Divemedic

Everyone likes to complain that healthcare costs too much, and then complains about the “healthcare system” as if it is some sort of unified national entity that is controlled from the top. It isn’t. What we call healthcare in this country is a marketplace made up of hundreds of thousands of companies, each reacting on an individual basis to market conditions.

The largest of these changing conditions is CMS, the Centers for Medicare and Medicaid Services. They set the conditions under which they will pay for medical services. For example, if a person comes into the hospital with signs of sepsis, that person must receive a blood test for lactic acid levels. If that level is greater than two, the person must be tested again within 6 hours, or the hospital doesn’t get paid. This is repeated all over the entire field of payments from CMS. They regulate everything.

They tell hospitals what procedures must be done, how they will be done, and what each provider can charge for all of those procedures and tests. They also dictate that CMS has to be charged the same amount as every other patient. With CMS directly controlling 32% of all healthcare spending in the US, and indirectly controlling another 40% of medical spending by dictating policies to insurance companies, they are the 800 pound gorilla in the room.

If a provider doesn’t play ball, they don’t get paid, and can be added to the national list of “CMS doesn’t let this person be involved in medical payments” blacklist that effectively ruins your career by making sure that 72% of patients can’t use insurance, Medicare, or Medicaid to pay for your services. No one will hire you. It’s even a question on hospital job applications- “Are you on the CMS naughty list?”

So the market responds to that by doing what they are told to do by the Feds.

Then there are the patients themselves. I can’t tell you the number of times that a patient comes into the hospital every day with COPD but is still smoking. There are the diabetics who come in complaining of numbness in their feet, blurry vision, and stomach pain with a blood glucose level over 500 and an A1C of 12, but will lie and tell you that they are watching their diet and taking their medication. There are the drug addicts who come in twice a week because they overdosed, and the drug seekers who come in nearly every day looking for a pain med fix. (We have one woman who has already been in the ED 14 times this month, and it’s only 17 days into December.) The person having a stroke who has a history of high blood pressure, but doesn’t take their medication. Yes, each of these were patients I saw during the last week, and each of them blamed doctors for not fixing their problems in an hour or less, even though their problems were entirely self created.

There is an endless parade of patients who come in with cannabinoid hyperemesis syndrome who won’t stop smoking weed, or STIs because they won’t stop mating with every person who will take their clothes off, Mental health patients, homeless who want free sandwiches, and illegal immigrants who use us as their primary care.

All of these people get seen under a law called EMTALA, which mandates that hospitals have them evaluated whether or not they can pay. Once they are evaluated, those CMS rules we talked about earlier dictate that they have to be treated. Then the entire thing gets paid for by your taxes.

Then after all of that, people then sue the practitioners, workers, hospitals, and drug makers who followed all of those rules and win millions of dollars in payouts.

The problem isn’t healthcare- we as a nation have the best healthcare in the world. What is screwing things up is market manipulation by the government. Imagine for a moment that the Feds were doing the same with the “restaurant system.” That is, 72% of all food was paid for by the government, who set standards on what everyone could eat, how much they could eat, how that food must be prepared, and under what conditions grocery stores and restaurants would be paid. Then they also dictated that anyone who went to a restaurant that had a drive through would have to be served whether or not they could pay for it, but then reimbursed the restaurant for the meal cost. All of this regulated to the point that there are hundreds of thousands of rules, each of which must be followed to the letter. What would a restaurant look like, and how much would a meal cost?

I don’t think most people have a problem with the care they are getting, and those who do frequently misunderstand why they got what care they did get. Most people are upset at the cost, and that cost is directly related to the government distorting the market, and the market’s entirely rational response to that manipulation.

What makes me laugh the most is that everyone then blames the doctors and other facilities, then demands that the government step in to fix the problems that the government created. That’s true whether you want more regulation, single payer, or some other government intervention.

Mammals, or humans in particular as it relates to this post, need to exchange gases. We take in oxygen and get rid of carbon dioxide. The process that we use to do that is breathing. There are two components to that process: ventilation, and respiration.

Ventilation is the mechanical process of moving air (or other gases) into and out of the lungs. Ventilation requires a functioning respiratory drive (provided by the CNS and portions of the PNS), an intact and functioning chest wall, the airways, and lung tissue that is functioning properly. Being a mechanical process, there are things that can affect it: physical blockages of the airway through trauma, inflammation, or even a failure to maintain open air passages because of dysfunction in the nervous system.

Respiration is the actual exchange of gases, first across the alveolar membranes, then into the blood, into the tissues of the body, then back to the blood and across the alveolar membranes to be expelled from the body. This process depends upon the relative pressures of the gases involved. Things like partial pressure, electrochemical gradient, pH, and other factors play a huge role in the moving of gases into and out of the lungs.

Entire textbooks are written on how this process works, so this limited post won’t be an exhaustive treatise on the function of the respiratory system. I want to mention mechanical ventilation and why intubating a patient and placing them on a ventilator is so important.

There are times when a patient’s respiration doesn’t function as it should. Perhaps the process of gas exchange has been disrupted because another gas has more affinity for the chemical reactions that are taking place, as is the case with hemoglobin’s stronger affinity for carbon monoxide than oxygen. Maybe the pH of the blood is shifting, causing gas exchange in the alveoli to cease. There are a lot of reasons why this can stop working as it should, and these can be addressed through multiple means. The simplest of these is simply putting a nasal cannula in place to deliver oxygen at a slightly higher partial pressure. Still, there are times when these tricks don’t work and respiration breaks down.

Once the breakdown in the processes of ventilation and respiration take place, a person will begin to struggle to breathe. The work of breathing increases, and the patient has to put in more and more effort to get a breath. This is extremely tiring. Sooner or later, the person becomes too exhausted to breathe, and slips into what is called respiratory failure. When this sets in, there are again numerous things that can be done to assist the person in breathing. BiPAP and CPAP are two ways to do this. However, if these measures don’t work, or if the person can’t breathe on their own, then someone or something has to breathe for them.

In the short term, a device called a bag valve mask allows medical personnel to breathe for the patient, but this isn’t a long term solution, nor is it very useful for delivering higher levels of pressure to the gases involved.

Ultimately, a person who is not breathing well on their own will wind up with a tube down their throat and a machine called a ventilator doing their breathing for them. This can be done because the person can’t keep their airways open when they are unconscious, like during surgery. It can be done because they have significant damage to the nervous system, for example a broken neck has damaged their phrenic nerve, are simply too tired to breathe, like during an asthma attack, and for a host of other reasons.

Here is a recent, real-life example. Steve is a known IV drug user who was found in his backyard by EMS. He is breathing with grunting, low volume respirations that are clearly ineffective. EMS tried giving him Narcan, but it had no effect, so they began ventilating him with a bag valve mask. Since he still had a gag reflex, they were unable to intubate the patient.

The doctor in the emergency room decides that he needs to be intubated and placed on a ventilator because he is simply incapable of maintaining and protecting his own airway. The staff gives him etomidate to sedate him, rocuronium to paralyze him, then the doctor inserts the tube before a respiratory therapist places him on a ventilator. The process is fast, taking less than 5 minutes.

The drugs used to place the tube will wear off in just a few minutes, so the patient needs to be sedated to keep him from fighting against the ventilator. Drugs like Versed, Propofol, Ketamine, and Fentanyl are used to keep the patient sedated. Of course, those drugs cause side effects that must also be dealt with. It becomes a delicate process of keep the patient sedated to the correct level while also maintaining the other parameters, as well as dealing with the drug overdose and the issues that it caused.

In the above case, the patient had rhabdomyolysis, liver failure, kidney failure, and a host of other issues that had to be dealt with. Dealing with those issues takes time, but unless a patient is breathing, time is what you don’t have. Ventilation buys you that time to deal with it.

There are COVID (as well as influenza and pneumonia) who get intubated to this day. Some make it, some do not. It’s not the ventilation that kills those patients, it’s the sepsis and the immune system’s response to it that kills them. In some patients’ cases, ventilation does more harm than good, but overall, mechanical ventilation is a process that saves thousands of lives per year.

It’s been a busy few days. I was at work one day last week, and we were simply overloaded with patients. In our 100 bed ED, we at one point had more than 220 patients. The waiting room saw every seat full, and some people were standing. Wait times were more than 6 hours for some people to even get a room inside of the department. I wound up working for 15 hours, and even then they asked if I could stay the rest of the night. When I pointed out that I still had to work the next morning, they asked if I could come in 4 hours early. I told them that I needed to get SOME sleep, so then they asked if I could come in 2 hours early. I agreed.

When I went in the next day, having only had time for 5 hours’ sleep, a shower, and a change of clothes, the backlog had been taken care of. My first patient of the day was a septic man who had a sore on his abdomen, and didn’t realize that he had a blood sugar of over 500. His A1C was 12.7, and he didn’t even know that he was diabetic.

My second patient was a 60 year old woman that had begun speaking gibberish the night before. The family let he go to bed. When she woke up the next morning and was still doing it, they decided that bringing her in was a good idea. We did all of the stroke assessments initially couldn’t find anything. Still, because of the delay, she was not a candidate for clot busters, so we did an angiogram of her head.

While we were waiting for the results, a new family member came in and began yelling at me, wanting to know why we weren’t doing a bunch of ridiculous stuff that she thought needed to be done. I guess her extensive Google search had recommended a bunch of things that she wanted us to do. I explained to her all of the things that we were doing, but she kept on making requests and went so far as to begin flagging down every hospital employee she saw to make these demands. She started getting really loud and mouthy. I finally had to tell her to wait in the patient’s room or I would have to call security. She came unglued at that point and said she wanted to speak to my supervisor so she could have me fired.

I know you would never guess that she was an Amish Canadian from Norway.

The patient eventually was transferred to another facility for brain surgery to fix the extensive blood clot that was found, but since the delay of over 12 hours meant that there was a lot of dead brain tissue there, her inability to walk or speak is likely permanent, and that’s on the family.

That mess was followed by a parade of people with sepsis, some diabetics, and a host of other issues. One diabetic had an A1C that was over 14, meaning that it was off the chart. He claimed to me that he always follows his diet and always takes his medication. Of course, he is lying. He doesn’t need to lie to me, it’s his feet, eyes, and life that he is playing with, not mine.

Every patient that I had wanted to argue and tell me that I didn’t know what I was talking about. Keep relying on doctor google and see what happens. As for me, all it does is keep me employed.