Overheaded to Bedside at 1900

Last week I did my first overnight on-call as a second-year resident.  I hoped that it would be calm and that nobody would call me.  When you’re an intern, sleep is impossible because the pager goes off every ten minutes, but when you’re a resident, sometimes you can sleep, precisely because the intern’s pager goes off every ten minutes - so long as you don't get called to help admit patients from the emergency room, and there are no emergencies on the wards, and the intern doesn't need help.  I was working through some dictation in the now-empty Adult Medicine Clinic around 7:30 when I heard the overhead system paging the "medicine resident on call to SDU" and was somewhat alarmed to remember that I am now the one who needed to start pelting down the hall when this happens.

I wrote a note after the ensuing situation stabilized, to document everything and for the primary team to refer to in the morning.  I have reprinted below the section which describes what happened, anonymized with some minor alterations for clarity (e.g. I have expanded many abbreviations).

Medicine R2 Backup Note

Overheaded to bedside at 1900.  Arrived to find Mr. C moaning and diaphoretic, with a systolic blood pressure in the 60s.  He complained of feeling faint.  BP confirmed by manual measurement.  Stat EKG showed sinus rhythm with junctional complexes and prolonged QT interval.  Ordered a 1 liter bolus and started dopamine drip.  BPsys continued to fall; external jugular line, which was patient's only vascular access, was displaced during manipulation and code blue was called.  ED team arrived, code run by ED Resident.  Brief period of pulseless electrical activity on monitor during which chest compressions where initiated, with spontaneous reversion to normal sinus rhythm – no antiarrhythmics given.  Oral airway was placed and bilateral femoral lines attempted, successful on the left.  Pt. began resisting strenuously and screaming, although BPsys remained below ninety.  L. femoral line was placed and bolus resumed.  Dopamine max dose reached in SDU.  BPsys stabilized in 60s-70s on dopamine drip.  Pt. continued to complain of dizziness and headache.  I supervised Mr. C’s transfer to ICU and started norepinephrine drip.  BP rose to BPsys 90, and fluids were stopped.  At the time of writing he is stable and says he feels much better.  Headache and dizziness have resolved.

As I wrote this, I was struck by the style of medical documentation I was writing in, (which I've been trained to write in and which is completely conventional).  The curt, assured tone is so at odds with the reality of these situations that it still feels somewhat ridiculous to assume.  This kind of documentation has been developed most clearly to meet one basic requirement beyond the simple communication of medical information, which is that it be medico-legally blameless - something must be written, because sub-standard documentation is a liability in and of itself, but it must not be something like, “shucks, I didn’t really know what the hell to do, so I gave him another shot of adrenaline."  But the process of evolution isn’t efficient or teleological; there are other elements to this style that are reminders of its contingent origin in a professional context heavily informed by science and Enlightenment rationalism generally.

For instance, objectivity is a basic tenet of this style.  The rejection of all subjective properties as fit subjects of documentation has evolved from an articulated philosophical principle into a subconscious aesthetic.  I work with people who routinely write things like "ambulate" instead of "walk," and "lower extremity," instead of "leg."  These are arbitrary substitutions which add nothing to their description except an aptmosphere of Latinate scientific legitimacy – but people adopt them compulsively, apparently because Anglo-Saxon words are somehow considered to be more emotional than Latin ones.  Like every aesthetic, this one has its connoisseurs and virtuosos.  I actually know someone who described an interaction which ended with the patient weeping in front of him with the sentence "left patient lacrimating with tragic countenance."

Another major commitment of the style is the exclusion of uncertainty.  Details which don't fit the overall picture are rarely included - moments of enigma and confusion are elided insofar as this has been rendered possible by subsequent events, collapsed into the test results they generated the impetus for obtaining, without ever being mentioned.    (This stands in stark contrast to the way doctors actually talk to each other, which often consists mainly of equivocation – more on that in the future.)

Finally, the overwhelming passivity one adopts when writing this was is striking.  "I" never start the dopamine drip - the dopamine drip always "was started."  Operative reports are particularly dense examples of this, most of which do not have a single first person pronoun in them, despite being eyewitness accounts of procedures performed by the narrator.  Instead, they are so detached that they seem to describe a magical anatomy executed by an invisible deity.  One imagines muscles dividing themselves, retracting themselves, organs revealing themselves and biopsying themselves.  A representative sample: “Hemostasis was obtained with a bipolar cautery. A thin strip of orbicularis oculi muscle was excised in order to expose the orbital septum on the right. The defect in the orbital septum was identified, and herniated orbital fat was exposed. The abnormally protruding positions in the medial pocket were carefully excised and the stalk meticulously cauterized with the bipolar cautery unit." (As an aside, I worried for a moment about whether and how to cite the source I got this from before I realized that the whole point of the style it’s written in is to be anonymous and reproducible, making any claims on such texts as intellectual property totally meaningless.)

Clearly, you can make arguments that these kind of things have a necessary rationale - say, concision to save time, or the objective conveyance of reproducible information as in "other” branches of science, and there must be some truth to these arguments.  But it's also true that these ways of writing and documenting (which are therefore also ways of structuring experience and reflecting) have aesthetic and conceptual tendencies which cast their writers in certain roles and which aren't simply about some commonsense efficiency but rather the result of a long and largely unconscious historical evolution.

I think we should pay attention to these tendencies, because, as I just said, in addition to simply documenting and communicating information writing structures experience and stimulates reflection.  The second part of the note I wrote is a good example of how this can work for one and one’s patient.  It's quite boring so I won't reproduce it here, but I took the opportunity after everything calmed down to write a systematic differential diagnosis which helped me think about the case as I went and arrive at an understanding of exactly what had happened in physiological terms, which then enabled me to confidently plan the management of the case for the rest of the night. 

I think the first part of my note is a good example of how the conventions I've been talking about can work against one, since, while they may placate lawyers, they exclude certain kinds of reflection.  Isolating and qualifying things like the style of medical documentation is important, because it allows us to see what exactly it is that the ways we’re asked to think exclude – in this case, the note provides an opportunity for extended reflection dedicated to imposing coherency on what was actually a fairly incoherent situation, and more importantly of making diagnoses and corrolary plans.  It does not provide any time to, say, think about both yourself and the patient as a subjective entitie characterized by emotional states which are powerful, difficult to control, and highly relevant to the interaction; it does not provide any means of self-criticism, of identifying weaknesses in one’s response to the situation and figuring out how to address them next time; it does not create a space to reflect on elements of the situation which remain ambiguous.

My point is not that it should.  Aside from rare flashes of intriguing material, it would probably be extremely obnoxious and a waste of everybody’s time if the medical record was full of this sort of thing.  My point is that things you do often and unconsciously shape you.  I can tell from some of my older colleagues that if you don’t use your capacity for other modes of thought than that implicit in the style of my note, you definitely lose them.

"Can She Go?"

I stopped by the ICU today to steal the only reliable opthalmoscope handle in the hospital and to check on Ms. S.  Ms. S. was my patient for the entire month that I worked in the ICU, and she is still there.  She is thirty years old, and she has a terrible disease called scleroderma, which is characterized most obviously by a progressive thickening and tightening of the skin.  Hers has a dull shine to it and has been getting gradually smaller over the last several years.  Her mouth is constricted as though it were being cinched closed with a drawstring; her fingers are curled into her palm to and cannot be fully extended; her nose is being drawn down towards her mouth. 

Ms. S. had advanced scleroderma lung disease to begin with.  She came to the hospital originally with flu-like symptoms, and her condition deteriorated rapidly.  She had to be intubated and attached to a ventilator.  She developed a loathsome condition called Acute Respiratory Distress Syndrome, which can be caused by almost any grievous insult to physiology (e.g. trauma, septic shock, pancreatitis, etc) and basically consists of generalized inflammation of the thin membranes in the lung across which oxygen absorption and carbon dioxide excretion are supposed to happen.  It ultimately turned out that in her case the precipitating even had been the dreaded H1N1 “swine” influenza. 

When we first met, she was intubated and lightly sedated.  I could wake her up, with some effort, and she could respond to my questions with nods and shakes of her head.  She was dependent on the ventilator to breathe, but we hoped to “wean” her off.  Unfortunately, this wasn’t how things went. She couldn’t tolerate any reduction in her level of breathing support, and she became increasingly uncomfortable and began having epic coughing fits during which her blood oxygen fell to dangerously low levels. The only thing we tried which worked in supressing these fits was heavier sedation, so for the last three weeks I took care of her she was basically comatose.  I saw her every morning, and almost every morning I took an arterial blood sample from an artery in her groin, which was the only one we could reliable find through her thickened skin.  Every day on ward rounds the attending physician and I tried to think of something we were failing to do that could improve her lung function.  We tried a lot of things, none of which worked.

This long pre-amble is by way of explaining that I was fairly interested in what was going to happen to her – you can’t see somebody who’s desperately ill and stab them with needles on a daily basis without developing some investment in their course.  When I walked into the room, I thought for a moment some kind of miracle had taken place, because she no longer had an endotracheal tube tied into her mouth and she appeared to be fully conscious.  Then I realized that the ICU attending physician had finally given up and gotten the surgeons to perform a permanent tracheostomy on her, so she could continue to be mechanically ventilated without requiring constant sedation to help her tolerate the tube in her throat.  The ventilator settings were exactly where I’d left them.

On my way out, I saw the intern who took over her care from me when I left the ICU. 

“Hey,” I said, “I saw Ms. S.  I guess things haven’t changed that much…”

“Yeah,” she said with a look of mock anger, “Thanks for the rock.  Jesus, she is never going to leave the unit.”

A “rock,” you’ve probably guessed, is a pejorative term applied to people who require extended hospital stays.  This strikes me as an odd appelation for a doctor to apply to their patient.  You really have to hear somebody say it to appreciate the implication of truculent intransigence it carries.  When I’ve handed over patients who were obviously going to require prolonged care, I’ve heard my replacement say dismissively “Oh, so she’s a rock,” and likewise when colleagues have signed their patients over to me they often begin by literally apologizing for their “rocks,” as though to suggest that they had done their bit, but the inconsiderate clod in bed 15 was refusing to hold up their end of the deal.  Aside from being offensive and dehumanizing, this strikes me as a pretty peculiar attitude.  After all, the people who talk about their patients like this have spent at least nine years in higher education, have worked remarkably hard both physically and intellectually, and have usually gone deep into debt in order to be exactly where they are.  So it seems strange that they should be trying to blame that situation on the ostended caprice of people who, by definition, are in a state of total dependence and to whom they have committed their professional lives, both tacitly by their conduct conduct and explicitly by doing that whole Hippocratic oath thingy.  

But the “rock” discourse isn’t anomalous; it’s part of a larger mania for discharge which often assumes a character that can only be described as surreal.  Some people are so consumed by it that they seem to forget everything they ever learned in school and every particular of the present situation in their mad yearning to get patients out of the hospital.  (As an aside, the language which is deployed around this is really singular – for instance, people often refer to discharge as “sending,” i.e., “I think we can send him today.”  Where, exactly, we are going to “send him” is seldom specified, and sometimes it is so vague that the goal sounds almost astral.)  For instance, when I was an intern on the wards about six months ago I had a patient who was admitted from the emergency room with a formidable list of active problems: she had uncontrolled diabetes, which had left her, at the age of twenty-six, legally blind.  She had no health insurance, and our county aid program does not pay for any of the prosthetic devices that allow blind people to accurately dose insulin, so her prospects or achieving adequate control at home were basically nil since her dosing strategy was to draw up, guided only by touch, “about as much” insulin as she thought she “probably” needed.  She had gastroparesis, a form of diabetic nerve damage which results in paralysis of the stomach, and the only thing she could keep down was high-calorie liquid nutrition.  She was dependent on narcotics, which had been liberally prescribed to her at another hospital when she had suffered a thigh muscle infarction the previous year (watchers of the show House will appreciate that this is a stunningly painful condition).  She had an extremely intimate and fantastically agonizing soft tissue infection.  She had been kicked out of her parents home, where she had been living, and was sleeping in unlocked cars, and, as though the ante needed to be raised any higher, she had a foot ulcer which had eroded all the way through her skin and muscle and set up a chronic bone infection. 

Even if the bone infection had been her only problem, she would have required weeks of intravenous antibiotic therapy, which given her catastrophic social situation could obviously only be reliably administered on an inpatient basis.  And yet, every single morning for three weeks, the resident on my team would say, “Hey man, that girl in twenty-one – can she go yet?”  And every single morning I would say, “Well, let me think about it – if her labial cellulitis resolved overnight, and you somehow got her one of those clicking insulin pens, and everybody else on the Center for the Blind’s waiting list died, and her stomach started working, and social work found her a place to stay, and we magically gave her four weeks of IV antibiotics in the last twenty-four hours, then, um, yeah – yeah, I guess she can go.”

What’s so bizarre about this compulsive fixation on discharge is that it has no detectable rationale.  From the point of view of the county hospital’s bottom line, of course, it’s clearly imperative to achieve the highest patient turnover possible, because our payors (mainly federal, state, and local charitable insurance programs) pay the most for admission and initial workup.  The longer someone stays in the hospital subsequently the more money the hospital loses.  But the housestaff don’t care about that.  We’re salaried, and there are no performance incentives.  We gain nothing from saving the hospital money, nor do we receive any pressure from our superiors or the hospital administration to incur fewer costs.  The fear of litigation, (even in our hospital, which primarily serves people who if they had the money to hire a lawyer would probably use it to buy health insurance,) is so pervasive that most patients are subjected to more tests and treatments than are medically indicated.  It’s called “treating the lawyers.”   In fact, the only incentive we do have relative to discharge is the “bounce back” system, under which patients who come back to the emergency room within a month of discharge are automatically “bounced back” to the resident who discharged them.  This system which was established to deter premature discharges, and it doesn’t even work that well – bounce backs are actually quite frequent.

Even if the bounce back system didn’t exist, even if your only abiding motivation was to spend less time at work, it still wouldn’t make sense to rush sick people out of the hospital, because the number of patients you get depends on the number of patients you already have.  On the wards, for instance, no intern is supposed to be taking care of more than ten people at one time.  The worst thing that can happen to an intern, then, is to have ten new patients who are all sick and require constant attention – that’s when you end up coming in at five and leaving at ten.  The converse situation, where you have ten “rocks” who are stable and simply undergoing a predictable plan of treatment, is actually quite manageable.

So where does this lust for precipitous discharge come from?  A possible answer is suggested by the experience of friends of mine from medical school who are working in England.  I talked to one of them recently, and he had exactly the opposite complaint..  On his account, (and this is consistent with my experience in medical school) patients on English wards who have nowhere to go and some persistent condition that makes discharge tricky simply get stuck in hospital limbo and remain there for far too long. 

What’s interesting is that again, this only really makes sense from the point of view of macroscopic economic relationships.  I don’t think that English house officers have any more incentives to discharge people according to any particular time frame than American junior doctors, (I invite corrections from readers here).  However, the English health care system, unlike the American, is based on a robust primary care infrastructure which is funded by taxation.  From the point of view of the National Health Service, the British taxpayer, and….ah…the patient, it is ideal to avoid needless re-admissions to the hospital by insuring that patients are actually, definitely well when they are discharged.  Because all medical and social services are publically funded, there is nowhere to pass the buck, and an approximation (which, lest I sound to Panglossian I should emphasize is still somewhat uncomfortable) is reached between economy and patient welfare. 

What this suggests to me is that the influence of economic ideology on patient care is actually much more pervasive and, in the context I work in, pernicious than you might initially expect.  It seems that junior doctors, the footsoldiers of any healthcare system, will obsessively instantiate the values of the system they work in regardless of whether those values serve their interests.  My successor in the ICU isn’t complaining about Ms. S. because her situation actually imposes some kind of preventable hardship on her – clearly Ms. S.’s situation is urgent and necessary (this is, after all, the intensive care unit) and discharging her from the ICU will not benefit my colleague in any conceivable way  (she’ll just be assigned to some other patient who is acutely unstable and will require her to stay in the unit until seven, unlike Ms. S. who will allow her to leave at five).  She is complaining because Ms. S.’s chronic need offends an economic sensibility which has been inculcated in her through a process of slow diffusion both vertically, from the hospital administration down through her attending physican and the resident supervising the team, and horizontally from the culture she was educated and lives in, which construes patients as value-generating commodities with a brief shelf-life, rather than people who need help.  Neither inculcation is explicit – both are transacted, not through direct injunctions or incentive systems, but through a much more diffuse and subtle conditioning that’s disseminated through things like the language which is used to describe patients and their condition, general conceptions of the role of the acute hospital in medical care, and other fuzzy background notions which she has picked up by osmosis throughout her acculturation into the world of hospital medicine. 

This does not, however, make things any better for Ms. S, or other “rocks.”