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A Stitch in Time - Two Rivers


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GP14Apr04: Heart Attacks and Aftershocks 1984-2004, Part II

Brian is still very much with us.  But he’d probably say (we have not asked him) that he’s alive and kicking in spite of, not because of, today’s health care system.  Heart and purpose seem to have gone out of health care.  Moreover, it is still trying to render crisis, one-off care when a growing percentage of those it encounters have chronic complaints requiring ongoing therapy that largely should take place outside the hospital.  Today, in health and business, you pretty much have to go around the system to get the job done: 

“Nine years later, we are living in Scottsdale. I am with the Arizona Heart Institute with yet another Ted, Ted Deithrich, a fairly well-known and highly regarded heart surgeon. I go for checkups and sign up for various drug trials to help enforce a good-life discipline. And managed care is in full flower. AHI is a great place and it is efficiently run. But they, like others, begin asking for your insurance as you enter the parking garage. 

Permit me a commentary. From my emotional perspective, health care costs began to skyrocket with the advent of managed care. Now I know rationally that managed care was developed to manage runaway costs, but for the life of me, costs continue to runaway and all managed care seems to have done is add layers of management and cost to a system in disrepair. I certainly don’t have any answers, but it seems that a starting point would be to address the fastest running of the runaway costs, prescription drugs.  

That aside, I was playing golf one day—we do that here in the Southwest—when the collar on my open-necked golf shirt began to shrink uncomfortably. Oops, I know that feeling and I’m now fairly savvy, heart-wise speaking. So I go to see my doctor at the Heart Institute, flashing my insurance card as I got within 5 miles. They do a stress test and say, “When would you like your angiogram, this afternoon?” We do the angiogram and find that the original bypass has clogged—restenosis, they call it—and there is another artery that is pretty much clogged. An hour after the angiogram, I am talking to Ted 2, Dr Deithrich. He explains the options. I ask him what he thinks and he says, “If it’s me, I’d want all the horsepower I can get and get on with my life.” “Me too,” I say. He says, “When do you want to do it, I’m available tomorrow at 5:00am.” “Done,” I say. “See you tomorrow morning,” he says, “have a good night.” All this has the tonality of a man making a bank deposit. Ted is a highly skilled surgeon, has great hands, and is utterly humorless. 

This time, there are all sorts of shenanigans regarding pre-certification, the pre-certifiers not being available (gone for the day), the reluctance of the heart hospital (Ted 2’s hospital) to check me in, etc. I’m a little disturbed, not with the medicine but with all the managed care taking place. My wife is rolling her eyes and telling me, sotto voce, to “Quit it, you of all people ought to know what this is all about.” (I have clients in health care and health care insurance.) The net result was a bypass to bypass the first one and another to bypass the new blocked artery. 

It’s another nine years. I have since taken up smoking again, inexplicably. I’m watching TV on 9/11/02 (hmmm) and I think I detect a tightening in my neck. “No, not this again,” I think. Being wishfully optimistic, I hope it goes away, which it does. So I get up, go outside and have another cigarette. I come back and so does you-know-what. Several more of these and I wake up my wife and say, “We need to go to the hospital.” She leaps up like she’s been shot from a cannon.  

We go to the local emergency room and an encounter with managed care’s finest. The on-duty person begins to go through what looks like a long questionnaire beginning with, “Have you been with us before?” I tell her “Yes.” She starts to continue. I interrupt and say, “I’m having a heart attack, get me back there and get me some nitro.” She tries to ask more questions including asking for my insurance card. My voice rises and tightens as I say, “Look you nitwit (uncalled for, I know), I’m having a heart attack and I’m not kidding, I know what they are. Get me some nitro quickly and I’ll tell you everything you want to know, including the name of my grandmother’s wet nurse.”  

Three floors of the hospital and the incoming med-evac helicopter have now heard me and someone else promptly puts me in a wheelchair and wheels me to a treatment area where I’m promptly taken care of by competent people. As they are getting the IV in, I say, “Now, I’ll answer everybody’s questions, give you my insurance card and anything else you want.” The young doctor grins and mouths some placation. Nurses scurry about. The young doctor leaves, comes back a while later and says, “Sir, you are fortunate, you are in the right place. You are having a heart attack.” My wife is grimacing quietly off to one side. (It is perhaps not coincidental that a few months later, just after New Years, she decides that the marriage—to me—is not for her.) Several conversations later with the young ER doctor, whom I like, he tells me that they probably want to put in a stent. (I think, “Just my luck, the new coated stents—the ones that prevent restenosis—are about ready to be approved, and I have to get an uncoated one.”) 

The on-call surgeon arrives and she has obviously been briefed. She looks a little like the East German Olympic swimmers from the before the fall of the Berlin wall, gives me a look that says something like, “Now you can cut the crap, buster,” and says with a crooked smirk, “I hear you’ve been a little testy.” I smile my most winsome smile and say “Not, now. Everything’s been great, this guy is terrific and so are all the people back here.” I give her the severely abridged version of the check-in events. She gives me a “Yeah, yeah, potty-mouth,” look and says, “Well lets get to it.” 

Several months later I learn that during the procedure, the young doctor I liked came out to my son and wife and said, “Now there’s a possibility that he won’t make it through this.” Apparently he had not yet taken the optional class in patient-family communications. A few minutes later, the beefy female surgeon had come out and muttered audibly, “If he hadn’t taken up smoking again, I wouldn’t have had to get up at 3:00 a.m. and come in here.” I can only speculate, unfairly, that she was still suffering from ‘roid rage. 

The recovery is uneventful, medically. Managed care-wise there was another incident. I get a letter from the hospital several months later saying, in effect, your insurance company hasn’t paid this bill, you had better talk to them or else you will have to pay. The bill was upwards of $40,000 so the letter got my attention. I call the insurance company. The woman checked and said, “We have no record of this bill from the hospital. They probably sent it to the wrong address; they do that all the time. The correct address is right on the card. Ask them to resubmit.” I did and—after several calls—they did. The bill got paid. But, don’t you know, the well-paid managed care couldn’t manage to send the claim to the right address. On top of it all, they got uppity and threatening in their first communiqué. Somehow the onus for managing managed care had shifted from managed care to me, the patient. 

It’s a month-and-a-half later and I’m feeling like I always do after heart repair, great, renewed, on top of the world and lucky to have dodged another bullet. I’ve lost 20 pounds, my clothes are all beautifully too loose and I take a trip to my New York office. And what to my wondering mind does appear? Unexplained throat tightenings. Several epithets later, uttered in a manner akin to the parson who has just hit his thumb with a hammer, I go back to New York hospital. I’m feeling like “I’m home. Now for some real health care.” Alas, it was a horrible experience. Endless waiting, snotty doctors and nurses so busy they whirl in and out of the room moving as quickly as a cook in a New York diner at 12 noon, with barely a word and almost all eye contact avoided.  

With apologies to Sartre, hell isn’t other people: it’s managed care run amok in a teaching hospital. Aside from the non-nurturing nursing, the doctor on my case displayed the attitude that the god damn patients keep getting in the way of my medicine. He would come in to my room start a discussion and then leave in the middle of the discussion to attend to something more important and not come back until the next day. He ordered a thalium stress test, and two other procedures, one every other day. I was in the hospital for a whole week for three relatively simple procedures, all of which could easily have been conducted in one morning (okay, one day). “Costs and the patients time be damned,” he could have said. “I have medicine to do and these stupid interns to instruct.” 

At the end of an agonizing week, he arrives with an entourage of stupid interns—his shortness with them and his sarcasm, left that impression—and addresses them and I guess I was included, saying, “I think there is restenosis in the stent that was put in a month ago and I think I’d like to treat it aggressively with drugs.” A week in the hospital and that’s what I got. 

Back in Scottsdale, I check in with the Heart Institute. I asked both the Scottsdale emergency people and the New York people to forward my charts to the Heart Institute. I nearly had another heart attack because both parties actually forwarded my charts in a timely fashion, undoubtedly in managed-care error. My doctor at the Heart Institute has me come in the next day for an angiogram which shows restenosis in the stented artery and another artery which needs fixing.  

In early December (still 2002), we have yet another procedure where another stent is inserted into the “new” artery. In the operating room, my doctor turns to me and says that it’s a rather involved procedure to clear the clogged stent and to perform Brachy therapy—placing radioactive seeds inside the stent for a specified period of time—which usually prevents re-restenosis. He thinks, though, that I’ve been on the table too long and suggests that we come at it again in a month or two. I agree. 

I see the doctor monthly for the next several months and everything is fine, no symptoms. Each time he says, “The question with you is whether we can do you any real good by getting more blood to the damaged part of the heart (the area the first-stented artery feeds) and I’m, inclined not to do it as long as you’re having no symptoms.” I keep agreeing. 

Then he says after several monthly appointments, “Come back and see me in six months, but call me if you have any symptoms.” I’m going in for my third six-month appointment on Monday. I’m still symptom-free. I play tennis three times a week. I go to the health club for aerobics and strength training four times a week and all’s well in my world.  

Meanwhile, I believe it was Fortune magazine that recently reported that drug companies are in the top three most profitable industries in the nation. And still they cry that they need these price levels to support their research. It just doesn’t make sense.”

P.S.  For more on health care, see Stitch in Time on Global Province.

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