Back to healthcare, about 18 months ago, I sat down to write a book on healthcare. I thought I knew a little bit about healthcare. I've been a trauma surgeon for over 15 years. My father was a family practitioner. I use to help him in his office. So, I've been around healthcare for more than 30 years. I have seen something as simple as an examination table cost more than $1000. But soon, after doing some research, I was overwhelmed by the amount of data and the simple size of the task. Healthcare is a vast monstrosity. It is extremely difficult to get your arms around the whole problem. Therefore, it makes sense to me, that we need to take this problem in small pieces. Let's look at the intensive care unit. In the intensive care unit, physicians practice some of the most advanced medicine that can be found anywhere in the world. Although I do not like case reports (anecdotes) to be an impetus for action, they can illustrate a larger point.
Case 1: a 90-year-old gentleman was driving a golf cart on the road when he swerved to miss a car. The golf cart rolled down an embankment and the gentleman was thrown from a golf cart and hit his head on a rock. A witness saw this crash and called for an ambulance. The patient was awake and alert when the ambulance arrived and he was taken to the trauma hospital. The patient arrived at the trauma center complaining of a headache. The CT scan of his head revealed a small subdural hematoma (a collection of blood between the skull and the brain) near the temporal lobe. There's a small contusion (bruise) of the temporal lobe. The rest of the CT scan was perfectly normal for a 90-year-old gentleman. (This subdural hematoma does not require neurosurgical intervention.) At this time, the patient began having some word finding difficulties. He was becoming a little confused. The patient was admitted to the intensive care unit. Interestingly, the patient son was a pathologist. He was informed of his father's condition. The next morning, per protocol, the patient had a repeat CT scan of his head. It was completely unchanged. Approximately four hours later, the patient's mental status began to deteriorate. He was now having severe difficulty finding the correct words to express himself. He was becoming agitated. At this time, the patient's son comes by for visitation. The son is extremely alarmed at the deterioration of his father. He demands that something be done. He informs the critical care physician that this patient lives independently and that he has highly functional. The pathologist wants a repeat CT scan. The critical care physician asked a few questions – what if the CT scan is worse? Do you want your father to undergo a neurosurgical procedure/surgery if necessary? How aggressive do you think we should be in a 90-year-old gentleman who was previously healthy? The pathologist, a physician, was unable to answer any of these questions. (please remember that none of the patients presented here are real. Instead they are presented to illustrate a point.)
What do you think should be done? Should we get a repeat CT scan emergently? Should we just keep the patient in the ICU (at a cost of $1000 - $1500/day) and watch him closely with continued IV fluids and supportive care? Should we transfer this patient out of the ICU to a regular room and institute "comfort measures?"
Update: I am overwhelmed by the response. I've posted many "thoughtful" articles to the Daily Kos but I have never had this type of response. Thank you.
To continue with this case, the patient did undergo a repeat CT scan at the request of the family. The repeat CT scan was unchanged. Neurology was consulted. They came by and explained to the family that the patient symptoms were coming from the bruise in his temporal lobe. It was unclear if these symptoms will resolve or not. Over the next 24 hours, the patient's symptoms improved and the patient was transferred out of the intensive care unit to a regular room. Over the next 48 hours, the patient continued to improve and was back to baseline. (He was walking, talking and eating without difficulty.)
I posted this case not as some sort of "miracle" but instead as an exercise in thinking about end-of-life issues. How can a physician whose father is 90 years old not have some sort of plan with regard to end-of-life issues? If a physician cannot have a plan than what chance do the rest of us have?