"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.”