Thursday November 19, 2009
Rush to Discharge? Don't Rush to Judge!
It's been one of the top news stories across Canada for a couple of days now.
Monty Vann, a 60-year-old man, had a brain tumour surgically removed at the Health Sciences Centre in Winnipeg on Oct. 8. According to a report on CBC News' web site, the surgery was considered high risk because Vann, who is blind, also suffered from heart problems.
Vann's family says that on Oct. 10, two days following surgery, the hospital discharge the man. He told hospital staff he wasn't ready to be discharged. However, after being told he'd be responsible personally for further charges in hospital if he didn't agree to leave, Vann left hospital on the morning of Oct. 13.
Less than 2 hours later, while being taken home in his brother's car, Mr. Vann suffered a stroke and had to be readmitted to hospital. A spokesperson for the hospital says his current stay is considered indefinite.
Whenever we hear a story like this, there's a tendency to rush to judgement. Here, we have a man who had just had major surgery and was pleading to remain hospitalized. Lined up against him were immutable forces urging him to move on and make room for someone else.
To judge the circumstances, we need all the facts. That said, as the host of a show whose mandate is to give an insider's look at the culture of medicine, I'd like to provide some context for the facts as we know them. I have no inside information regarding Mr. Vann. However, I do know a thing or two about the system.
Over the past twenty years, the provinces have taken somewhere between thirty and forty percent or even more hospital beds out of the health care system. This has been done for a number of reasons. First, for many conditions, prolonged bed rest isn't needed. Laparoscopic or keyhole surgery has taken care of much of that. A generation ago, if you had your gall bladder removed, you had a big incision on your belly; you were admitted for ten days to two weeks, and didn't return to work for six weeks. Today, you get three tiny incisions on your belly. Smaller incisions mean much faster recovery. Most of the time, you can go home the same day, and are back at work a few days later.
Second, in some cases, medical science has learned that prolonged bed rest actually makes patients do worse. For example, when I graduated from med school, we admitted heart attack patients for a month to six weeks of bed rest. Today, we'd never do that, since prolonged bed rest leads to poor recovery and can even cause blood clots.
All that said, there's no question that fewer hospital beds mean more pressure to discharge patients as quickly as possible so that other patients can be admitted. Remember, for every patient who needs a few extra days in hospital, someone else in town, across the province, or elsewhere, can't be admitted.
On the other hand, all of us have encountered patients who have refused discharge when all objective evidence suggested they were more than ready to go.
Does that mean I support the idea of pushing a guy who has just had brain surgery out the door? Certainly not! Some of my worst mistakes as a physician have occurred when I was determined to send a home a patient who was just as determined to be admitted.
Health Sciences Centre is a teaching hospital. Some reports suggested that a resident or residents looking after Mr. Vann got into an argument with him prior to his initial discharge. I can tell you that residents often feel pressure from their mentors to make room for new patients by pushing admitted patients out the door. When the dust settles, I do hope the senior doctors take at least some of the responsibility for what happened.
The facts in the case of Mr. Vann will be known soon enough. The fact the hospital CEO has rushed to apologize suggests mistakes were made.
If lessons are to be learned, I do hope the people involved are paying attention. Right now, I can't imagine anyone involved feels too proud or happy about the way things have turned out.