Discharge Summary by Brandon Barrett
Associate fiction editor Sarah David on today's bonus story: Brandon Barrett's "Discharge Summary" takes us on an off-kilter ride past health care's peculiarities and the hospital staff's dirty laundry. Also included: an unexpected dose of heart.
***PRELIMINARY RECORD--NOT FINALIZED BY PHYSICIAN***
(Note from Medical Records: This file is queued for adjudication in conjunction with Risk Management. It is severely past due for final signature, and is required for Medicare reimbursement of this hospitalization. Note that Dr. Howard is no longer affiliated with Gold Lake Medical Center. Also note that Risk Management strongly advises all personnel reviewing this file to ignore Dr. Howard’s real estate offer.)
I. PATIENT: Ellen Tabor, DOB 1/12/24, MRN 7847326
II. ATTENDING PHYSICIAN: Katherine Howard, MD, FACC
III. DATE OF ADMISSION: Feb 2, 2015
IV. DATE OF DISCHARGE: Feb 6, 2015
V. REASON FOR ADMISSION: Chest pain
VI. DISCHARGE DIAGNOSIS: ST-Elevation Myocardial Infarction
VII. PROBLEM LIST: Coronary artery disease, acute kidney injury, hypertension, hyperlipidemia, obstreperousness
VIII. HOSPITAL COURSE: (abstracted from daily progress notes)
Day of admission: Ellen Tabor, 91-year-old woman with a medical history of hypertension and hyperlipidemia, initially presented to an urgent care walk-in clinic complaining of four hours of intense substernal chest pain with radiation to the left arm. Why she waited for four hours is unclear. Why she didn’t call 911 is unclear. Why she felt that a Walmart walk-in clinic was a reasonable place to get her crushing chest pain evaluated is the stuff of deepest mystery. An electrocardiogram performed at the clinic was worrisome for an acute anterior myocardial infarction. Despite her vocal protests that this was “quite a bit of nonsense,” the patient was transferred via ambulance to Gold Lake Medical Center where I met her in our emergency department. The other Dr. Howard was on call, but I was more readily available and so took on the case.
After confirming the diagnosis of myocardial infarction, I had the patient taken urgently to the cardiac catheterization laboratory. I say “urgently” but the process—to an untrained eye not accustomed to our modern way of doing business—would have seemed quite leisurely, since the computer system recently installed by the hospital’s new corporate overlords confounded all attempts to register the patient. The lovely high-definition monitor repeatedly flashed a blue screen indicating the presence of a “fatal error,” especially apt terminology should the patient have expired while waiting. In any event, this glitch gave the staff an interesting opportunity to grapple with some deep epistemological issues vis-à-vis how certain they were that this woman in front of them actually existed.
The administrator-on-duty was paged. I told him I had a patient we couldn’t register. He yawned loudly into the phone, clicked on his keyboard and said that he couldn’t help because he couldn’t find the patient in the database. Rather than follow him down this rabbit hole, I asked whether we couldn’t get on with the mundane work of saving the patient’s life and after that nagging detail was dealt with, then let’s hunker down for the real meaty work of registering her into the computer. The AOD responded that we should wait and figure it out after the patient arrived. Beginning to question my own sanity, I put the patient on the phone to assert both her existence and her physical presence in our emergency department. The AOD responded that the voice could have been anybody’s and that Gold Lake Medical Center was maintaining a stance of agnosticism regarding Ellen Tabor. An additional ten minutes passed until an IT professional could convince the computer that the patient was a corporeal entity, during which time I personally wheeled her into the cath lab and put her on the table myself.
Is it of interest to note that since Gold Lake was acquired by Janus Health Systems last year, a graph of our response times to myocardial infarctions would demonstrate a linear increase? Potentially owing to a fixation on stock valuation above all else, Janus Health may be under the misapprehension that larger numbers are always better.
Vascular access was obtained via the right radial artery. Angiography demonstrated a completely occluded proximal left anterior descending artery, which was opened with a single 3.0x15mm drug-eluting stent with a good final result. Left ventricular function was mildly decreased with an anterior wall motion abnormality. The patient’s chest pain resolved, but blood pressure remained marginal.
At the conclusion of the case I requested a bed in the intensive care unit for close monitoring, as is routine for post-MI patients and is, I believe, still the official hospital policy. I was informed by staff that there were no available ICU beds. I wondered aloud why I hadn’t been previously informed of this, and that the hospital should be diverting emergencies to institutions with available ICU beds. Into the ensuing silence I then clarified that this wasn’t a rhetorical question, and that the staff should again page the administrator-on-duty. The AOD responded that Chairman Gurtz felt the hospital should categorically never divert myocardial infarctions, a decree which I have to imagine owes something to the relative profitability of this diagnosis. I politely requested that Mr. Gurtz be called at home so that a spirited conversation could be held. This request was not carried out on account of the lateness of the hour, although I’m awake and working and don’t see why he can’t be also, considering he makes a lot more money than I do.
In this specific case, I did not feel that transferring the patient out of town was warranted and she was ultimately admitted to the general medical floor. She remained pain-free but rapidly issued a volley of complaints regarding the temperature of the room and the quality of the bedding. I listened carefully for some utterance of gratitude but this was not forthcoming. She requested a cheeseburger and chocolate pudding, which also will not be forthcoming.
She is hemodynamically stable. Her renal function is slightly impaired and her skin turgor is poor. I suspect mild dehydration, given the high temperatures lately and the patient’s admission that she had been working out in the garden all day and rehydrating herself only with Starbucks coffee, to which I had no polite response. I am skeptical of her capacity to continue living alone. I started her on aspirin, ticagrelor, metoprolol, atorvastatin, and will continue IV fluids. Echocardiogram in the morning.
The patient’s RN will unfortunately be Nurse Charles. I have formally put in a request for either Annette or Travis, but the unit coordinator is the other Dr. Howard’s girlfriend and so I think we know how that’ll go.
Hospital day 2: I arrived at the bedside amidst some commotion this morning. Nurse Charles had convinced himself, after a brief and uninformed examination of the telemetry monitor, that the patient was experiencing life-threatening ventricular arrhythmias. This seemed refutable based solely on the patient’s complete lack of symptoms and robust blood pressure, but there was also the fact that she was fidgeting non-stop with her rosary which had entangled itself with the EKG leads. All the tugging was producing some (not particularly convincing) artifact on the monitor, a hypothesis easily proven by asking the patient to simply hold still for one single moment. I was therefore able to deflect the fine Dr. Turtle—who’d been collared and successfully stoked into a nervous lather by Charles—before he could whisk the patient off for unnecessary testing. I realize that the only manner in which this interventions can viewed by Janus Health Systems is as a blow to the profitability of this admission, and I plead guilty to the charges.
Because of this morning kerfuffle there was a delay in administering the patient’s oral anticoagulants, which of course is unacceptable given the recently placed coronary stent and the risk of acute thrombosis. Nurse Charles is a convenient target to blame—since he is a fool—but to be fair, even a very experienced nurse would have difficulty managing six complex patients all day long. The ratio in this wing used to be four patients per nurse, but Mr. Gurtz’s belt-tightening measures have ensured a persistent nursing shortage. I wonder when the hospital last hired a nurse who wasn’t a fresh graduate, who wasn’t offered a salary that was frankly insulting, and if Administration worries about our poor nursing retention rates or if constant churning of underpaid staff is just evidence of a ruthlessly calculated labor policy doing what it does.
The echocardiogram demonstrated an ejection fraction of 40-45% with mild residual anterior hypokinesis and no clinically significant valve disease. Blood pressure is now elevated. The patient’s and probably also my own. I increased the dose of metoprolol. Her lipid panel reveals a cholesterol level only slightly lower than a stick of butter’s. The patient is complaining about taking the atorvastatin but I told her to buck up. Renal function has improved but is not yet back to baseline.
Hospital day 3: I was late today in performing morning rounds since Dr. Johnson had fallen asleep in the physician’s lounge in front of the only working computer terminal—as I suppose 85-year-old men are occasionally wont to do—and had to be gently escorted to the couch so that I could actually do some work.
The patient’s admission will be approaching the 72 hour mark this evening, so I expect that Utilization Management will be paging me shortly to inquire why she is still here beyond that financial sweet spot. I would like to state for the record that I am not a fool. I understand that in communities like our—cow towns with tiny 80-bed hospitals that hemorrhage money and have absolutely no economies of scale—behemoths like Janus Health function as necessary economic rehabilitation and that without their pecuniary shepherding Gold Lake Medical would be shuttered and seeking a buyer to turn it into a retirement home or minimum-security prison. I understand that Mr. Gurtz is not a mustache-twirling villain and that Janus had to bring in this 45-year-old MBA from New England—who no doubt had to Google “Gold Lake Medical” to find it on a map—to run the place because former Chairman Stoll was the kind of man who took “non-profit” status as a commandment to actively avoid balanced budgets. I understand that I can’t outright lose money for the hospital as a matter of course.
But: the patient stays another night. She is ambulating in the halls without chest pain but remains unsteady on her feet. She is at high risk for falling and needs additional physical therapy. A hip fracture at her age and frailty would herald the end.
Her renal failure has normalized and her blood pressure remains on the high side. I added a small dose of lisinopril which she may not agree to take once beyond these walls, but I’m going through the motions here.
And finally, it would seem that Nurse Charles overheard my interaction with the patient today. Or at least the part with me yelling “for the love of God, Mother, just take the pills.” Nurse Charles, of course, is young and driven and has his eyes on that nurse coordinator position on Four East, and is consumed (consumed!) by a passion for medical ethics. Which explains why I received a call from Risk Management today advising that I was to immediately transfer care of the patient to one of my colleagues and recuse myself from further involvement. To which I would love to record my response for posterity, but the electronic medical record appears to censor out many commonly used expletives.
Hospital day 4: The patient is refusing to take atorvastatin, claiming a fear of side effects. The patient, it should be noted (since this could never be ascertained based on her behavior alone), is herself a retired physician. The first female surgeon in this county and only the fifth in the state. I know this to be true because when I was growing up, a vaguely familiar woman would occasionally pop up in our house in the evenings for a few moments and start to read a book to me, before a device on her belt would start beeping and she would run away, and my father would say “there goes your mother.” He told me that my mother had to go help strangers every night so that other mommies and daddies could be alive to come home to their little girls. I thought my mother was probably the most glamorous, vital person in the world, and I thought myself very generous to sacrifice her to the hospital for the greater good.
I would love for Chairman Gurtz to please tell me which physician should have cared for the patient, if not myself. Elmer Johnson, the senile dinosaur? Leonard Turtle, the idiot? (Did poor Lennie finally pass his boards, by the way? No?) Jerry Howard, my drunk ex-husband? If Mr. Gurtz’s mother has the misfortune of experiencing a heart attack in our little town while she is visiting from Martha’s Vineyard, oh to be a fly on the wall as he faces the Sophie’s Choice of Jerry or Lennie or Elmer (if he is still alive and can hear his pager going off), and we will see if the Chairman truly feels that these individuals provide acceptable medical care.
I am informed that as a result of this breach of guidelines set forth by the state medical board, my hospital credentials are in the process of being revoked in committee. I hardly see how it matters. Tomorrow is my final day as a practicing physician, a date I am sure Mr. Gurtz is well aware of since he chose it himself.
The patient could have been discharged today, except that my father died ten years ago and my mother is a nonagenarian living alone and gardening in 100 degree weather while drinking Starbucks and she still drops her blood pressure twenty points when she stands up and so no, she is going to come live with me and I haven’t gotten the safety rails installed in the bathroom yet. For any Medical Records personnel pursuing this file (especially you, Janice): the patient’s house in beautiful neighboring Boostwich will soon be on the market and old friends might get a deal. There is a hot tub.
Hospital day 5: The patient was found this morning in a room three doors down from her own, trading recipes with a congestive heart failure patient even more wizened than herself. I informed her that by distributing her achingly salty pasta sauce recipe on a cardiac ward she could probably be prosecuted for attempted murder. The patient has spent a significant portion of her retirement failing to master the culinary arts. I wonder that pedestrian hobbies I will pursue in my dotage, the official onset of which I consider to be tomorrow.
Who was the first cardiologist in this hospital, in this one-horse town? Who convinced the dearly departed Mr. Stoll that the community needed a cath lab so that our sick coronary patients weren’t being shipped over the mountains in bad weather? Who was on-call for three straight years until we finally hired another body? (Although given that it was the other Dr. Howard I helped to recruit, maybe I owe Janus a mea culpa on that point.) Who spent her potential child-bearing decades taking care of strangers at two in the morning instead of raising a family? Who followed in her mother’s footsteps and threw her life onto the pyre of service, who gave her lumbar spine to this hospital, who accepted her varicose veins from this hospital? And who is the first to be shown the door? The drunk, the idiot, the doddering old man? Or the obnoxious grey-haired woman who shook the bushes.
I considered acquiescing at the eleventh hour and transferring the patient’s care to the other Dr. Howard, so that he could enjoy a brief reunion with his mother-in-law as he arranged her discharge. She could ask him if he ever got his driver’s license back, like she always does. But I’m tired of being passive-aggressive. Tired of everything. I’m ready to go.
Heart exam is regular rate and rhythm. Lungs clear. No edema. Blood pressure stable. Tolerating meds. Discharged from hospital in good condition.
Katherine Howard, MD, FACC (final signature pending)
Brandon Barrett is a practicing cardiologist, originally from Oregon and now living in rural Virginia with his wife and son. His stories have appeared or are forthcoming in The Carolina Quarterly, The Literary Review, The Cossack Review, Tahoma Literary Review, and elsewhere.