the cost of health care

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

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time is brain

Tuesday, April 9, 2013

To every life, an end must come and for the Iron Lady, Margaret Thatcher that end came because of stroke. She is not alone. Stroke is the number three cause of death, trailing only heart attack and cancer. The death can come quickly. If enough brain is damage, whether it is because of a blocked artery or because of bleeding, swelling can put pressure on the automatic centers of the brain that control the heart and breathing and death is inevitable. But death can occur later and much more slowly. The ability to swallow can be lost and the risk of aspirating saliva and food can cause pneumonia or an infection of the lung. The inability to easily move can cause blood clots that travel to the lung or skin can break down and cause major infection.

Stroke is bad but there is potential salvation if the patient gets to medical care fast enough. The window to make the diagnosis and inject clot busting drugs is measured in minutes and many of those are lost because the patient or the family do not recognize the signs of a stroke, or choose to ignore them, hoping that they will resolve on their own .Sometimes they of. It’s called a TIA or a transient ischemic attack, better named a stroke that the body fixed itself. Unfortunately, there is no guarantee that the slurred speech, loss of vision or weakness will get better.

There is a simple tool, known as the Cincinnati Prehospital Stroke Scale. If the patient has a problem with:

  • Smiling, the face should move symmetrically
  • Raising both arms: looking for weakness on one side of the body
  • Speaking, a simple sentence

Call 911

Stroke is stressful for emergency personnel as well. There are many hoops to jump through in hope that the patient is a candidate for tPA, the clot buster. The history and physical exam needed to qualify the patient takes time. Blood tests and a CT scan of the brain need to be completely. IVs, EKGs, catheters need to be in place and a long discussion need to be held with the patient and family. The risk reward equation is challenging. One third of 33% of patients may see benefit but up to 6% of patients may bleed in the brain because of the drug. Still, the benefit outweighs the risk, especially if tPA is injected as early as possible. The widow of opportunity runs our quickly. The magic number is 3 hours from time that the symptoms began, not the time that the patient showed up at the hospital door. That 3 hours can be extended to 4 ½ in some circumstances and perhaps up to 6 hours if there is an interventional radiologist or neurosurgeon waiting.

The sadness for many stroke victims is that they do not make it to the hospital in time. Instead of focusing on reversing the problem, the treatment team looks at salvage, minimizing further brain damage and hoping that weeks and months of rehabilitation will allow the patient to return to a functional life. For that reason, the American Heart Association has worked hard at including stroke recognition as part of basic life support. The public knows to call 911 for a victim with chest pain and the potential for heart attack. The public has to learn that the same urgency is needed for the patient with stroke symptoms.

Call 911. Time is brain

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