Critical

15

It doesn't look good," Dr. Tom Flanagan said. "It doesn't look good at all."

Dr. Tom Flanagan was one of eight intensivists employed by University Hospital at great cost to supervise care in the intensive-care unit, or ICU. He was either there at the unit or on call 24/7. He was speaking to Dr. Marlene Ravelo, who was board-certified in internal medicine and infectious disease and who ran the University Hospital department of infectious disease.

"Unfortunately, I agree," Dr. Ravelo said.

They were standing at the foot of Ramona Torres's bed in a special isolation cubicle off the main ICU room.

On the right side of the bed was Dr. Raymond Grady, a pulmonologist. He was busy adjusting her positive-pressure ventilating machine in an attempt to give adequate volume. It was becoming difficult. He glanced at the readout for the central venous pressure and the other one for the pulmonary wedge pressure. "We're not ventilating her very well," he called across the bed to Dr. Phyllis Bohrman, the cardiologist consult they'd called. She was watching the ECG on another monitor. Next to her was the chief resident in medicine, Marvin Poole.

"It's pretty clear why" Dr. Bohrman said. "Look at that last chest X-ray. The lungs are full of fluid."

"Let's look on the bright side," Dr. Flanagan said. "We're getting a lot more practice handling sepsis with septic shock than usual with these Angels Healthcare patients."

"That's true," Dr. Ravelo agreed. "But it would be nice to save one of them now and then."

"We can't be faulted. Having had a liposuction, this individual's surgical site infection covered a significant percentage of her body's surface area."

"Let's not forget what I believe is necrotizing pneumonia," Dr. Ravelo said.

"Do you think the pneumonia is a result of seeding by her surgical-site infection, or do you think it is primary – I mean, isn't primary staph pneumonia rather rare?"

"It is, but the time interval seems strange. Weren't we told the pulmonary symptoms preceded the symptoms of cellulitis?"

"That was what was on the record."

"It's very strange, especially considering last night's case was so similar, although the surgical-site infection was so much smaller."

"Okay, guys and girls," Dr. Flanagan called out. "Pulmonary function is heading south to Antarctica, cardiac function is going in the same direction so that the blood pressure is in the basement. There's no longer any urinary output, so that tells us what's happening in the kidneys, and the liver is not doing what it should be doing. Thank you all for your hard work, but we've clearly lost the battle."

Dr. Flanagan and Dr. Ravelo turned and walked back to the central desk, where they got Ramona Torres's chart to write their final notes.

"Do you think we should have done anything differently?" Dr. Ravelo asked as they took seats side by side.

Dr. Flanagan shook his head. "We followed the newer protocol to a T, so I don't think so. Hell, we gave her everything we've got, including the activated protein C and corticosteroids. Equally as important, you changed the antibiotics the instant we knew we were again dealing with MRSA, so we can be confident we had the right cocktail. And remember her APACHE II score was off the charts when she arrived, so we didn't have much to work with."

"Why can't we get Angels hospitals to send these patients sooner?"

"That's a damn good question. What I'm guessing is these patients' infections develop just too damn quickly postsurgery. I mean, this woman was operated on just this morning at seven-thirty a.m. In her chart, it says the first nonspecific symptoms started a little after four p.m. That's one hell of a rapid course."

"With all the nasty toxins potentially at staphylococcus's disposal, it's understandable. I'd be willing to put some money on this patient's bug to have the Panton-Valentine leukocidin, or PVL, gene."

"Does it surprise you that the Angels hospitals are having so many MRSA cases?" Dr. Flanagan asked.

"Yes and no. Staph is the most common surgical site pathogen, and whereas MRSA comprised only two percent back in the nineteen seventies, today it is sixty percent and rising all the time."

"Actually, what bothers me most about these cases is the whole specialty hospital dilemma. They don't have the resources for this kind of case, and they have to outsource it. In fact, in one specialty hospital, I think it was also an orthopedic hospital, a patient had a heart attack. And you know how they dealt with it?"

"No."

"They called nine-one-one."

"You are kidding!" Dr. Ravelo blurted in total disbelief.

"They didn't have any doctors on duty. Can you believe it?"

"Did the patient survive?"

"I don't think so."

"That's a travesty."

"I agree, but what can you do? Are you aware of the specialty hospital debate in general?"

"I know a little about it, I suppose. It's one of the advantages of being in academic medicine. We don't have to get so involved in various private-sector squabbles."

"I would not be so sure. It might eventually influence our salaries. The biggest problem most people see in these private specialty hospitals is that they are only interested in the cream of the patients: i.e., the healthy, well-insured who come in to have a quick procedure and then are out. It's really a moneymaking machine, because they get paid the same as the university gets paid, but because they don't have ICUs like ours or an ER like ours, which are not moneymakers, their costs are significantly less."

"I heard the government had a moratorium against them for a while. Was that the reason?"

"No," Dr. Flanagan said. "The government was against them for a time, actually from late 2003 to late 2006, because the specialty hospitals involve some level of physician ownership to guarantee a continual flow of patients. There is an existing ban in Medicare law for physicians to refer patients to medical service organizations in which they have ownership interest, like imaging centers or clinical laboratories or the like. But there is a loophole as far as a whole hospital is concerned. Ownership in that situation was not banned because it was thought that in a whole hospital, there would be little risk of a conflict of interest."

"But a specialty hospital is not a whole hospital!" Dr. Ravelo said indignantly. "They only do a very limited number of services."

"Exactly! Yet it is by claiming they are a whole hospital that they are taking advantage of the loophole."

"Why was the moratorium lifted then?"

"I haven't the foggiest idea. There were a number of hearing on the issue in which all these points were clearly raised. Most people familiar with the debate, who'd either attended the hearings or read about them, thought for sure the moratorium should be sustained and actually strengthened because the existing moratorium was only against new specialty hospitals getting Medicare provider numbers, which are necessary for reimbursement."

"What happened?"

"Suddenly, the moratorium was lifted with little explanation. My guess is that it was a behind-the-scenes lobby competition with the lobbyists from the AMA pitted against the lobbyists for the AHA, or American Hospital Association, and the FAH, or Federation of American Hospitals. I guess the doctors spent more money than the hospital admin groups."

"That's awful. Everything comes down to money. I'm embarrassed for our profession."

"Well, it's not all bad. Patients generally like specialty hospitals, and for routine procedures, they are certainly more comfortable.

"Maybe we should ask Ramona Torres," Dr. Ravelo said. "Maybe she'd have an opinion about which is best: a specialty hospital and its comforts or a truly full-service hospital. If she'd been here from the start, from our statistics, she would have had a significantly higher chance of surviving her infection."

"Good point," Dr. Flanagan said. "A very good point."