Saturday, August 05, 2006

Smack It Down, Take It Up

It was 10:30 and we'd been in the ER since 6:30. At nine a pleasant nurse finally brought my mother to a room, warning us that the doctor would not be in for another hour. At least there she was able to huddle under four blankets and a sheet to stave off the ungodly hyper-airconditioned chill of the department.

Late that afternoon my mother's wonderful, attentive doctor, a young alumna of my own medical school, had phoned up to tell me the blood tests were a bit worse, and she felt an admission to the hospital was warranted. There was no awful crisis, but she'd been lethargic, her anemia and renal insufficiency were worsening, and tests for various non-specific antibodies and markers of inflammation were alarmingly high. Could it be a bloodstream infection ? She directed us to the ER of a local hospital.

"Uh, could she be a direct admission ?" I asked, my heart sinking at the phrase "emergency room."

"No," she replied. It would be better to have a doctor examine my mother and review her admission labs. She'd call ahead and speak to the ER doc.

So five and a half hypothermic hours later father and I were shivering at my mother's bedside in the hospital's spiffy, renovated ER.

"I'm cold," my mother commented. "My nose is cold." We pulled the blankets up over her nose.

"My nose is cold too," said my cheerful Dad. "Now I understand why eskimos are said to kiss by rubbing noses -- it's to warm them up !"

The laugh lines around my mother's pretty eyes crinkled. The rest of her was buried under a mountain of blankets.

The doctor finally swooped in. He gave a hearty greeting, but it was easy to see that he was busy and a bit annoyed. I attempted a synopsis of the issues, mentioning the extraordinarily high sed rate and rheumatoid factor, and the possibility of infectious endocarditis.

He shot me a pointed, hostile look. "Oh, oh. In coming smack-down," I thought, flinching. Anyone who's gone through medical training will recognize it, this mini-PTSD response. To this day, I still can't approach a radiologist without steeling myself for abuse because of one unpleasant, sarcastic radiology attending from my internship.

"You don't get elevated rheumatoid factor in endocarditis," he sneered.

"Yes, you do," I hissed, my cheeks reddening.

I thought of the movie we'd seen over the weekend, a darkly comic, magnificently, excruciatingly grim Romanian movie, The Death of Mr. Lazarescu. It was about one poor, old fellow's last night on earth -- his voyage through four different emergency rooms full of various hostile, contemptuous, indifferent and frankly abusive providers, shepherded by an ambulance nurse determined to get him the care he needed. In one scene she makes the mistake of telling the attending MD that she thought Mr Lazarescu might have a colon cancer. She'd examined his belly, she explained, and it was rock hard. The doctor had smelled liquor on our hero's breath and had already dismissed him as just another alcoholic. "You pig," he said. "You drink yourself sick then expect us to make you better." He turned to the nurse.

"Colon cancer ?" he sneered, "So you're the doctor now ? A nurse, making a diagnosis ? Questining the doctor ? How dare you !"

Incoming smackdown.

The ER doctor finished examining my mother. Eventually he asked me whether I was some kind of medical professional.

"I'm a physician," I said. He became a little more respectful and explained that he didn't understand why my mother had been sent to the ER rather than being directly admitted.

"Frankly," I replied, after repeating her doctor's reasoning, "neither do I. But I am my mother's daughter, not her internist, so I did as she requested."

He went off to review her blood tests, ordered an EKG and a chest xray, and disappeared.

By 12:30 I was feeling addled and claustrophobic. I kept calculating how many hours of sleep I could get, factoring in drive time from the north shore to Waltham, supper (no, skip that, no time) and an alarm clock poised to go off at 5:30. I'd left a stack of paperwork unfinished at work. I'd have to go in early. Ugh.

"I'm cold. When will they bring me to my room ?" came a small voice from under the mountain of blankets.

I was cold too. I snuck a sheet from a shelf and wrapped myself in it. My cheerful father made a Ku Klux Klan joke.

I suggested my Dad go ask a nurse what we were waiting for.

Eventually, a nurse arrived and announced that the doctor was waiting to review one more test that hadn't came back yet.

"What test ? And when will it be back ?"

"A BNP.It will be back in half an hour."

BNP is a test for cardiac decompensation. One of the only major organs of my mother's that was currently, albeit tenuously compensated, was her heart. I grew impatient.

"My mother's doctor sent her here with the thought she would be admitted," I said. "Are you saying her admission will be based on this one test ? If, after being here over six hours, she's not admitted I'm going to be pretty pissed off !"

"We are the Emergency Room, and we have our own standards and protocols for admission. Your mother's doctor knows she has ways available to her to admit patients. If you are unhappy, you should take it up with your mother's doctor." She grew haughtier and haughtier by the word. "Is there anything else I can help you with ?"

My cheerful father piped up. I cringed.

"Yes, it's freezing in here. Can't anything be done about how cold it is ?"

"You can take it up with engineering," she snapped, and left.

"I'm cold. When will they bring me to my room," came the plaintive voice from the blankets.

Five minutes later the doctor returned. By now the ER was quieter. I had hit the four hours or less of sleep mark in my calculations, and my core temperature was headed toward the low nineties. I'd have to take that up with engineering. Or check myself into the ER for hypothermia. The BNP was normal, he said. He'd call my mother's doctor and admit my mother. He was sorry he'd been impatient. The night had been busy, and patients like my Mom -- who could have been admitted without a sojourn in the ER -- were not the ER's real mission, and racked up unnecessary costs.

"Take that up with my mother's doctor," I said.

Pretty good smack-down, eh ?

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