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I’ve been silent on this blog for about five weeks. I’m sure everyone has missed me dearly. I (Ben) have been back in the US on a neurology rotation at one of the biggest hospitals in Washington, DC.

As a nation we are contemplating a major rebuild of our medical system, claiming that it costs too much and that people are getting poor care. Yes, health care in the US is expensive and the current situation can’t be maintained. I’m coming closer to getting a solid stance in the health care reform policy debate, but right now I want to make some observations.

Last week the neurology service was called in to evaluate a patient who had suddenly collapsed. Bystanders gave him 8 minutes of CPR, the ambulance initiated more advanced resuscitation techniques, and the emergency room at an outside hospital “coded” him for 15 minutes before getting a pulse and blood pressure back. He had no brain reflexes after his heart started beating again. He was transferred to my hospital so he could get a balloon to open his arteries in his heart. We were called in the next day to evaluate for brain death. Still no brain reflexes. This man was requiring a cocktail of three different drugs just to keep his blood pressure high enough and his brain showed every sign of death. His other organs also showed the effects of prolonged ischemia. The man was dead and had been since getting to the ED at the other hospital. But we gave him a cardiac cath, an electroencephalogram, a somatosensory evoked potential test, multiple evaluations by squads of doctors, and kept him in the ICU for 48 hours. We spent tens of thousands of dollars on a man who was dead and everybody knew it. But nobody wanted to tell the family that it was hopeless and that they should switch off the ventilator.

In contrast, on one of my last afternoons in Ghana, I was seeing patients in “my” office when there was a pound at the door. The Cuban doctor called me, saying, “Doctor Ben, emergency case! Please come!” I grabbed gloves and trotted outside to find a 40ish woman lying on a stretcher somewhere between home and the hospital she had stopped breathing, but nobody could tell us how long it had been because she had gotten to the hospital on a motorcycle sitting between two men. I listened to her chest for breath sounds or a heart beat. I felt for a carotid pulse. I checked her pupils. And then I said that she was dead because I knew that even if I started CPR I had no defibrillator to shock her heart, no ventilator to breathe for her and no advanced recussitation drugs. In other words, I had no tools to reverse the process that led to this woman’s heart stopping.

There MUST be some middle ground between the no-holds-barred approach utilized in my hospital in DC and the lack of care I provided in Kete Krachi. I think that the right balance is closer to the American style than the medicine practiced on the shores of Lake Volta. Interestingly, I’ll be on the front line of “heroic” resuscitation of patients like my guy here in DC. So I need to start thinking about how far I should go.

I’m about to take a policy stance on an issue here…so if you don’t like it, fine, but don’t be rude in the comments you choose to leave. With almost every patient I saw over the past four weeks decisions were made on the basis of medicolegal risk assessment rather than clinical judgement. Some of hese decisions were small while others will very expensive, like keeping a patient an extra two or three days in the hospital for an MRI just to have photographic proof that there was no stroke in the brain in case the patient decided to lawyer up and sue. Talking about reforming the health care system and controlling costs without including tort reform is foolish…sort of like puting a lot of fancy paint and sweet rims on a car with a blown engine.

So this morning I’m thinking of the two times I have personally performed CPR. One guy, a 60 year old man, collapsed while riding his bike in the park. I started chest compressions within one minute. He’s back to teaching middle school these days and continues to ride well over 1000 miles each year. Between good CPR, very skilled paramedics, and the best, most expensive medical care money can buy, he beat the odds. The other time I gave somebody CPR was in Ghana when a 4 year old boy’s heart stopped while I was trying to get an IV going for him. I literally felt his heart stop beating. I gave that little kid 45 seconds of CPR before recognizing that there was nothing I could do to reverse the process that led to his cardiac arrest. I wanted to do so much more but couldn’t.

So maybe it all boils down to balance. Doesn’t it always come down to that?

I leave Sunday for Vienna and four weeks of experience in the Austrian health care system (it’s a tough job but somebody must do it). I’ll see if they have it right and I’ll report back.

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