I spend my days downtown in a university hospital known for its innovations, for practising “accountable care”. Instead of doctors and nurses and patients, they have teams and “feedbacks” and outcomes. It’s the way of the future; they want to apply it back home, where we apparently have an unsustainable system. Enter the lobby and you could be in a five-star hotel: polished solid timber and deep leather armchairs, every surface designed to be easy on the eye.
The handover from the night staff to the day staff takes place in the tearoom on the medical ward. It looks the same as an Australian tearoom, except the mugs are all neatly stacked and there’s no threatening notice above the sink about how your mother doesn’t work here so you’d better wash your own mug. There are a lot of whiteboards for a tearoom, and they’re covered in flow charts and motivational affirmations, written by the clinicians who’ve all morphed into managers. There’s a cork noticeboard with a T-shirt pinned up at the armpits. It’s black with green text: Help Trent Get New Lungs. A flyer next to the T-shirt explains that Trent is nineteen, has cystic fibrosis and is trying to raise $50,000 to pay for his lung transplant. Buy a T-shirt for ten bucks! Help me in my quest!
The night was a tough one, but the staff aren’t allowed to use negative words, not even “busy”. Instead they smile like adverts and say the shift was “active” and “challenging”. Before the staff can get out of there, they have to formulate a team-building goal of the day for one of the whiteboards. They come up with “Execute the day with joy” and “Work together”, but settle on “Spread the cheer”.
We gather in the corridor ahead of the ward round. One of the doctors takes a call and announces, “She’s on her way.” “Who?” I ask. “The social worker. We can’t start without her.” Social workers in Australia never join our ward rounds. They have barely enough time as it is to organise all the respite and residential care, family meetings, emergency funding and home help.
The social worker arrives, and we crowd in the doorway of the first patient. He’s recovering from a bout of pneumonia, and the doctor thinks he needs a few weeks in rehabilitation to get him strong enough to return home. The social worker steps forward with her clipboard: “Unfortunately, Mr D’s insurance doesn’t cover rehab.” The doctor turns back to the patient: “Unfortunately, your insurance doesn’t cover rehab and so you’ll have to go home directly. Be careful, take it slowly, see your family doctor in a week.” Mr D nods. We move on.
The next patient is ready for discharge. The social worker asks the doctor to change drug X to drug Y as the insurance company won’t pay for drug X. The doctor changes X to Y. The next patient, a pensioner, is informed that he needs two more days of inpatient antibiotics for his infected prostate. He pleads to go home: “Doctor, please, it’s costing me $250 a day in co-payments. I can’t afford this.” The doctor says he’s sorry. The social worker says nothing.
After work, I drive around downtown. Dozens of young fit black men mill outside soup kitchens and in car parks, their portable bedding close by. I see a woman and baby wrapped in a quilt, lying under a scraggy tree beside a mess of men and clothes and boxes. I haven’t eaten all day and suddenly feel faint. I order a shake at a deserted diner. It is unimaginably delicious: chocolate ice-cream made just soft enough to move through a fat straw.
I join the gridlock back to the suburbs; the streets grow quieter, greener, wider. I attend a party in a beautiful house. We are mostly doctors, drinking wine, eating steak. Our children roam the streets, clutching cups of homemade lemonade. I get to talking with one doc. To whom is he accountable, actually? How does he negotiate the health insurance minefield? What happens if the patient can’t pay? He looks over my shoulder. “Oh, we don’t get involved with that side of things … The hospital interviews them. They work something out.” Interviews them? About what? “You know, helps them calculate their assets …” I stare at him. He looks annoyed and says, “Do your patients have to wait twelve months for their hip replacements, like they do in the UK?” I raise my glass: “God save the Queen.” He spreads his winning smile. “Well, Americans sure wouldn’t put up with that!”
I couldn’t wait to get back to our overcrowded hospitals that stink of hot chips, where bad things are called bad names and you can swear freely in the tearooms. Where you’re a patient, not a customer, so the lack of a fatal car crash is the only thing standing between you and a new set of lungs. You may have to wait months in pain for your new hip and then share a room with three snorers, but you’ll get the drugs the government lets me prescribe you, and if you can’t walk post-op you’ll have physical therapy someplace ugly, and if despite all that you can no longer leave your house, the social worker will hook you up with Meals on Wheels. Spread the cheer.
Medicine’s Mission to Mars
When I was a trainee doctor, I worked for a time with a physician who would conduct his limits-to-treatment discussions like this: he’d lean over the gravely ill person in the bed and say, “You know the reason we don’t send people to Mars? It’s not because we can’t get them there, it’s because we can’t get them back.” He’d nod slowly, as if sharing a moment of sad understanding with the patient. Then he’d walk out of the room.
There’s a lot of talk around the wards about limits to treatment. No one wants to prolong a patient’s agony or squander resources for little gain. A researcher recently wanted to quantify how much of what we did on our general medical ward was futile. It sounded interesting, until we realised that futility could only be judged in retrospect. If the patient died, then what we had done was torture; if they lived, we were bloody heroes.
At base, doctors in hospitals tend to your threatened organs: we treat them and support them. Increasingly, we can also replace them.
A few years ago, I saw a guy walking out of the cardiac ward with a neat black briefcase on wheels. There were wires running from the briefcase to his belt. “What’s that?” I asked the cardiology fellow. “It’s his heart,” he said. “You know, a VAD – ventricular assist device.” I didn’t know. I’d never seen a VAD before. I didn’t know you could walk around with your heart in a suitcase. What if someone tried to steal it? What if someone accidentally kicked it and it went skidding across the road? How did the patient summon the courage to leave the house, to leave their chair? The cardiac fellow thought that was funny. “They get the VAD so that they can leave their chair.” The case contained the battery that powers a pump sewn into the patient’s failing heart. It was a temporary measure to buy some time until the surgeons could cut the whole lot out, chuck it in the bin and replace it with a fresh heart, harvested from a brain-dead body. Now it’s possible to keep your VAD indefinitely; the briefcase battery has shrunk to a holster you can clip on your belt.
Mechanical organs that hang from your body are everywhere, redefining futility, liberating limits to treatment. There are a couple of ECMO machines in our intensive care unit. ECMO means extracorporeal membrane oxygenation: external lungs. A steel cannula as thick as your garden hose is inserted into a vein in your neck to suck your entire circulation through a hose into a machine that looks like a mini front-loading washing machine filled with blood; another line pours it back in. If it breaks down, the ICU doctors can use the backup hand crank to keep it spinning. If you’re about to die unless your lungs and heart get a few days’ respite, then ECMO is for you. You can even stand up and do some physio, as long as someone holds your hoses of blood. I always stand at the door, my ankles aching with the fear that I’ll trip over those hoses. I know I would never have been brave enough to imagine diverting all that blood into a washing machine, let alone to try it out.
Extracorporeal organs aren’t as good as real flesh, and doctors can pretty much transplant every organ except the brain. Kidneys, livers, pancreases, corneas, skin and hearts do very well. Lungs are harder: they’re fragile, secretory nets, exposed to a toxic world with every breath. I saw a young man with severe cystic fibrosis in ICU a day after his lung transplant. I asked h
im how he felt. He was groggy but he looked up and said, “It’s incredible. I breathe in” – he took a deep breath, winced at the pain from the surgical incisions, and smiled – “and, for the first time in my life, I don’t feel all the crackling of my breath pushing through gunk.” It was thrilling, but a few months later the young man was dead: his new lungs had become catastrophically infected.
It seems like a fresh start, but you’ve just swapped one disease for another. You get rid of the old organ and replace it with a chunk of someone else that your body will attack for the rest of your life as if it’s an intruder. The organ transplant physicians are the most heroic of doctors. When an organ fails, they don’t give up. They get the patient a new one and treat the hell out of it.
Organ transplantation is a wildly expensive undertaking. And these extravagant, cutting-edge programs are rarely threatened by budget-slashing governments. Our resources and efforts could arguably be directed towards the more pedestrian afflictions of the global masses. Malnutrition, diabetes and malaria require access to a little medicine, a bit of food, a trickle of clean water. The money spent on one transplant could save hundreds, even thousands. But please, allow me to grab that old physician’s aerospace metaphor and run. Trying to fly to outer space might be seen as a reckless waste of resources. A lot of ugliness could be fixed with that kind of money. But that grainy black-and-white footage of Neil Armstrong bouncing on the moon also instils in me a crazy kind of hope, like, “Look at us, insignificant, but leaping for the universe with our scraps of science and gigantic imagination.”
We need to work towards a minimum for all, but that’s not enough. We set aside some of what we have for scientists to dream, so that what is futile today may be routine tomorrow. This is why doctors can plug someone into a VAD or ECMO, why they subject a patient to the brutalities provoked by an alien organ, why we tolerate the huge resource expenditure and the terrible risks taken with the would’ve-been-dead. Pack them up, send them to Mars; one day we might be able to bring them back.
Last Resort
June is eighty-three, lives alone and still drives herself to the shops. When she doesn’t answer the telephone one morning, her daughter drops by to check on her and finds her lying naked in bed, in a soak of urine, staring at the ceiling. June turns her head at her daughter’s call but does not seem to recognise her, nor does she respond to questions. Her daughter panics and calls an ambulance; she runs to the bathroom, throws June’s pills into a plastic bag and gets her into a nightgown. Then she sits on the edge of the bed and cradles her mother’s head in her lap. The ambulance officers arrive within half an hour; they note that, apart from a low-grade temperature, all the patient’s vital signs are normal and she can spontaneously move all four limbs. They bring her to the hospital where I work as a doctor.
Excepting elective admissions for surgery and the like, beds in a public hospital are guarded by the emergency department; if you are sick and need admission you have to come through the ED. Most people have some idea of the drill: the triage nurse ranks the severity of your problem, and that ranking determines how quickly a doctor will see you. If you turn up in the morning and the nurse or ambulance suspects you are having a heart attack, you will be deemed a Category 1 patient and will be seen to immediately. If it is a large, acute heart attack you will likely be on the table having your angiogram and stents within the hour. If all goes well in the angiography suite, by late afternoon you’ll be in a large white room, hooked up to monitors, watching the news, swallowing all your new pills and eating dinner. If you are June, or someone equivalent to her on the triage scale – an older person who has fallen down and can’t walk, someone who’s had a faint, has a fever, is dizzy or delirious or looks starved to death – you are considered a Category 4 or 5. This means that by dinnertime you may still be lying on the trolley, perhaps in a corridor of the emergency department if things are really frantic, waiting to be seen by a doctor.
Informally, these patients are known as “crumbles”: they are not crashing towards their death like the guy with the heart attack; they are merely engaged in a slow, crumbling demise. When the elderly and not-crashing patients are finally seen, it will be by the most junior doctor in the department. This doctor may take a long time to work out what is going on. Meanwhile, the inexorable crumbling continues.
In theory, the triage system seems sound and unavoidable: if someone is dying in front of you – exsanguinating from an amputated limb, unable to breathe because they have a hole in a lung – you cannot ask them to lie down and wait their turn. If they are not helped immediately they will certainly die. If you don’t immediately help the crumble – June, for example – she will not die, or at least she will not die in front of you. However, according to a report published by the Australasian College for Emergency Medicine, the mortality associated with excess waiting time in emergency departments in Australia exceeds 1500 deaths a year – more than the national road toll. The crumbles are engaged in slow-motion crashes that we cannot see until the final metres, by which time it is too late.
In 2011, the government commissioned an investigation into emergency department waiting times. The result was the formulation of National Emergency Access Targets. The stated aim was to “improve patient safety and quality of care by removing obstacles to patient flow that contribute to emergency department overcrowding”. By 2015, 90 per cent of all patients would be moved through emergency departments within four hours. I do not know if I can convey how radical this proposal was. It was like telling someone who jogs an easy 5 kilometres in forty-five minutes every weekend that in a few years they will be expected to do the same distance in fifteen minutes. Changes have been trialled in Western Australia since 2009 and there has been progress. Emergency waiting time targets are being met and patient mortality is down. But these improvements have come at a significant cost. An army of administrative staff spend their days on phones and on the floor policing and pushing patients through the funnel of the ED. Doctors and nurses are exhausted and relationships between medical and administrative staff are strained. Are we sacrificing good training in our desire for efficiency? Meeting the targets within the current triage system is proving extremely difficult. What is needed is a radical new way of running emergency departments so that everyone is seen quickly, so that somehow everyone takes precedence.
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There is no waiting room in front of the ED at the Royal London Hospital. There is no triage nurse. If you arrive sick, no matter your degree of morbidity or your age, you will be seen within ten minutes by the most senior doctor. She will look at you, talk to you, briefly examine you and, though she may not come up with a definitive diagnosis, she will at the very least be able to decide where you will best be managed and thus where you should go: to the medics, to the surgeons, to the ED proper for further stabilisation and investigation, or home.
It makes sense. I have a friend who is an art curator. After completing her basic degree, she hung out at art galleries, volunteered at the Heide museum, wrote a couple of theses and landed a job in a major public gallery. Her visual apparatus from eyes to occipital cortex is different from mine: it has been trained. She sees more and better. Where I see a pretty object on a stick, she sees a complex creation with a place in history, heavy with implication in the present and future. She assesses most of this in the time it takes me to appreciate that the object is suspended from a wire that reminds me of the line my dad used in the ’70s to catch flathead. She is the senior emergency department physician and I am the intern doctor. The patient is the work of art.
The idea of adopting this streamlined model in Australia has met with some resistance: it turns the seemingly natural order of things on its head. Senior doctors have done their time; they don’t want to be on the ground, running with the pack. They want to supervise, be offered pre-digested summaries, teach, hand out gems here and there, some advice, point out their registrar’s blind spots. They are the bosses.
At the Royal
London, if you are the equivalent of a Category 4 or 5 general patient, you will not languish in the ED corridor for five hours before the intern takes your history, your blood, comes up with an interim diagnosis, discusses it with a consultant and then rings a ward medical registrar to come and admit you. At the Royal London the emergency consultant will deliver you directly into the hands of the general medicine team for immediate assessment and treatment in their acute ward.
Of course, there are several barriers to the flow of patients from the ED to the ward, such as the number of beds available and staff levels. But a major barrier is also the traditional model of what an emergency department does: sort, package and sell patients to teams. These are ugly words to describe sick people with, but they are the words that are used and they represent the practice as it stands. Ward registrars (the most senior of the trainees) will not traditionally accept (buy) any patient who has not been sorted (thoroughly investigated) and packaged (diagnosed or at least had a single organ system nominated as the main problem). This all takes time. After four hours the patient may well remain unseen, undiagnosed or diagnostically undifferentiated – and if you can’t nominate an organ system in which the pathology lies, it will be difficult for you to sell the patient.
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When I first started out as a medical registrar there would be daily arguments in the emergency department or over the telephone about which teams should accept the care of “non-differentiated” patients with “general” or multi-system decline. To be clear, registrars were not fighting to take the patients; they were fighting to avoid taking them. One of the most common arguments I heard was from the sub-specialties that perform interventional procedures such as angiograms (cardiology) or gastroscopies (gastroenterology): “We won’t take the patient as we don’t need to do anything for them.” Doing something for a patient was reduced to a procedural intervention, as if everything else the patient needed (assessment, monitoring, medicine, care) could be offered by anyone, and therefore not by them.
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