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Thursday, October 15th 2009

Acute Care Resources

Lexington, a pseudonymous columnist for my favorite magazine The Economist, had the following to say about efforts to reform American health care,

We are all going to die. And the demand for interventions that might postpone that day far outstrips the supply. No politician would be caught dead admitting this, of course: most promise that all will receive whatever is medically necessary. But what does that mean? Should doctors seek to save the largest number of lives, or the largest number of years of life? Even in America, resources are finite. No one doubts that $1,000 to save the life of a child is money well spent. But what about $1m to prolong a terminally ill patient’s painful life by a week? Also, who should pay?

I couldn’t agree more. I’ve long been a proponent of the idea that expectations of healthcare in the United States are something else, more demanding as compared to the rest of the world. We try everything here in America for a patient, cost not prohibiting, before the plug is pulled. This trend is especially prominent in acute care situations. Situations of immediacy, of life and death.

[zdvideo width=550 height=420 theme=simple1 border=no]http://www.youtube.com/watch?v=F2n7H-8o5GI[/zdvideo]

Consider I’m at a major trauma center for training right now. I know I’m not seeing unique scenarios and I, with some frequency, am witness to scenarios like the following. An 80 year old man comes in following a motor vehicle crash. He was the restrained driver. There was a death at the scene.

He had a prolonged extracation from the vehicle

On the scene he had a Glasgow Coma Scale of 9 and was combative and was intubated for such. En route to the emergency room his hemodynamics become a little marginal and he starts with progressive fluid requirements. On arrival to the emergency room a FAST scan is inconclusive and his pressures, while marginal, are stable enough for him to make a quick run through the scanner. His injuries are documented by imaging as bilateral femurs, open pelvis with active extravisation, splenic and liver injuries with active extravisation, a subdural hematoma on the right with marginal shift and bifrontal contusions.

Coming out of the scanner his pressures collapse as he’s being rolled emergently to the operating room. At this point his TRISS score predicts a mortality approaching 95%.

Intraoperatively he loses close to 20 liters and requires massive resuscitation. Resuscitation includes more than 50 units of packed red blood cells and corresponding fresh frozen plasma and cryo and platelets. He is transported to the SICU status post a splenectomy with an open packed abdomen. He requires continued resuscitation with another 10 of pRBCs and 10 of FFP. He requires ACLS overnight although a pulse is returned. He is not stable enough to make a trip back to the operating room as planned through the whole of the next week. At one point he has a reexploration of his abdominal wound at bedside under sterile conditions because he is too unstable to be transported to the OR.

He continues like this for a week despite the clear non-survivability of his injuries, until finally made comfort care and allowed to peacefully expire.

There are plenty of places in the world where this gentleman would’ve never gone to the operating room emergently, would’ve never gotten the incredible efforts at resuscitation. Not because the resources didn’t exist for such; but because such was essentially futile.

The costs of futility in terms of currency are one thing. The costs in terms of limited healthcare resources are quite another. For instance where should valuable blood products be spent? Especially in scenarios like above where the odds of the patient surviving are tiny, even in the face of the massive use of scarce blood products. That’s one less unit of packed red blood cells for a patient who needs them with better odds.

Playing the rationing game in acute care scenarios is horrifying in some ways I admit. Often these scenarios have arisen on the spur of the moment, the seriousness of a patient’s condition has not had time to set in. Rationing calls for us to accept the following scenario: One minute a patient is playing with his or her family, the next they’re in a terrible accident and the patient’s family is being told that there’s almost no chance of survival therefor the healthcare system is not going to even attempt everything they can to save the patient.

I’m not sure our social expectations of healthcare will ever allow that in the U.S. Maybe, hopefully over time however.