Lessons from an Emergency Room Nightmare

By Harold Pollack, The American Prospect. Posted December 18, 2008.

The team whisked Veronica upstairs for the angiogram. They threaded a catheter into her groin area and ran it up near the heart to examine arteries that might have been blocked. I sat pensively in the waiting area. The cardiologist shortly emerged to report that the angiogram had gone well. There was no observable tissue damage. There were no blockages. Her arteries were squeaky clean.

Days later, I looked up the local rankings. Our hospital wasn't ranked badly. Its cardiac catheterization is 40 percent cheaper than the fancy university hospital I preferred. The bad news: Its post-operative mortality rate was 40 percent higher than that of another community hospital I never held in much regard three miles from our home.

The various waiting rooms were especially sobering. Dozens of tight-lipped people filled them, worried, first and foremost, about their loved ones. The hospital is located in a gritty South Chicago suburb. Many of the people sitting with me were surely wondering, how will I pay for this?

I wasn't worrying about money. I remember thinking: Thank God we have good insurance. At least I think we do. Six months later, I still don't know how much this episode will ultimately cost. I am confident we will not go medically bankrupt, as many patients do with limited or no insurance. Jonathan Cohn's book Sick describes Chicagoans' struggles with medical debt, including a poor, semi-retired nun sued by a Catholic health system. Sitting in that waiting room, I was also struck by the responsibility each of us has to care for our mind and body. We are vulnerable to genetics and bad luck. Still, the intensive care unit brutally displays the consequences of poor health behaviors. Surprising numbers of young people are there, suffering and sometimes dying when this doesn't have to be.

It was hard not to notice something else. That waiting room, like so many others I have frequented in my 15 years in public health, was filled with people of color. Public perceptions of racial and ethnic disparities are shaped by headlines about homicide, substance abuse, infant mortality, AIDS. Mundane cardiovascular diseases exact a far heavier toll in minority communities, within which child and adult obesity have markedly worsened. I fear that waiting rooms may need more chairs.

Within a few hours after the angiogram, Veronica was in intensive care, and we began to digest the bizarre news. Once the anesthesia wore off, she felt real chest pain but was otherwise amazingly normal. Wired up to the monitors, she was soon sitting up doing her cross-stitch, joking with my sister, asking about the kids. An infectious-disease specialist came through and treated her cold sores. Things became boring.

Veronica stayed in that ICU for three days. A pneumatic messaging tube thwonked loudly and randomly throughout the night. Various machines would beep if Veronica moved her arm and impinged on some tubing. On top of that, Veronica was in pain, which the cardiologist explained later was a normal reaction to blood returning to the damaged heart areas. The effect is grueling. Sleep disruption is a prominent cause of what is charmingly labeled "ICU psychosis." Despite that, the staff provided much wonderful care. A community-hospital ICU resembles what hospital care often used to be: kind nurses in an unhurried environment where they could pay close attention to patients.

Veronica spent her last 24 hours in that hospital on a regular floor. Fewer nurses were responsible for more sick patients. Veronica was in pretty good shape by then. She saw her nurse one or two times, not much more. The cardiologist and the local attending shook our hands, assured Veronica she would be fine, and sent us packing.

I was nervous but happy to bring Veronica home. Forty-eight hours earlier, she had been wired up in a cardiac ICU; now no medical provider seemed all that interested in seeing her. We made an appointment to see the cardiologist nearly one month later. We called Veronica's young university internist. I would have thought the words: "I had a heart attack" would provide some scheduling advantage -- apparently not. The medical center is de-emphasizing primary care. It's hard to make money on these services in a tertiary-care setting. During the 10 days before we saw the internist, Veronica dutifully took her medications and set about recovering from her illness and from the grueling days in the hospital. Recovery was slow. She had trouble climbing stairs, got winded a lot, and needed a lot of sleep.

Internists have taken some hits in recent years. A New York Times story in March noted that dermatologists earn twice as much and work 10 fewer hours per week. The Times quotes an aspiring dermatologist as saying that internal medicine is "viewed as easy because anyone can get into it." Since preventive medical care cases can be "humdrum," he said there is a "lack of respect for what they do."

Although that student doesn't know it, internists are the linchpin of our medical system. As described in Jerome Groopman's beautiful book How Doctors Think, physicians make sense of a disorganized jumble of data, recognize latent signs of trouble, chase down patterns when things don't look right, and help patients form a coordinated care plan. Veronica's internist started the 30-minute appointment with a jaw-dropper: "I want to hear what happened straight from you. I should say at the outset that I don't think you've had a heart attack."

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Harold Pollack is an associate professor at the School of Social Service Administration, and faculty chair of the Center for Health Administration Studies at the University of Chicago.

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