CHOOSING WISELY...

Sometime ago an elderly man in his 80s walked into a hospital Emergency Room. He had a fever and associated symptoms of influenza. The symptoms cleared after two days in the hospital. Yet he stayed on in the hospital, moving from the Internal Medicine unit to the Intensive Care unit and thence to the Orthopedic unit and finally to the rehabilitation unit.

The crossroads of guidelines and mandates and the cross-currents of ambiguous thoughts create the bed where the conflicts between implied welfare and the resulting seeds of disastrous medicine take root.

On the third day, the potential day of his discharge he (our patient) became slightly confused. The order for an MRI was placed immediately and the results within 24 hours were negative for any pathology. The confusion continued and with it he developed a minor headache. Acetoaminophen (Tylenol) was prescribed that helped abate the headache temporarily. The confusion continued till the fifth day when he became slightly irritable. The reporting nurse asked the physician for assistance and that help came in the form of a sedative tranquilizer. The irritability subdued a bit but for the patient’s sake he had wrist restraints placed on him to protect him from falling off the bed at night.

On the seventh day, he developed constipation and an enema was ordered. During the daytime with assistance he walked to the toilet to relieve himself. Upon returning he had difficulty maintaining his balance and fell on the floor, in spite of the assistance. He was helped onto his bed. He laid there for 12 hours undisturbed due to his ordeal. On the eighth day while changing the bed sheets and rolling him over, the nurse determined his left leg was abnormally rotated. X-Rays were called for and a diagnosis of a left hip fracture was made.

After recovering from his surgery and a short stint in the Intensive Care Unit he was transferred to the orthopedic unit. All medications were renewed as before. His blood sugar levels rose requiring periodic dosing with Insulin for control. His mental disorientation waxed and waned along with the rising and falling tides of headache.

On the fourteenth day, the patient’s daughter asked the nurse what medication her father was being given. A list was proffered reluctantly. She questioned the need for the Statin drugs and a host of others including, Thorazine, Compazine, Insulin. She received appropriate answers for each of the medication and their need.

On the fifteenth day, the daughter asked that no further Statin be given to her father. The health care workers protested but the physician acquiesced to the daughter’s demand. The Statin was discontinued and on day twentieth her father was back to his former mental frame. He was discharged for home on day 21 with outpatient rehabilitation services.

This drama plays out in our institutions and at homes daily. In this case the need for the Statin to lower Cholesterol was a requirement at the institution based on the set guidelines.  Not heeding to the guideline would not win the hospital some useless award for the hospital and potentially risk the wrath of Insurers who would heave a financial penalty upon it. So they followed their protocol to the “T.” A Perfect Score! Yet, the entire chain of reactive medicine stems from the use of that particular drug in this case. Speaking of harm in medicine, maybe it is time to find the keys to that harm where there is no lamplight.

Trace back the history and you will see the folly in the Universal Guidelines that litter the medical scene. Population medicine harms the individual in such subtle ways that more harm follows if not for a careful and dedicated daughter in this case. How many daughters would question such benevolent dictates of the guidelines? Not many, I venture.

So, clearly much is to be reflected upon in our current state of medicine. As physicians are being trained to abrogate their right as critical thinkers, and legions of notepad -carriers scour the halls of the hospitals and other medical facilities in hopes of finding fault, something is gravely wrong in the field of medicine. The “evidence” we all seek to mollify our desire for the “best” practice of medicine through the lens of such correlational science is harming the very people we seek to heal.

Maybe it is time to rethink?