Diagnosing Chaos: My Trip Through the Healthcare System

We were riding deep in the North Carolina mountains on a no-name ribbon of asphalt tracing a contour in cool shadow. There are two cardinal rules when taking turns on a motorcycle. The first: Do Not Go In Too Hot. The second: Look Where You Want the Bike to Go, NOT Straight Ahead. You riders out there know the consequence of violating rule two. The bike straightens up and forgets all about making it through the curve.

I bent rule one and shattered rule two. I crossed the road onto gravel and went down – hard – on my right shoulder and side. The pain was bad, bearable, and unusual. Fair warning that all was not well within. The bike was hurting too, but the frame wasn't bent; the important controls were intact, and it started. Such loyalty I did not deserve.

With no level one trauma center in the 'hood, my faithful and graciously non-judgmental buddies decided we should head back to Raleigh. I dry swallowed 2 oxycodones from my first aid kit, used my left hand to lift my strangely uncooperative right arm to the throttle, and u-turned toward the interstate slab and its 250-mile straight shot home.

My wife, exuding an exquisite blend of concern and reproach, drove me to the emergency room. That is where this story begins. It is a story of my now eight-week relationship with the healthcare system and an interesting test case for the existence of Chaos as described by Thomas H. Lee, M.D., a Harvard professor and CEO of Partners Community Healthcare.

In a recent interview with Harvard Business Review, Lee contends that chaos is brought on by the overwhelming amount of information and technological innovation flooding into a disconnected community of providers and physicians. Like Lucy and Ethel on the chocolate candy production line, providers and physicians are unable to assess and selectively assimilate legitimate innovation into improved standards of treatment. Lee believes that the resulting confusion – chaos – leads to poor communication, overuse of tests, low levels of standardization, inefficiency and high cost.

Lee says that the way to attack chaos is twofold, a dual revolution of sorts. The first revolution is a cultural one, where autonomy is replaced by collaboration and seamless communication. The second he likens to the industrial revolution, where the assessment of new technologies is centralized and graded on the basis of diagnostic accuracy and therefore improved outcomes.

It was still early on a Saturday evening and the ER wasn't crowded. I was triaged by an LPN then put in an exam room, my home for the next three hours. After a "what-did-you-do / where-does-it-hurt" debrief by an RN, I went to have x-rays taken. A PA came in 30 minutes later to tell me that the images showed no broken bones. This did not jibe with my level of discomfort, but I thanked her for the good news.

The RN brought in an arm sling and started to Velcro me up. We were still adjusting when the PA returned, looking a bit sheepish. By then my images had been reviewed by a radiologist on the main campus five miles away. (I assume this is SOP, despite the earlier ill-timed bruised muscle diagnosis.) Turns out I did have broken bones: three ribs and one snapped scapula. All broken parts were aligned. Good news. But the undisputed pain leader, my shoulder, remained a mystery. To me, anyway.

With the discovery of broken bones, my ER status surged. One of the ER physicians came by to probe me for internal abdominal injuries. Finding none, he urged me to see an orthopedist on Monday and let me go home.

I'll move quickly through the ensuing eight weeks:

Week One – First visit to orthopedist. Patient stops by ER on the way and hand delivers disc of x-ray images. Patient complains of shoulder pain. Doctor (a saint) believes him and orders MRI.

Week Two – MRI sheds light on shoulder mystery and proves patient is not a cry baby. A fifth fracture is found in the acromium (a bone patient wishes he had never heard of). Better fitting sling prescribed.

Week Three – Another set of x-rays taken at doctor's office. All bone parts appear to be aligned and healing process is beginning. Patient hums Beatles 'Come Together' on way out.

Week Six – Patient complains of continuing pain in shoulder. Another set of x-rays taken. Acromium healing, but doctor very concerned when x-rays show the scapula fracture is now misaligned. Doctor orders CAT-scan.

Week Seven – CAT Scan shows that scapula fracture is, in fact, misaligned but healing is advanced, indicating misalignment took place at time of trauma.

Week Eight – Patient experiences marked decrease in pain level during week. No longer constantly curses acromium. Wears sling sporadically, primarily to elicit sympathy…marginally successful.

Ongoing – Next doctor visit in 2 weeks. Patient's muscle atrophy triggering nightmares with themes of emasculation. Counting down the days for green light to gym.

So, in bringing "I Should Be Dead By Now" to a close, is my experience a case study in support of Dr. Lee's Chaos theory? Each of you can draw your own conclusions. Mine are still a work in process, as my visits continue and my diagnosis/prognosis is still a bit uncertain. I do know that the aggregate cost will be very high, perhaps reaching five figures. The ER visit alone was billed at an astounding $1,800. I have had four series of x-rays, one CAT Scan, and one MRI with another one looming. To date, my diagnosticians have included a PA, two radiologists, and an orthopedist. And worrisome residual symptoms leave me concerned that they haven't completely figured me out yet!

I have to believe that a better culture of collaboration would have resulted in a more accurate, timely, and less expensive diagnosis. Future technological innovations surely will enable injuries like mine to be evaluated in one session. However… since my actual treatment to date has been to wear a sling, will this future technology pass the cost/benefit test? The answer to that question must come from a centralized and respected source, supported by the entire provider community. And if the answer is "yes," new diagnostic protocols must be communicated and implemented system wide.

Comments

[Mike Danckert]

As a motorcyclist who also enjoys riding in the NC mountains, I am constantly aware of the potential for crashing. I hope that you recover fully from your accident.

I have seen similar diagnosis issues like yours in the past and look forward to the future where technology is fully utilized to facilitate the equivalent of a “one-stop-shop” for a correct diagnosis and treatment plan.

[Mike Merwarth]

Thanks for the kind words, Mike. As you know there is a lot more to the NC mountains for bikers than the Blueridge Parkway and Smokey Mountain National Park (and the Vegas-style abomination just outside its borders). Ride safe. I'll be back there with you by spring.