It will break your heart.
Somebody’s smartly-dressed, elegant grandmother is comatose. Hadn’t been to church. Goes every Wednesday and Sunday. Found in her kitchen in a puddle of vomit and stool, barely breathing. Had been healthy all her life. Prognosis very poor. In profound shock and admitted to the intensive care unit where every possible maneuver and diagnostic test is thrown at her. Codes several times during the night and on each occasion is snatched reluctantly from death’s jibbering embrace. Fluids. Fluids. Fluids. Horrific substances to goad the heart. Antibiotics. Chemicals. Ions. Suction. Dark blood in the canister. Pink froth in the breathing tube. Tubes. More tubes. A bamboo grove of tubes and poles. Lights. More lights. Scrolling banners of green lights telling the news. Bells. Doctors. More doctors. Somebody will decide if she is brain dead in the morning. Organ procurement starts to circle expectantly.
Urine drug screen positive for cocaine. I guess that explains the tattoos.
Death of a Paradigm
In days of old when kindly doctors smiled beatifically on appreciative patients and carefully diagnosed them them through a combination of a careful history and skillful physical exam there was what was known as the “Review of Systems.” The Review of Systems was a careful series of questions starting in a very general manner and becoming more specific as the patient thoughtfully answered questions. So important was the Review of Systems that the physicians of those bygone days bragged how patients themselves told you everything you needed to make the diagnosis, no matter how obscure it might be, and expensive labs and imaging were only really necessary to confirm what was ridiculously obvious.
We don’t have the Review of Systems today. Like the physical exam and other quaint medical traditions, it has fallen by the wayside. In fact, in our soft, entitled age where my typical Chief Complaint is “Vaginal Discharge, Headache, and Cough” I hardly know where to begin and I grow fearful of asking questions lest I uncover another problem to fit into the crazy constellation of medical, lifestyle, and psychiatric problems that is my usual patient.
I don’t dare ask about Chest Pain, for example. Everybody has chest pain nowadays. I even have three-year-olds whose mother’s write on the the Triage Sheet, “Diarrhea…and Chest Pain.” Then they look at me like I’m an idiot for not getting an EKG. Headaches? Please. Every headache is now “The Worst of My Life” and a “Twelve” on the regrettably ten-point pain scale. Abdominal Pain? Don’t make me laugh. It’s there, It’s excruciating, and it’s ubiquitous.
Instead of questions, I find myself relying on subtle hints and careful observation to ferret out the real Chief Complaint. If, for example, I walk into the room and the patient is stuffing his face with a cheeseburger their abdominal pain is likely a red-herring and I can probably safely ignore it. By the same reasoning, if I find the patient texting and laughing with her friends my suspicion for meningitis decreases precipitously despite the triage note listing “Fever, Ten-out-of-ten Headache, and Vomiting” as the presenting symptoms.
And you’l laugh at my naiveté but I only recently realized that many of my well-looking, happy, healthy patients with a dire Review of Systems but a shiny, sparkly physical exam are, in fact, looking for a work note and are not sick in any manner whatsoever. I’m a proud cynic but I did not want to believe anyone would purposely waste a half hour of my time just to avoid work. At least ask me for some drugs. Have a little respect.
So we toil along, trying to sort it all out. Occasionally I get a patient who denies almost every problem except those related to his chief complaint and I marvel that I can get the correct diagnosis, like those Giants of Old, almost every time.
But for everyone else I’ve started asking, “On a scale of 9.9999 to ten, how bad is your pain?”
Took a little break from writing. Maybe I got tired of hearing my own voice. Maybe I was fed up. I had the urge to bang out an article many times and just as many times I looked outside at the sun and decided to go mountain biking instead…or take the dog to the pond…or do anything but bay uselessly at the Internet moon.
They say that writing is therapeutic but I find it the opposite. It may have been pleasant initially but writing eventually became a tortuous obsession to which I sacrificed sleep, family time, and maybe even a little perspective. My blog contributed to my divorce and maybe I could have used the sleep, especially because, as you may recall, I was a sleep-deprived resident when my blog was at its peak.
And I must confess that the absurdity of American Medicine has finally overwhelmed me and I have come to accept that it is just a smaller part of the rapidly accelerating absurdity of American life. I work pretty hard and though it is not uncommon to for me to see forty patients in a 12-hour shift (with my record being 52) and although I often walk into the department with everyone in a panic because four ambulances have just rolled in and the department is packed with a full-to-capacity waiting room, three of the ambulances are non-acute patients with a little bit of stomach flu, the fourth is a routine elderly chest pain resolved with one sub-lingual nitroglycerin, and the waiting room is mostly colds and back pain.
I’m not exactly saving the world. Out of forty patients maybe ten have medical problems that really need to be addressed and four have real emergencies. I’m kind of naive as I mentioned above so one day, after examining a well-looking twenty-year old and finding absolutely nothing wrong I realized that he had waited three hours to be seen because it was Sunday night and he wanted a work excuse.
You can do that nowadays. Tie up a nurse and a doctor for twenty minutes without having to pay a dime just to get a work note, or a pregnancy test, or drugs, or any and all kinds of things that do not need this kind of attention. And nobody cares who can do anything about it, locked as we are in the suffocating coils of the bureaucracy and the lawyers. We are a nation now fit for nothing but decline, led by the worthless and directed by the likes of those overweight blue-shirted TSA agents who through some kind of utterly bizarre logic strip-search a mother with her three toddlers, chemically test her formula to make sure that this harried suburbanite from Des Moines has not substituted Semtex for her Enfamil, and completely ignore a big, dangerous-looking, unshaven guy like me.