This article will be something of a departure from many of the above articles. Previous articles emphasized the unusually inefficient system we have and the enormous cost savings our system could achieve by reform. However, this magazine is called OMRUM (Optimal Medical Resource Utilization Magazine). The best (optimal) use of medical resources should not only save money as emphasized above but also maintain the core mission of any medical system, helping the patient. Hence, the following is a case review of a patient’s presentation which the author witnessed.
As a fourth-year (senior) medical student, one is given a number of assignments to expand the clinical skills learned in the third year of medical school. This author was assigned to an emergency room which was a “rotation” of medical school. The session in question was an extremely hot July evening. A patient in his early 50’s came to the ER because of exquisite right flank pain radiating downward and toward his midline of fairly abrupt onset. The pain was the worst he could recall in his life. He had urinated once since the onset of symptoms and the urine color was dark. On examining this most unfortunate patient, he could not find a comfortable position and was wiggling/writhing on the gurney. He was vomiting and objectively appeared very uncomfortable. His heart rate was in the low 110’s. He had no fever. Upon tapping mildly near his right kidney, the patient demonstrated “tenderness” (objective discomfort).
As those who have had some clinical background have now likely surmised, the patient presented with a kidney stone painfully marching from his kidney down his ureter toward his bladder. This was his first episode. As is true with many presentations to the E.R., the patient experienced excruciating pain and suffered greatly.
The good news was an emergency room is stocked with very good analgesics which can address exquisite pain such as this. The bad news is, without an order, the medication will not be given and this was the case with the patient who did not receive pain relief for 90 minutes (which, from his frame of reference, was several lifetimes).
After a few minutes of witnessing the patient writhing and vomiting on the gurney, the author asked the attending of record (the E.R. physician in charge of the patient’s care) why wasn’t the patient receiving pain medication. His answer was that the laboratory had not yet evaluated the urine and the attending would only give medication after blood was found in the patient’s urine (blood in the urine would support the diagnosis of a kidney stone causing all the pain). Absent that, the attending was concerned that this patient might be a drug user seeking opioid analgesics. Sadly, because the E.R. was packed, the urine evaluation would not be performed for over an hour.
This explanation was not satisfactory although as a fourth-year medical student, one has insufficient clinical depth to sort this easily. However, the problem could be better analyzed as this. The patient had 2 concerns-his primary concern was unremitting, odious pain. His secondary concern would be the correct diagnosis of the problem so that it could be addressedand (hopefully) prevented in the future. If, in good faith, the E.R. attending had given an opioid analgesic to an addict, there would have been little harm. Indeed, it might have given the physician a chance to discuss treatment options such as a rehabilitation center for the patient. In distinction, withholding treatment from a “more legitimate” patient was, in this author’s opinion, a grave mistake. As a primary care physician whose own patients have been so (mis-)treated, one can be assured that no patient managed in that way would be complementing the E.R. physician for withholding pain medicine just in case he was an opiate seeker. Rather, the patient will, for the rest of his life, tell people how horrible he felt (sometimes even experiencing it as a near-death experience) and how helpless, frustrated, and possibly even angry he felt that his excruciating pain was not addressed. For patients so treated, the system earns an “F”.
The choice made that day, in this author’s opinion, made no sense. 1 of the goals in fixing the medical system is to make it more adaptive. The patient’s goal was timely relief of pain and the attending’s goal was not to give an opiate addict opioid. In the new medical system, the patient will be an “owner” of his insurance plan as well as its insured. Under the new system, the patient could directly or after consulting with his PCP request a review of the timing of the pain relief. This assumes that overt malpractice was not committed but rather a system failure. In this author’s opinion, the priorities were confused. Giving the patient some ability to initiate a “root cause analysis” of the behavior so other patients would not have to suffer might offer some partial satisfaction to the patient for a very difficult situation. Although some primordial systems for this exist, they need to be expanded.
In summary, today’s article discussed optimal resource utilization to ameliorate patient care and improving the system’s adaptability. Each patient should be a shareholder in the care entity and should be entitled to offer feedback for the care given. A more fully invested patient will be a happier patient. This is also what the magazine is about.
Philip J. O’Donnell, M. D.