Last year in a Southern city, a middle-aged man experienced stomach cramps, diarrhea and lightheadedness for three days. Upon standing from a seated position, he briefly fainted, striking his forehead on the floor.
No seizure activity was observed by his wife, who estimated that he was unconscious for a few seconds before becoming fully alert. His wife drove him to a nearby emergency room.
His prior medical history was unremarkable. He took no medications and had no prior symptoms to suggest heart or nervous system problems.
On examination, he had a small cut on his nose and an abrasion on his forehead. His blood pressure dropped when he sat up. His lab studies suggested dehydration for which IV fluids were initiated. He was admitted to an intensive care unit.
Over the next 18 hours he had CT scans of his face, brain and chest. An MRI scan with and without vascular contrast was obtained of head and neck along with an ultrasound study of the arteries in his neck. An electroencephalogram was obtained following a consultation by a neurologist. All studies were normal.
His symptoms resolved completely as he received four liters of IV fluids. A Band Aid was placed on the cut on his nose. He returned home.
The hospital bill for his overnight stay exceeded $40,000. This did not include bills submitted by the three physicians who examined him and the radiologist who interpreted his scans. It is unclear how much his health insurance will pay and how much the man might be expected to pay out of pocket.
An acceptable, alternative treatment plan in this case would involve admission of the patient to an observation ward where he could be closely monitored while receiving IV fluids. If any further symptoms occurred, these could be evaluated with appropriate tests. He could be transferred to an ICU if warranted.
The management of this patient raises several questions:
• Did his physicians fear a lawsuit if they overlooked an underlying condition that might cause his brief faint?
• Did his physicians routinely test patients for every possible cause of symptoms? Possibly his doctors trained in teaching hospitals with this philosophy.
• Did the admitting hospital routinely yield to a "technological imperative," employing sophisticated imaging simply because it was available?
• Were the physicians aware of issues of cost or radiation exposure from multiple CT scans?
• Were there subtle, financial incentives to order numerous tests?
• Did the patient or his wife demand extensive testing?
Perhaps on this evening, the emergency room was overwhelmed and there was no time to consider alternatives to multiple tests and placement in an ICU.
This case highlights the difficulties of controlling runaway health care costs. A patient places his trust in a physician to evaluate and treat symptoms in a timely manner.
In an acute setting, options to a treatment plan are rarely presented. Costs that the patient may incur are not mentioned. The physician ordering multiple tests may have no idea how much these cost. Depending upon his insurance coverage, the patient may never learn the price tag of his various tests and treatments.
When we make major purchases such as automobiles and large appliances, we can shop, compare costs and adjust our selections to our budgets. No such choice exists in emergency rooms and other acute-care settings.
An estimated half of all personal bankruptcies involve medical expenses. Large deductibles and co-payments can leave insured persons with big bills they must promptly address. Uninsured persons do not enjoy discounts which may be offered to those on insurance plans. The uninsured are held responsible for the full costs of care.
My next column will examine possible solutions to this complex issue.
Contact Clif Cleaveland at firstname.lastname@example.org.