Can’t Touch This…

Actual Patient Conversation:

“Man, that Dilaudid didn’t even touch my pain.”

“Uh, Okay.  Your CT was negative so you’re fine to go home.  I’ll ask your nurse to come discharge you.  Come back if you get light headed or start to vomit but otherwise, just take Motrin for your headache and you should be fine.”

“Can you give me a prescription for Vicodins.”

“No.  If the Dilaudid didn’t even touch your pain then this must be the kind of pain that doesn’t respond to narcotics and a couple of Vicodin would be useless…I mean Dilaudid is one of the most powerful narcotics we have and it didn’t do a thing.  Stick to the Motrin.

“How about some Demerol.”


Another Actual Patient Conversation:

“Vicodin doesn’t even touch  my pain.”

“I’m sorry.  That’s all I’m going to prescribe.”

“Can you give me a ‘scrip for my Methadone?”


“Well, how ’bout a shot of somethin’ before I go?”


“Aw, man.  Fuck you.  I want to speak to the manager.”

“Sir, this is not the International House of Pancakes.”

Darn You, Manny Rivers!

More than the usual number of incredibly sick, incredibly old, incredibly senile, incredibly decrepit, and incredibly still alive patients today.  There must have been a convention because for the first half of my shift the average age of my patients was around 86 and between the eight of them they had 112 distinct medical problems, 38 doctors, 26 artificial joints, six pacemakers, 18 coronary artery stents, and, as three of them had ileostomies, only five functioning rectums.  The presenting complaint for seven was some variation of decreased mental status and one had stroke-like symptoms consisting of a slight facial droop although it was later confirmed that this was an old finding, first observed during the Clinton Administration.

A couple of the families were reasonable and declined any further medical care except hospice but the rest wanted “everything done” and committed us to expensive and extremely futile workups and admissions; three of the patients in particular went to the Intensive Care Unit where they are even now laying insensate and demented in their cocoon of medical equipment, either spending their grandchildren’s money or screwing our Chinese and Arab creditors depending on how likely you think it is that we can ever pay back all of the pretend money we are printing to pay for this insanity.

A day in the ICU costs Medicare approximately $4000 once all the costs are factored in.   A week or two and we’re talking serious money, much of it totally wasted in the sense that many of the patients on whom it is spent have almost no chance of ever leaving the ICU and, if they do, will be essentially vegetative until they finally die.   ICU charges under Medicare are in the Neighborhood of 40 billion dollars per year and rising.  Medicare itself spends around 300 billion per year, almost half of that for hospitalizations of all kinds.

I blame Manny Rivers and his surviving sepsis campaign.  Sepsis is an infection that leads to shock  and, until very recently, was largely fatal especially in the elderly who regularly succumbed to septic shock from bad urinary tract infections or pneumonia (so much so that pneumonia was once know as the “Old Man’s Friend” as it regularly relieved the suffering of the senile and bed-bound).  Dr. River’s great gift to medicine was what now seems like a simple method to aggressively treat sepsis that has significantly decreased mortality, extending the lives of many patients who would have otherwise been almost untreatable.  The foundation of his method is a five or six liters of inexpensive Normal Saline and, stripping away all of the fancy equipment and the flashing lights, that’s pretty much it.

While generally a good thing, especially as I have seen many elderly septic patients returned to the full enjoyment of their glorious old age, just because we can do something doesn’t mean we need to do it all the time.  I don’t always know when care is futile and I am not so arrogant to think I can judge the worth of anybody’s quality of life but there are some cases that are so obviously futile, that for example of a nonagenarian  whose every bodily function comes through and out of a tube and who hasn’t so much as moved purposely in a couple of years, that what we do is not only insanity from an economic point of view but also from a human decency one as well.  We do what the families want, however, rational or not.  First because we are conditioned to never give up.  Second because we have surrendered a great deal of medical decision making to the patients and their families even if they are not qualified to make the decisions and, more importantly, as they are not paying for any of their treatment have no skin in the game.  Third because we are afraid of the legal implications of withdrawing care, so much so that hospitals have ethics committees for the rare occasion when enough is enough whose principle purpose is to spread the liability.

And fourth, as there is a lot of money changing hands there is little incentive for hospitals not to aggressively treat everybody who comes in.  It’s either that or have ICU beds sitting idle generating no revenue whatsoever.

But the madness needs to stop.  What we need is a Futility Scoring System, perhaps a simple sum of points given for co-morbid conditions and age above which only comfort care or home hospice will be reimbursed by Medicare.   And it needs to become the standard of care.

Now if we could only find someone to put the bell on that damn cat.

13 thoughts on “Can’t Touch This…

  1. If you talk to your patients like that, are you ever afraid that they might sue you?

    (What did I say to the patient that was either objectionable or actionable? You can’t just sue a doctor because you didn’t get what you wanted? -PB)

  2. Panda, I’ve seen several things throughout the ED blogosphere and laughed at a couple. One doc was giving “Tylenol Number Three” (Three 325 mg APAP tablets). Here sir is your Tylenol Number Three, be sure to take all three!!

    Elsewhere, I’ve heard somebody said they prescribed Dolobid. However, they pronounced it duh-LAW-bid——only phoenetically related to it’s hydromorphone cousin of proprietary nomenclature

    Unfortunately, I don’t know who to credit for these gems, but nonetheless funny

  3. Another powerful post, Panda (sorry for the alliteration; I just can’t help myself sometimes). I have to say that your December 2007 post on “Putting Granny down” was one of the most disturbing things I’ve read anywhere, mostly because at the time I was going through some of those very issues with my ailing mother, who died three days after Christmas 2007. She was far from being one of those unaware, semi-comatose folks who hadn’t spoken since the Clinton administration; she was more than aware that her body was slowly and then more rapidly failing her in appalling ways. It was painful for us to witness her deterioration, and there was little we could do about it except keep her as comfortable as possible, love her, and get her medical treatment when she had a life-threatening crisis.

    We didn’t take heroic measures to keep her alive, but I think that in a desperate effort to keep her with us there may have been one too many Emergency Department visits towards the end, resulting not only in prolonged suffering for her but also in medical bills that we may never be able to pay. (Medicare doesn’t cover everything.) I feel just terrible about that, not only for her sake, but for the sake of the medical service providers who didn’t get paid.

    I know that for many reasons it is never easy for the attending physician to inform the family when a patient’s situation is hopeless, and I detected true concern in the eyes of the doctor who attended my mom as he began, hesitantly, “She really isn’t doing very well at all…” He went on to explain why the only things keeping her alive (if you can call it “alive”) at that moment were the machines to which she was hooked up. He seemed genuinely relieved when we made the decision not to prolong her misery.

    As difficult as it may be for some people to read, much less to accept, I think you need to continue to write about the issues involving futile care. Aside from the economic considerations, which of course are significant, this is an issue of compassion. There has to be a middle ground between longevity for its own sake and quality of life.

  4. Futility Scale?

    What an absolutely great idea! If we can stage Alzheimers by adding up observations, we should be able to do the same for those who are actively being called toward the light.

    As a hospice/home care nurse, I really think half the folks in any given hospital belong with us anyway, and not to boost our census and billing. Why is it so hard to die comfortably at home these days??

  5. I just wanted to know the extent that I can smart off to the patients I see in clinic that deserve it. I’d like to make comments like that but maybe I dont have the balls for it?

    (I do not “smart off” to patients. They are adults. I am an adult. We interact on the basis of mutual respect and in no wise am I required to kiss their ass and applaud all of their actions. The patient said “Fuck You” to me and made a silly request. I made a sardonic and appropriate reply, neither cringingly condescending nor overtly aggressive in which was contained the essence of his major malfunction in life, namely his conviction that the entire world of nurses, doctors, and other functionaries of The Man exist to serve his whims and his craving for a quick hit of his favorite drug. -PB)

  6. Like the Futility Scale. Just wish my state would change the statutory living will to amend the option to have everything/anything done regardless of cost and prospective payment. Somehow, I find that appalling.

  7. I’m not sure where these comments of PB mouthing off to the patients are coming from. If some drug seekers came to me and started begging for Vicodin, it would start to irk me as well. I think he handled it well and the IHOP comment is absolutely hilarious while not being over the line.

  8. panda,
    it’s great to see you blogging again. been keeping up w/ your posts on sdn, too. sorry to hear about things. still i had a question. did you say your salary was starting in the 300K range? i couldnt find the post on sdn

  9. I think you’ll be in the ideal position as the ER doc to plant the idea in patients’ families’ heads that maybe this one is the big one. I’m sure a lot of families get the idea down in the ER that their dad will get admitted, treated and released, because that’s what the hospital does, right?

    Just a few comments – maybe to the tune of “Elmer is gravely ill” or “I would try to get all your loved ones to see Hilda….”

  10. ” . . . although it was later confirmed that this was an old finding, first observed during the Clinton Administration.”

    Another spectacular line.

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