Box of Birds publish date September 9th 2023

Recent Experience With Procedure Oriented American Health Care During My Mother's Hospitalization

My mother is a frail 95 year old who developed recurrent deep vein thrombosis and was started on first line therapy with a oral blood thinner Eliquis. For some reason the aspirin she was prescribed was not discontinued this caused her to developed a gastrointestinal bleed after about a week on the blood thinner and aspirin. She was hospitilized and the blood thinner and aspirin were discontinued and she recieved a blood transfusion. The next day she underwent upper endoscopy which was negative except for a small hiatial hernia. The bleeding stopped and her hemoglobin stabilized at 8.6. After an ultasound showed clots still present in the deep veins of the legs the hospitialist scheduled her to undergo an invasive procedure called a inferior vena cava filter to prevent a blood clot traveling to the lung. My mother has had blood clots in her legs before but never had a blood clot go to her lung so it did not appear that she had a clear indication to have this invasive procedure. I spoke with my sister and we communicated to the doctor before we agreed to the filter we wanted to talk more about doing a invasive procedure on a 95 year old with renal insufficency. We were concerned about the adverse effects of a contrast load on the kidneys. We were told the interventional radiologist who does the procedure was out of town and wouldn't be back until the morning the procedure was to be performed. The next day my brother was unable to get some help from the nursing staff to get my mother up to the the bathroom and my family was continually irritated by the lack of responce when they called for assistance from the hospital staff. When asked why she didn't get breakfast we were told she was NPO for the inferior vena cava filter procedure. My sister quickley called the hospitialist and cancelled the procedure. My mother is now home on a lower dose of the blood thinner Eliquis and contnues off the aspirin and is stable without any evidence of further bleeding. I continue to be disapointed in the emphasis on procedures in the American health care system. Inferior vena cava filter procedures bring in thousands of dollars to hospitals, but have no proven outcome benifit over medical therapy with blood thinners for deep vein thrombosis in preventing tromboembolic events. While inferior vena cava filters have an important role in preventing blood clots traveling to the lung in a small select group of patients, they are associated with multiple complications, and do nothing to address the painful leg swelling assoicated with the clots. It's a sad state of affairs when you can't get someome to empty a bed pan in the hospital today, but if you want a expensive invasive procedure it will be done urgently without careful consideration of the risks involved.

SIR MARTIN DURIE ON SPIRITUALITY AND THE JOURNEY TO WELLNESS

Another Māori belief is the physical health is dependent on spiritual health. A prominent Māori psychiatrist Sir Mason Durie gave us a lecture that brought that point home to me. He said when he was in training a 14-year-old Māori girl had come into our hospital with a several days history of behavioral changes in school. When the local general practitioner heard about her visual hallucinations and strange speech, he wanted to have her committed to a mental hospital. When she developed fever, headaches, delirium and a stiff neck her grandfather brought her to the emergency department, and she was admitted to our hospital. After a through workup the consultant in charge gave the family the diagnosis of viral encephalitis. The girls grandfather told the doctor that the problem wasn’t a virus, but the girl was the victim of a makutu (curse on her) he said, “her mother (my daughter) had left her and had gone to Australia with another man and her husband’s family took their revenge by placing a makutu on my granddaughter.” “That sounds a little hard to believe. An illness such as this does not develop because of an unseen curse or mysterious force.” exclaimed the doctor. Anti-inflammatory drugs and antiviral treatment were initiated by the hospital, while the grandfather spent most every day at the bedside and brought in leaves of kawakawa, karamu and kowhai to heal her spirit. “The treatment has been successful, and she has recovered from the virus” said the doctor one morning on rounds. The grandfather stepped forward and corrected the doctor he said, “the girl had recovered because the curse had been lifted.” The grandfather then asked the doctor “what did the virus look like?” The doctor had to admit he had never actually seen the virus. The grandfather smiled and said, “doctor I admire your faith in the power of invisible forces, in something you have never seen.” It was then he realized the girl’s loss of spiritual health was closely connected to her physical health. The girl’s poor mental health from the loss of her mother in her life led to suppression of her immune system and an illness from a viral infection. From that day forward he never forgot the need to “recognize spirituality as part of the journey to wellness.” Thanks to Dr. Durie I never forgot his powerful message.

LOST DREAM

I have been asked why are you moving to New Zealand to practice medicine?  First and foremost I have become disillusioned by American physicians loss of control of their patients care and the over emphasis on productivity and profitability. There is a important philosophical shift in American medicine where the first priority is no longer what’s in the best interest of the patient but rather what’s in the best financial interest of the health care system. For 29 years, I practiced in NE Florida. I was very happy in private practice and was living the American dream of owning my business. I could build close and lasting relationships with my patients. As I watched reimbursement for my services decline, my referring doctors’ practice was bought out by competing hospital networks. I could no longer admit my patients to the hospital. They were admitted by a hospitalist. My overhead escalated, so I sold my cardiology practice to the hospital. As a hospital employee, my dream turned into a nightmare. The local hospital administrator used to ask how can we help you deliver better care to your patients, corporate medicine now asks how can we make you more productive To emphasize this this shift in philosophy they changed the name of the hospital, from the patron saint of doctors to the name of the money oriented corporation. I became an outsider in my own institution. I lasted for 19 months and my last day of employment was Nov. 15th 2012. It is sad that the American dream of owning your own medical practice is fading in the United States. I was hit with this shocking realization that I felt like a refugee, no longer owner of my own business in charge of my own life. So I started a new life in New Zealand. While living in New Zealand, there was a moment when I realized I no longer was the same person. Life had changed. And the me before slowly faded in the fabric of the years. If I looked closely, the scars were there, but they no longer caused pain. Now they were simply part of my story. Instead of being something I ran from they became something that created the strength in who I am now.

JUDDER BAR FLUTTER

On rounds one day I was presented a case of a elderly gentlemen with chest pain who had a episode of a life threatening heart rhythm disturbance “VFIB/VTACH" while being transported by the Ambulance Service to the Hospital. The Paramedic’s notes said the patients vital signs were stable with a BP of 136/74. The notes also said he looked remarkably well during this rhythm disturbance. At the bedside the patient told us they had taken a especially rough and bumpy road to the hospital. Looking at the rhythm strip I notice normal sinus rhythm followed by wide undulating complexes that return to sinus rhythm. The Heart tracing spikes or QRS complexes marched out unchanged so I concluded that this was artifact caused by the ambulance going over a rough patch of road or a speed bump. Speed bumps in New Zealand are called judder bars. So I explained the house staff that this was judder bar artifact. One of my colleagues suggested I write this up and call it "Judder Bar Flutter". So this is the world premiere of a new rhythm first described by Stephen Stowers MD FACC Senior Consultant in Cardiology Palmerston North Hospital. Cheers from Palmy on the North Island of New Zealand!

A SHOCKING STORY

I would like to relate a story about judder bar flutter that is not so funny. A young lady at home with chest pain called the community rescue unit which evaluated her and decided to transport to our hospital. She was placed in the back of the ambulance with a new trainee on a monitor that had defibrillation (shock) capability while the experienced veteran was in the front seat driving. While going over a rough patch of road the monitor alarmed and its automated voice blared out “shock advised”. Just as the trainee reached for the flashing orange shock button the veteran seeing the patient was sitting up in no distress and realizing it was judder bar flutter shouted out don’t shock the patient. It was too late the flashing orange button was already compressed, and the patient shocked. The veteran quickly pulled over the ambulance and told the trainee to get up front and drive he would stay in the back with the patient. In the hospital the patient expressed her surprise about being shocked. “I DON’T KNOW WHY THEY SHOCKED ME I WAS FEELING FINE “

FLUID AROUND THE HEART AND LOW BLOOD PRESSURE FOLLOWING ESOPHAGEAL SURGERY

I was roused from sleep at 2am by the tense voice of the intensive care physician who had called me to come in and perform a emergency heart echocardiogram on a postoperative patient. He was having a heart attack with low blood pressure that was not responding to his frantic attempts to raise it. Upon arrival with the echo machine to the dimly lit unit the patient was in the corner with clear plastic bags of medicated fluids supporting his blood pressure hanging on a metal pole next to his bed with multiple infusion pumps blinking like lights from a Christmas tree. The bedside echo showed moderate amount of fluid around the heart with normal heart function but some impaired filling from the external pressure from the collection of fluid around the heart . While performing the echo I sensed someone behind me and when I turned peering through the darkness, with the image from the echo monitor reflecting off his glasses, was the surgeon who had performed the operation . Could he have been cutting near the heart during the operation I asked. I "put surgical staples through the diaphragm to tack up the esophagus" he responded. Knowing the inferior wall of the heart rest on the other side of the diaphragm I instantly understood why the heart tracings and blood tests looked like a inferior wall heart attack. I immediately contacted Wellington our referral center for open heart surgery. My colleague in Wellinton advised us under echo guidance to put a needle in the fluid around the heart and drain it and they would transfer the patient in the morning. With my adrenaline surging I said rather forcefully the blood would just reaccumulate and the patient would not be around in the morning. Thankfully we prevailed in sending him to Wellington by life flight. In Wellington my colleague performed a coronary angiogram which should no damage to the arteries supplying blood to the heart and then tried to drain the blood around the heart with a needle only for it to reaccumulate. The patient subsequently had a cardiac arrest and was taken to the operating theater with my colleague sitting on the stretcher frantically draining blood from a tube in the pericardium. The cardiovascular surgeons opened the chest and found staples through the diaphragm into the heart causing bleeding from the cardiac viens.The bleeding was stopped with repair of the cardiac viens and the patient made a complete recovery. Lesson learned don't try to drain a traumatic pericardial effusion without a cardiovascular surgeon present.