In another shining example of the law of unintended consequences, what began as a well-meaning policy in healthcare has lost all sense of logic.
John Brown* lay motionless on a bed in the intensive care unit. His pupils were fixed and dilated, an endotracheal tube connected him to a ventilator, and his blood pressure hovered somewhere around 90 on multiple pressor drips. To say he was "circling the drain," was not an exaggeration. Brad, his ICU nurse, said to me with no restraint of sarcasm, "Uh doc, the clipboard people were here and they want to know why you haven't ordered an echocardiogram."
"You're kidding," I said.
"I wish I was," he said.
I just shook my head in disbelief. You see shortly after admission for a surgical procedure, a complication ensued, and he was now in shock with multi-system organ failure and had a prognosis somewhere between slim and none. Some observant house officer must have ordered cardiac enzymes. No, let me make that multiple sets of cardiac enzymes. All of his CK-MB's were normal, but one out of five tropnonin determinations returned slightly above normal. Instantly, John became a myocardial infarction and had to meet hospital core measures.
Here was the checklist: Aspirin? Nope. His platelets were only 30,000. Beta blockers? No. His BP was barely compatible with life on three pressors. How about an ace-inhibitor? No and ditto. A statin drug perhaps? No to that as well with shock liver and an AST>3,000. Okay, then thought the core measure police, can we at least have an echocardiogram to show the cookbook medicine bureaucracy that we weren't ignoring his heart attack?
As absurd as it sounds, this is what medicine has been reduced to now. Forget about common sense and clinical judgment. In another shining example of the law of unintended consequences, what began as a well-meaning policy has lost all sense of logic.
You see too many of us were forgetting to use aspirin or beta blockers after an MI. So now let's just mandate that everyone with a glimmer of myocardial damage come under the same umbrella of treatment. Better care? I think not.
I had another patient who had a cardiac arrest from a drug overdose last year and again one cardiac enzyme was elevated. A Core Measure RN wanted to know why we had not given him aspirin within twenty-four hours of admission.
"Perhaps," I said, "it is because he was comatose, on a ventilator, with little blood pressure, and the abnormal enzyme did not return for more than 24 hours."
The sad thing is that we have to justify and document all of this nonsense in the medical chart. I have to continually educate and explain to the "clipboard people" that a B-NP level of 102 does mean someone has a diagnosis of heart failure. The hospitals are not entirely to blame here, since if they don’t meet these arbitrary “standards of care” they are penalized by Joint Commission and soon to be by Medicare reimbursements as well.
So in the end, I refused to order the echo on John Brown, describing in the chart his grim prognosis and how it would not change how we treated him. I guess somewhere a government or Medicare bureaucrat is smiling, but as for me I just can't see how this has produced consistently better and more cost-effective healthcare.
*not his real name
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