Why Physicians Matter: Jon's Story

Jon.
A human being, suffering.
Transferred to the lady, a hospitalist,
at an 18-bed critical access hospital near his home.
For sub-acute rehab, apparently.

As paramedics wheeled him in,
she knew he was dying.
The look on his face, and
the look on his devoted wife's face, spoke volumes.

She was handed the 4-inch transfer packet.
Discharge summary on top.
“Failure to Thrive” was the “top” diagnosis
“Edema resistant to diuretics” was second on his list of diagnoses (??!!)
and the obligatory 20+ additional (useless) (billing) diagnoses followed suit.

How?

How was this man sent here to “get stronger”
when he was water-balloon head-to-toe-swollen
without a diagnosis….or a treatment plan?
(administrators know how).

Peg tube.
Too weak to pick up his head.
Gasping between words.

Wife hovering.
Critical access hospital.
Not a single sub-specialist.

How??

$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

She sat with pen and paper.
Sifting through the extensive hospital records.
Jotted down notes, increasingly aware of the
dangerous
unconscionable
happenings in corporate health(no)care.

“Formerly healthy.”

That phrase struck her
because it was almost unbelievable.
Jon had been healthy 10 weeks prior.
Somewhere in all the cut/pasted notes,
that critically important fact was lost.

Gone.

He was now a placement issue.
From community hospital
to city hospital
to tertiary care hospital for “subacute rehab.” 
A “dump.” 

Daily notes 17 pages long,
without direction of thought.
Details drowning
within the depths of
mindless upcoding chatter.

Same notes
over and over.
Jon saw every 'sub-specialist' Nurse Practitioner/Physician Assistant
one could think of.

Sick.
Very sick.
Too many “discussed but did not see/agree with above”
Physician attestations.

How??

Jon,
worsening despite being “formerly healthy.”
Replaced by the ominous
“failure to thrive” diagnosis.

Jon was dying.
4 echocardiograms and 1 trans-esophageal echocardiogram had been performed. 
All had been read as “normal.”

So so swollen.
No idea why.
The answer: “get him to a subacute rehab” so he can “get stronger.” 

(You know why…..)
(I know why……)
(The formerly healthy Jon and his worried wife have no idea why…)

The lady hospitalist was trained in Internal Medicine.
She could not accept this.
It is ingrained into her brain to
treat the patient, not the results (or lack thereof).

The diagnosis is somewhere
in the history and physical.
Keep thinking.
keep digging.

The details matter.
This patient matters. 
Her training matters.

Talk to the patient.
Examine the patient.
Listen to the patient.

Over and over again.
And again.

Ask more questions.
Create a story.
Talk to your colleagues.

Patients need you.
You are their voice.

With her 2 pages of notes in hand,
the lady hospitalist sat down at the bedside 
and spoke with Jon and his wife.

Examined him.
Laid hands on him.
Got more history.

She didn’t sleep for 2 nights.
He had been there for 3 days. 
His vitals were worsening.
He was a ticking time bomb.

She reviewed every imaging study herself.
She asked the local general radiologist for a favor.
He cannot bill for studies he did not order.
Studies that have already been read, signed, coded, billed.

She told him everything she knew.
And cut by cut, he took his time. He looked.
And then, “the pericardium looks a bit off.”

He had 4 normal echos
and 1 normal TEE, she told him.
Radiologist said “get another.”

She let the on-call cardiologist to the small rural Critical Access Hospital know…
Jon is going to have his 5th echo.
Because the pericardium looks “off” 
to the nice local general community hospital radiologist who had done her the favor.

She pages the cardiologist 
Gives her the “heads up” that the tech is sending over the echo images.

Tick. 
Tock.

Jon is dying. 
Failing to thrive. 
Time is of the essence.

She gets a STAT call from the cardiologist an hour later.
“Get this man to a CT surgeon ASAP.”
“Restrictive filling patterns in diastole.”

Oh my God.

She gets him transferred back to the tertiary care hospital stat.
Jon’s pericardium is removed.
“Thickest one I’ve ever seen,
like the skin of a navel orange,” says the cardio-thoracic surgeon.

Apparently very easy to miss on echo.
Apparently was subtly present on
Jon's first echo, the one he had done 10 weeks prior.

The one “read” by the fancy tertiary hospital cardiologists, radiologists, internists
with their teams of Advanced Practice Providers in long white coats.
Who rounded on Jon daily.
Who wrote the fancy-sounding 17-page progress notes, discharge summaries, consultation requests.
Who transferred him to subacute rehab so he could “get stronger.” 

POST-SCRIPT

Jon loses all his water.
Jon breathes,
and eats,
and talks,
and walks.
Jon recovers.
“presently healthy.”

Corporate health(no)care:
        Failing to thrive.
        Presently very “unhealthy.” 
        Dying. 

Thank you, Jon, for allowing us to share your story.
Thank you to the nice community rural hospital radiologist who took the time to over-read Jon’s prior echocardiograms and recommended the 5th echo. 
Thank you to the cardiologist-on-call who didn’t scoff when she was paged to read an after-hours echo on a man who had 4 normal prior studies. 

Most of all, thank you to the persistent lady hospitalist whose training matters. 

Who shared Jon’s story.

Who persevered.

Who didn’t give up on Jon, on his wife, on his children.  

Who reminds us all of why we became physicians in the first place.