Fast Freddie Johnson and the Man

The patient, a young black man, eyed me suspiciously. Apart from telling me that his name was Kareem, he had said very little during the initial assessment in the trauma bay and had made it to the CT scanner and back without saying more than ten words, total, to anybody. His GCS was 15 and he was hemodynamically stable so this was initially attributed to pain and fear. Other than the obviously fractured tibia, he was uninjured but as the pain medication kicked in and things settled down he still seemed reluctant to give us any information.

A group of his friends were in the hallway outside the trauma bay and they, too, were noncommittal even in regard to his last name. They eyed the two police officers from whom their friend had been fleeing before he smashed his stolen car into a tree and elected to plead the fifth in regard to their alleged friend.

“Come on,” said one of the cops, “You hang out with this guy and you don’t even know his last name?”

Shrugs all around. They had the police in check.

“Kareem,” I said, “I’m Doctor Bear, one of the residents on the trauma service. We’re going to get the orthopedic surgeons to look at you and I imagine they’ll be taking you to the operating room to fix your fracture.

“Kareem?” said the patient’s mother who had pushed her way into the trauma bay, “His name ain’t Kareem, it’s Freddie, Freddie Johnson …Baby, why you be tellin’ them yo’ name is Kareem?”

Mr. Johnson, demoted and revealed, shot his mother an angry look and I fully expected her to deny knowing her son.

The police left after we assured them that Mr. Johnson wouldn’t be going anywhere for awhile which was probably a mistake as only one day after an ORIF (Open Reduction, Internal Fixation) of his tibia, the taciturn Mr. Johnson limped out of the hospital on his crutches and we never saw him again. I guess we underestimated his desire to evade the law. Although we never really had a conversation and he glowered at me whenever I went into his room, I can’t find it in my heart to dislike Mr. Johnson. If you have to leave Against Medical Advice (AMA) this is the best way to do it, avoiding as it does the usual song and dance, the cajoling and stroking, that these things usually entail. I have often found myself earnestly trying to persuade a recalcitrant and unappreciative patient to stay when my heart yearns to say, “Hey, if you want to leave before I can arrange to have home IV antibiotics then don’t let the door give you a staph infection as it hits you on your ass on the way out.”

Of course you can’t really say something like that.

Residency and Call Revisited.

I despise call. And I don’t care to justify my dislike for it by claiming that patient care suffers if the residents are tired. I don’t even know if I really buy into the notion that tired residents make a lot of mistakes, and frankly, I don’t care. It certainly seems like a difficult hypothesis to test and I would hate to have my sleep dictated by the results of some pointy-headed geek’s study.

No, I dislike call for the more visceral but just as legitimate reason that it is inhumane to deprive a person of sleep for anything short of combat operations or genuine medical emergencies. The problem is that everything nowadays is an emergency, even things that aren’t.

“Call” is a misnomer by the way. It’s not “call,” it’s “work.” Attendings have call. They get to go about their business until called in for an actual emergency. Otherwise they take a phone report from the resident on call and say, “Okay, admit the patient and I’ll see him in the morning.” Residents on call generally work nonstop from the early evening until they are allowed to go home the next day. If it’s not an admission in the Emergency Department it’s an issue regarding one of the many patients they are cross-covering.

There was a time, many years ago, when the whole crazy system began when resident call did not mean a sleepless night every third or fourth day. Because people routinely died from the first major illness they acquired instead of collecting them over the years and living longer thanks to medical advances, hospitals were a lot slower-paced then they are today with a more stable census for a service (as hospital stays used to stretch for weeks for things that are treated as an outpatient today) and fewer acute issues that needed to be managed. As a result, the house staff in the fifties may have stayed overnight in the hospital often but I guarantee they slept a lot more than we do today.

But, as I said, today everything is an Emergency and has to be done right away. Not only are we dealing with an older and sicker population but expectations of the public are a lot higher than they used to be. Fifty years ago it was recognized that some diseases were death sentences and the priest and the undertaker were more likely to be called than the doctor. Today, we never say die and we routinely admit, treat, and discharge people who fifty years ago could not possibly have lived long enough to acquire so many comorbid conditions. The combination, for example, of congestive heart failure, diabetes, emphysema, chronic renal failure, morbid obesity, and ischemic heart disease (any one of which was fatal a generation ago) is so common that I’m thinking of having a stamp made so I don’t have to keep writing it on the chart.

So there is very little down-time on a typical medicine or surgery service and you can count on a steady stream of admissions from the Emergency Department to keep you occupied through the night. The Emergency Department, for it’s part, is turning into a miniature and almost self-contained hospital complete with a census of admitted patients who linger in the department waiting for a bed.

What to do about it? Who knows. I only mention it because, with the exception of one month next year, this month is officially my last call month in my medical career. Nothing but shift work from here on out. Emergency Medicine, Baby!

No point, just wanted to gloat.

Letter to A Patient’s Husband
(With a nod to Scalpelorsword for the idea-PB)

Dear Mr. Jones,

I know you accused me of not caring and, on the surface, it may appear that way but I assure you the reality is more complex than that. I know your wife is morbidly obese. I know she suffers from a host of serious and eventually lethal medical conditions. I realize she was in a car accident last week but other than a few bruises, she is all right and while I can understand your reluctance to take her home, you must because she can’t stay here.

Yes, she is a big woman. In fact, she could barely fit into the CT scanner. Yes, she has trouble walking. I have had physical therapy working with here and they inform me that they have done all that they can do. I also am well aware that he has trouble breathing. This is a combination of her emphysema, her current smoking habit, and obstructive sleep apnea from her obesity. I also realize that she seems tired but as you probably noticed, she’s not getting a lot of sleep at night, particularly because she refuses to wear her CPAP mask.

Yes, I understand it’s uncomfortable. I’d hate to have to wear it myself but it’s all I’ve got in my bag of tricks.

I am sorry. We can’t keep her. She came to us in poor health after an automobile accident and she’s going to leave in the same condition that we got her because there is nothing more that we can do about her chronic medical conditions. We took great pains to rule out any occult injuries to her brain and spinal cord and she has been in the hospital on our service many, many days longer than we typically keep uninjured trauma patients, many of who we discharge from the Emergency Department after a few hours of observation.

I can understand your reluctance to take her home. I believe you when you tell me that all she does is sit on the coach and watch TV except when she struggles out of it to use the bathroom. I wish that we could send her to a skilled nursing facility but as she has no insurance and you can’t afford it, this is not an option. She may or may not qualify for Medicaid but we can’t keep her here waiting for the decision. You will just have to take her home.

How will you get her up the steps? You have two sons. I saw them here yesterday. They may live a couple of hours away but they’re just going to have to drive back to town and help their mother. She is your responsibility and theirs. That’s why they call it a family. In fact, the stability of our world depends on families acting as self-supporting units. Break the bond of family and you have either a decaying European-style welfare society dying a selfish and lingering death or a catastrophe like the former Soviet Union which proved that if everybody is responsible for everyone else, no one is.

I’m sorry to place the whole burden of Western civilization on your shoulders, what with you living in a trailer with nothing but basic cable, but there it is. She is your burden. We need this bed for the never ending backlog of patients, some even sicker than your wife, many of whom are sitting in hall beds in the Emergency Department as we speak.

So you see, it’s not that I don’t care, it’s that I can’t care. I can’t take her home with me and assign my wife as her nurse. We can’t keep her in a scarce hospital bed for the rest of her life with her own private nurses and therapists to assist her. Despite what you may have heard, we are not magicians and I we cannot cure what afflicts your wife. I’m not even sure that we could help her if she wanted our help which she apparently does not. I can’t, for example, hold the CPAP mask on her face all night against her will or force her to take insulin shots. She could have me arrested for assault. She’s an adult. We all lay in the beds we make. We’re not doing a thing for her but catering to her whims, something you might want to stop doing by the way.

She can get up if motivated. I have seen her, just this morning, heave out of her bed and transfer to the bedside commode. I suggest if she asks you for some food you tell her to get it herself.

You asked if I am sending her home to die. Of course not. But she is going to die. I’d say her chances of being alive five years from now are zero as she is a setup for all kinds of medical badness. But, like I said, we can’t keep her here for the next year or two hoping to preempt the next medical crisis. Call the ambulance if there is any sudden change in her condition.

You were right about one thing. In the end, hiring a nurse to help you at home would be a lot cheaper than the inevitable hospital costs your wife will incur over the next five years as her health continues to deteriorate and fruitless regular hospital admissions turn into fruitless and spectacularly expensive ICU admissions. But I’m just a resident. I don’t make public policy. Even if I did, while your idea makes sense economically, I’m not sure I’d want to structure society to completely remove the burden of individual responsibility.

Good Luck. I wish I could do more but I can’t.

Sincerely,

Dr. Bear