware of that.

    I still thought it was stupid, and that you should consider your comments before you post them.

  21. Can I proudly say that I've had the pleasure of a physician giving me a house call...

    ...but this was in England and was my grandmother's private doctor(one she paid herself). One of the best Doctors visits I've ever had. I for one wish they were still around here in the States.

  22. "Hah, Hah!

    I was well aware of that.

    I still thought it was stupid, and that you should consider your comments before you post them."

    But that would be against my FrankDrackman operandi.

  23. Woo hoo! Crappy primary care for essentially healthy people, and a total halt to advanced medical therapies and research for people with devastating illness! Who cares about those people, anyway, right? As long as Joe and Jane lazy 20something can get their NuvaRing and po Zithromax/Rocephin shot, so what if we deny a heart transplant to that 30 year old mother with peripartum cardiomyopathy? After all, it's all about the number of people you can say are "insured", not what the pinnacle of advanced care is and becomes, and sick people are expensive, dammit!

    I relish having to write a letter asking some GS-7 social science major if I can pretty please get some immunos on those challenging cases! And if the govt insurance sucks, well, I guess we can just stop accepting it...right?

  24. I love hearing all these liberal politicians spouting their "we need more money for preventive care" shit, "if we only had another 40 trillion gazillion dollars". Look, anyone with a TV, which is everyone, even the very poor in this country ( not to mention their cell phones and their 24 inch rims ) can pretty much figure the preventive stuff out.
    1. Don't stick a needle in your arm.
    2. Don't smoke.
    3. Don't drink to excess.
    4. Don't place an unsheathed penis into an anal cavity.
    5. Don't eat so much crappy food. Apples are CHEAP.
    6. Multivitamin once/day.
    7. Walk every day.
    8. Wear a seatbelt and put your little rug rats in a car seat.
    9. Take a concealed-carry course. ( Just for a little added security, makes me feel better anyway)

    There. Most everything else is up to God and tiny mutations in your DNA. Put your titties in an xray, hop on a treadmill, and have a hose and finger place up your butt and you should catch a good number of other diseases early. ( All those can be done for around $2000, about the price for 4 chrome rims and a case of Old English 88). Solved the problem without a Senate Committee of jack-asses.

  25. just a med-surg grunge nurse here but medicare has turned my floor into what looks like the color-coded terrorist alerts with yellow signs for falling, flamingo pink for skin alert and other assorted color alerts. The never event phenomenon has people running around like chicken little. Clipboard nurses multiplying like rabbits to make sure all those x's and o's are in the right place while the floor nurses are getting sent home because we're playing lean and mean. Medicare is like the goose that lays the golden eggs with all these ravenous cottage industries waiting to gobble them up....fancy beds and scales and bed and chair alarms that usually break as soon as we get them only to be replaced by the new round of carnivores selling their equally crappy equipment. A fecal management system costs 400 bucks!!!! It's probably got 2 bucks worth of materials in it. I could go on and on but don't want to bore anyone. Just thought you might to hear about some of the ways we're lighting the match to the tax dollar on the floor.

  26. Neuro PA

    Just an amen here to 911 sentiments. Our hospital had in one night 40% of the ICU beds filled with 9 illegal aliens without insurance. How many insured patients had to pay $10 for an aspirin to pay for that? Before I get the predictable smear of racist I should say that I volunteer at a free clinic 2 to 3 weekends a month where we see a ton of hispanic patients.

    Somebody in congress should read Adam Smith and at least compare it to all the John Maynard Keynes they have believed.

  27. erdoc85 and the cat are alive? I thought you guys kicked it months ago...

  28. midwest woman is dead on. People who think that govt granted universal insurance will "let us just see patients and not worry about bureaucracy" are forgetting what a bureaucratic nightmare that system is for docs, nurses, and hospitals. I assume they have some mentally retarded highschool dropout deciding what documentation is required for reimbursement, along with the idiotic "never events."

  29. Neuro PA:

    Not only will you be a "racist" for pointing out your observations. But those who don't want to acknowledge your observations will try to derail you with their most compelling argument....."you're wrong". Man they're some scary intellectuals!

    Amy, I'm not dead. Just on life support.


  30. Dear 911 Doc;

    I do absolutely agree that the overall problem is that there are so many who will not lift a finger to pay for their own care. The way this country is going, however.....more for those who don't work and/or don't save and/or don't accept responsibility and less for those who do. Unless things change rather quickly, I don't know that the tide can be stemmed.

    My favorite hospice patient was 93 years old and the first day I met him he said "why me?". I was a bit astonished. 93! But he had been in good health pretty much his whole life. To have pursued treatment would have turned his life from a well lived one to one of prolonged suffering, prolonged dying. This is what we do when we don't know when to say 'stop'. This is the other reason I fear rationing is coming.

    Another patient was a relatively young 68 years old and had many co-morbidities; hypertention, diabetes, anxiety disorder and a history of bipolar disorder. When she contracted cancer of course her MD recommended (or at least agreed to) chemotherapy followed by a bone marrow transplant. So, 'therapy' commenced. After several weeks in isolation (agony for someone riddled by anxiety) she died. A waste of resources and prolonged dying/suffering for this lady. Me, with 'only' my nursing education had known immediately that that lady would never make it out of the hospital alive. MD's MUST be able, and willing, to make better decisions about what care is appropriate for their patients.

    While an oncology nurse, I saw so many people suffer terribly up to the time of their deaths while undergoing desperate attempts to be 'cured' (a word that should never be uttered by an oncolgy MD....if I had a dollar for every time a patient said to me "but the doctor said he got it all"...!).

    I guess my point is, we need to make much better decisions about how to proceed with an individual's care....even including denying those with a poor prognosis expensive and prolonged treatments. We need to embrace (!) death and dying and learn to understand it's role in our lives.

    schrodinger's cat is absolutely correct. Now, how to enforce it?

    I suppose this is more a commercial for hospice than an argument for or against socialized/rationed health care. Thanks for letting me ramble....

    Liz, hospice RN

    PS: You're welcome! Thanks for the care that you give, also!

  31. liz,
    i and my colleagues will continue to fight the tide even if it has flowed over us.

    you remind me of the old joke about why morticians nail the coffin shut... it's to keep the Heme-Onc docs away.

    i must say that in my relatively short career that i have seen a huge shift from browbeating patients into futile care to recognizing futile care and i work in a small town.

    i will disagree with you on one point and it's probably semantics. 'we' don't need to make better decisions about patient's care, even at the end of life, we DO need to provide accurate information about futile care and accurate information about quality of life should aggressive treatment be chosen SO THAT the patient can make the right decision.

    as for me i hope to embrace death and dying when it is my turn, but in the meantime my job is not like yours in that many of my very sick patients WILL walk out of the hospital. that being said, if someone does not want to be intubated, poked, prodded, or shocked, and it is formalized so i wont get sued then i'm on board.


  32. The Dead Collector: Bring out yer dead.
    [a man puts a body on the cart]
    Large Man with Dead Body: Here's one.
    The Dead Collector: That'll be ninepence.
    The Dead Body That Claims It Isn't: I'm not dead.
    The Dead Collector: What?
    Large Man with Dead Body: Nothing. There's your ninepence.
    The Dead Body That Claims It Isn't: I'm not dead.
    The Dead Collector: 'Ere, he says he's not dead.
    Large Man with Dead Body: Yes he is.
    The Dead Body That Claims It Isn't: I'm not.
    The Dead Collector: He isn't.
    Large Man with Dead Body: Well, he will be soon, he's very ill.
    The Dead Body That Claims It Isn't: I'm getting better.
    Large Man with Dead Body: No you're not, you'll be stone dead in a moment.
    The Dead Collector: Well, I can't take him like that. It's against regulations.
    The Dead Body That Claims It Isn't: I don't want to go on the cart.
    Large Man with Dead Body: Oh, don't be such a baby.
    The Dead Collector: I can't take him.
    The Dead Body That Claims It Isn't: I feel fine.
    Large Man with Dead Body: Oh, do me a favor.
    The Dead Collector: I can't.
    Large Man with Dead Body: Well, can you hang around for a couple of minutes? He won't be long.
    The Dead Collector: I promised I'd be at the Robinsons'. They've lost nine today.
    Large Man with Dead Body: Well, when's your next round?
    The Dead Collector: Thursday.
    The Dead Body That Claims It Isn't: I think I'll go for a walk.
    Large Man with Dead Body: You're not fooling anyone, you know. Isn't there anything you could do?
    The Dead Body That Claims It Isn't: I feel happy. I feel happy.
    [the Dead Collector glances up and down the street furtively, then silences the Body with his a whack of his club]
    Large Man with Dead Body: Ah, thank you very much.
    The Dead Collector: Not at all. See you on Thursday.
    Large Man with Dead Body: Right.

  33. Ah, Amy.
    Once again, you steal my heart.
    I told my boys, when you find a girl who likes Monty Python, marry her.
    My first son misunderstood me and found a girl who looks and acts like Prince Herbert.
    There's still hope for the second......


  34. Well, I'd say better a girl who acts like Prince Herbert than a girl who acts like Prince Humperdink...

  35. I love it when Amy talks dirty...