By Steven Kron, MD
The shaking chills rattled me out of a deep sleep. If only I could raise the temperature in my spaceship. My eyes opened—it was 2 a.m., and I was home in bed, not on a medical mission to Alpha Centauri. I pulled the covers higher, to no avail. By morning I was achy, weak and febrile, and spent the next 24 hours in bed barely able to eat or drink. The next day, my right leg was red and swollen and my doctor, who is almost always available, was out of town, so it was off to the emergency room. It was my birthday and I was as sick as I have ever felt.
As she took my vital signs, the efficient triage nurse got my basic information and chatted. “But you must have forgotten to list your β-blocker. Your blood pressure is 110/60 and pulse 62,” she said. I proudly explained that those numbers were typical for me. I was as healthy as a horse and my only medication is a baby aspirin.
I heard the same comments, more or less, from the emergency physician and nurses as they asculted, thumped, prodded, drew blood and placed an IV catheter. “And,” each said, “you look great—15 years younger.” Despite feeling very ill, I sucked it up. Looking back, I don’t think I made it clear enough that I felt lousy and had taken little by mouth in more than a day.
It took a few hours to get admitted to the best room in the house: private, top floor, corner with views of the park. My afternoon nurse and technician introduced themselves, hooked up my catheter to a pump and administered my first dose of antibiotic. My vital signs remained similar to those during triage. And of course, “Doctor, you look so young. If there is anything we can do, just ask.” Everyone was so nice and complimentary.
I poked at dinner but couldn’t eat, and managed only a few sips of ginger ale. The night shift arrived and told me how the night would progress and, naturally, how great I looked. It occurred to me that hours had passed since I had gone to the bathroom—many more than usual. It took minutes to get out of bed; everything hurt. I passed a few drops of urine and, feeling dizzy and hot, stumbled back to bed. I glanced at the IV bag: only 300 cc had been infused since I was admitted. But for those few sips, I was NPO for 36 hours. My fluid deficit had to be four or five liters.
“Nurse,” I called. “I am dehydrated. I need fluid, lots of fluid—stat!”
My nurse said he would call the covering physician and turned to walk out. But I begged, “Take my vital signs,” and to humor me, he did. My blood pressure was 155/87, my pulse was 95 and my temperature read 101.6 F. “So, you have high blood pressure?” “No, no,” I tried to explain. “These numbers are misleading; I’m hyperdynamic.” He quickly received approval by phone to bolus me one liter over a few hours, after which I would receive more as needed.
As the saline trickled in and I unhappily contemplated my options, the light bulb went on. I paged the on-call anesthesiologist and, like the cavalry riding over the hill, he soon appeared carrying two liters of Ringers and a blood pump. He closed the door, pulled the curtain and quickly infused the life-giving fluid.
As my cerebral perfusion improved, I began to wonder how this issue had been missed and what would have happened had I not self-diagnosed and been aggressively, although unofficially, treated. I imagine that my next vital signs would have been even more abnormal. The staff would have increased my IVs, although not nearly as much, and I would have improved—eventually, but not as fast. Had I more comorbidities, the outcome might not have been quite so good.
Of equal interest, I thought I had wonderful care and attention from all the staff. What was missing? An answer arrived three weeks later in the form of a four-page questionnaire which was similar, if far more detailed, to the one sent following a hotel stay or automobile oil service: Was I treated with respect by nurses, aides and dietary? Check. Was the bathroom clean? Check. Was my pain treated? Check. Was the food hot? Check.
Although these aspects of a hospital stay certainly are important, are they critical? Does the quest for perfect customer satisfaction equate to the delivery of excellent medical care? There is evidence out there suggesting that the two do not necessarily correlate but like the No Child Left Behind program in public education, the hospital is teaching to the test.
Then, there is nursing time devoted to the electronic medical record—the one we are assured will bring health care to new and unimaginably improved heights. Aggravating the nursing shortage, this represents a further loss of face time with the patient and may result in the nurse missing subtle (or not so subtle) changes in the patient’s condition.
Lastly, where were the doctors? My physician returned from vacation and saw me the following morning. He devoted time and effort to my illness and cured me but where was that crew of interns and residents, the hardworking slightly disheveled physicians in training who used to round on us sick folk looking for just such issues as I had? Gone, baby, gone. When I asked him, my doc simply said, “Welcome to the 21st century.”
On Dec. 16, the day of my admission, no less an authority than The New York Times gave its imprimatur to the way things are and will be: “There is plenty of evidence,” an editorial in the paper declared, “that well-trained health workers can provide routine service that is every bit as good or better than what patients will receive from a doctor” (italics mine). The piece went on to glorify the abilities of various providers, including patients themselves, as superior to those of MDs. How long before hospitalized patients will have to bring their own bandages, medicines and toilet paper? The 21st century, indeed!
I was discharged after two days of IV antibiotics. As my wheelchair went past the front desk, I caught a reflection of my sad and aging face.
Dr. Kron is an anesthesiologist in Southington, Conn.