On Anger at the Healthcare Machine.
I follow our INR patients on coumadin on a weekly to monthly basis. There was one patient, Randy, who was never quite compliant, but was always cheerful and friendly.
Randy liked his drinks, and would joke when his INR was too high or too low that it “must be the whiskey”. Randy was on warfarin because of a heart valve replacement about 10 years ago. In the beginning, I always chastised him - nicely - to not drink and to do better to have his INR taken when I told him to take it. But overall, he was not a difficult patient and I always looked forward to getting to talk with him.
On one of our monthly calls, he had a congested cough, and I heard his wife gasp in the background. He was saying, “No, no, don’t tell them.” and his wife took over.
“Randy is coughing up blood off and on for weeks now! And he won’t tell the doctor because he doesn’t want to have to take time off work.”
Rightfully concerned, we made an appointment to see him in the office that week. The doctor ordered an urgent CT scan, only to have it denied by Randy’s insurance.
Really?! You’re going to deny a CT scan of a man with a mechanical heart valve who’s coughing up blood? Insurance drives me mad.
After two weeks of appeals and peer-to-peer calls, the insurance finally let us move forward, and he got his CT. I came in the next morning to a flurry of messages in my EMR - radiology apparently hadn’t been able to get ahold of the physician, but there was a problem with the valve and the troubling signs of the beginning of an aortic dissection. The back up doctor called the patient at 5am and urged him and his wife into the ER.
I checked the chart and saw, thankfully, Randy had followed advice and gone to the ED. Reading through the ED notes, it looked like there were no beds available in the hospital, so he was being held in the ED to await workup with the heart team. I felt anxious and checked his chart every couple hours for updates, along with our physician who called the ED docs for report a couple times that day. We both lamented that it was terrible he had to sit in the ED because of a lack of ICU beds - he should be in surgery already! My doc decided to ask them to transfer to another hospital, but got roadblocked at every turn.
And then…at 3pm that day, I went to check his chart again, and received the notification - “You are entering the chart of a deceased patient. Would you like to proceed?”. I instantly clicked “no” - I must have clicked the wrong Randy!
Typing in the info again, I again got the warning, and my heart sank.
Randy’s pressure had been climbing, and despite repeated administrations of IV beta blockers, they couldn’t get his pressure down. He gasped, screamed, and began to code. The team knew he’d fully dissected. In less than two minutes, he went from v. fib to asystole, and in less than 15 minutes, they called time of death.
I was mad for days. I still am mad, and that’s part of why it took me months to write this. At every turn, if something had gone better, he’d likely still be alive.
If his insurance hadn’t denied and fought us for the CT.
If our CT availability hadn’t put him off two more days.
If the physician could’ve been reached immediately.
If the hospital would’ve had available beds.
If they would’ve transferred him to a hospital that had availability.
So many of the ifs caused by a broken healthcare system in which people you’ve never met determine whether you can have the tests ordered by the physician who has known you for 15 years and went through years upon years of schooling. A system in which state hospitals are overrun with people who cannot afford primary care, often blocking access to people who need it most.
A system in which sees dollar signs in open heart surgery instead of a life to save.
