How We Do Harm (16 page)

During my first ER rotation, I realized that on a busy night I would see as many as forty patients, and at least a dozen of them were not physically ill.
Once you’ve recognized that nothing is physically wrong with your patient, your life doesn’t get easier.
Quite the opposite, it gets harder because (a) you don’t know whether you are right or are just missing something, and (b) she just might return to your ER in cardiac arrest forty-five minutes after you told her to go home and rest.
Eventually, gomers have to die, and many will experience genuine medical emergencies.
You want to make sure that you are not the idiot who sends a dying woman into the night.

To be defensive, it’s possible to admit Norma Shevchenko to the hospital, but admitting bullshit patients will quickly make you a pariah among your colleagues.
An ER doc who sends every Norma Shevchenko to the ward (or, worse, to cardiac intensive care) becomes known as a Sieve (another
House of God
term).
A Sieve has no ability to filter impurities, everything runs through it.

The opposite of a Sieve is a Wall.
No gomer gets through a Wall, but you don’t want to be a Wall, either, because eventually you’ll make a mistake, and a Norma Shevchenko will pay the ultimate price for your determination.

My decisions could have enormous implications on Norma’s life.
Depending on what I conclude—or what I guess—Norma would end up either in the cardiac intensive care unit or back at the parking lot.
Was this what she bargained for when she dressed up to see a doctor in the middle of a particularly distressing night?

*

AS
I examine Norma, I perform every test and scientific evaluation I can think of to rule out a cardiac event.
Then I perform them all again.
The result is unchanged: nothing suspicious.

On the way to see an attending, I keep asking myself whether I missed anything.
I can’t think of anything.
Nothing is obviously physically wrong with this patient.
Under
The House of God
nomenclature, Norma is a classic LOL in NAD—a Little Old Lady in No Apparent Distress.
She could probably use some psychiatric help, or perhaps simple human companionship will do.
I do feel compassion for her, but in my role as a second-year resident on emergency rotation, I can do nothing to ease her despair.

The attending agrees with me.
“Another gomer?”
she asks after I present the case.

I nod.

“It never ceases to amaze me how these people are just not sick.”
She signs off on my decision and I return to Norma’s examination room.
She is still in her examination gown, still hooked up to the EKG monitor, which is still showing a healthy heartbeat.

“Mrs.
Shevchenko,” I say, and wait for her to look up.
“We have checked everything we can think of, and we can’t find anything that would make us suspect heart disease.”

I am careful to say “we can’t find” any heart disease, because that’s really all we know.
I don’t say “you don’t have heart disease,” because there could be disease we haven’t detected, or disease preparing to strike suddenly, without warning.

I’ve had many patients argue with me when I give them news that would generally be classified as good: there is no reason to think that you have a lethal illness.
Luckily, Mrs.
Shevchenko doesn’t argue.
She seems accepting of my diagnosis.
It’s possible that she got what she wanted: a focused physical examination and confirmation that she is still among the living.

I catch sight of Mrs.
Shevchenko leaving the ER.
“Oh, shit,” I say to the nurse.
“What if she returns in cardiac arrest?”

*

A
patient such as Edna Riggs seeking to reattach a breast is very different from a patient such as Norma Shevchenko, whose problems are primarily existential.
But they do have one thing in common: their appearance in the ER is an indication of failure of the system.
Emergency rooms are the only places in America’s health-care system that are legally obliged to care for everyone—and then they get bashed for doing it.

The problem is vast, its cost enormous.
Yet, it’s studied mostly in snapshots.
One of the most intriguing of these snapshots emerged in a study by a group of researchers at New York University and Bellevue Hospital Center.
The researchers, led by Maria C.
Raven, of NYU, attempted to identify patients like Norma Shevchenko, repeat customers.
They identified 139 patients at high risk of returning to emergency rooms at urban public hospitals like Grady between 2001 and 2006.

Mean Medicaid expenditures for these patients were $39,188 and $84,040 per patient for the years immediately prior to study participation and immediately following it.
Perhaps not surprisingly, 56 percent of these patients said that the ER was their usual source of care.

Misuse of the ER is almost never the patient’s fault.
If you are poor and living in Atlanta’s inner city, good luck finding a private primary-care physician.
No mammogram for Edna Riggs.
As for mental health services—forget it.
It’s off the table.
No psychiatric social worker for Norma Shevchenko.

I admire doctors who are able to thrive in emergency medicine.
They put up with excruciating boredom that eats up most of their time for the sake of the adrenaline rush that comes with handling genuine life-and-death cases.
They get to save lives, and they are among the finest raconteurs in all of medicine.

Yet, after ER rotations at Case Western, I realized that I couldn’t be one of them.

Chapter 10

Saving Mr.
Huzjak
FRED HUZJAK’S HANDS
tell a story.
They are the calloused hands of a steelworker.
The rest of seventy-eight-year-old Fred Huzjak is in no condition to engage in storytelling.
I would never learn whether he even knew we had met.
It’s October 1986, and I am a second-year resident in medicine assigned to Hanna House 4 at the University Hospitals of Cleveland.

Mr.
Huzjak lies in front of me, obtunded, mentally dulled, eyes open, not responsive to questions.
I am not sure how conscious he is.
The guys at the ER who first evaluated him determined that he reacts to pain, but that’s about it.

Mr.
Huzjak was brought to the ER for “failure to thrive,” which is another way of saying that he doesn’t seem to have any idea of what’s going on around him.
His daughter brings him in because the family had realized that he had slowly grown unresponsive.
This is not unusual.
A sick person often does not talk or socialize much, and sometimes it takes the family a little while to realize that the familiar quietness has changed to unresponsiveness.

I look at the charts and see that Mr.
Huzjak has a plethora of underlying problems, including a five-month history of Stage IV non-small-cell lung cancer (NSCLC).
He was a pack-a-day smoker for forty years and has been treated for chronic obstructive pulmonary disease for the past six years.

The cancer had spread to both lungs, and to his spine, pelvis, and liver.
He was treated with cisplatin and VP-16 for four cycles over twelve weeks.
(In 1986, that was the standard of care, the best we could do.) The disease progressed while on therapy and treatment was stopped.
From that point on, the goal was to manage the symptoms.

Huzjak’s dry skin indicates that he is dehydrated.
That’s because he is too out of it to know that he needs to drink.
We can’t tell how much of his brain function is still intact.
We don’t know whether he is able to see or smell or taste or hear.
When we ask him to follow a finger with his eyes, he doesn’t.
He remains inert when we ask, “Mr.
Huzjak, can you hear me?”
His face is completely placid.
Is this because he has no control over facial muscles?
Maybe.

His extraocular muscles appear intact, though.
His pupils are equal and reactive to light and accommodation.
His neck is supple.
His lungs have some wheezing-breath sounds.
He has bilateral pleural effusions, fluid in the chest cavity.
This is common in lung cancer and prevents the lung from fully expanding.
He seems to respond only to noxious stimuli (medicalese for pain we cause in examination).
Labs show that his white blood count is 10.3 with a slight left shift.
This is doctor-speak for evidence of infection.

The systems in Huzjak’s body are failing in a relentless, rapid cascade.

*

IN
a big university hospital, you have patients who have private attending physicians and patients “on the service.”
Patients who are on the service don’t have a regular doctor.
They are almost always admitted through the ER and usually are poor and under-or uninsured.
They get care from the residents, with some input from an attending designated by the medicine department for the month.
At CWRU, we take pride in giving these folks extraordinary care.
Huzjak has a private physician, Jim Claren, a good guy, whom we residents like.

We enter Huzjak’s room and introduce ourselves to the patient even though we know he can’t respond.
You always work to show respect to the patient.
In the case of Huzjak, introducing ourselves may not help the patient, but it helps the family, or so you hope.
We introduce ourselves to the patient’s daughter, too.

I go through my usual introduction.

That day I have a team of two interns, Beth and Tony.

We ask Huzjak’s daughter what occurred over the past week.
She confirms the history: lung cancer that grew through chemotherapy, then, recently, social withdrawal.

We examine Huzjak and verify what we have been told by our colleagues in the ER and by his daughter.
When we finish gathering all the data, it’s 5:30 a.m.
I suggest to the interns that we wait till 6:00 a.m.
to call Claren, Huzjak’s private physician.
Even though we didn’t get any sleep, it’s better not to wake an attending for a nonemergency, especially if he is a decent attending who doesn’t abuse us.
At 6:15, we page Claren and he calls back almost immediately.

Beth presents the patient as I listen in on a second phone.
Claren remembers the history, a sign of a good doc.

“What do you suggest?”
Claren says.

Beth notes that we had started Huzjak on three antibiotics.
The goal is to drain the effusion.
We are hydrating him by IV and watching for fluid overload.
Claren agrees.

We can’t do a thing about the root cause of Mr.
Huzjak’s problems: the galloping lung cancer.
This man is near death, and we have to accept that we are helpless to stop it.
Allowing him to exit with dignity would be the only responsible, the only humane, thing to do.

Claren says he had repeatedly tried to get a DNR—a “do not resuscitate” order—from the daughter.
He tried at every office visit and every hospital admission after it became clear that the drugs weren’t doing any good.
Efforts along these lines are called “hanging out black crepe”—they are to lower expectations, prepare the family for bad news.
Alas, Huzjak’s daughter is determined to hang on to hope.

In part, this is about our culture.
As Americans, we are a never-give-up, pull-yourself-up-by-your-bootstraps kind of people.
To us, death is a failure of medicine.
Death has to be somebody’s fault, and we are generous in assigning the blame.
This ideology is unfair to patients who, as we say, “fail” therapies.
And it’s unfair to doctors, who fall short of producing miraculous cures.
Unable to accept the inevitability of death, we can’t make plans, can’t talk reasonably about our preferences for the circumstances of our passing and about what we want to happen after we are gone.

I wonder whether the Huzjak family’s denial of reality is in part caused by their reaction to Claren.
He is patrician, a person from a planet different from theirs.
His country-club sport coats, his bow ties, his penny loafers with dimes in place of pennies, are images the Huzjaks may find intimidating.
He is a good, compassionate doc, but maybe his message is coming through as patronizing, or simply hard to relate to.

Might class be larger than race for the Huzjaks?
Would the difficult message be heard if it came from a young black man who came up the hard way, who faced the same hardships they face every day?
It’s worth a try.

“Would you allow me to talk with her?”
I ask Claren.
(You don’t meddle with a private’s patient without his permission.)
“Be my guest,” he says.
“Just remember, the daughter has unreasonable expectations.”
He tells us that she was upset when Claren declined to give further chemotherapy, and she said no to hospice care.

Claren’s situation would have been easier had she simply fired him.
He would have been off the hook.
Yet she did nothing of the sort.
She let the doctor stay on the case, but rejected his recommendations.
She did not even get a second opinion.

When I arrive at Huzjak’s room, his daughter is in a chair, asleep.
I gently awaken her.
She is in her forties, obviously tired, obviously distressed.
I tell her that I know that this is a difficult time for her.
I tell her Mr.
Huzjak reminds me a lot of my father.
I tell her that I have had to deal with my father’s illness, which was similar to Huzjak’s.
My father, too, was a World War II vet, and he, too, had NSCLC and had a rough course with it.

I tell her that Huzjak is stable for now, but his condition will change over the next few days, and some decisions should be made.

“I would like you to talk with my brothers,” she says.

There is hope.

We agree to meet at 8:30 a.m., and I arrange for her to have a phone and some privacy.

*

AT
8:30 a.m.
I enter Huzjak’s room and meet his two sons.
They are in their forties.
Also, I meet the wife of a son and the husband of the daughter, and one grandson.
Something tells me that the sons, like their father, work in the steel mills.
I had recently watched the movie
Deer Hunter,
which was set in part among Slavic steelworkers from a rust-belt town.
I asked one of the nurses.
Huzjak is a Croatian name.

I explain that we are working with Claren, that he will be in later in the day, and that he asked me to talk with the family.
I explain the extent of Huzjak’s lung cancer.
It’s in the liver, both lungs, the mediastinum (the chest between the lungs), pelvis, ribs, and spinal bones.
We are concerned that it has spread to his brain (we’d need to do studies to find out for sure).
He has already received the best chemotherapy we have, and the disease grew despite it.
The cancer is progressing, and nothing can be done to halt it.