Changing Conditions for Hospital Admissions (My Baptist Courier column for August.)

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When we take our sick or injured loved-ones to the hospital, we often hope that they will be admitted. In many instances this is a very reasonable request. When heart or lung disease are at work, when severe infections, dehydration, fractures or strokes occur, admission may well be the only option. However, sometimes our desire to admit our family members is a throwback to a simpler time in medicine; particularly where the elderly are concerned. I don’t know how many times I have heard this, or some variation: ‘Doc, I know you say she’s fine, and all the tests are normal, but if you could just put mama in for a few days so she could get some rest, I think it would work wonders!’

When I was a younger doctor, without reading glasses and a gray streaked beard, we called them ‘social admissions,’ but we all knew that they were often necessary for pain control, or simply because the patient’s home life was so horrific. In the days when people were generally admitted by their own physicians, it was simple stuff.

‘Hey Billy, Mr. Mason is feeling very weak. We can’t find anything wrong, but he just doesn’t walk well.’

‘Wow, Ed, that’s odd. He’s never like that! Let’s just watch him overnight.’

And it was a done deal!

Alas, it’s not that way anymore, and for a number of reasons. First, insurance companies, along with Medicare, are imposing much stricter controls on what they will pay for, both in and out of the hospital. Honestly, many things we used to do as inpatients can be done much more cheaply as outpatients (and without risk).

Second, health care costs are rising. As we live longer, as we learn to treat more severe illnesses and injuries and simultaneously extend health insurance coverage for more people, look for a lot fewer admissions to the hospital as insurers cut costs wherever they can.

Third, admissions are increasingly done by ‘hospitalists,’ who do only inpatient care. They do excellent work, but they are under enormous pressure to admit only what is necessary and to discharge patients as quickly as possible. Otherwise they (and their hospitals) have to answer to chart reviews and face denial of payment by insurance companies.

Finally, (and perhaps most important) we have less admissions because most of us in medicine have figured out that being in the hospital isn’t inherently safer. You see, in hospitals, mistakes are sometimes made. Medication mistakes, transfusion mistakes, surgical mistakes. Falls and other accidents happen. The modern hospital is a chaotic environment, and for all the heroic efforts of the staff, they are entirely human and their patients are remarkably complex, both adding to the risk of error. In addition, even the best hospitals harbor terrible viruses and bacteria which patients can contract from one another. One is well advised to avoid them whenever possible.

It would be nice if we could keep everyone who wanted to stay. Wait, no it wouldn’t. It would be terrible and crowded and unsafe! So the next time you or a loved one has a condition that might lead to admission, take a step back and ask, ‘is there any way to do this as an outpatient?’ The results might be just as good. Or even better.

Stroke treatment; my December Wholly Healthy column.

Brain Attack!

Brain Attack!

Here’s my column in stroke for the Baptist Courier.


Among the many things that we all fear, stroke has to be one of the worst. Stroke, or cerebrovascular accident (CVA), is one of those medical events that can fundamentally change the way we live. It can affect our speech, our ability to use our hands or to walk, our vision or balance, our comprehension — or any other function that our brains provide. Around the country we now see myriad billboards and television commercials about stroke. The message seems to be that if you have a stroke and you get to the hospital in time, there is a magic drug that will invariably fix the problem. So I want to briefly explain the ups and downs of that drug. The drug most often used is called TPA (for tissue plasminogen activator), and the class of drugs to which it belongs is called “thrombolytics.” The idea is that if you have a stroke that appears to come from a clot in a blood vessel in your brain, the drug will dissolve that clot and lead to resolution of your symptoms. We have done this for years in heart attacks, and it works well. It’s medicine mixed with plumbing. Drano for the heart. Or in this case, “Drano for the Braino.” In theory, it makes so much sense that it’s difficult to see the downside. Have a “brain attack”? Go to your nearest hospital and have the pipes cleaned out! (Mind you, it has to be given in three to four-and-a-half hours, depending on the protocol of the hospital where you are treated.) Nevertheless, for several years this has been a source of great controversy in medicine. A lot of ink has been spilled in the debate, and a lot of research and analysis of the research has taken place. And the answer is that, just like so many questions in theology, it varies with who you read and what you want to believe. The bottom line is this: Some people in the studies completely recovered from their stroke symptoms. I’ve seen it happen, and it’s grand! However, the research also shows that 1) not everyone recovers from their stroke, 2) some people have dangerous bleeding due to the side effects of the drug, and 3) some people die from the bleeding caused by the drug. Remember, the drug dissolves clots everywhere, not just at the stroke. You can imagine that you might have a leaking blood vessel in your brain, or might already have an ulcer or mild nosebleed. In those instances, serious bleeding can occur with thrombolytics. However, for many patients, the risk is worth the chance to recover their normal lives or to keep from being bedridden or otherwise disabled. I hope that you, dear reader, never face a stroke. You can reduce your risk by eating a healthy diet, exercising and controlling your cholesterol, triglycerides, blood pressure and blood sugar. But if you do have symptoms, don’t wait around at home. Go to the hospital. Once there, you may well be offered thrombolytic drugs. Talk to the doctor and assess the benefits and the risks of the drug. But go into it knowing that no drug is a magic drug, and that every drug therapy, however wonderful and promising, has inherent risks. And it’s nowhere more true than in the treatment of stroke.