It was the middle of winter in downtown Chicago in 1995, and I was sitting across from an apologetic alcoholic holding a slimy NG tube. Mr. Smith, an emaciated man in his sixties, had been on my service for three days with acute pancreatitis, and this was the fifth nasogastric tube that had “slipped” out of his nose.
Subsequently, his morning labs were just as bad as they had been on admission, and my chief resident was not pleased. This was Cook County Hospital. We were supposed to admit, treat, and discharge. Beds were at a premium, and my inability to fix Mr. Smith was keeping someone else in an ER hallway. The solution, I was told, was to “bridle” the NG tube — and not to let Mr. Smith know what I was up to until it was done.
This technique consisted of passing a red rubber tube down each of his nostrils, suturing them together in his mouth, and then pulling one up and out so that a single tube bent around his nasal septum. Removing the second tube and suturing the first to itself, I passed the sixth NG tube and sutured it to the red rubber tube. Although bridling is used in pediatrics and ICU patients who inadvertently dislodged their device, I was using it to undermine Mr. Smith’s objective and, by the end of the procedure, he was well aware of it.
“Hey,” he complained, “that’s not fair!”
“If your tube keeps coming out, your pancreas is going to get worse. I’ll take it out once your numbers look better.
Two days later, I was doing just that.
“That was a sneaky trick you pulled,” said Mr. Smith with an easygoing wink. “I’ve been in here a lot, and that’s the first time anyone’s done it.”
“Do you feel better?”
“Yeah,” he said as he pulled on his unwashed jeans and thin coat. “But, I won’t fall for that one again. See you around, Doc.”
At the time, I was proud to have done my job and undercut my patient’s plan to stay sick. Now, I know I missed the boat.
I failed to see past my standardized training, the business model that said my duty was to discharge patients with good numbers as quickly as possible, and so didn’t see Mr. Smith’s side of things. The hospital provided a warm bed, clean clothes, and human interaction — things he had no other way of attaining. When I suggested he stop drinking, it earned me a colorful declarative and an eye-roll. Cheap booze kept him warm when nothing else would, and he only played his hospital card when it got too dangerous on the street. A “frequent flyer,” Mr. Smith’s routine was well known to the staff, and all my little procedure had done was kick him out into the snow a few days earlier than usual.
Twenty-five years later, I worry physicians are having an even harder time seeing the world with Mr. Smith’s eyes. Indeed, we are the comic sailors frantically patching holes in a ship floating on an ocean of acid. Alas, unless we tackle the real cause of our patients’ medical conditions, nothing will keep us from sinking. In addition to encouraging our patients to quit smoking, we should be passing laws that prevent tobacco lobbyists from influencing our elected officials. Instead of lambasting our patients for not taking their medications, we should acknowledge their justified fear that Big Pharma does not have their best interests at heart. Instead of discharging at-risk patients back into the world from which they came, we should be doing more to change that world. Otherwise, they bounce back like a rubber ball thrown against a schoolhouse wall.
Medicare designed its Hospital Readmission Reduction Program (HRRP) to reduce payments to hospitals with excessive readmissions. But health care is a business, and so hospitals write these penalties off as losses on their taxes or recoup their costs by increasing hospital charges for the general public. An alternative, and potentially more effective, program would have hospitals lose their non-profit status if their readmission rates didn’t fall. Doing this would essentially bridle hospital profits to the welfare of the community and incentivized them to knock down the walls their rubber balls are bouncing against.
I saw Mr. Smith again as he was wheeled to the OR for a gunshot wound to the belly. He was wearing the same jeans and thin jacket I’d discharged him with two weeks earlier, and he winked at me as he passed as if to say he was somehow more prepared for this admission than the last.
I’d like to say he was right.
Instead, he died on the table that night.
I don’t want another Mr. Smith to be discharged into the snow with nothing but cheap booze to keep him warm. If we want our patients to do more, we have to do more to help them, and that can only happen when hospitals see profit in treating their patients as well as the community in which they live.
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