They Treat Horses, Don't They?

At a time when the American public is worried about the state of their medical insurance coverage and questioning the wisdom of the Health Management Organizations, and when Newsweek is running an article about the aforementioned issues nearly every week, it's probably no surprise we saw a bit of what I consider to be the fundamental problem with health care in the United States this week. I'm thinking specifically about the patient Carter resuscitated, despite her being marked DNR. This is horrible for staff and patient alike, but there isn't much we can do about it -- without proper documentation on-hand immediately, we're kinda stuck in a bind, and it's safer to go ahead and resuscitate than not and get sued for not doing anything or let someone die who didn't want to.

I don't know too much about the HMO system (please educate me), but what I do know worries me. My understanding is that approval is required from the insurance provider prior to beginning a diagnostic or therapeutic procedure; I also understand that the people approving or denying these requests are not physicians or nurses. To me, this sort of decision making is tantamount to practicing medicine without a license, so I question the legality of the system. But that's neither here nor there; Carter was left in a tough spot. He performed an apnea test, taking the patient off the respirator to see if she could breath on her own, and since she had spontaneous respirations, he discontinued the use of the ventilator. Her rhythm passed from normal sinus to ventricular tachycardia, which is usually treated with DC countershocks if the patient is unstable and lidocaine and procainamide if they are stable. It progressed from there into ventricular fibrillation, which is also treated with DC countershocks and drugs, and went into asystole, which doesn't have any really effective treatment outside of CPR, pacing, atropine and epinephrine. Since she was marked DNR, no ACLS procedures were performed. In Canada, she would have been admitted to the ICU (if we could find a bed for her, that is) where, given how fast she decompensated once Carter took her off the ventilator, she probably would have coded. The result is the same, but it would have cost more.

Kerry demonstrates that she's not really fit for duty as the head of the department, in my mind. As an attending physician, she has a responsibility to supervise the activities of the residents and provide advice to them when asked. Simply saying, "Deal with it," when Carter came to her with the problem of his accidental resuscitation is not an acceptable situation. He's a second-year resident, and while he needs to learn, he needs to be able to depend on his attendings to back him up and provide support, which Kerry didn't do. To be fair, Mark more or less Carter figure it out on his own, but it was at least better than simply saying "Deal with it."

I understand why Dana's parents were angry with Doug -- I've seen it enough and it bugs the hell out of me. For what it's worth, I agree with Dr. Ross; kids, particularly once they're over the age of 14 or so (but this age will depend heavily on how mature they are), should be told the truth about their medical conditions and allowed the make decisions about how they'll be treated. Overbearing parents are a pain in the ass, both for the patient and the physician. It's important for parents to be involved in the decision making process, but I firmly believe the final decision should, if possible, be left up to the child -- after all, they're the one who's going to have to live with it.

I had previously assumed that Dana suffered from a simple osteogenic sarcoma, but it turns out that she's got Ewing's sarcoma instead. This is a horribly aggressive tumor that doesn't give up easily; primary lesion sites are usually in the pelvic bones, femur, humerus, and ribs. It generally shows up in adolescents, though as with everything in medicine, there are no hard and fast rules as to when it shows up. The main predictor of survival is whether the tumor is metastatic or not, and in Dana's case (since I apparently didn't notice she even had Ewing's sarcoma in the first place), I don't know what Doug found. Resection is the treatment of choice, coupled with multidrug chemotherapy and radiation. If you really want to know, the standard chemotherapy for Ewing's sarcoma is an alternating course of ifosfamide and etoposide with VAdriaC (vincristine, doxorbuicin, cyclophosphamide, and dactinomycin). Despite all of this, Ewing's has a mortality rate approaching 50%, which is why Doug was so adamant about telling her the truth.