Five Patients - Crichton Michael. Страница 12

He was seen in the morning by the neurological consults, who felt that he was "still quite ob-tunded," confused and disoriented. Nonetheless his progress since admission was striking. He could answer questions. When asked where he was, he said, "the hospital," though he could not specify which one. When asked his name, he said, "John." He could state his age. He was taken off Valium entirely. His temperature continued to fluctuate in the range of 99°-101°F. Dr. Minna wrote: "He is better in all ways."

Lab values, back from the day before, continued to climb. CPK had now gone to 2900, the highest in the history of the hospital. There was still no explanation for these enzyme changes. The patient continued to improve in alertness and responsiveness, though his mental function was far from satisfactory. In answer to questions, he said that one plus one was "one," and two plus two was "five."

He was able to carry out verbal commands such as "Squeeze my hand" and "Open your eyes." However, for the most part he lay in bed with his eyes closed; he initiated little spontaneous activity, and never spoke except in reply to questions.

His Foley catheter was removed. He was able to urinate in the normal manner. He was more active mentally, and remembered his last name, for the first time.

Blood cultures now revealed growth of a gram-negative bacillus, identified as Bacteroides, probably of bowel origin. The patient was sufficiently improved that he could be questioned about toxins, drugs, mushrooms, work exposure, and possible ingestions of heavy metals; there was no evidence for any of these. He was seen again by surgeons, who concluded that his abdomen was soft, with normal bowel sounds.

Barium enema was repeated, looking for diver-ticulitis or other sources of infection. None was seen.

He was seen by the neurological consults, who observed mild proximal muscle weakness and suggested study of the electrical activity of the muscles, by electromyography. He was also noted to have mushy swelling of his extremities.

Electromyography was normal. It was decided to discontinue his chloramphenicol antibiotic and see if he remained without fever.

Chloramphenicol was stopped. The patient did well, taking liquids by mouth.

The patient's mental condition continued to improve. A repeat kidney X ray was read as normal.

On his second day off antibiotics, his temperature fluctuated in the range of 1000-101°F.

There was continued improvement. Enzymes had dropped to near-normal levels. He had no fever.

The patient had an upper gastrointestinal series of X rays, which were normal. On his third day off antibiotics, the temperature began to spike again, to 102°. Tenderness and guarding of the right-upper abdomen reappeared. 

The surgeons concluded that the patient had cholecystitis, or infection of the gall bladder, which had probably begun initially as cholangitis, infection of the bile system. They also wondered, however, whether he might have a liver abscess. The patient was put back on antibiotics.

Mr. O'Connor was transferred from the medical service to the surgical service as a pre-operative candidate for exploratory abdominal surgery. His mental state continued to clear slowly.

The neurological consult saw him and agreed his mental status was improving. The surgeons, moreover, found that his abdominal tenderness had disappeared with the antibiotics. X rays of the gall bladder showed no filling of the bladder sac, but the films were of poor quality. Radioactive scans of the liver and spleen were negative.

The scheduled operation was canceled in order to allow time for further pre-operative studies. A repeated gall bladder X ray definitely showed no filling, although this time the films were of good quality. A celiac angiogram was scheduled.

The weekend. Specialized procedures such as celiac angiography could not be done, and further work on the patient was postponed until Monday.

Celiac angiography was performed. Under local anesthetic, a thin, flexible catheter was passed up the femoral artery in the leg, to the aorta, and finally to the celiac axis, a network of arteries coming off the aorta to supply blood to all the upper-abdominal organs. A dye opaque to X rays was injected, and the vessels studied. No space-occupying lesion (tumor) was found and the vessels were normal in appearance. The patient made a good recovery from the procedure.

The abdomen was soft and non-tender. The patient felt well. He was still on chloramphenicol. Enzymes were, by now, fully normal.

The patient had no fever and felt well. The surgical staff decided to stop antibiotics and see if the fever and symptoms recurred. was now clear that he was not an operative candidate. Plans were made for his discharge the following day.

He was taken off antibiotics. Temperature and white cell count remained normal. The patient himself was in good spirits.

There was no demonstrable worsening of the patient's condition on his second day off antibiotics. His wife expressed the opinion that his mental state was entirely normal once more.

His condition remained stable on the third day. He said he felt well. He had no fever and no elevation in white count.

His condition was still good; his abdomen was soft without tenderness. He said he felt well. It

Discharged. His discharge diagnosis was fever of unknown origin with bacteroides septicemia. The opinion of the house staff remained that this patient had probably had a bile-collecting-system infection.

Five days after discharge, he was seen in the surgical clinic by Dr. Jack Monchik, who scheduled another set of gall bladder X rays for the future, and noted that if the patient had further trouble with infection, it would probably be necessary to remove the gall bladder. For the moment, however, the patient was fully well.

"To do nothing," said Hippocrates, "is sometimes a good remedy."

On the surface, Mr. O'Connor's hospital course seems proof of this ancient dictum of "watchful waiting." But this is not really so: had Mr. O'Connor received no treatment, he would almost certainly have died within twenty-four hours. He received vital symptomatic therapy (lowering his fever) as well as acute support of vital functions (assisted respiration). He was closely monitored by teams of physicians who were prepared to intercede in his behalf, supplying more assistance should his body require it.

He also received a vigorous diagnostic work-up, which did not produce as much information as one might like. His therapy was successful, but no physician at the hospital could claim, at discharge, that they really knew what was going on in his case. A diagnosis of cholangitis and cholecystitis was likely, but never demonstrated.

His hospital bill for a month of care was $6,172.55. This is just a few dollars less than Mr. O'Connor's annual salary. But he did not have to worry about it; unlike most patients with some form of health insurance, Mr. O'Connor had coverage that was essentially complete. His personal bill amounted to $357.00.

In this, as in many other things, Mr. O'Connor was a very lucky man.

The single most important problem facing modern hospitals is cost. This cost can be analyzed in a variety of ways, most of them confusing and unhelpful. But the following points are clear:

First, the cost of hospitalization has skyrocketed. The average MGH patient today pays per hour what the average patient paid per day in 1925. Even as recently as 1940, a private patient could have his room for $10.25 per day; by 1964, it cost $50.10 per day; by 1969, $72.00-$ 110.00 per day. This staggering increase is continuing at the rate of 6 to 8 per cent per year. Each year

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for the past three, the MGH has had to raise its charges. Nor is the teaching hospital unique in its financial squeeze. All American hospitals are raising their charges at this same rate.

Second, hospitalization cost has increased much more rapidly than other goods and services in the economy. Medical care is the fastest-rising item in the consumer price index in recent years, and per day hospital cost accounts for the largest proportion of this increase. [Physicians' fees have also been rising faster than other items in the consumer price index. However, hospital costs have been nearly doubled in the past decade, while physicians' fees have increased 30 per cent].