Tuesday, July 9, 2013
Washington’s approach to health care legislation has forgotten its good intentions. The politics of health care has confused improving the care provided with how much it will cost to provide it. In a generation, technology has changed the way medicine is practiced, from high touch at low cost to high tech at a very high price. My career has followed this evolution and the technology genie is now permanently out of the bottle.
Twenty patients in an 8 hour shift can keep me very busy in the ER. At the beginning of my career, that would be a slow day. Why the difference? It’s about being able to intervene and abort an acute event. Not too long ago, my job was to make a diagnosis, since there was little that could to treat many diseases. Patients spent little time in the ER once the diagnosis was made because little could be done acutely. Heart attack or stroke patients were whisked away relatively quickly. EKGs, blood tests, a couple of IVs and hand holding were the treatment options of the day.
Today a stroke patient is all consuming for a team of people in the ER. Time is brain and the sooner a blocked artery can be opened and return blood supply to the brain, the better chance that the patient may recover from a stroke. TPA can dissolve a blood clot but it has to be given within 3 hours (in some cases up to 4 ½ hours) of onset of symptoms and the patients have to be screened carefully to minimize the risk of bleeding. That screening may start in the field with trained paramedics recognizing the potential for a stroke and delivering the patient directly to the CT scanner to make certain there has been no bleeding in the brain to cause stroke symptoms. Then it’s to the ER, where nurses, emergency doctors and neurologists descend upon the patient to examine the patient, get blood tests and EKGs and decide if this patient is a candidate for TPA. The clock is ticking. Not only does the patient have to qualify for the drug but they and the family have to agree to the treatment. There is a 33% chance that TPA can reverse the stroke but there is also a 6% chance that it will cause bleeding in the brain and make things worse. There are other potential treatments depending upon the situation and they can involve interventional radiologists and neurosurgeons.
It takes a system to treat a stroke and systems don’t come cheap. The price of a CT scan has to cover the cost of the machine, the specially trained radiology technician to run it, the radiologist to read the scan, and the radiation physicist who has to monitor the scanner function, minimizing the radiation exposure to each patient. The hospital has to have a fully equipped emergency department and all the technical bells and whistles that come with that, including emergency nurses and doctors and access to a neurologist, either in person or by telemedicine, 24 hours a day. Depending upon the stability of the patient, some stroke patients don’t do well, the time I spend at the bedside and with family can last an hour or more.
That same system approach needs to be available for heart attack patients where heart muscle damage can be minimized if the blocked artery can be opened. The goal is to open that blocked blood vessel within an hour, either by heart catherization or by clot busting medication. The clock is ticking and the diagnosis, confirmed by EKG, sets the wheels in motion to get the patient, the cardiologist and the cath lab team together ASAP. The cost of having people available, just in case, 24 hours a day is not inexpensive.
The acute MI is pretty easy for me but those patients who present with chest pain who are not so clear cut may take time to sort out whether there is a potentially lethal diagnosis. The patient may worry about heart attack but I also get to consider other pulmonary embolus, aortic dissection and other causes of pain and it takes time and technology. Abdominal pain follows the same path. There are potential catastrophes that need emergency surgery and other causes where watchful waiting is the appropriate treatment.
Technology marches on, improving the ability to diagnose and treat but the cost is great. Legislators try to figure out a budget to pay for all that can be done but there lies the rub. With a population that is aging, demand for medical care will continue to increase. The health care budget will not be controlled by employer mandates or healthcare consortiums. Instead, there is a need to decrease demand for care and that will occur only through prevention. The list to be tackled is long from obesity and smoking to drunken driving, drug abuse and violence, every facet of society has an impact on the health care system and the cost to the patient and society.
There is a right to health care. But people have a responsibility as well, to deliver as a healthy a body as possible for that health care to happen.
“My fellow Americans, ask not what your country can do for you, ask what you can do for your country.” JFK