Of them all this story cames to mind first today.
I was working ICU one night when emergency called me. I was asked to assess an old Ukranian man whose Gastroenterologist had admitted him for an elective gastroscope. The gastroscope had just become available and overnight the medical beds for GI were being used increasingly solely to allow the gastroscope procedure. Because it was a novel procedure whose risk wasn’t fully known at the time, the assessment, usually a half hour to an hour was paid thousands of dollars. It became a controversial fee schedule item because the risk turned out to be minimal yet medicine was getting paid more for this procedure than surgeons were getting for other actual operations with far greater risk and requiring far greater training and skill.
I didn’t know any of this at the time
I just went to the emergency where the patient had been noted by the admitting ER doctor as having palpitations and chest symptoms more significant than his GI symptoms.
Not uncommonly posterior heart ischémia may show up as acute upper abdominal pain. It’s one of those diagnosis that are often hard to sort out at first.
The ER doctor felt just such a mistake had been made and that the patient should spend the night monitored in ICU because of the suspicious EKG, électrocardiogram he’d done.
« I don’t want to ze another docteur. My doctor is the best doctor. He say I have an ulcer. I have an ulcer. There is nothing wrong with my heart. »
Screamed the little Ukranian man
I arrived to over hear my colleague explaining the need for him to see me. A plump little older man , obviously afraid and quite overwhelmed by the ER. .
While coming here I had had 2 more calls and had only one more ICU bed. My main focus was making the right call but I didn’t like using up my last bed so early in the night.
Mr. X I’m sorry. We’re just concerned for your heart. If you’re doctor is going to do something stressful tomorrow you’re going to need it in good shape so we have to check it again. ». The ER doctor was trying to get the man to accept the tech doing the full EKG but he’d rebelled as the goo being put on his chest.
« I don’t need it chccked again. If my doctor thought I needed this he would have ordered it. Now go away. I want to go to bed. I need my rest for tomorrow. » he insisted turning on his side and showing his back to the doctor.
I stepped through the curtain and said, « I’m here to decide which bed you’re staying the night in so lets let the technicians check your heart again. »
I was blessed to have this authoritative manner and in this situation came off as the bad cop to the good cop, my sweet ER colleague and friend. The man turned on his back and accepted his fate.
The tech spread the goo put on the leads and we got another EKG. There had been more anomalies on the lead but this EKG showed that the single inverted T wave which had looked suspicious in the admission graph was now joined by more since I got the tech to place the leads to get a better picture of the posterior wall of the heart.
No longer merely suspicious the poor old guy’s EKG looked like he was about to have a myocardial infarction right in front of us. Probably from the stress of admission was worsening something brewing for days. Whether there was ever a GI problem was now irrelevant, his heart was what was causing his pain and if the right thing wasn’t done fast it might well do him in. Even now the guy was asking for ‘tums’ because ‘my stomach is hurting ‘something bad’. My ulcer is terrible. Call my doctor. You leave me alone. » he said holding his chest not his stomach while my colleague was ordering morphine.
I told the ER doctor « « I’ll take him. Good call »
« Thanks. » he said relieved. He had one less concern in a ward full of emergencies. He was also thankful he’d caught the anomaly.
« I m taking you to ICU. « I told the little guy. I explained his heart needed monitoring and was very nice about it as the nurse was giving him some nitro instead of tums. My beeper was alarming. I’d another call where they wanted a patient in general medicine assessed for possible transfer. There were problems in the ICU. Three or four emergencies were happening at once. This was par for the course And I was facing with this resistance in the ER.
My beaper continued to scream. The old man had turned his back on me and said. « I’m not listening to you. I’m only going to do what my doctors says. »
« Mr. X I’m transferring you to ICU where you can be watched all night by the very best nurses and we can keep that monitor on your chest to watch your heart. »
« I don’t want to go. I want to go where my doctor wanted me to go. »
It was to be the beginning of my gift for clarifying difficult decisions for patients which stood me in good stead over the next many years practice. My skill in what has been termed ‘plain English’ has saved countless lives but has got me in trouble with administrators and others as many times. I believe these other idiots would have served the world better by staying in English or fine arts discussing philosophy in the safety and confines of the university and the limitations of their minds would have done less damage. I’d learn over the years that many people die because so many people speak as if they are lawyers talking to people so that the ‘record’ would show them speaking in ‘politically correcct’ ways. They appear to have a genetic lack of common sense. Sick people just can’t make sense of their adultérations of the English language. I on the other hand have a gift for speaking plain English. It’s saved countless lives and never killed one sick person. It’s truly offended malingerers, administrators and psychopaths though. . There’s marvellous clarity in plain English. There is tremendous obscurity and ambiguity in legal English and beurocratic English.
« Let me make this simple for you , sir. « I said. « I believe if you come with me to the ICU you will live but if you go to a general medicine room where you won’t be monitored you will die. Would you like to live or die? »
He accepted the move to ICU.
I came out of the ER with all the nearby staff smiling. I had a knack for saying things that others feared saying because they had to pay the rent and put their kids through school.
I had hardly assessed another case when I got a 99 call to the ICU.
Mr. x had hardly been hooked to the monitors there when his ‘abdominal pain’ got very very bad. His QRS rebelled and more T waves spiked as he made his last call for ‘tums’. I was there giving him morphine when the heart simply stopped beating and Mr. X stopped being in this world. I had the the benefit of the best nurses in the world, respirator and all the right medications handy we kept him going. I even inserted a Swan Ganz monitor and saw his pressures so was able to work miracles. At this time we were just learning about pre and post load on the heart and the right medications for reducing the heart work while keeping it pumping. We could jump start a heart with adrenaline but just because it was ticking didn’t mean it was working. The swan Ganz was one of the medical break throughs I was there to behold.
We did it all right and rather miraculously brought the poor guy back from the grave when the staff man for ICU came in. The heart enzyme CPK at the time was spiking and the great ICU staff man did his magic with adjusting the flows and dosages for the meds for pre and post load . He was amazing at ‘fine tuning’. Like most surgeons I had a slash and burn approach to such situations excellent in the emergency but really out of my depth when it came to the finest details that made all the difference in the next hours. My staff man was thankful for the Swan Ganz. I got a well done for getting that in first so we could ‘see’ what needed to be done. We were in the scarey part for a couple of hours before we were sure he’d pull through and the heart was no longer throwing PVC ‘s and the the EKG had normalized with blood gasses coming back happy.
We’d had to pull in the other resident from home to help manage the ICU that night because this old guy took all my time. The incredible staff man stayed and advised everyone on my cases and the other cases at the time. I don’t know how many times he stayed up all night with all the staff but was there the next day running the ward and teachinga and managing all the mundane matters regardless. One of the great teachers of many I’d be blessed to work with at University of Manitoba. .
The family of the old man were so happy in the morning.
His doctor wasn’t.
« Stole my patient, didn’t you. ». He said in an aside.
« Stole your patient? » I said in befuddlement.
« Never mind. « he said and stomped out of the ICU.
He had glowered at me and frankly I didn’t have a clue what his problem was. He’d misdiagnosed his patient, something any one could do, The ER doctor caught the error and I made the right decision to admit him to ICU. As a team we’d saved his life. The patient was alive and well and the family was there caring for him. His beautiful daughter and her husband thanked all of us.
He recovered well and a couple of days later he was discharged to the Medical ward for a couple more days before going home. He’d had a myocardial infarction of the posterior wall and had to be a week in hospital before discharge. The politics were such that he went to the admitting ward and cardiology consulted.
That’s how I and the other ICU resident, several Cardiology interns and residents were on the GI ward to see him during consultation rounds
This delightful old man jumped out of bed upon seeing me and threw his arms about me kissing both my cheeks and thanking me. « I want to live! « he shouted triumphantly sharing the inside joke. « Thank you. Thank you. ».
« You save my life doctor. Here. Take this. Take this. : He thrust a magnificent painted wooden Ukranian Easter egg into my hand It was truly beautiful. I tried to refuse it but he wouldn’t let me.
The cardiologist ,a stiff upper lip Brit had been clearing this throat all along , not amused by any show of emotions, especially on his almost military medical rounds. He finally said, ‘yes, Mr. X, but we must carry on the rounds. Come along. Come along.
When we were further down the hall, out of earshot, he turned to me and said.
« Dr. Hay, you must discourage such histrionics from patients. It’s not proper. Now you can keep that trinket if you want. You obviously earned it but do speak to the man about proper decorum for the hospital. We simply can’t have patients shouting even if it is with glee and we certainly don’t want them kissing us on the cheeks. Teach him a proper hand shake would be sufficient. »
I was laughing inside at this obvious clash of ‘culture’. The whole of my career I’d watch doctors believe that their culture and upbringing was the only ‘proper’ way to behave and demand others around them conform to their opinions. I was amused along with my younger colleagues who joked about the cardiologists ridgidity and lack of emotion. He was everything British and probably considered all Ukranian men ‘gay’ because they commonly in my experience expressed their emotions unreservedly.
My classmate was a Ukranian who was part of the Canadian Ukranian dance group. We’d drunk vodka and danced like Coassacks at many a Ukranian party over the years so I’d met my share of Ukrainians. . Just as living in England I’d seen how Spock like many English especially those who’d served responded to emotional challenge. It was to be admired. Monty Python however made the best jokes about English reserve. Our Cardiologist could have starred in a number of their skits. It was indeed that very English réservé that gave rise to the marvellous British humor I so enjoyed.
Well it was great this guy lived and I have that egg still if only to remind me of the wonderful times I had on ICU where life and death were right there and doing the right thing could result in immediate success.
A couple of days later I came back to see the old man in an ICU bed. I’d been off a day and he’d been admitted while I was away.
« What happened » I asked the nurse.
« He had another infarction on the table when he was being gastroscoped. » she said with obvious disdain.
« He was being gastroscoped!? » I asked with shock.
« His doctor didn’t want to waste the bed so scoped him insisting his first diagnosis of ulcer was correct and he wanted to confirm it. »
Not only had the guy ‘missed the correct diagnosis’ but now his ego was in play trying to prove he was right all along. The bastard. We all figured too it had a lot more to do with the $2500 scoping fee and the war going on over the GI beds and the new hospital scopes which were being shared between surgery and GI. The joke was everyone was getting a scope on GI because everyone could use an easy $2500 for a half hour work.
When a favourite patient was made sick by nonsense the staff and myself were none to pleased. But we were just working there.
The key though was the tried and fast rule which said ‘no elective procedures to be done after a Myocardial Infarction for at least 6 months.’ Cardiology hadn’t been consulted and neither had ICU. The GI doctor had done a quickie hoping he’d get away with it but now the cat was out of the bag. We could all tell the head of ICU was unhappy. When the brilliant British cardiologist came by he was pleased to see the man was coming around but let it slip, under his breath, « this was totally unneeessary.’ I think the ICU doctor was as miffed at the unnecessary use of an ICU bed because at the time we were overwhelmed. It was before the hospital administration descided in their wisdom to do nothing about overcrowding but start calling the hallways of the hospitals ER and ICU.
The poor man’s heart showed that he’d extended the infarction. His enzymes were all elevated and the EKG had flipped the t waves again. The staff man himself had put in another swan Ganz and was carefully monitoring the medications. We were all pleased with the man’s ins and outs. He was soon off the intubation, breathing well on his own and in a few days discharged to the regular medical ward. Twice now he’d escaped death.
The man was discharged to the medical ward. All seemed to be going well.
The daughter and her husband approached me a day or two later when the man was to be discharged. This beautiful young woman was frantic.
« My father received this note and he’s going to do as he’s told. He’s Ukranian, old world. He does what the doctor tell him. But this is insane. » she cried showing me the note the GI doctor had given the old man.
It said, « because mr. Xsky had ‘not cooperated with the gastroscopy it would be repeated next week » at another hospital. The hospital named was and suburban hospital without university affiliation so no troublesome sorts like me and the other residents. No university oversight either.
Unbelievable. The doctor who’d been confronted by the Cardiologist and ICU doctors about his doing ‘elective’ procedures post MI was bypassing the teaching hospital system and arranging a ‘scope’ a week later at a hospital without the oversight or even the excellent ICU back up that had twice saved his patient’s life.
I ‘borrowed’ the letter and gave it to the ICU head.
« That bastard. » he whispered. « He’s going to kill the little guy for his ego and $2500. Unbelievable. « He said that spontaneously and then turning to me apparently upset at himself for speaking negatively of a colleague in the presence of the junior staff said formally , « Thank you for bringing this to my attention. It was the right thing to do. We’ll take care of it from here. »
Next I saw the cardiologist, come by with his stiff no nonsense walk. Then the rumors began.
The GI specialist actually lost his privileges at the teaching hospital. His colleagues professionally removed him from the hospital and the university. He’d been a professor and literally stripped of everything. My case was apparently the last straw. He’d continue to work at the local hospital, sadly without oversight. But it was a real lesson in good medicine. It didn’t matter how senior you were your senior colleagues weren’t about to let you kill patients for profit or ego.
He came by and almost spat in my face the last time I saw him.
« This is all your fault. You fucking little shit. You’ll never be a doctor. How dare you have questioned what I was doing. You know nothing of medicine. I’ll ruin you. I’ll ruin you you little prick. »
All very properly and quietly said with just the right touch of ‘hiss’.
I spoke to my staff man.
« You did the right thing. The guy was wrong on several accounts. Not the first time. Either. Made other mistakes and wouldn’t learn . I’ve had to clean up his botches before as had the Cardiologist. I don’t know why he’s come after you. Probably only because you’re junior. He wouldn’t dare to come after us. He’s no longer in the unniversity but he’s lucky to have his license and still be able to admit to any hospital. Still watch out. He’s not a good doctor but he has some powerful political friends. Guys like him don’t survive this long alone. So they have allies in the rudest places. But don’t worry. You did the right things. You saved a man’s life. He would have died for sure if you hadn’t told me. His daughter saved his life really. Lovely man with a lovely family. Now don’’t worry about it. You can’t do the right thing without getting enemies but you’ll always gain allies in this too. You’re a good doctor. Just keeping doing good work. «
The Easter Egg sat on my desk for years as a reminder of many lessons.
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