Relaxin’ in the ICU

by Armand Gelpi, MD

From: Sonoma Medicine, the Magazine of the Sonoma County Medical Association, Fall 2006

I enjoy convalescence. It is the part that makes illness worthwhile. -George Bernard Shaw

People must wonder if doctors react the same as their patients to expectations of hospitalization, surgery, pain, possible complications-even death-and to the attentions of other health care professionals. What goes through our minds in the weeks and days before hospitalization and in the early post-op period?

A week or so after undergoing carotid endarterectomy, I paid a follow-up visit to my surgeon. He asked me if I was scared when the staff prepared me for anesthesia before the operation. “Why such a question?” I asked. He said that I seemed to be so clinical and detached about the preparations for my surgery-waiting for the anesthesia’s early effects-that he thought I might be fearless.

I had to tell him that I was scared, but not with the rush-of-adrenalin, pounding-heart fear that one might have facing a burglar or barely missing an auto collision. No, it was an unrelenting ill-at-ease feeling that allowed me to think more analytically than emotionally, if only for a minute or so. I felt I was losing control and entering the realm of dependency, which promotes free-floating resentment, rather than fear.

Slipping away under anesthesia blends almost seamlessly with the confused awareness of recovery. The only difference is that something hurts postoperatively, and the hurt becomes discrete, propelling you awake. The first thing you do is to check if all systems are operating: close and open each eye, move each extremity, say something. And then, someone or something is moving you. Lights change overhead and doors go by on the side. A stop, a slide, then off the gurney and into bed. The side-rails go up with a clang.

Can’t kiss spouse because of nasal prongs and intervening lines and wires, but I wave, and then I clasp her hand. Spouse vanishes, smiling nurse materializes and looks at all attachments: EKG electrodes in place, wires intact, two IV lines going, one arterial line sending blood-pressure and pulse rate to monitor, and one oximeter clip-on attached to right index finger. There are comforting beeps, clicks, and muted bells. There is a quiet buzz of conversation among the nurses to-ing and fro-ing outside my door.

The ICU has 10 beds and six to eight nurses. I later learn that on this and the next two shifts, there are only eight patients: post-ops like myself, and terribly sick medical patients. For now, however, I only know that I am trapped, and that the pain is increasing… “Uh, we can start with Tylenol and then go with a little Demerol, if you need it,” says my nurse. I settle for the Tylenol, and within an hour or so (time is blurred, except when I try to fall asleep), I’m getting some relief. Enough so that I can let my mind wander, rather than have it riveted on pain.

With a little squirming, I can look over my right shoulder to the monitor that displays a continuous EKG trace: Man, look at those T waves! This is the EKG of an adolescent-an athletic adolescent-an adolescent who never has any chest pain or shortness of breath. The ST segment is horizontal-a string on the QRS-T necklace-neither elevated, curved, nor depressed. The oxygen saturation reminds me that I am still connected to nasal prongs. According to my nurse, I am receiving four liters of oxygen a minute. No surprise that I have 98% oxygen saturation. So far, so good. My situation could have been a lot worse: I could have been one of those terribly sick medical patients, with an entire staff of physicians and nurses trying to keep me going.

I do not want to read, even if a book or magazine were available. The light is poor; I am trussed up in bed and bound down by wires and tubes, with no good back support or head elevation; my mind is wandering; I am urinating frequently because of rapid IV fluid delivery; and my neck is stiff and sore. I might as well continue to daydream.

Lighter thoughts skip through my mind: I reflect on how lucky I am to be spared continuous music of the sort heard in an elevator or department store. If I could select my own music, I would probably be listening to a jazz ballad, or perhaps something profound and lovely, like Mozart’s Clarinet Concerto or Fauré’s Requiem. I guess I’m not quite ready for the requiem, however, as I seem to be recovering, and I fully expect to walk out of here tomorrow.

But what if things were not working out for me and I was faced with the final solution? Depending on age and attitude, death means different things to different people. To the very young, death often has little significance because it seems so remote. To the very old, it may seem a welcome event. To the very ill, it is often not appreciated or anticipated because of the never-never land in which they exist. A diminished life or an uncertain afterlife are not the hardest things to accept. No, the hardest thing to accept is oblivion. Oblivion is like thinking about eternity or the cosmos. One would rather think about a universe with borders, or circular time. But oblivion-that’s tough.

Our job in medicine today is to keep death at bay. It’s often a losing battle, even with the best intentions and the best that science has to offer. The demography of death hasn’t changed much during my lifetime. We can win a few battles by conquering disease, but we can’t win the war in our fight against death. And now, as I lie in the ICU, I can’t help but think about the other patients, wondering how they are faring. It’s one thing to have undergone some uncomplicated vascular surgery; it’s quite another to be recuperating-maybe in considerable pain-from something like a hip replacement, or worse. Then there are the medical patients: the cancer victims, pneumonias, and others. These are the ones whose souls are straining for release.

Epilogue

I was discharged on schedule and went home, even back to work, within a couple weeks. During that interval I had more reflections on my experience as a patient. I thought about the lack of “laying on of hands.” Patients are rarely touched; rather, they are monitored with the ultimate in modern technology. Does this distance between the patient and caregivers blunt the therapeutic response in subtle ways? Is there such a thing as a healing touch? Does a hand on the brow or a squeeze of the shoulder make the pill work better?

Actually, what I have written here was part of a rough draft that I submitted to the ICU staff. That version began a little differently: “Thanks for everything-your time, your dedication, your professionalism, and especially for neither addressing me as Doctor nor letting deference get in the way of good judgment. Hope to see you again, but under different circumstances.”

www.smcma.org
Dr. Gelpi is a Sonoma internist.

Pay for Performance? Don’t Hold Your Breath

by David Goldschmid, MD

From: San Mateo County Medical Association Bulletin, Nov-Dec 2006

Pay for performance. It sounds pretty cool. It sounds like a great idea. Who could say no? You can only imagine hearing Borat say something such as “I like.” There are a couple of issues that strike me as strange though. So why has it taken so long to approve the concept of payment for performance? I may be wrong, but if the federal government is advocating that physicians get paid for performance, I for one am owed big time for past performance for which I have not gotten paid.

If we are to be paid for performance, then when do I get my check? If we are to be paid for performance, then why is it that I do not get paid when I am awakened in the middle of the night to answer a patient’s questions over the telephone? Why is it that a surgeon can peer into the bowels of a human being in a procedure that results in the removal of a part of that person and get paid about as much as the cost of a good meal? Is that payment for performance?

Why is it that I must work on holidays and weekends tending to the Medicare-worried well (some of whom earn far more than I do) for less payment than my plumber or veterinarian? Is that payment for performance? Why is it that when I come in to see a critically ill patient in the middle of the night to snatch the patient from the jaws of death, the value of my payment seems less than the value of my sleep?

I want to get paid for performance. I am ready to get paid for performance and will be happy to issue a large past-due bill for the many times I performed but have not gotten paid.

Somehow, I doubt that the government has the honest notion that we should actually get paid for performance. Sometimes the message we get from our politicians is confusing. So what do you suppose this is all really about? Maybe they mean they want to sometimes pay us for performing a particular task in a particular manner. I think that is really what they mean. We should ask them to rename the program. “Payment for doing a few things we want in the manner we want, when we want, if you can prove that you did it in the way we want you to prove it.” Doesn’t sound as catchy, but seems more accurate.

In the end, payment for performance as a government initiative seems impossible to believe. After all, who in the government gets paid for performance? Well maybe the ones who put on a good show. Maybe we are completely off the mark in trying to understand what the government wants us to do. The dictionary defines performance in several different ways. Maybe we have misinterpreted what the government really wants. The dictionary defines “performance” as the act of presenting a play or a piece of music or other entertainment; “we congratulated him on his performance at the rehearsal;” “an inspired performance of Mozart’s C minor concerto.”

When we see a patient we are actually performing or acting in a manner. When I see the literature on patient satisfaction it seems to reinforce the notion that we are performing for the patient. Our behavior, movements, words, facial expressions profoundly influence what our patients think about us. Maybe the government means that our performances have not been very good, and we need to improve on the ballet we dance with the patient when we deliver care. Maybe they will pay us for a good performance, like they do themselves. Well, seems very confusing to me.

I think that no one really means they intend to pay us for performance for good medical care. I think perhaps they will be paying us for putting on a good show. Their constituents might believe they are finally doing something real to improve care. More likely, this is a way to find more reasons not to pay for care. That is something Medicare is pretty good at and finding new ways to get better. We need to stop pretending that this program is actually a clever way of improving medical care and expose the truth. We need to expose the real goals of “pay for performance,” and we need to demand that we actually get reasonable pay for reasonable care.

www.smcma.org
David Goldsmith is SMCMA President.