[ Pobierz całość w formacie PDF ]

extraordinary range of services, including some eighty special diets.
The true hospital costs the expenses incurred in a hospital but not in a hotel are, on the other hand,
very high. They account for 82 per cent of the total per-day room charge. And the question, really, is
whether these charges are reducible. No sensible businessman would bother to try to get his hotel and food
costs below thirteen dollars a day; if there is to be a decrease in costs, it must come from the non-hotel
charges.
These in turn largely reflect the increased tech-nological capacity of the hospital. Mr. O'Connor's
example is a case in point: most of the tests per-formed on him were not available in 1925, when he could
have had his room for one twenty-fifth of what it cost him today. The maintenance of this new
technological capability costs money and to a large extent, in medicine as in education, law en-forcement,
sanitation, and a variety of other ser-vices, you get what you pay for. If you are going to enter a
high-quality acute-care facility that has six employees (most of them non-physicians) for every patient, and
if you are going to pay these employees a decent wage, then your care will be expensive.* If you are going
to purchase techno-
* All this is sometimes easier to see if it is taken out of the hos-pital setting. If a man had to hire six secretaries for an
eight-hour day, at $2.50 an hour, it would cost him $120.00 a day. If a man had to hire two gardeners at $4.00 an hour,
for a single eight-hour day, it would still cost him $64.00 a day.
70
FIVE PATIENTS
John O'Connor
71
logical hardware, maintain it, and keep it up to date, this costs money. If you are going to keep the hospital
in continuous operation twenty-four hours a day, three hundred sixty-five days a year, this costs money.
All this becomes clear in the instance of a sim-ple procedure such as a chest X ray. A private
ra-diologist in his office will perform this for you at one half or one third of what the hospital charges. His
charge largely reflects the fact that his unit can operate on an eight-hour day and a forty-hour week; other
costs, such as equipment and supplies, are the same. In medicine today as in every other
industry people are more expensive than any-thing else. Sixty-three per cent of the hospital bud-get now
goes to the salaries and benefits of employees. And much of the rise in hospital costs is directly attributable
to the demand of these em-ployees that they not be personally forced to sub-sidize the health business by
accepting wages incommensurate with similar jobs in other indus-tries. Their demands are justified; most
employees are still underpaid. Their salaries will increase in the future.
One cannot, however, fairly claim that hospitals are superbly efficient. Especially in a teaching hos-pital,
attention to cost in the medical, non-hotel sector is less central than one would like it to be. One can argue
about whether too many tests are ordered, and the argument can continue endlessly. But certainly, when
physicians who order these
tests don't know what patients are charged for them, eyebrows must go up. In general, doctors tend to
operate on a "spare no expense" philoso-phy which will, eventually, need to be tempered.
But, more fundamentally, the present cost struc-ture of the hospital seems to lead to a rather
old-fashioned conclusion: no one should go there unless he absolutely has to.
If a diagnostic procedure can be done on an am-bulatory, out-patient basis, it should be; if a series of
tests and X rays can be done outside the hospi-tal, they should be. No one should be admitted un-less his
care absolutely depends upon being inside the hospital; no one should be admitted unless he requires the
hour-to-hour facilities of the house staff, the nursing staff, and the laboratories.
For decades, admission to the hospital was nec-essary because there was no other facility avail-able.
For a large segment of the population, care was either given in the hospital, or not at all; and the hospital's
clinic system was a poor compro-mise, with hordes of patients being brought in to wait hours sometimes
literally days to have rel-atively brief tests performed.
There is hope that the satellite clinics will help solve the problem; one study of a satellite clinic in Boston
reported that there were fewer hospital ad-missions as a result of the clinic's work.
In any case, alternative facilities must be found, because it is unlikely that hospital costs will ever go
down. The best anyone can hope to do in the foreseeable future is to stabilize them somewhere
72
FIVE PATIENTS
in the neighborhood of $100.00 a day. This makes the hospital an expensive place but it has its uses,
and indeed will be an economically tolerable place, if it is used appropriately.
PETER LUCHESI
Surgical Tradition
at 3:15 p.m., the emergency ward was notified that a patient was being transferred in from an
outlying hospital: a young man with a nearly severed arm resulting from an industrial ac-cident.
He arrived an hour later and was seen first by Dr. Hopkins, the triage officer, who ordered him sent to
OR 1. The surgical residents, Drs. Eugene Appel and Terry Mixter, were called to examine the new
patient.
He was twenty-two years old, of medium height and muscular build, looked quite pale, and was speaking
weakly. His left hand was bandaged and splinted. An intravenous line had been inserted in his right arm, but
it had infiltrated. There was also a bandage over his chin. The bandages were re-moved and a new
intravenous line started. He had a moderately deep two-inch laceration in his chin; the medical student, Sue
Rosenthal, was called to suture it. Meanwhile, Appel and Mixter turned their attention to the injured arm.
Three inches above the left wrist the forearm
75
76
FIVE PATIENTS
Peter Luchesi
77
had been mashed. Bones stuck out at all angles; reddish areas of muscle with silver fascial coats were
exposed in many places. The entire arm above the injury was badly swollen, but the hand was still normal
size, although it looked shrunken and atrophic in comparison. The color of the hand was deep blue-gray.
Carefully, Appel picked up the hand, which flopped loosely at the wrist. He checked pulses and found
none below the elbow. He touched the fingers of the hand with a pin and asked if Luchesi could feel it;
results were confusing, but there ap-peared to be some loss of sensation. He asked if the patient could
move any of his fingers; he could not.
Meanwhile the orthopedic resident, Dr. Robert Hussey, arrived and examined the hand. He con-cluded
that both bones in the forearm, the radius and ulna, were broken, and suggested the hand be elevated; he
proceeded to do this.
Outside the door to the room, one of the admit-ting men stopped Appel. "Are you going to take it, or try
to keep it?"
"Hell, we're going to keep it," Appel said. "That's a good hand."
The patient was started on two grams of cephalothin antibiotic intravenously, and was given more
tetanus toxoid. He had received pain medi-cation at the other hospital, and so far had not requested more.
As a workmen's compensation case, the opera-tion would be done by private surgeons: Dr. Hugh
Chandler for orthopedics, Dr. Ashby Moncure for general surgery. At 5:15, Moncure arrived and looked at
the hand, satisfied himself that it was in-deed viable, and put the patient on call for the operating room. He
also called Chandler and sum-marized the case: "It's a circumferential crush injury to the left hand with
compound fracture of both radius and ulna. Innervation and arterial sup-ply look pretty good."
Meantime, the portable X-ray machine was brought in to take a chest film, and two views of the injured
hand. The medical student finished su-turing the chin laceration. Moncure came back to check that a
sample had been sent to the blood bank. He then went off to try to hasten scheduling for the operating
room.
At 5:30, the patient complained for the first time of pain in his hand. The surgeons were debating what [ Pobierz całość w formacie PDF ]