Checking in, checking out
by Seamus Sweeney
[ fiction - june 04 ]
The surgical intern on call was having a quiet night. Down below in Accident & Emergency some patients were spending their fifteenth night on trolleys, the Senior House Officers and Registrars were managing heart attacks on stretchers, the Nurses were pacifying the angrier patients. All worked methodically through their tasks, never catching up. Drunks shouted abuse, relatives shouted abuse, drunk relatives shouted abuse and all working there that Saturday night silently counted the minutes until the end of their shift. But Sean Collins, the surgical intern on call, was having a quiet one.
The interns on call in St Aloysius' Hospital didn't cover A&E, being responsible for the first line management of patients on the wards. In other words, they carried out all the routine tasks on the wards and, if anything particularly complicated came up, rang the SHO on call. Ward closures, which overall had the effect of making a doctor's life harder, made the Intern's life easier. There were less wards to visit, and a good number of the patients who were in the hospital were medically fine and awaiting placement in a nursing home. If asked, Sean Collins would have said that the bed crisis was a terrible social problem, but secretly he rejoiced at the relative lack of pressure.
He was making a round of the surgical wards. Sean was a fairly popular intern among the nurses, meaning he did what they asked uncomplainingly. He walked down the corridor of Surgical Ward B, exchanged a bit of banter with the girls at the nurses' station, and looked at the whiteboard. There were only three jobs - "1-4 - Fill out incident form after fall. 2-3: chart IV fluid. 4-3 review low urine output." Nothing too worrying, the low urine output was the most important; but seven months into his internship, low urine output was no challenge for Sean.
Cecil Grouse was a 67-year-old man, two days post transurethral resection of his prostate. Sean read the notes quickly, noticed that he was for removal of his catheter the next day and for discharge the day after.
Grouse's urine output was down slightly. Nothing huge - in the last 4 hours he had a total of 90 millilitres; about 22 mls an hour. Less than the 30 ml lower limit, but not radically low.
Grouse was asleep. He reacted good-humouredly to being woken by the unfamiliar intern. He was not in any obvious distress.
Sean listened to Grouse's lungs to check for fluid overload, looked at his unswollen legs and eyeballed his neck, looking for a raised jugular venous pressure - a sign Sean was actually completely unable to elicit, but, being a conscientious intern, he didn't feel comfortable writing "no raised JVP" in the notes, without at least making an effort to see it. He was trying to rule out any excess fluid, before possibly giving some extra IV fluid or a diuretic.
Sean considered whether or not to do a renal profile, a quick blood test to assess Grouse's kidney function. He had a normal renal the morning before, but that was twenty hours ago. He got a bleep from Jane, his co-intern on call that night.
"Sean, your package has been delivered."
The nurses giggled at this very obvious code for "your dinner is here."
In one timeline, or in an infinite amount of universes among the infinite number of possible universes, Sean didn't bother doing the renal profile there and then. He ordered it for the phlebotomist the next morning. It was largely normal, and in any case Cecil Grouse's catheter was filling merrily away at that stage, after Sean had increased the rate of his IV fluids. Grouse was discharged two days later. Lots of other things (infinitely many, possibly) happen in that timeline. But this story does not follow that path.
For completeness' sake, in our timeline Sean performs the renal profile. Lab investigations are accurate, but all have some margin of error. And there are such things as slightly freakish results; the blood test is atypical for one reason or another, for example some blood cells can break down if the blood sample is left standing too long. Grouse's sodium was a couple of points higher than it would have been if the blood test was taken by the phlebotomist in the morning. The next morning the team looking after Grouse puzzled over the slightly raised sodium
The registrar on the team asked his intern to get another medical team to look into the case. They investigated the sodium, and one thing lead to another and Grouse stayed an extra three days, leaving exactly as healthy as he would have been if discharged on schedule.
Like the legendary butterfly flapping its wings in Mexico causing a hurricane in China, Grouse's extra two days had an effect far larger than Sean Collins could have foreseen. He wasn't fully aware of the spider's-web of complexities of bed management, with dire emergencies leapfrogging mere emergencies, with well patients ready for discharge taking up beds indefinitely, waiting for a nursing home placement. Two patients spent another five days on trolleys in A&E as a direct result of the Grouse case. Ambulances were redirected to other hospitals, their A&E's also overflowing with the desperate, the sick and the dying.
For months, health had been the dominant political issue. Politicians had staked their careers on reforming the health service, and had seen their careers destroyed. The Grouse case, unbeknownst to Sean Collins, was the breaking point. In one hospital the entire staff spontaneously went on strike - this quickly spread. Other unions joined in. The Minister for Health resigned, and his replacement promised radical and immediate action. She in turn fell, when after three months nothing had improved much at all. Government after government fell, the headlines screamed about the health crisis for months on end. A truly radical solution was needed.
It was agreed - by all the influential commentators - that to solve the problem, it was necessary not just to solve the short-term issue but to make health top of the social agenda. Dr Simon Burgess, head of the Medical Council, observed that as the World Health Organisation defined health as complete physical, mental and social wellbeing, nothing came outside the definition of health. He argued that to take health truly seriously, we must recognise it as not just the most important political issue, but the only political issue. In a desperate times, Dr Burgess's solution; what he called the "healthification of the nation" (Burgess was not noted for his felicitous turns of phrase) was trumpeted by many as the only solution. At a subsequent election, the Health Party with its new constitution (Article One: "The health of each is the concern of all, the health of all is the concern of each") swept the polls.
In effect the medical profession was given complete control of the affairs of state. The parliament had a token role, but as the second article of the Constitution stated: "Health above all other considerations, health of all and health of each above all." Small hospitals were closed and three massive hospitals for the whole country were set up. Within a few months, waiting lists were a thing of the past; indeed some consultants tried to bring them back because people were taking their greatness for granted. And at the same time as the health crisis, crime had spiralled further out of control. By redefining lawbreaking as a medical rather than criminal act, the new Central Medical Authority (President: Dr Simon Burgess) managed to slash crime, largely by admitting patients "guilty" of criminal acts for indefinite treatment. Worldwide, there was excitement about the "Irish miracle", with the healthiest and most law-abiding society on Earth. First the rest of the European Union, then the United States of America and soon the whole world followed Ireland into Iatrocracy. Burgess' Central Medical Authority (Burgess was merely one of fifteen Co-Presidents, but all bowed to his experience of statecraft) dictated protocol worldwide.
The invention of rapidly acting agents to lower blood pressure and cholesterol levels, along with a lowering the thresholds for hypertension and hypercholesterolaemia, was the pharmaceutical side of the medical revolution. A patient with a blood pressure of 120/80 or a fasting cholesterol of 3 was dangerously "borderline non-optimal" and required urgent admission for treatment with these exciting new therapies, with of course close monitoring of their potential renal and hepatic side effects. The Compulsory Admission Act was drafted to allow doctors to admit patient with general medical conditions even if the patients failed to agree. In discussion the Central Medical Authority decided to not merely allow doctors to do so, but to compel them. As Dr Burgess said "it is unethical for a doctor to allow a patient with a potentially fatal illness to go untreated, and it is therefore unethical to allow a patient with the possibility of developing a potentially fatal illness go without the treatment that would save them." On admission other issues such as dangerously non-optimal bone mineralisation (patients who might develop osteoporosis in the future) or one of the ever-expanding psychiatric syndromes arose, and thus required treatment.
*
The CMA started with Asperger's Syndrome and soon all sorts of psychiatric syndromes required admission. What was once colloquially called shyness or "being quiet" became Pre-Aspergers Withdrawal Disorder. Insufficient interest in one's own health, or insufficient worry for the health of others, became an adjustment disorder requiring admission for slow acting psychotropic medications. The CMA no longer issued guidelines but binding protocols. Failure of healthcare staff to follow these protocols was Dyssocial Healthcare Worker Adjustment Disorder, itself an admission-worthy disease.
Soon the whole world was an enormous hospital. Every non-inpatient was a doctor or nurse or some kind of paramedical line. Indeed, not wanting to work in health care became an adjustment disorder: Dyssocial Behaviour Tendency Type CXXVI.
Dr Sean Collins was now ten years into his career. Like all doctors of his generation, rather than choosing his speciality he was sent to Eurasian Health Sector 7, Western Area (a place formerly known as Glasgow) as a Senior Non-Specialist Protocol Supervisor. His job was essentially to ensure that the nurses programmed the Care-Bots to deliver the right doses of medications. Occasionally he had to admit a new patient, a process which consisted of using the CMA's Admission Protocol to find exactly what constellation of disorders the patient in question had. After work, like all health care workers, he attended compulsory non-competitive exercise. Then he would go home, to the Healthcare Home Facility where a regime of educational and instructive activities was set out for each evening.
It was ten years to the day since he had chosen to take that renal profile. Sometimes, during the Planned Walks around the Home Facility, he thought of the old days. He was fairly sure that a reverie during these walks wouldn't attract the interest of the Occupation Health Department, ever present at work and in the Home. He thought of his old life, of some heavy drinking sessions, of women he had enjoyed the favours of (the CMA kept sexual desire and activity under careful surveillance), of fatty meals he had enjoyed. Today, ten years after unconsciously starting the health revolution, he allowed himself, taking an appreciable risk, one of these pleasant reveries at work.
The phone of his desk rang. He broke off his voluptuous daydream and felt a fear grab his stomach. Perhaps the Occupational Health people had spotted the tell-tale signs of Pre-delusional Fantasy Syndrome on the surveillance camera. With great relief, he recognised the voice of Anne, one of the nurses.
"Sean, could you come to Medical-Psychiatric Ward B12, Second Level."
"What is it?"
"Sean, I'm... not entirely sure. You'll have to come down."
Sean put his pending tasks on AutoDoc and took the shuttle bus to the main hospital building. It was rare for doctors to actually visit the hospital any more. He wondered what it could be. Anne and the other nurses were exemplary professionals, the CareBots in this health sector were proverbially reliable.
He entered the unfamiliar surroundings of the Ward Complex. All was gleaming glass and steel; it reminded Sean of old science-fiction films. Up escalators, along walkways, down elevators, he eventually reached his destination. Med-Psych B12 was a ward like any other; a long, serene corridor, with soothing pastel shades on the walls. Each of the two hundred patients had their own room. The nurses' station was at the very end of the corridor. Just as the doctors rarely left their block, while the nurses were actually on the wards they rare left their station; health and safety regulations discouraged it unless absolutely necessary. Sean walked as fast as he could down the corridor; it had been years since he had actually seen a sick patient, and the unfamiliar prospect terrified him.
Anne was in the station. She pointed to the computer screen.
"This is her. Maggie Brown. Twenty-one years old."
"What's wrong with her?"
A pause. "That's the trouble, Sean. None of us can work it out."
"What was she admitted with?"
"Some musculoskeletal trauma, due to mouse use during her nursing studies. PhysioBot and Remote Occupational Therapy have sorted her out."
"Any underlying tendency to musculoskeletal trauma?"
"No, it was an ergonomic fault."
"And anything else?"
"No. No psychiatric adjustment disorders, or pre-adjustment disorders. No genetic or personal health issues we can identify and treat. This patient is in optimum health."
"I see."
"We can't find the protocol for that. What do we do?"
"It's been so long since I've had a patient who was in … optimum health. Let me think about it. Actually, I suppose I should see her."
Sean went to Maggie Brown's room. It had been so long since he had heard the word, he thought. He tried to remember what he had done in the old days. Maggie Brown was sitting up on her bed, her face a perfect blend of concern for the health of both all and each and an eagerness to please. She was dressed in regulation patient's smock. Sean had to quickly repress the thought that she would be good fodder for his reveries. Occupational Health had sensors for that sort of thing.
"Hello Maggie, I'm Doctor Collins. How are you feeling?"
"Fine, doctor, I feel fine."
Sean had brought the Admission Protocol, to see if any new issues had arisen. Nothing had. Maggie was co-operative, neither too quick with her answers (the Protocol advised that this was a sign of dissembling to get out of hospital) or too slow. After finishing the protocol, Sean asked some questions of his own. How did she feel, did she really feel better, what did she intend doing? He asked these hesitatingly at first, then more fluently. At the end he performed a brief physical exam, although this was largely a formality if the CareBots hadn't found anything. She was fine. He wished her a good day and returned to the station.
He knew what he had to do, but the logistics of doing it were another matter. When he returned to the nurses' station, Anne interrogated him with a look rather than words.
"Anne, I don't think we have a protocol for this. This woman needs to be discharged."
