Medical literacy: another point of view

Sometimes it is useful to put yourself in patient’s shoes. It is an interesting perspective. The complexity of health care and the challenges of the landscape make this a subject for discussion—and improvement. Jim Bagnell is 75. He has long retired from truck driving, and is now spending a fair amount of time gardening, house renovating and tinkering with his ‘57 Chevy. One day, he experiences sudden onset of fatigue, dizziness and nausea. It came on suddenly, after walking the dog. He comes home, tells his wife Megan and the neighbour (a retired nurse), and finds himself in the local ER. He’s never been there before and gets a thorough COVID-19 shakedown before being meeting the triage nurse. “Have a seat, show me your health card please, let me take your vitals.” He surrenders to her demands, which seems a good idea. He’s worried he won’t understand medical terminology. He’s cursing the fact he had vegetable ratatouille for lunch, it’s coming back on him, but the Pepcid he took should kick in soon. Read: Physicians as effective educators The nurse has had a busy morning. With a smile, she says:“Had heart problems before, love?” “Eh, no, do I have one now?” he replies. “Well, your pulse is 128 and irregular, so I guess you are in atrial fibrillation.” And it goes downhill from there. “Half my friends have atrial fibrillation,” he murmurs. Someone puts a needle in a vein and whisks him to a monitored area. “Don’t worry, Mr Bagnel, we see this a lot, it’s fixable—mostly.” Mostly wasn’t what he wanted to hear. “No infarction on your EKG, yet.” “Is that good?” “Well, let’s call the ST changes non-specific for now.” She’s off to put through a requisition for lab work. Megan wonders if it’s better to be ‘non-specific’ or ‘specific.’ Jim has a pee problem. His nurse isn’t someone he wants to share this with. The lab tech seems hurried, the doctor is coming soon, but 40 minutes has passed, and boy, he has to go. “Yes, you can use the shared toilet, but don’t lock the door…. By the way, are you on an anticoagulant?” Jim comes out of the toilet in a cold sweat. He feels faint, and hears: “Stat attendance required cubicle 6.” He notes the fact he is on a stretcher in the corridor—outside cubicle 15. “Is there something about my condition that might moves things forward?” he asks, and the nurse looks puzzled. He’s worried about the worsening heartburn feeling in his central chest, and tells his nurse, Liz, who now looks pale. Maybe if you gave me some Gaviscon, I could go home now,” Jim suggests. Liz is overheard at the nursing desk, asking “Where’s the troponin result on bed 15? 143.6? O.K…DOKEY. Let me call Dr. Johnson, and maybe Dr Ali-Ben-Mohammed-Al-Haboubi, our specialist on call.” Read: When listening to your patient pays off Liz gives Jim ASA and nitroglycerin, and starts taking his blood pressure—a lot. His arm is now getting sore. The IV has run dry, and he needs to pee again. He vomits, and worries that his visit to the grandkids tomorrow might be postponed. Dr. A (Jim can’t remember his full name) arrives and grills him for 20 minutes. Dr. A orders various injections (metoprolol iv, heparin sq). He asks about allergies, but doesn’t seem that interested in his gout, his gluten intolerance or vitamin D use. Jim says:“I drink a bit, just to be social,” and wonders if two bottles a day is social enough. Dr. A is more interested in his prior smoking habit, his uncontrolled blood pressure and brother Richard’s pacemaker. “You are having a subendocardial lateral myocardial infarction with an associated atrial dysrhythmia.” “Right on.” “But we will slow you down, don’t worry.” Jim wonders if his daily walks with Rusty, his retriever, are a bit too fast. “No way you are going home, not until your converted and cathed.” Jim had always wondered if there was a down-side to being a Protestant, now he knows. Megan makes a call to her neighbour, Ms. Rollins.“Can you get my roast out of the oven as soon as possible? Things over here are heating up.” The weekend for the Rollins family wasn’t going to go smoothly either. “Shall I call your daughter Nancy?” she asks, knowing that she’s a four-hour drive away. Megan says: “No, I’ll let her know he’s being kept in,” and she parks that thought for later. By now, Jim’s bladder is full, and he’s ready to use the bottle, any bottle, NOW. There’s none there, so he gathers up courage and asks the nurse. She turns to get one, is called to the Code Blue down the corridor (Cubicle 6), and never returns. Dr. A shows up, sans bottle, and looks anxiously at the cardiac monitor. He confronts Jim.“Well, you’re still in AF at 110, I’m afraid we need to shock you!” Jim has seen ‘ER-in-the-City,’ you know the episode when they zapped Brad Sanders—the lights dim, his back arches, a dial on the National Electrical Grid falls, a team of docs look anxiously at each other, and the background music goes eerily quiet. “I’m already in shock,” says Jim. Dr. A flashes a worried look at the nurse. “You didn’t tell me that, nurse,” to which her response “BP 140/100” seems to ease tensions. “I need you to sign a permission slip, for the electrical signal, you know…. Don’t worry, the risk of death and stroke is very low….” Jim thinks the form has something to do with paying the electrical bill. The mention of death and stroke was an unexpected surprise. He pees himself. “Or I could give you an anti-arrhythmic….” “Sounds good, doc, I’ve been constipated for a week.” Jim stays eight hours in the ER, and is moved to the cardiac floor. He gets a new nurse, a cold dinner, and a view of the parkade. Reassured, Megan goes home, but the chicken is well and truly burnt. She knows he needs his pyjamas, a toothbrush, and a good book (‘nothing too exciting,’ they’ve told her…) Jim meets Frank, 84, who has dementia, heart failure and an acute kidney injury. Frank had tried to climb into bed with Jim at 4 a.m. Jim expands his vocabulary, and now identifies hypertrophic cardiomyopathy, hypotensive presyncope and implantable cardio-defibrillator as unbeatable Scrabble words. Megan is told to scale back her sexual expectations (but only for the first 6 weeks): she becomes hugely optimistic thereafter. Both learn a menu of side-effects that could sink a battleship, and Jim is bundled off to tertiary care, for ‘the yellow snake.’ He is given a route map of his coronaries, and he wonders why they left his 40% lesions alone. They did fix his electrics, it seems; he now has a pacemaker/ICD. Although he can’t pronounce clopidogrel, he knows it is responsible for his easy bruising. He has been promised it will be stopped IF HE BEHAVES himself for six months. He leaves hospital with a stint (which will last 20 years, guaranteed), and instructions to be less sociable with alcohol. Jim is now one of a herd of complex, closely-watched and heavily-medicated elderly. His GP gets Jim’s report from the hospital, and announces his retirement the following week. Megan worries every time Jim (now 285 lb) walks up an incline and starts to puff. Neither took Anatomy or Cardiac Physiology 101. There is no cardiac rehab for 50 miles, but someone will do a telephonic check of his ICD in a month or two. Most of their day-to-day information comes from Nellie Malone, in room 406 across the corridor. She is the retired paediatric nurse that started this whole journey in the first place. Could we do better? Maybe. Read: Blood pressure: an important target

Casebook of a Community Internist

Medical literacy: another point of view

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Hector Baillie

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