When things don't go as planned...

Several months ago, I met a patient who had already been in and out of the hospital for months. He already had had many complications and was pretty sick. This guy had bladder cancer and had to have his bladder taken out. His ureters - the tubes that carry urine from your kidneys to your bladder - were instead fused to a part of his colon so that urine was diverted to his colon instead of his bladder. Immediately after the surgery, he had a heart attack, which is not common, but can happen because surgery takes such a big toll on your body, including your heart. He recovered well from this, and went home. Unfortunately, two days later he came back to the emergency room looking incredibly sick. It turns out that his wound had started to come apart, which is a potential complication of any surgery. His ureters were de-attaching from his colon, leaking urine into his abdomen, and he possibly had an infection within his abdomen. They had to open him back up and fix everything. In the end, it was all still leaking, so they had to place stents within his kidneys that led outside his body to drain the urine instead. He was discharged to rehab.

One week later, he was having his stents changed, and he suddenly became very very sick - he had a fever, the chills, and looked really sick. That's when I saw him. He had developed a very serious infection called sepsis where the infection is basically all throughout your blood. His blood pressure started becoming way too low and he had to eventually be transferred to the ICU where they could start him on special medications to keep your blood pressure up and your heart pumping. It turned out he had multiple types of bacteria growing in his urine, as well as fungus growing in his blood! That's pretty rare, but he had many potential sources of infection - not only did he have the normal sources that every else has (lungs that can develop pneumonia, urine that can develop urinary tract infections, and blood that with even just a blood draw can potentially develop bacteremia or sepsis), he had stents in his kidneys as well as an ostomy (his colon came to his skin and his stool came out through a bag) that were at high risk for infection. Moreover, he was a pretty sick guy, and he'd been in the hospital quite a lot over the last few months, so he was immunocompromised and at higher risk for infections, including hospital-acquired infections. Eventually, he was discharged about two weeks later to yet another rehab facility after being treated with multiple antibiotics.

Two weeks later he came back again. Actually, he had two emergency room visits in between as well. This time, he had developed serious bleeding from his gastrointestinal tract, requiring many blood and platelet transfusions. Over the next 6 weeks, he developed sepsis again and multiple infections, and also developed respiratory failure requiring intubation to help him breathe. Although after several weeks we were able to take the tube out and he could breathe on his own, he was still incredibly sick and his prognosis was very very poor. After many discussions and having dealt with this for nearly 6 months, his wife decided to make him DNR. After 6 more weeks in the hospital and the ICU, he eventually died.

I tell this story because sometimes, it can be amazing what a relatively simple procedure can lead to. I would not call a bladder removal a simple procedure, but I'm pretty sure this patient and his wife went into the operation with an optimistic attitude. He had bladder cancer, but it would be removed, and he would have to pee in a bag for the rest of his life. Traumatic, perhaps, but something you could live with. Instead, he had 6 months of increasing medical complications that eventually led to his death. I don't think the doctors did anything wrong at all, or could have done anything differently - sometimes it's just bad luck and unfortunately, patients and their families are often not prepared for things like this.

Medicare sucks

There are a lot of changes going on in health care. One is that pretty soon in Pennsylvania, it will be mandatory for hospitals to report hospital-related infections. Now, I believe this is a very good step overall. For one, it's important for hospitals to keep track of something like that, and to take steps to lower the numbers. It is probably impossible to completely eliminate it, but it's crucial to reduce it as much as possible. Although hospitals should already be taking measures to do so, I think mandatory reporting will go a long ways toward speeding hospitals along. Secondly, I think it's good that patients will be able to access this information and see the rates of hospital-related infections at different institutions. This may help them make health care decisions, which in turn, will pressure these institutions to lower their rates of hospital-related infections.

However, I also see some potential problems. For one, I have heard that Medicare is going to stop paying for hospital-related complications and infections. Now while I believe that many hospitals will be able to reduce these by quite a lot, hospital-related infections will never be completely eliminated. Let me give an example.

A patient comes in because he had a heart attack. He's on the older side, also has hypertension, and congestive heart failure. The heart attack really does a number on his heart and it starts failing. He can't pump his blood well, fluid builds up in his lungs, he can't breathe, and he gets sent to the ICU and gets intubated - that's getting a tube thrust down your pharynx so that you can breathe with the help of a machine. This is a life-saving intervention. Without it, this patient would have died. However, several days after intubation, the patient develops a rip-roaring pneumonia. He gets treated with antibiotics and gets better. Eventually, the patient's heart gets better, he gets extubated (the breathing machine is removed), has open-heart surgery and lives another happy 20 years.

A relatively high percentage of patients that are intubated develop pneumonia. While this is serious, it can be treated with antibiotics. Medicare is saying that they will not pay for the antibiotics, because this type of pneumonia is a hospital-related infection - even though this infection was the result of a life-saving intervention! This is not the only example of something like this - there are many others.

Who is going to pay for the cost then? The patients? No - they never have enough money. So it will go to the hospitals. They will have to eat the costs and make up for them by billing more for just about everything else. Would it be ethically okay for the hospital and doctors and nurses to say, well, this patient will probably develop pneumonia if we intubate him, and we won't get paid for that, so nevermind. Let's just let him die. Of course that would not be ethically acceptable, and of course that won't happen.

I think it's ridiculous and sustainable for neither the insurance companies nor the hospitals.

Paul Levy, the president and CEO of Beth Israel Hospital in Boston posted about this topic and I think he also brought up some very good issues.

Past ICU stories

Today was just an okay day – the whole ICU thing sorta blew over, so it was alright. Dr. Stefanski basically said that no female student should ever go into the ICU alone, and he, Boipelo and I all went in to the ICU as a group to see our patient today. And the doctor was very civil. They both told me all these stories about this ICU doctor. Boipelo told me that when she was an intern, she had a patient in the ICU, and this doctor said “go away, and never talk to me again! I don’t talk to interns.” And that’s just crazy! Often an intern is the only person taking care of the patient!

Dr. Stefanski also told us a story about how he had this critical asthma patient that he transferred to the ICU. The ICU doctor refused to use epinephrine on this asthma patient, who was breathing like 50 breaths per minute and really struggling. And for those of you non-medical people, epinephrine can be a huge life-saver for asthmatics – it can open up your airways until the attack has died down a little bit, otherwise patients can literally suffocate to death. Anyways, the ICU doctor refused to use it because he said it was never done, and there was no proven benefit. So Dr. Stefanski got two big legitimate papers that described in large multicenter randomized studies that epinephrine was of benefit for severe asthma attacks, and he gave them to the ICU doctor. The ICU doctor just threw them away. Apparently, the patient kept going in her awful suffocating state for about 3 or 4 days, and then the ICU doctor finally said, okay, she’s not getting better, maybe we should try the epinephrine. And the day they finally tried it, it was basically too late – the woman was so tired from breathing so hard for so long that her body just gave out and she died. I would say that this ICU doctor was personally responsible for this woman’s death, which was very preventable.

Oh, and in case anybody cares, his name is Mkubwa. So if you ever bump into a Dr. Mkubwa that runs an ICU in Gaborone, Botswana, I hope it’s not as a patient.

STUPID ICU DOCTOR

I was the only one on my team that showed up today – the MO Boipelo was sick, and Dr. Stefanski is not at Princess Marina Hospital (PMH) on Tuesdays, plus he’s been sick himself. So I had a few problems today. The morning was great! I got all my work done, and it generally went smoothly as I rounded by myself, but I definitely hit a few snags this afternoon.

The main person that ruined my day was this stupid ICU doctor. The first thing he did was yell at me in the morning, as I was standing there doing nothing but writing my note in the chart for my one ICU patient. He was yelling at me about all the other ward doctors not coming everyday to round on their patients in the ICU. And went off on a tangent about how the ward doctors d/c (stop) medications inappropriately once their patients get to the ICU. He must have ranted for about 10 minutes and all I could say was that, well, I’m rounding on my patient in the ICU and this the reason we d/c’d the tuberculosis medications. So he was like, ok that’s reasonable, and said he didn’t mean to rant directly at me. But he did.

So my patient in the ICU was supposed to get a CXR (chest x-ray) two days ago when he was transferred, and they dropped the ball and never got one, so I asked for one this morning. Then this afternoon, I looked at it, and I was a little panicked because he had a collapsed lung and a left pneumothorax! That’s air in the thoracic cavity, and can be really really bad if it starts compressing other structures, like the heart. So I run all the way back to the wards to ask an attending about the CXR to make sure I wasn’t totally interpreting it wrong, and she said I was right, and that I should call a surgeon immediately to put in a chest tube and decompress the air in the thoracic cavity. So I did. The surgeon said he’d see the patient in the ICU, and I went there right away. He got there at the same time I did, and the ICU doctor saw us right away, and came in storming. “WHO CALLED SURGERY?” And that started another rant. I told him the patient had a pneumothorax and he said there was no way. I said I was pretty sure, as both Dr. Gluckman and another attending had seen it. He still didn’t believe me and made me show him the x-ray, and then he got really mad. I think showing him wrong set him off – he started accusing me of trying to tell him how to do his job, and doing things the wrong way (apparently I’m supposed to tell him about the problem, and then he would call surgery). He must have yelled for about 10 minutes and went off on me with things like “WHY did you not call me first?”, “YOU AMERICAN DOCTORS THINK YOU CAN WALK IN HERE AND DO WHATEVER YOU WANT?”, “YOU’RE TRYING TO TELL ME I DON’T GET THINGS DONE RIGHT??” and “YOU DON’T THINK I’M CAPABLE?” I couldn’t get a word in edgewise, and finally I said I’m leaving, and he said FINE GO I DON’T NEED YOUR HELP HERE GO! I was super upset and, actually, pretty angry. I didn’t realize that I had to tell him first – I thought that since we rounded on the patient, and he wanted us to round on the patient, that we were calling the shots. But apparently he just wants us to round on them and not do anything. Absolutely ridiculous. And he definitely could have told me that I did things wrong in a better way than yelling at me for 10 minutes. Plus, he’s a moron – he didn’t diagnose that pneumothorax and I think he was pissed that I did.

So after I calmed down a bit, I called Dr. Gluckman and told him there might be a problem with the ICU doctor. He told me three main things. One, that I probably should have told the ICU doctor first because they are super super territorial. Apparently about two years ago there was a huge fight between the residents and the ICU doctors because the residents were changing the vent settings because they didn’t think the ICU doctors were setting them correctly. And the ICU doctors resented it. I understand their feelings though – I would probably resent it too if a bunch of foreign doctors came in and started trying to tell me what to do. Still, I think this is a stupid system – what’s the point of us rounding on them if we can’t do any management? If we transfer them to the ICU, the ICU doctors should just take over their care. The second main thing Dr. Gluckman told me was related to this – that in general, the ICU doctors resent all foreigners and automatically are biased against them. So it’s difficult for us to get anything done with them. And finally, he told me that they have a problem with women. So being a foreign woman, he probably didn’t like that fact that I pointed out that he didn’t see the pneumothorax on the CXR, even if it wasn’t my intention to highlight his stupidity. And actually, Dr. Gluckman said that he wrote a note (which I didn’t see) saying that if the pneumothorax was stable, we could probably wait until tomorrow to call surgery.

Anyways, at the end of the conversation, Dr. Gluckman said that if I was brave enough to go get the ICU doctor’s number, he was willing to talk to the guy. I told him who it was, and he was a little surprised – he said that he and the guy were sorta buddies! I was a little surprised too. I wonder if I mispronounced the name, or if Dr. Gluckman was thinking of a different guy. So I went back after calming down a bit, and talked to the guy. I apologized for any misunderstanding there might have been, and said that my intentions were not to imply that they were doing a bad job, but to help the patient. He was actually quite civil, but still quite condescending. I know now I should have gone to him first, but it sort of galled me to have to apologize to the guy when he couldn’t even diagnose the problem. And then he had the nerve to say that he did call the surgeon, but he didn’t think it was a pneumothorax!! He was going to let the surgeon make the decision about what to do, but he thought it was a mucous plug! I highly doubt it, and I argued for a brief second, but then I said, well, why don’t you just talk to Dr. Gluckman about it and asked for his contact number. He sorta was like, OH, Gluckman is your attending? And I said yes, because he basically was today, and has been helping me out for the last few days since nobody else on my team has been around. When I talked to Gluckman a few minutes later, he was like there’s no way that is a mucous plug. It doesn’t look like it on the CXR, and plus, this guy has PCP pneumonia, and getting a pneumothorax is actually pretty common in patients with PCP pneumonia.

That wasn’t it – after I finished with that ordeal, I had to come back and the relatives of this comatose guy were all there asking about him. So we had a family meeting (which I was hoping Dr. Stefanski or at least Boipelo would be around for) and I told them the prognosis really was not good. I told them they could meet again with Dr. Stefanski the next day, but I think I conveyed everything pretty well. But it was pretty tough too.

So that was the day… I was pretty drained at the end, and I went home at about 5pm. I felt guilty about that too – I normally stay and help Phil and Lisa out until we can all go home together, but I was drained. I didn’t tell them the story, but I think they understood.

ICU incident #2

I had another run-in with the ICU doctor today. My team went to the ICU to see our patient with PCP pneumonia and the pneumothorax. He had ended up getting a chest tube that night I had the first confrontation with the ICU doctor. We were in there seeing the patient when the ICU doctor came in. He asked me what I thought was wrong with our patient – I said the oxygen saturation was 86% (for normal people the oxygen saturation in the blood should be 100%), which is super super low, and pretty worrisome. He asked if that was okay, I said I didn’t think so, that I would prefer that it be above 90%. He asked if I knew why the patient had such a low sat, and I said because for some reason, he was unhooked from the ventilator. He said I was wrong, and in this case it was okay for the saturation to be this low. Then he asked Boipelo the same questions, and she answered the same way, and he just turns to both of us and says, you are both wrong and YOU KNOW WHY! And he stalks out of the room. We were like, okayyyyy. And we look at Dr. Stefanski, and asked him if he knew why, and he says no. That ICU doctor is such an idiot. So we write our note, and then we leave the room and run into the ICU doctor again, and Dr. Stefanski says to him “so I think you were trying to make a really good teaching point back there – could you tell us what the reason was?” And I pipe up and ask if it was because the patient looked clinically well despite having a very low oxygen saturation, and he just interrupts me and says “YOU INSULT ME LITTLE GIRL” and he stalks into his office. I was absolutely dumbfounded, as was the rest of my team! Boipelo starts laughing and Dr. Stefanski just says don’t worry about it. What an ass.

I was on call today too. It was finally pretty busy – I admitted 3 patients, and there were two more to admit when I left. That’s when Boipelo came back (she leaves from 4-9pm, but has to stay overnight) and she saw the two patients sitting there. I felt pretty bad, but I was pretty busy with other admissions and also from getting calls about random patients needing IV’s or falling out of bed, or getting nose bleeds. Things like that. She kinda gave me a hard time about leaving her all that work, but I think she was joking. Plus when we take call, we’re sort of “extra” help anyways – if we weren’t there they’d have to take all the patients themselves, so I don’t feel too bad. I had to get home, I was so tired, and I was still sick and coughing up a lung.

When we got home, it was really nice though – Kristy and Kiona had made dinner for us! They made us eggplant parmigiana and salad! They complained that it tasted like barbecue sauce, because the pasta sauce here is different from in the states, but I still really liked it. I had two servings! I was pretty excited, because the next day, we were going to go to Tau!

TB patients

I was on call tonight and I admitted 4 patients, which is a lot for me. There wasn’t anybody to really help me either… on the pink female side, they have 3 team members all working on the same number of patients. However, it seems like the female side gets many more admissions than the male side. I have a theory about that. I don’t think it’s that different than in the states. Women tend to come in for the health problems and for health maintenance more often, and sooner, than men do. So there are more women admissions. Our lists of patients on the male side also seem to be a lot smaller than on the female side. I think that’s also related to the men not coming in soon enough. So many times we get a male patient that comes in comatose, or barely breathing, and it’s really too late to do anything for them here. So more men die than women, and less men come in the hospital in general, keeping our lists smaller.

It’s pretty sad – the other day, we had a man come in because he was barely conscious, and really struggling to breath. For those of you know what I’m talking about, he was already having Cheyne-Stokes respirations and barely responded to sternal rub. He had this huge mass in his neck that we FNA’d (fine-needle aspirated – it’s a way of taking a biopsy) and stained it to look for AFB (acid-fast bacilli – the sign of TB). And it was swimming in TB. We made a token effort of putting him on anti-TB medications, and giving him oxygen, but really we were just waiting for him to die. It wasn’t worth sending him to the ICU because in this resource-limited setting, only people who have a pretty good chance of making it through an ICU stay go to the ICU. And he was definitely not one of them. Not to mention the fact (as you’ve seen in previous posts) that the ICU doctor is horrible and has no idea what he’s doing, so most patients, even though with relatively good prognoses, rarely make it out of there alive. Anyways, he lasted until 11:30pm that night. And this is a disease that is easily treatable. If only he had come in a week or two earlier. It’s awful.

Tonight I also admitted an XDR TB patient! So a patient first diagnosed with TB is put on first-line anti-TB treatment (ATT). They have to go to the clinic every single day to get their medications, as part of the DOT (directly-observed therapy) program for TB treatment. This program was started because patients weren’t taking their medications, and they weren’t getting better, but more importantly, their bad drug adherence was resulting in the emergence of resistant strains of TB! And we just had a lecture about this – because there’s no money in developing TB drugs, and it’s really a third-world problem, the last effective TB drug was developed in 1960 (or something like that)! So we only have a limited set of drugs to work with. Anyways, so I had a patient who was diagnosed with TB in 2005, was on 6 months of treatment, and then relapsed and was diagnosed with TB again a month later. He probably had multiple-drug resistant (MDR) TB. So in 2006 he was placed on second line treatment for 6 month, got better, and then after another month, relapsed again! They finally cultured his sputum (which is tough to do here), and it turns out he’s resistant to 4 of the 5 commonly-used TB drugs (XDR TB). So now he’s on all these weird medications, many of which aren’t indicated for TB, but probably have some effect. There’s really no other choice for this guy.

However, the problem isn’t that we can’t treat this patient, the problem is that he’s in the hospital! In the states, there are all these negative-pressure isolation rooms that you can put patients in. Here, there is no such thing. There is an isolation room that you put all the MDR patients in, but sometimes patients who aren’t even proven MDR go into the room. And our XDR patient went in there too – meaning he’s probably going to give all the other patients XDR TB. Plus the room is not negative-pressure. We just open all the windows to improve ventilation, and try to keep the patients in the sun for the UV exposure (which actually helps to kill TB). We wear these N95 masks that are supposed to protect us to some extent from TB, but it’s not 100%. If you’re lucky, you can sometimes get your MDR or XDR TB patient put into a private room in the private ward (no such thing in the public wards – there are 10-12 people per large room, or cubicle). But those rooms are still not negative-pressure. I’m not too worried because I’m only working here for 6 weeks, but apparently of the students who have stayed for a year or more, 3 of them (I don’t know out of how many) have converted their PPD – meaning they have TB in their system, although it might not be active. Scary.