taking time to care

Monday, April 13, 2015

After the first week of the season, the rules to speed up the game of baseball may be having some effect. Games are taking a little less than 3 hours to play, about 6 minutes shorter than last year’s average. It seems that what was once America’s past time, is suffering because the combination of a shortened attention span and the inability to be patient has caused its popularity to wane. People don’t tolerate waiting very well, even if the reason for that wait is compelling. And that brings us to why people wait in the ER.

If one were to watch Grey’s Anatomy ER or Nurse Jackie, it would be quite reasonable to assume that all medical problems could be solved in 44 minutes; the rest of the hour is filled with commercials and next week’s preview. But technology has yet to catch up to what is portrayed on television and movies. The idea that technology cannot be rushed is anathema, not only for the patient and family who are actively being cared for, but also those who are waiting fro the next ER bed to be open or nurse who can provide can provide care.

Patient flow in the ER is at the whim of available technology and even though the calendar says it’s the 21st century, high tech does not necessarily equal high speed. Consider the child with abdominal pain. Parents often are concerned about appendicitis, an inflammation that if unrecognized, can lead to bowel perforation, significant infection and major complications. Patients often don’t read the textbook and forget to present with the classic symptoms of umbilical pain moving to the right lower quadrant, accompanied by loss of appetite and vomiting. Physical examination can be compelling and an elevated white blood cell count, that often accompanies inflammation, seals the diagnosis and the patient is taken to the OR for an appendectomy. That was the standard of care forever, or until the availability CT scans became the norm, and that standard had surgeons removing normal appendixes 15-25% of the time. It was a reminder that other things could cause right lower quadrant abdominal pain.

The good news about using technology to look into the body is that it can help make the diagnosis. The bad news is that it takes time and radiation. And here is where technology can’t be rushed. In many hospitals, if appendicitis is a consideration, blood tests might be ordered to help give direction. Depending upon the tests ordered, it might take 30-60 minutes having the blood drawn, delivering the tubes to the lab and getting back the results. Instead of rushing to CT, an ultrasound might help make the diagnosis, but that is labor intensive and is helpful only if the appendix can be identified. If not, a CT scan might be required. Often the images can be taken with just intravenous contrast injected through a vein, but some radiologists prefer having the patient drink oral contrast to help outline the intestine. If that’s the case, the drinking time takes an hour, the scan itself 10-15 minutes and then another 30 minutes or more for the images to be reconstructed and interpreted by the radiologist. Even new math can’t make the answer add up to 44 minutes.

In chest pain patients, blood tests can help decide whether a heart attack has occurred. Troponin, a chemical contained within heart muscle cells, can leak out and be measured by a blood test. An elevated blood test equals a heart attack, but it may take 6-8 hours for the test to turn positive. That means a patient who presents within a few minutes after experiencing chest pain and has a normal EKG (electrocardiogram) might have to wait many hours to find out if his heart was damaged.

The worry for women who have vaginal bleeding in very early pregnancy is not only that they may be miscarrying, but instead might be experiencing a tubal or ectopic pregnancy. One test that might help guide diagnosis would be a quantitative beta HCG, a chemical that is produced by the placenta. Its value should double every couple of days in early pregnancy and in stable patients, they may need to return in two days to help sort out the diagnosis. Meanwhile, the evaluation and care of the patient involves significant amount counseling and that take time.

Medicine and baseball share the concept that the game is not a prisoner of the clock. It’s done when it’s done, when the final out is made and when the diagnosis and treatment are complete. It is fair to try to make efficient use of time but not at the expense of the integrity of the game or the care provided. While the late Ernie Banks was quoted as saying “it’s a beautiful day fro a ballgame…let’s play two”, most people would rather get the diagnosis right the first time, no matter how long it takes, and avoid a second trip to the ER.

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