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.