The Other Side

It is hard being on the other side.
Twice in the past few months I've had a family member near death with a medical problem. I've felt helpless, and  worse.

First my wife's father - and my next door neighbor -- was hauled into the hospital by ambulance while we were up huckleberry picking. They worked him up for chest pain, but really it was upper right quad pain with vomiting after eating corned beef hash. I know -- gallbladder right?  Seems the hospital they took him to (not my hospital) never even worked him up. He got an EKG and some morphine and zofran in the ambulance. They did a PO fluid challenge and sent him home.

I had to talk him into going to see his provider, who set him up with an ultrasound for stones. No stones, but he kept getting worse. I didn't want to be intrusive, so I didn't check on him -- and anyway I was busy working. He continued to get worse. Finally he went in for a follow up, got a CT and was recommended to a surgeon at another hospital. His gallbladder had burst, and he'd been walking around for two weeks like that getting septic. The surgery was massive. He was on TPA for two weeks and went home with JP drains. He's doing better now.

A few weeks ago my mom called to tell me my sister was in the hospital. She had a cough that her doctor thought was pertussis. Follow up Xray showed shadows, CT showed fluid building up around her heart and lungs.

I visited her in the hospital while she was getting her tests and fluid drained from her lung. She was across the hall from where my mom recovered from her cancer surgery one year ago. Her husband is an RT, he and I knew too much, based on the tests, based on the language that they used. She was getting worked up for Cancer. Mindy and I talked about it. She had been my mother's caregiver exactly a year ago when mom was fighting lung cancer. She knew the drill but mom's cancer had been caught early and by accident.

"You know it's bad when you doctor calls you personally and says I'm sorry and starts sobbing on the phone," Mindy told me. "All my doctors start with an apology. I always thought I'd get cancer, it seems like everyone does, but not this early. Not when I'm this healthy."

Her cancer is stage 4. If she is lucky and with chemotherapy, she may live to see her 16 year old son graduate from high school.

I feel helpless. I don't know what to say or do. So I talk to her as a patient when she asks a questions and like a brother who loves her when I can't do anything else. I can explain things when it hurts. I try to cry when she's not looking.

The history of the Dainese airbag system

Regulation vs. Self Interest

Interesting article by Tim Noah at Slate (Anesthsleazeology) regarding the inter-profession conflicts and how they influence healthcare regulation. Noah, like most writers, is pretty confused about a lot of things (the difference between RNs and CRNAs for example) but he brings up a couple good points about the future of healthcare. Alabama  is proposing regulations that would prohibit CRNA's and NPs (and presumably PAs) from doing interventional pain management.: It states:  "The interventional treatment of pain may be performed and provided only by qualified, licensed medical doctors and doctors of osteopathy" because it "constitutes the practice of medicine."


Of course CRNA's do a lot of work in rural areas. I worked at a rural hospital that had a busy surgery running all week. We used nothing but CRNA's and most were fantastic. Noah says the Alabama law is born out of a conflict between CRNA's and Anesthesiologists.

 Unsurprisingly, the Alabama medical board's proposed rule arose from a complaint by an anesthesiologist about a "disturbing situation occurring in several facilities in Alabama where … [a CRNA] was providing epidural steroid injections to patients." The anesthesiologist claimed this practice threatened patient safety and asked the Alabama Board of Nursing to stop it. The state nursing board ruled that the anesthesiologist appeared to have an economic interest in preventing nurses from performing these procedures, said the nurses were authorized to perform them and had been doing so for some time, and told the anesthesiologist to buzz off. The spurned doctor got a more sympathetic hearing from the more physician-centric State Board of Medical Examiners.

There's no evidence that CRNA are any less safe in performing the interventions in question, Noah writes. Indeed he cites evidence to the contrary.

Earlier this year, the peer-reviewed journal Health Affairs ran an article under the self-explanatory headline "No Harm Found When Nurse Anesthetists Work Without Supervision By Physicians." The article drew on the experience of 14 states that let nurse anesthetists work unsupervised by doctors when treating Medicare patients.  

Advanced practice nurses are often seen as a solution to two of the big problems in the American healthcare system - cost and access to primary care. CRNAs are well paid, but cheaper both to educate and to pay than MDs. There's also the question of access, Nurse practitioners are increasingly becoming the only accessible primary care providers because more and more MDs specialize and avoid primary care. Similarly, you're going to see more CRNAs out in rural areas that cannot afford to have Anesthetists.

The notion of allowing nurses and doctors' assistants to perform routine medical tasks in order to reduce medical costs and make certain services more widely available is controversial only to the particular doctors whose economic interests are at stake (and not even always to them). It has no discernable left-right valence, and the FTC has promoted it under presidential administrations both Democratic and Republican.