I am conflicted. I am having doubts about some of the benefits of medicine. Let me be more specific. In our state, we are told to advise a patient at least three times to go with us to the hospital before we can accept a refusal of care against medical advice (AMA). (For legal purposes all of our refusals are considered AMA). On the other hand, as a medical professional, we are bound by the fundamental tenet, first do no harm.
Sometimes I feel that my required recommendation of transport is actually against the patient’s best interest. (Examples to follow.) In these cases, I may say, “I am required by law to advise you to go to the hospital three times. My advice by requirement is always to recommend transport to the hospital for evaluation by a doctor.” Other times clearly I ardently believe the patient needs to go to the hospital and I will use every trick in my book to get them to go. “I believe you will die a horrible death if you don’t get to the hospital, so we are going to take you to city hospital, okay?”
So why am I losing faith in medicine and in the benefits of patients going to the hospital? Clearly, I am not in every case, but in others, I do have my doubts. The history of medicine is not a stellar one. Think blood letting and hospital acquired pneumonias. Even in my years as a paramedic, it turns out that many of the things we were doing that we thought were helping patients were harmful to them. MAST trousers, high volume fluids in trauma, lasix. A recent study of spinal immobilization in penetrating trauma showed that for the one out of every 1200 patients we were possibly helping we were likely killing one out of every 68.
1999 Institute of Medicine Report, Too Err is Human, estimated that 44,000 – 98,000 people die in hospitals each year as a result of preventable medical errors. That’s more deaths than motor-vehicle wrecks, breast cancer, and AIDS. I also think this seriously undercounts people who may die from medicine contributing to their morbidity. What about people with unnecessary operations? What about people put on meds that may not have been necessary? The tendency in medicine is always to do something. That is what we get paid for. We don’t get paid for recommending against unnecessary treatment.
Now I understand that I am not a doctor and that I do not have the battery of tests that are available at a hospital not the extensive medical education and experience of a physician. It is just that I see so many people taken to the hospital and getting workups that don’t show anything or that show what any one else could see. A patient has the flu, the patient has a GI bug, the patient is dehydrated, the patient has a muscle strain, the patient is old and has wobbly legs.
I guess what I am getting at is in the larger scale on a risk benefit ratio, I am curious the number of people who benefit from their evaluation versus those who may be harmed by the evaluation.
Here are three cases in point all that happened in one day.
A frail old man has grown weaker over the last day and has fallen twice in the last day. His family wants him evaluated, but more than that, they want our advice. We, of course, tell them the weakness could be a sign of any of number of serious illnesses, and that he should be taken by us to the ED for full evaluation by an emergency room doctor and hospital specialists. But the family really wants our advice. They are worried that if he goes to the hospital he will get the flu from all the sick patients already there (like the two we brought in earlier).
The the truth is I see their point. What if we bring him in and he does get the flu or another infection that further weakens him? What if he gets put on other meds to battle whatever irregularities they find at the hospital and he dims because of them?
If he is my father, what would I want for him? In this case, with these symptoms, I would want him to stay home where I would care for him, feed him, and see that he rests in his own bed. I would be more patient. I would wait before sending him to the emergency department. I suppose I would wait for what I saw was a true acute emergency. I think his wife and his daughter are capable of providing such care. This is what I want to tell them, but instead I am bound to follow my script. I am not upset when they decide that they will keep him home, and only call if things change.
An 88-year-old Vietnamese man passes out at the pharmacy. He lives just a few blocks away. he walked over to get his meds, but had to stand in line for over fifteen minutes. He felt woozy and was helped to a chair. He barely speaks any English. His vital signs are good and his 12-lead is normal. He doesn’t want to go, but due to language it is hard to communicate. When we finally get hold of a family member, who, on our advice, tells him he has to go, he agrees to let us take him. Maybe he has had a cardiac event and will walk out of the hospital on many wonderful meds and perhaps with a pacemaker. But maybe he just has the flu, and would better benefit from being taken care of at home by his family and hand-fed hot soup.
Nearly the same scenario plays out later in the day with a Croatian woman who collapses at the post office while waiting in line. She is old and looks pale, but everything checks out okay. We still end up transporting her for an evaluation after getting hold of an English speaking nephew. Maybe she won’t get sicker in the hospital, maybe she will be better able to rest there than in her own bed, surrounded by her family.
I know this is unrealistic, and we do need to pay for gas, ambulances, equipment, mine and everyone else’s paychecks, as the hospitals also have to pay for their staff and physical structures. Still I wonder about runaway health care costs. I wonder about the scientific evidence and if it would show we are truly making a difference but universally urging transport.
I want what I do– what we do–to matter, and I know it does in many ways. There are just those times where I think it might be better if we could just transport someone home, set them in their own bed, with their family now gathered around them in a familar setting, and perhaps we would leave with some homemade soup as payment for our kindness.