Central  South  Dakota  Medical News
The Clinical View
by Phillip Hoffsten
4 August 2004

HOSPITAL CARE GETS BETTER AND BETTER

     Trying to satisfy the public’s expectation in regard to medical care is rather like trying to empty the ocean with a teaspoon.  It seems that no matter what improvements or successes our medical facilities achieve, the media will hone in on the mistakes that happened in some hospital.  Medical care has gotten so complex that it is very difficult for the public to have any idea of the relative safety of hospitals.  To be sure, it is certainly safer not to need to be in the hospital than it is to be there.  But when hospital care is needed today, we are doing amazingly better than healthcare providers could do in the past.

     As an example, I remember June 23, 1963 as my very first day of working on a medicine ward at St. Louis City Hospital.  A father had come from Connecticut to visit his son and the father had a heart attack while on an excursion boat on the Mississippi River.  The gentleman had collapsed on the boat and harbor patrol had to go pick him up and bring him to the hospital.  On arrival, he was having terrible chest pain with an acute heart attack and was in shock.   In order to get his blood pressure up, we infused him with a drug called norepinephrine which we now know is more harmful than helpful.  We didn’t know that then and thought that we were doing the right thing.  Somehow over a six week hospital stay with multiple complications, the gentleman finally recovered enough to leave the hospital but was a cardiac cripple for the rest of his life.  I remember him well because he was the very first patient that I took care of and he went home the day I left the student rotation six weeks later.  He was a textbook learning experience for this young medical student.

     More recently a very similar case was seen.  Only this time it was a farmer who was harvesting wheat and developed chest pain while on his combine in the middle of his wheat field.  Fortunately, in today’s world he had a cell phone with him and called for help.  The ambulance arrived from 18 miles away to find the gentleman having a severe heart attack and in shock just like my patient in 1963.  But now this wheat farmer was brought to the hospital and given a clot melting medicine.  Two hours after the onset of his heart attack, the clot melted and blood supply was re-established to his heart.  His blood pressure came back up to normal without the use of our 1963 drugs, his chest pain went away and all that he could think about was needing to get back to his combine and finish harvesting the wheat.  It was explained to him that this really wasn’t going to happen quite that way and he was transported to a heart specialty hospital where a spring like device was placed inside the artery that was blocked to open that artery up permanently.  Two days later, he was home again.  In spite of medical advice to the contrary he was back combining again four days later.  He said, “A man has to do what a man has to do.”

     In 1963 we were not sure how to measure a blood cholesterol level but we know how to  now.  In 1963, there wasn’t a medicine to lower a blood cholesterol even if we found it high.  But now we have a host of medications that bring blood cholesterols down.  This gentleman’s cholesterol was 320 mg%, a very high and dangerous value.  He did agree to take a medicine to get his cholesterol down and six weeks later, when rechecked, the value was in the normal range of less than 200 mg%.   In 1963, there wasn’t a meaningful blood pressure pill other than hydrochlorothiazide which only works for some people.  A month after our wheat farmer had had his heart attack, his blood pressure was 180/ 100 mm Hg.  Grudgingly, he agreed to go ahead and take a blood pressure lowering medicine that was very effective with the fringe benefits of decreasing the amount of work that his heart had to do.

     It is now a year since the wheat farmer above had his heart attack at 52 years of age, and he is fully recovered doing all of the wheat farming that he did prior to his heart attack.  He is not a cardiac cripple like the gentleman I cared for in 1963.

The above example shows a rather remarkable contrast of medical care in 1963 compared to now.  The improvement, however, is not limited to people with heart attacks.  I remember in the early 1980’s when artificial knees and hips began to be done in Pierre, SD.  Patients were hospitalized for three weeks.  In June of 2004, I got a new knee and went home in three days.  In the early 1980’s, a gallbladder was surgically removed and patients were hospitalized for 5-10 days with a tube down their nose and nothing to eat until the intestine decided to work again.  Now a laparoscopic gallbladder removal is standardly done with an overnight hospital stay and the patient gets bacon and eggs for breakfast for the next morning.  We have learned that blood clots in a person’s legs can now be treated with a self administered injection at home.  We used to hospital people for a week leaving them in bed the whole time so they wouldn’t break the clot loose.

       As you might imagine, a major force in shortening hospital stays has been the managed care arm of medical insurance companies. They now dictate how long a patient can stay in the hospital with a given illness.  A lot of shabby things have been said about managed care and I have to admit they are not my favorite people either.  Earlier this year an article appeared in the Archives of Internal Medicine describing what happened to patients who did have a heart attack that could not be quickly reversed as we did with the wheat farmer above.  In 1986, the average hospital stay for a person who had a heart attack was 11.7 days.  By 1999, that decreased to only 5.9 days of hospitalization for people who had a heart attack.  The article described what happened to people after they went home in 1986 and after they went home in 1999.  Was there a difference in the complications and mortality because people went home “too” early from the hospital in 1999?  The answer is no.  There was no increase in complications or mortality in spite of going home from the hospital almost 6 days earlier than people had done just 13 years before.

     Newspapers and magazines and television don’t tell you about the vast majority of people who came into a hospital and went home healthier, happier and still alive.  Instead, they talk about the person who got a mismatched unit of blood and died at a major university hospital or other such juicy stories.  They report on how dangerous medications are, not the amazing success stories we have with modern medications.  The healthcare community is always working to put “investigative reporters” out of business.  The people of central South Dakota are very fortunate to have excellent hospitals both in Gettysburg and in Pierre.  We are not perfect yet, but we are working on it and hospitals are getting better and better.  When you need one, it is the safest place to be.