As night fell the intensive care unit called me to see a patient in trouble. I was a newly minted Family Practice doc in my 30’s, moonlighting the emergency room in a sleepy little Southern California hospital while serving a brief obligation to the Navy. I was proud of my education and confident of my skills, and I assumed the nurses on duty were caught in a dilemma and thought they might trust me to know what to do.
The patient was poorly responsive, sweating profusely, skin pale, cold, and clammy. Pulse was rapid and thready, blood pressure low, blood sugar over 300. Other than rapid heart rate, the EKG was essentially normal. Diagnosis seemed immediately obvious: diabetic ketoacidosis with life-threatening shock.
Treatment demanded two things: IV fluids to bring the blood pressure back up as quickly as possible and restore circulation to the brain and kidneys while reducing the strain on the heart. Plus administering IV insulin so the body can slowly begin to metabolize sugar again, instead of having to get its energy from fat, which creates toxic ketones and acidic wastes that lead to shock.
The ICU nurses, as usual, seemed already to know all this. They just needed a doctor to make the official diagnosis and write the orders. But I did not know them well, and they seemed somehow hesitant. The admitting doctor was a well-respected staff cardiologist, and his admitting diagnosis was rapid heartbeat with some chest pain, rule out heart attack.
I told them the diagnosis was not entirely correct; it might involve a heart attack but the man was clearly in diabetic shock and would die within hours if that aspect were not treated aggressively. I would call and speak with the admitting physician.
They got him on the phone. I introduced myself and described the situation, my assessment and plan, and assured him I would remain available through the night to monitor the patient’s progress. He thanked me and hung up. It was a very briefphone call.
The night wore on; the emergency room was seeing the usual minor emergencies. About midnight, the intercom came on with “Code Blue, ICU — Code Blue, ICU”. Somebody was in cardiac arrest, but I felt sure it had to be another patient — the last I had heard, my man was stable.
It was him, though. He was in full cardiac arrest, flat line. Now, I am good at CPR. I’ve brought more people back from the dead than Jesus ever did, not too difficult for an ER doctor. The nurses were already pumping his chest and breathing him with a mask and bag. I intubated him, thus getting control of the airway and preventing aspiration in case he should vomit. Then I began chest compressions while we administered defibrillator shocks. But there was no response at all.
I can circulate enough blood for the patient to wake up if the brain is functional, but he was still in a metabolic coma. He did not wake up. If a heart attack had produced electrical fibrillation, it would show on the monitor as a pulseless quivering line, and the heart would be reduced to an ineffective quivering muscle. An electric shock to the chest can convert fibrillation to normal rhythm and restore a steady heartbeat. He had no fibrillation pattern to defibrillate – just flat line.
The nurses explained that they had called the admitting doctor to report the patient’s status. His vital signs seemed stable but he continued unresponsive and still had a rapid heart rate. The doctor said to stop the rapid IV fluid drip, and ordered a sizable dose of IV Inderal (propranolol). The patient’s heart stopped.
Inderal is a beta blocker, a new class of drugs in the 70’s. They block adrenaline beta-receptors. To oversimplify, during fight-or-flight, adrenaline stimulates alpha-receptors to constrict blood vessels in the skin, while beta-receptors speed up the heart and send blood to the muscles. Taken in pill form beta-blockers lower blood pressure, and IV they dramatically slow the heart. They were a powerful addition to the cardiologist’s formulary, and we were all still learning how to use them. But I knew Inderal well enough to know the game was over. It would not wear off for at least a couple of hours, and we could not keep him alive that long. A few more minutes of CPR, a couple more shocks, and we called it enough.
I pronounced the death and wrote a note in the chart. I was furious. The nurses still seemed very quiet. I let them notify the doctor. I finished my shift.
I sincerely hoped that he was at home, drunk. That would explain his pitiful, incomprehensible behavior. I remember learning how to drink and practice medicine – I had an upperclass mentor in medical school who explained it to me. He said to always go to the bedside, no matter how late the hour, and never just give orders over the phone. You might get by with it, but if anything goes wrong, only the doctor at the bedside can fully understand the situation. He also explained how many times the police had given him a ride home in the squad car after they pulled him over. Those were the days.
After a day or two I wrote a letter to the hospital staff. I probably shouldn’t have accused the doctor of murder, but to me it wasn’t just malpractice. Any doctor can miss a diagnosis. But this was more like drunken driving leading to a fatal accident and a charge of manslaughter. I thought they’d want to know.
After a few days I got a call from my boss, the medical director of the emergency room. In a sad, quiet voice, he offered me the opportunity to resign. I objected that I was right, and he said perhaps so, but this doctor was a highly respected member of the staff and I was an unknown. I resigned, and fell into a deep and prolonged depression.
That was forty years ago, and yes, it seems like yesterday. And I still don’t have an answer. Certainly that was sickcare. The cardiologist was bringing in big money for the hospital – testing, medicating, catheterizing, referring. My role was to see enough patients to keep the ER open, but mainly to admit a portion of them to the hospital for more services, where fees were more profitable. And my special role as family doc was to sign off on the medical necessity of it all.
But anger and blaming are not the answer. We have plenty of that already in this country. Who wants to live in a world of such violence? Our major health problems – obesity, smoking, drug addiction, suicide – all are ways to avoid pain. So maybe poor healthcare is what we subconsciously seek and deserve. Let’s all die soon! Have a nice day!
I think there may be another way. It might involve conflict management and resolution. Instead of proving who’s right and who’s wrong, maybe we could look for ways to get along and work together. This would require honesty – deep and rigorous honesty. I want to propose a Foundation for Healthcare Transparency. I need founders for this foundation. Citizens who own one human body. No choice of sex, skin color, or family – but who would like to choose healthcare. Who are willing to research what that really means, and work toward making it happen.
You may have guessed that I believe there is one electronic medical record system that can help us, and it is old, not new. It is the VA system known internally as VistA, and it has already been shown to save patient lives without driving doctors to commit suicide.
More on this later, but for now, thanks for reading this. And I do need your encouragement
*One of my favorite writers, Lawrence Block, said to put your second chapter first. Don’t begin at the beginning