Five Patients, page 6
Without question, the notion of the doctor as a legitimate fee-for-service entrepreneur, making his fortune from the misfortunes of his patients, is old-fashioned, distasteful, and doomed. It is only a question of time.
Ultimately, however, it is not useful to lay blame, whether on physicians, health-insurance administrators, politicians, or an apathetic public. For they all seem to share a common blindness-a total failure to understand why hospital costs are rising. In 1967, the average cost of a hospital room in America increased 15 per cent. What is happening?
The per-day room charge is the largest single item in the hospital bill. There are many ways to break down this charge-as many ways as there are accountants-but the clearest is the following.
In 1969, the cost of a semi-private room at the MGH was $70.00. Breaking this down, we find:
Per-Day Room Charge: $70.00
Utilities, housekeeping, maintenance,
plus business offices ("hotel expense") $ 6.96
Food and special diets 5.82
Nursing 18.42
Labs, records, house staff,
X rays, and pharmacy 28.80
Overcharge (to cover welfare debts) 10.00
Total $70.00
Now this breakdown contradicts one of the oldest complaints about hospitals, as quoted in a national magazine: "My work puts me in contact with hotels and hotel management and I know that a good hotel can give you a beautiful room for $30.00 a day, with three meals, and make a profit and pay taxes. And yet any hospital, which doesn't pay any taxes, operates in the red for $65.00 a day. I say it must be poor administration."
If the analogy were true, the conclusion would be correct. But the hospital is not a hotel-and in any case, its "hotel" costs are quite reasonable at $6.96 a day; this is approximately half the cost of a decent motel room in Boston. The charge of $5.82 for food, or approximately $1.95 a meal, is equally reasonable, especially when one considers that as a restaurant the hospital must provide an extraordinary range of services, including some eighty special diets.
The true hospital costs-the expenses incurred in a hospital but not in a hotel-are, on the other hand, very high. They account for 82 per cent of the total per-day room charge. And the question, really, is whether these charges are reducible. No sensible businessman would bother to try to get his hotel and food costs below thirteen dollars a day; if there is to be a decrease in costs, it must come from the non-hotel charges.
These in turn largely reflect the increased technological capacity of the hospital. Mr. O'Connor's example is a case in point: most of the tests performed on him were not available in 1925, when he could have had his room for one twenty-fifth of what it cost him today. The maintenance of this new technological capability costs money-and to a large extent, in medicine as in education, law enforcement, sanitation, and a variety of other services, you get what you pay for. If you are going to enter a high-quality acute-care facility that has six employees (most of them non-physicians) for every patient, and if you are going to pay these employees a decent wage, then your care will be expensive [All this is sometimes easier to see if it is taken out of the hospital setting. If a man had to hire six secretaries for an eight-hour day, at $2.50 an hour, it would cost him $120.00 a day. If a man had to hire two gardeners at $4.00 an hour, for a single eight-hour day, it would still cost him $64.00 a day]. If you are going to purchase technological hardware, maintain it, and keep it up to date, this costs money. If you are going to keep the hospital in continuous operation twenty-four hours a day, three hundred sixty-five days a year, this costs money.
All this becomes clear in the instance of a simple procedure such as a chest X ray. A private radiologist in his office will perform this for you at one half or one third of what the hospital charges. His charge largely reflects the fact that his unit can operate on an eight-hour day and a forty-hour week; other costs, such as equipment and supplies, are the same. In medicine today-as in every other industry-people are more expensive than anything else. Sixty-three per cent of the hospital budget now goes to the salaries and benefits of employees. And much of the rise in hospital costs is directly attributable to the demand of these employees that they not be personally forced to subsidize the health business by accepting wages incommensurate with similar jobs in other industries. Their demands are justified; most employees are still underpaid. Their salaries will increase in the future.
One cannot, however, fairly claim that hospitals are superbly efficient. Especially in a teaching hospital, attention to cost in the medical, non-hotel sector is less central than one would like it to be. One can argue about whether too many tests are ordered, and the argument can continue endlessly. But certainly, when physicians who order these tests don't know what patients are charged for them, eyebrows must go up. In general, doctors tend to operate on a "spare no expense" philosophy which will, eventually, need to be tempered.
But, more fundamentally, the present cost structure of the hospital seems to lead to a rather old-fashioned conclusion: no one should go there unless he absolutely has to.
If a diagnostic procedure can be done on an ambulatory, out-patient basis, it should be; if a series of tests and X rays can be done outside the hospital, they should be. No one should be admitted unless his care absolutely depends upon being inside the hospital; no one should be admitted unless he requires the hour-to-hour facilities of the house staff, the nursing staff, and the laboratories.
For decades, admission to the hospital was necessary because there was no other facility available. For a large segment of the population, care was either given in the hospital, or not at all; and the hospital's clinic system was a poor compromise, with hordes of patients being brought in to wait hours-sometimes literally days-to have relatively brief tests performed.
There is hope that the satellite clinics will help solve the problem; one study of a satellite clinic in Boston reported that there were fewer hospital admissions as a result of the clinic's work.
In any case, alternative facilities must be found, because it is unlikely that hospital costs will ever go down. The best anyone can hope to do in the foreseeable future is to stabilize them somewhere in the neighborhood of $100.00 a day. This makes the hospital an expensive place-but it has its uses, and indeed will be an economically tolerable place, if it is used appropriately.
Peter Luchesi. Surgical Tradition
At 3:15 p.m., the emergency ward was notified that a patient was being transferred in from an outlying hospital: a young man with a nearly severed arm resulting from an industrial accident.
He arrived an hour later and was seen first by Dr. Hopkins, the triage officer, who ordered him sent to OR 1. The surgical residents, Drs. Eugene Appel and Terry Mixter, were called to examine the new patient.
He was twenty-two years old, of medium height and muscular build, looked quite pale, and was speaking weakly. His left hand was bandaged and splinted. An intravenous line had been inserted in his right arm, but it had infiltrated. There was also a bandage over his chin. The bandages were removed and a new intravenous line started. He had a moderately deep two-inch laceration in his chin; the medical student, Sue Rosenthal, was called to suture it. Meanwhile, Appel and Mixter turned their attention to the injured arm.
Three inches above the left wrist the forearm had been mashed. Bones stuck out at all angles; reddish areas of muscle with silver fascial coats were exposed in many places. The entire arm above the injury was badly swollen, but the hand was still normal size, although it looked shrunken and atrophic in comparison. The color of the hand was deep blue-gray.
Carefully, Appel picked up the hand, which flopped loosely at the wrist. He checked pulses and found none below the elbow. He touched the fingers of the hand with a pin and asked if Luchesi could feel it; results were confusing, but there appeared to be some loss of sensation. He asked if the patient could move any of his fingers; he could not.
Meanwhile the orthopedic resident, Dr. Robert Hussey, arrived and examined the hand. He concluded that both bones in the forearm, the radius and ulna, were broken, and suggested the hand be elevated; he proceeded to do this.
Outside the door to the room, one of the admitting men stopped Appel. "Are you going to take it, or try to keep it?"
"Hell, we're going to keep it," Appel said. "That's a good hand."
The patient was started on two grams of cephalothin antibiotic intravenously, and was given more tetanus toxoid. He had received pain medication at the other hospital, and so far had not requested more.
As a workmen's compensation case, the operation would be done by private surgeons: Dr. Hugh
Chandler for orthopedics, Dr. Ashby Moncure for general surgery. At 5:15, Moncure arrived and looked at the hand, satisfied himself that it was indeed viable, and put the patient on call for the operating room. He also called Chandler and summarized the case: "It's a circumferential crush injury to the left hand with compound fracture of both radius and ulna. Innervation and arterial supply look pretty good."
Meantime, the portable X-ray machine was brought in to take a chest film, and two views of the injured hand. The medical student finished suturing the chin laceration. Moncure came back to check that a sample had been sent to the blood bank. He then went off to try to hasten scheduling for the operating room.
At 5:30, the patient complained for the first time of pain in his hand. The surgeons were debating what pain medication to give him when a nurse came in to say the patient was on call to the OR and would get pre-operative medication. He received atropine, Nembutal, and Demerol, which settled the question of pain medication.
Dr. Hussey, looking at the now-elevated hand, concluded that it appeared a little better; the color had improved. He wrapped the injured area in soft gauze, and went off to the X-ray unit to examine the films. He went directly to the residents' reading room, a cubicle with lighted, frosted glass walls for examining X rays. The resident was busy reading other films; Hussey went back into the developing room, past signs which forbade him to do so, to get Luchesi's films. A female technician scolded him; he said he was in a hurry.
He gave the films to the radiologic resident, who put them up and dictated: "Unit number zero zero six, AP and lateral of the left forearm. There is a transverse fracture of the radius in the distal third, as well as the ulna, period. Numerous fragments of bone are scattered around the fracture site, period. Considerable soft tissue swelling…" Here he stopped, realizing Hussey was impatient. "Chest film normal," he dictated, and gave them all to Hussey, who returned to the patient and supervised his transport to the operating room on the third floor.
It was now six o'clock. The operation was scheduled for 6:15, at which time on the OR blackboard was written:
KM 7 PVT. SERVICE SEVERED ARM MONCURE/CHANDLER
In the operating room, Dr. Brian Dalton, the first of three anesthetists who would work during the six-hour procedure, was administering an axillary block, injecting lidocaine (a novocaine-like drug) deep into the armpit, to dull, during the preparation, sensation in the nerves that ran out to the hand. While this was being done, Moncure discussed the operation: "What we're going to do here is stabilize his bones, and then deal with soft tissues as need be. I think we'll find a lot of crush damage to muscle bellies, particularly flexors, but intact vessels and nerves." He observed that while clinically there was questionable nerve damage, a crush injury could produce this without any actual cutting of nerve fibers; under such circumstances the damage was probably fully reversible.
At 6:10, while the axillary block was being administered, Hugh Chandler, the orthopedic surgeon, arrived and looked at the X rays. He said that he would stabilize one bone, the radius, and worry about the other, the ulna, later. Moncure was outside the OR, scrubbing according to the MGH version of the ritual: three minutes of washing to the elbow with a hard bristle brush, using orange sticks to clean under the nails, followed by a dunking to the elbows in an alcohol-germicidal solution. When he finished his scrub he came in, put on a pair of sterile rubber gloves, and began to wash the arm with a safety soap and alcohol. The nerve block was beginning to take effect, and it was possible to move the arm less gently without hurting the patient.
The patient was still awake, but dazed. He stared at his arm curiously, as if it did not belong to him. Moncure asked him how it had happened. Peter Luchesi explained that he had been working in a private shipyard and a boom had fallen on him. It weighed seven hundred pounds and it had struck his shoulder glancingly, knocking him overboard. But as he fell, the boom had somehow landed on his hand, leaving him dangling over the side, with his hand pinned down. This was just after lunch. The other workmen were not on the boat, so Luchesi had managed to get back up on the deck alone, and attempted to lift the boom. He could not do it without help. Fifteen minutes passed before the others arrived and were able to lift the boom.
He delivered the entire story in a monotone, while he stared at his hand. Moncure asked him how it felt now, and he said it was beginning to hurt again. As the surgeons began to drape the injured arm with sterile cloths, which entailed considerable manipulation of the hand, he complained more. The axillary block was not working well. With all preparation made, now was the time to produce general anesthesia.
Dalton, the anesthetist, leaned over Luchesi and said: "I'm going to put this mask over your face. You'll breathe only oxygen. Then I'll give you an injection that will make you fall asleep. Don't worry about a thing, just breathe and relax."
Luchesi nodded. The mask was put over his face and he breathed, staring up at Dalton, who proceeded to inject pentathol intravenously. Luchesi blinked once and closed his eyes. He was sleeping soundly, but would continue to do so for only a few minutes. Then he would wake up, unless more pentathol, or a different anesthetic, was administered.
Luchesi was fed pure oxygen for several moments, to be sure he was fully oxygenated. Then Dalton injected succinylcholine, a substance that paralyzes the entire body-including respiratory muscles-briefly. He removed the mask, opened the mouth, squirted a jet of cocaine down the throat to anesthetize the windpipe and prevent reflex coughing, and slipped a tube down the mouth into the windpipe. This provided a direct channel from the mouth into the windpipe and lungs, and prevented a major cause of death from anesthesia, namely, vomiting up of food from the stomach and blockage of the windpipe with this material.
The entire process of intubation took only a few seconds. Once intubated, Luchesi was fed oxygen and nitrous oxide, a mild anesthetic. Alone, nitrous oxide would not provide sufficiently deep anesthesia to permit surgery, but the axillary block was also helping. When it wore off, halothane, a more potent gas, would be added.
The operation began shortly before seven. There were seven people in the operating room at that time. Five were scrubbed: Moncure and Chandler, sitting on one side of the outstretched hand; Dr. Charles Brennan, an orthopedic resident, and Steven Kroll, a medical student, on the other side; and the scrub nurse, standing with two trays of instruments at her fingertips. Also in the room but not scrubbed were the anesthetist and the circulating nurse.
Around the hand, it was tight quarters. The scrub nurse first pinned sterile towels across the backs of Moncure and Chandler; this was because the upper-most portions of their backs, where the sterile gowns were tied, were unsterile, and she did not want to touch them by accident.
In general, the operating room is divided conceptually into "clean" and "dirty" areas. The operative field, meaning the exposed area of skin which has been shaved, scrubbed-and generally covered with plastic-is clean. The rest of the patient, covered with sterile drapes, is dirty. The fronts of the surgeons are clean; their backs are dirty. Anything above the level of the table is clean; anything below is dirty, and surgeons never let their hands fall to their sides. Hands, scrubbed and rubber-covered, are clean; faces, capped and masked, are dirty, and it is poor form to get one's face too close to the operative field or to touch one's mask with one's gloved hand.
The first incision was made over the underside of the wrist, just back from the thumb. The object was to find and locate the radial artery in that area. Moncure and Chandler discussed their procedure as they went, and agreed to find and evaluate the principal structures first: the radial and ulnar arteries, which run toward thumb and little finger respectively; the radial and ulnar nerves, which run with the arteries; and the median nerve, which enters the hand at mid-wrist.
As they began work, they found that the crush injury, with its hemorrhage and swelling of tissues, made identification of structures difficult. Five minutes into the operation, the radial artery was accidentally nicked. A fine, thin stream of blood spurted up in a foot-long arc. This was quickly clamped, and Moncure sewed it up with a small needle, perhaps no larger than twice the size of a typewriter parenthesis mark, and the operation proceeded. Moncure isolated the radial artery for a distance of several inches through the wrist. Everyone commented on the fact that pulsations through the artery were not as strong as they would like. The artery was flushed with heparin to prevent clotting further along its course in the hand.
At 7:20, Dr. Leslie Ottinger, another surgeon, entered the operating room. He had been working next door in OR 8 for six hours, repairing a crush injury to a man's thigh. Moncure, without looking up, said to Ottinger: "Were your vessels intact?"
"No," Ottinger said. "The femoral artery and vein were completely crushed. They were separated by three centimeters." "How's he doing now?" "Fine," Ottinger said, "if he stays open." He watched the dissection of the hand for some moments. "You find the radial artery yet?" "We nicked it," Moncure said. "Well, that's a good way to find it," Ottinger said, and left.
As the operation progressed, Moncure noted that the surgical field was more bloody. He felt the radial artery and concluded that it was pulsating more fully now.
