Homemade Soup

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 patientís best interest. (Examples to follow.) In these cases, I may say, ďI 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.Ē 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. ďI believe you will die a horrible death if you donít get to the hospital, so we are going to take you to city hospital, okay?Ē

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 Ė 98,000 people die in hospitals each year as a result of preventable medical errors. Thatís 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 donít 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 donít 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 doesnít 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 wonít 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 elseís 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.

8 Comments

  • Mary says:

    From the patient side, there’s also a lot of uncertainty about what’s a good idea and what’s not. Good idea or not, you’re certain to have a bill!

    I’m 40. Yesterday I went in for my first ever physical as an adult. I had expected a head-to-toe exam, questions about my physical state, ailments, weight, nutrition, emotional state, advice on healthy living, etc. At least, as a layperson, that’s what I would have expected such a visit to include.

    Instead, she addressed the specific issues I brought up (answering none of them with satisfactory answers), listened to me breathe, and ordered a fasting blood workup. The questions I was asking weren’t complicated – what’s the real risk of STD transmission for frequent, protected sex for someone of my age bracket? Why do my lips peel and how can I fix that? I got an IUD a month ago and I’m still bleeding. Is that normal? Every question was met with a version of ‘I don’t know’ or ‘you should contact someone else about that’.

    I was thoroughly unimpressed. I will dutifully go in for my blood work, but I will never have another routine physical. There seems to be no point, and from my observations of other people’s interactions with the medical industry, most of what I see, even so-called critical end-of-life interventions, are pointless. Sometimes they’re actually worse. In the last two years, I’ve known two people who discovered they had cancer very late and died within a month of diagnosis. Both of them had good deaths, as much as such a thing could be. Compared to a couple years of guaranteed agony and a crapshoot for gaining a few more years after? I’ll take the good death, thanks.

  • BH says:

    Mary, for what my advice is worth, I don’t think your problem is with medicine s a field. You just ended up with a craptastic doctor. That’s an easy fix.

  • Omar says:

    I have recently been having the same thoughts. As a paramedic, I see myself as a patient advocate, as such, advocating that every sniffle or cut finger go to the hospital, especially by ambulance, I am not advocating for them, but conforming to a system geared to the weakest links. Do I really want an unemployed already in dept person stuck with thousands of dollars of more debt because my employer says our job is to transport no matter what the CC. I think that for many of our customers, checking them out and advising them to see their PCP is being a conscientious advocate for my patient and the system as a whole.

  • JVH says:

    Mary,

    I mostly agree with BH. There are definitely some doctors that are better than others. The one you saw sounds like one on the lower end of the spectrum. It’s something I understand a little too well. I’m a Paramedic (albeit, taking a break from the field for various reasons) and take care of my very sick fiance. Through several years as an EMT and Paramedic, I’ve seen some less than stellar doctors in the ER. I’ve also seen some great ones. The same goes for doctors my fiance sees. The last two Family Medicine physicians she saw before our current one (who is great, along with the other doctors in the practice) were absolutely atrocious. One even went so far as to tell us “I don’t know what it is, but you need to accept the possibility that it’s psychological.” This was after minimal testing, even!

    Don’t let this one negative experience deter you. If I had let my fiance give up after the first two doctors, we wouldn’t have found the one we’re seeing now, wouldn’t be getting to see all the doctors we need to in order to get her better.

    I would also suggest some reading. I’ve taken great interest in patient advocacy and “healthcare navigation” as of late, and have found a couple of books invaluable.

    You Bet Your Life! by Trisha Torrey
    http://www.amazon.com/Mistakes-Patient-Makes-Healthcare-Deserve/dp/1934938882/ref=tmm_pap_title_0

    The Empowered Patient by Elizabeth S. Cohen
    http://www.amazon.com/The-Empowered-Patient-Diagnosis-Insurance/dp/0345513746/ref=tmm_pap_title_0

  • Peri says:

    Mary, a joke that I love: What do you call the guy who graduates medical school at the bottom of his class? Doctor.

    I’ve had awful doctors, doctors that are fine, and a couple who are fine. You got a lemon. Last year, at 53, I started with the best doctor I’ve had since I was a kid with the classic family, house-call doctor.

    Get recommendations from friends you trust. And a word about blood work: there’s the typical workup that doctors do, and there are very extensive workups which can give a good doctor very good insight into your overall health. I’d always gotten the usual–and usually felt…ok. My new doc did the extensive test (it’s more expensive), and was able to diagnose thyroid issues other doctors missed. I’m being treated and feel the best I have in years.

    Don’t give up.

  • medicscribe says:

    Great comments by all. I also see where Mary is coming from. I always find it interesting to go to the doctor’s as a patient and then compare their demenor and commitment to the patient against my own. In some cases I learn ways to improve what I do based on how a physcian treats me, and other times, I know what to avoid, and how to try not to appear. If I didn’t hate going to the doctor so much, I would go to more and different ones just to learn from the experiences.

    Thanks again for commenting.

  • Travis says:

    Very interesting post. I definitely feel that hospitals and doctors like to prescribe medicine when it’s not ALWAYS necessary.

    I’m curious–what are your thoughts on immunizations–be it based solely on your opinion or actual evidence/experience? It’s been such a raging debate for years, and I know many feel that immunizations can hurt you in the long run, due to what’s actually in them.

    • medicscribe says:

      Hi Travis-

      I get the flu shot every year. I know there is controversy, but the science behind them is very strong. They save lives.

      Best, Peter

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Peter Canning

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  • Comments
    BH
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    Two of my major hospitals now employ scribes that accompany their assigned MD all day for the sole purpose of recording their H&P with the patient. It not only makes the doctor/patient interaction more... interactive, but since all the scribes have to worry about is documentation and not patient care, the reimbursements for the doctor's…
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