This experiment demonstrated that under the right circumstances, the brain activity of doctors mirrors that of their patients. If that is true of physicians whose patients experience pain relief, it’s probably also true of physicians whose patients are anxious.
Anxiety makes the doctor less likely to consider all of the pertinent diagnostic possibilities and consequently more likely to make mistakes that harm and even kill patients.
In some instances, the impact over-anxious patients have on the medical staff can be so profound that doctors and nurses are tempted to use drugs to medicate the anxiety away. When ER patients are agitated, it’s considered medically appropriate to give them intravenous medications to sedate them. On the other hand, it would probably be considered malpractice to give an anxiolytic drug such as Lorazepam to patients simply because their anxiety is making it more difficult for the doctor to think!
That may be true in the ER, but in the operating room, it’s a different ballgame, says Dr. Jay Ross, an anesthesiologist. “An anxiolytic like Midazolam can often take a really anxious patient down a few notches,” says Ross. “They’re nice and calm and relaxed or just quiet.”
Not surprisingly, patients about to undergo surgery are very anxious. When that happens, they hold their breath, making it difficult for the anesthesiologist to prepare the patient to be intubated and placed on a ventilator. It’s medically appropriate to give patients a medication that helps them relax enough to breathe deeply before intubation. But there’s another side to the use of sedating drugs in the OR that’s in more of a grey area. Although most patients undergoing surgery receive a general anesthetic, some receive a spinal or epidural anesthetic instead. Spinal and epidural anesthetics work by numbing the part of the body where the operation takes place; the two techniques are different, but both involve delivering medication through a needle inserted in the lower back.
These forms of anesthesia have fewer side effects. Patients usually recover faster and go home from hospital sooner than those who receive a general anesthetic. But they aren’t ideal when the patient is having extensive surgery.
Of course, the other difference compared with general anesthesia is that with spinal and epidural anesthesia, the patient is wide awake. And talking. Sometimes, far too much for the surgeon and the anesthesiologist to tolerate.
“The patient is just wondering if everything is okay,” says Ross. “Or they’re just chatting about the news or whatever happens to be on their mind. But sometimes, they’re excessively chatty to the point where they’re actually distracting you from doing your job.
“They try to look over the drapes if that’s possible, or start to move their legs around. They’re getting tired of lying in a particular position. Their arms are moving. They’re trying to scratch their nose. It’s getting a little dangerous for their own safety because you don’t want them to disrupt the surgeon, who may cut something accidentally. So we try to keep things safe.”
Ross says one piece of coded language used in the OR is a signal that tips off the anesthesiologist that the patient is becoming a distraction and needs to be given a drug to quiet him down. The code phrase is SFU 50, which sounds scientific. But like a lot of medical slang, the root of it is a neat pun, says Ross. The phrase, which Ross says he’s heard but doesn’t use, is inspired by the scientific term ED 50 or Effective Dose 50, which is the drug dose that produces the effects for which it is administered in 50 percent of patients. “In anesthesia,” says Ross, “there’s the SFU 50 dose. That is the dose [of sedative or anxiety-reducing medication] at which 50 percent of the patients will shut the fuck up [or SFU].”
Until Ross mentioned it, it would never have even occurred to me to administer sedating drugs just to get an awake and anxious but non-agitated patient to keep quiet! I polled some of my ER colleagues, and they said pretty much the same thing.
* * *
A 2013 article in Psychology Today lists treatments that patients can use to deal with health anxiety. These include confronting one’s fears and learning to face worries about illness realistically. My favourite is to not seek absolute certainty or safety.
Useful though these suggestions are, they won’t work in a busy ER where people like me don’t have the time to get to know patients who might be more anxious than ill—or who might not.
The truth is, no matter how seductive it might seem, I dare not snuff out the anxiety of my ER patients. Every once in a while, their fear of imminent death is bang on.
One night many years ago, I was working in a community hospital when a 60-year-old woman I’ll call Abigail came to the ER complaining of sharp pain in her chest. An electrocardiogram and a blood test showed no evidence of a heart attack.
“Good news,” I said to Abigail. “Your tests are normal. You can go home now.”
Instead of being relieved, my patient looked and sounded worried.
“Please don’t send me home,” Abigail begged in a quiet voice. Her brow was furrowed and her tone and manner told me she meant it.
It was a busy afternoon in the department. I had a lot of patients to wrap up before I could go home. Now Abigail was adding to my list of unfinished business.
I sighed and began to retake the history of her symptoms. The first thing I thought of was to rule out pulmonary embolus, a blood clot on the lungs. I ordered a lung scan—a standard test at the time to look for a pulmonary embolus.
Late that evening the lung scan was completed. The result of the scan was what we call indeterminate; it failed to show a blood clot and yet the scan was not completely normal. I told Abigail she could go home, and this time she did so without protest. That night, she died in her sleep. An autopsy showed that Abigail had an aortic dissection—a tear in her aorta that caused her to have pain.
If I had diagnosed Abigail’s dissection, she could have been saved. Instead, she was sent home. There, her weakened aorta broke wide open and she bled to death in seconds.
Abigail’s plea not to be sent home sounded like the importuning of a woman in status dramaticus. Instead, it turned out to be—literally and figuratively—a cri de coeur that will haunt me for the rest of my life. She reminds me that when it comes to patients in status dramaticus, SFU 50 is one thing I dare not use, tempting though it may be.
5. Failure to Die
In the novel The House of God, the most famous offering of medical slang by far is the word GOMER. Author and slangmeister Dr. Stephen Bergman defined GOMER as a patient who is frequently admitted to hospital with “complicated but uninspiring and incurable conditions.” The definition is bland, but the acronym immediately and irrevocably touched a raw nerve with residents, attending physicians, nurses and other health-care professionals for several reasons.
GOMERs are usually old, demented and sick with half a dozen or more illnesses pressed into a package of decrepitude. For good measure, throw a pinch of utter futility into the mix. Doctors can perform all manner of medical miracles on a GOMER, but what you end up with is a GOMER who is less ill than before, but a GOMER nonetheless.
Oh, and one more thing: unlike young people in the prime of life with serious illnesses, GOMERs don’t die (at least they don’t die easily). So true is that statement that Bergman made “GOMERs Don’t Die” top of the list of the Thirteen Laws of his fictional hospital.
Make no mistake. If you’re a health professional, unless you love geriatric patients, chances are you can’t stand GOMERs. And that’s a huge problem in health care today.
By the year 2030, according to the U.S. Administration on Aging, 19 percent of Americans will be 65 and older. Currently, the Alzheimer’s Association estimates that five million Americans have Alzheimer’s disease; by 2050, the number is expected to rise to 16 million. They may be your grandparent, your mother or father, a favourite uncle or aunt, or even you or your partner.
The loved one you see as special is a patient seen by most health p
rofessionals as someone who takes up a valuable bed on a packed hospital ward. And increasingly, they ask: “Why are you here?”
And “Why haven’t you died?”
* * *
11:35 p.m. The Bunker.
“We’ve been consulted from emerg to see a 93-year-old man with aspiration pneumonia,” a senior medical student I’ll call Cynthia reported to the senior resident. “Am I going to get a history out of him?” asked Cynthia, who was on call for general internal medicine.
“Why don’t you go see for yourself,” said the senior resident with a chuckle.
It’s the job of the on-call team of budding internists to assess, diagnose and, if necessary, admit patients who arrive at the emergency department.
“I went to visit the patient. He was in end-stage dementia,” Cynthia remembers. “He was blind in both eyes, completely bed-bound and non-verbal.”
The senior med student quickly sized up that her patient did have aspiration pneumonia, a disorder in which the lungs have become inflamed due to the presence of oral and stomach contents. There are many causes—strokes, multiple sclerosis and intoxication, to name three. But by far the most common cause is advanced dementia associated with old age. That was the first thing to come to Cynthia’s mind as she pondered her new assignment.
The old man’s complexion was blue. He was breathing rapidly in a physiologically instinctive way to make up for the lack of oxygen passing through the alveoli, the tiny membranes deep inside his lungs. He was also gasping for breath. With each sharp intake of air, the man made a thick, wet, gurgly sound that meant his airways were filled with mucus and pus. His heart was galloping along in a vain effort to make up for the lack of oxygen by sending deoxygenated blood coursing through his arteries ever faster. Without quick treatment, Cynthia’s patient was on a path to almost certain death from suffocation.
Her assessment finished, the medical student went back to the Bunker to confer with her teammates. As she presented the cold, clinical facts, a simple choice emerged: Give the man antibiotics and delay his death or hold back the antibiotics and make the man comfortable.
“This is cruel, to keep this guy alive,” Cynthia argued to her teammates inside the Bunker. “I don’t want to step him up to a more potent antibiotic. I think that this guy should return home [to die].”
There were murmurs of support, as Cynthia and the team spoke in a cold and spare way about the futility of keeping the man alive. What strikes her later as she recalls the episode is that they were joking about the choice; to the team, the fact that there was a choice at all was amusing. The idea that there was any point to the man being saved was that preposterous.
Deliberations complete, Cynthia stepped outside to discuss the man’s prognosis with his family, and to ask what they thought he would want were he able to speak for himself. What she remembers most about the encounter with the family is that she had to shrug off the amusement she’d just shared with her teammates and present the “options” in a deadly serious tone of voice—when the team had decided there was only one appropriate option: no treatment.
The family chose the antibiotics, and the man lived.
“You try and persuade people to do what you think is appropriate,” she concludes about her conversation with the family. “I think there’s a real disconnect between what goes on back there [in the Bunker] and then how we portray ourselves out there. I don’t think patients are at all aware of that.”
What also bothers me about the case Cynthia described is that these life-and-death discussions took place around the man, as if he didn’t exist. To the team, in a cognitive sense the man had already died. The man was too demented to realize it himself.
Cynthia’s patient was old and decrepit. He had dementia, and no amount of medical care could change that. What the team in the Bunker thought he needed was some TLC at home or in a nursing home and die. Instead, he got good acute-care medicine—powerful antibiotics, advanced airway management, and lots and lots of blood work—all of it, from their point of view, irredeemably futile.
That’s what it means to treat a GOMER.
* * *
The origins and derivations of GOMER help shape the meaning in the culture of modern medicine. The word can actually be found in the Merriam-Webster Dictionary, defined as “medical slang, usually disparaging: a chronic problem patient who does not respond to treatment.” Stephen Bergman says GOMER was already in use when he was an intern back in 1973. That same year, in an article titled “The Language of Nursing,” published in the journal American Speech, the American author and English professor Philip C. Kolin offered this mention of GOMER in the lexicon of medical slang: “Those patients who require long-term care and who are usually sent to a nursing home are known to the RN as gomers.”
The July 1972 issue of National Lampoon referred to GOMER as “a senile, messy, or highly unpleasant patient.” According to John Algeo’s book Fifty Years Among the New Words: A Dictionary of Neologisms 1941–1991, GOMER might go back as far as the 1950s.
The derivation of GOMER is somewhat unclear. In The House of God, GOMER is an acronym for “get out of my emergency room.” But Algeo’s Dictionary of Neologisms says that on the West Coast, GOMER stands for “grand old man of the emergency room.”
In his 1982 book What’s the Good Word?, William Safire quotes Dr. Adam Naaman, a physician in Clifton Springs, New York, who says GOMER derives from the Hebrew verb l’gmor which means “to finish.” Safire quotes Naaman as saying a GOMER is a patient “in the process of finishing his existence on the face of this earth.” Naaman says that the word “started in New York City, where many Jewish house-staff officers [interns and residents] sprinkled the medical language with words from Hebrew and Yiddish. Obviously, WASP interns had to find other explanations for the term, and hence the acronym was invented for ‘get out of my emergency room.’”
In “The Language of Nursing,” Philip C. Kolin speculates that GOMER possibly derives from gomeral, a Scottish word meaning simpleton or fool. In a 2006 blog post, Michael D.C. Drout, the Prentice Professor of English at Wheaton College in Norton, Massachusetts, declared he was “as close to certain…that the actual etymology of ‘Gomer’ in medical slang is not an acronym, but from the character ‘Gomer Pyle.’”
The title character of the television show Gomer Pyle, U.S.M.C., which ran on CBS from 1964 until 1969, was an unsophisticated yet kindly gas station attendant who joined the Marines. The character was first introduced on The Andy Griffith Show. The simple-minded Gomer Pyle served as a foil to a by-the-book drill instructor named Sgt. Vince Carter.
Drout wrote that in the early 1970s, GOMER was medical slang for a stroke patient, head-trauma victim, or someone afflicted by senile dementia. On his blog, Drout says he’s pretty certain of the origin of GOMER because his father was an intern and resident at New York Hospital from 1973 to 1976—the same time that slangmeister Stephen Bergman did his internship. Drout says his parents often entertained his dad’s colleagues, who told stories about the hospital.
“Although I heard the word ‘Gomer’ used very often, I never heard the ‘get out of my emergency room’ acronym and, if it had been invented, I am sure I would have heard it: med students, interns and residents loved that kind of thing,” Drout wrote on his blog.
The point is that GOMER means different things to different doctors. If you’re a patient’s family member, it might be worthwhile trying to figure out which of the definitions I just gave you is meant by your loved one’s doctors. It might just give you an important clue about where they’re coming from.
Though just about every doctor and nurse knows the word GOMER, the term is rarely if ever used now. That’s because it has made its way into the public vernacular. GOMER has been used on TV shows including Scrubs and ER. When that happens, it’s no longer insider slang, so it gets discarded.
Today, health professionals use a
multitude of other slang terms instead. Dr. Zubin Damania has honoured the word GOMER by inventing a variation. “We call that status gomaticus,” says Damania, echoing status dramaticus. “It basically means that this guy is never going to get well enough to resume any quality of life but he’s never going to die.”
There’s a multitude of newer slang terms for GOMERs—each of which illustrates something about these patients that doctors find very frustrating. At the top of the list is the reality that once GOMERs are admitted to hospital, it can be difficult—bordering on impossible—to get them out. Not surprisingly, they’re called bed blockers.
Bed blocker is the slang term for a patient admitted to an acute care hospital for acute medical problems—issues such as dehydration and infection. The acute problems are treated, and the patient is designated for transfer to a rehabilitation hospital to receive additional care before returning home. Or the patient may be earmarked for transfer to a long-term care facility for the rest of her life. Either way, the patient must remain in the acute care hospital until an appropriate bed opens up elsewhere. As long as these patients remain in hospital, they block another patient from being admitted.
When a bed is blocked, an internist can’t admit new patients and surgeons can’t admit patients who need operations. That hurts doctors in their wallets.
The impact of bed blockers on the overall functioning of the health-care system can be enormous. In Canada, a 2011 report by the Wait Time Alliance found that bed blockers take up one in six hospital beds—causing ERs to fill up with acutely ill patients and resulting in the cancellation of elective surgeries. The report found that, on average, one bed blocker admitted to the ER denies access to patients seated in the waiting room at a rate of four per hour.
The Secret Language of Doctors Page 9