Commentary & Opinion
12:40 pm
Fri September 20, 2013

A Man Who Worked Too Hard

Influenza rocked our community hospital for weeks this winter just as the first snowstorms came. Our hospital medicine service was swamped with patients. I was working the night shift.

One emergency physician dramatically recounted how a queue of ambulances had clogged the parking lot. Once all of the emergency department beds, hallway spaces, and waiting room seats were taken, patients waited outside in ambulances. With the usual triage system in gridlock, he had climbed into ambulances one by one to help triage or stabilize patients.

Such are the undignified consequences of a system that encourages hospitals to run themselves like factories or just-in-time warehouses. 
One patient’s admission stood out.

A young-looking man in his early 40s had keeled over while shoveling snow. As I admitted him to the hospital, National Weather Service advisories that mention the dangers of snow shoveling and warn persons at risk for ischemic heart disease to be cautious (mostly those who are past our chance at preventive medicine) flashed through my mind.

Yet, this person had not been merely shoveling some snow. He had been running a snowblower, as well as manually shoveling, from shortly after 3:00 a.m. until a quarter past 6:00 p.m. – just over 15 hours straight, without a break. I asked what he had eaten. Nothing. He had consumed only about a half gallon of liquids all day. The previous day he had tried to eat a chicken salad sandwich but managed to down only about one third of it because a sore tooth prevented him from eating. 
In fact, he had not had much solid food for more than a week.

The patient had an untreated breaking, decayed molar with an adjacent gum abscess. He had no health insurance. Seeing a dentist meant an outlay of cash that he didn’t have. Our patient, able to find steady work only in summer months, had jumped at the chance to earn money during the snowstorm. He concluded his explanation with a stoic shrug, saying that his tooth was beginning to feel better now that part of it had broken off.

I finished taking the patient’s history, performed a full examination, and retreated to review his data in full. His test results were normal. Apart from his dental abscess, he seemed rather healthy. He received no medicines and had no chronic illnesses. Assessment: He had worked himself into the ground – and this wasn’t his fault. He had done what he could to help himself. Unfortunately, he also needed to pay attention to taking enough fluids and food to sustain his exertion. Like an increasing number of our patients, this man was living at the very edge.

 From a physiologic point of view, our patient had just had a big all- day-long stress test. His outlook and insight; history of good health; normal vital signs; and normal results on his physical examination, EKG, laboratory values, and head CT all spoke of someone who had passed the test with flying colors. A sick person might have collapsed before dawn, not after sunset, on such a day of work.

As we discussed these findings, I sought to reassure him. When I suggested that perhaps he really didn’t need more tests, he seemed shocked. “We need to get to the bottom of this!” he exclaimed.

In spite of his meager means, he wanted admission to the hospital and the full work-up promised. He mused that he might apply for Medicaid but recognized that if he didn’t qualify, the ambulance and hospitalization might cost thousands of dollars, with bills for years to come.

Once admitted on observation status, our patient found one of the only available beds – in the intensive care unit. He was released the next day after receiving more normal laboratory results.

On reflection, the experience left me feeling less like a doctor and more like a hapless worker bee in a buzzing but somehow misguided hive, fraught with unnecessary and avoidable endeavors.

Moreover, if the patient had access to dental care, he would have been able to take adequate fluids and calories and perhaps never would have collapsed in the first place. Lastly, here was a glimpse of the health consequences of an economy increasingly reliant upon temporary, part- time, and seasonal jobs.

It was redeeming to recognize that I had helped him by initiating treatment for his dental infection. Yet, the experience also reaffirmed my strong belief that our nation needs, at minimum, a public, single-payer program that will provide care – and system planning – for every patient. What good we could do if we mustered, rather than squandered, our resources.

This case of a man who worked too hard illuminated how feeble, even irrelevant, our profession may seem when it comes to basic requirements of personal health in the 21st-century United States. We have earned great scientific and human insight into the lives of our patients. To practice the art and science of medicine, to fulfill the calling of our profession, we must ultimately learn to articulate our insights to guide social resources toward the health of each and all.

If we continue to embrace the role of worker bees, focused upon chart checklists and testing algorithms and petty incentives to generate revenue, we will place ourselves in a role unworthy of our profession. 
To eliminate unnecessary tests and treatments – and to prevent so many avoidable illnesses – our profession will need to heal itself.

Dr. Andrew Coates practices internal medicine in upstate New York.

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