Tertiary Inertia
Tertiary Inertia
In the movie Star Trek IV: the Voyage Home, the crew of the star ship Enterprise somehow return to 1986 Los Angeles. Captain Kirk suffers a head injury, is unsure of what course of action he should follow, but thinks better of going to the hospital to seek care when Spock tells him something like, “you mustn’t expose yourself to the risks of 20th Century medicine”. Happily, he doesn’t need to: Doc McCoy comes along and restores the captain to perfect health with a simple hand-held device.
Medicine, at least in a technological sense, has indeed moved on in the last 37 years. In stroke care, my own area of special clinical interest, the three main advances have been thrombolysis (dissolving the clot causing the stroke), intravascular clot retrieval, and telemedicine. Not all these interventions are indicated for every patient. In New Zealand, all three of the interventions have been partly pioneered and championed by the specialist medical staff at Wellington Hospital. Part of the programme is to extend the use of reperfusion strategies, which are now practised routinely in the bigger centres, to make them available to selected patients who have strokes in rural areas and present to smaller hospitals like the one I work in at Dunstan.
In 2023, I arranged to spend my week a year, which we are required to spend each year in a big hospital as part of maintaining vocational registration, in the Wellington unit. I learned a bit about stroke, thanks to the Wellington team and their patients, and a lot about tertiary hospital medicine. Unfortunately, most of what I learned turned out to be as a mystery shopper rather than as a doctor.
Apart from the highly technical hyper-acute care, there are other aspects of stroke care that are important. Too many people are having strokes in the first place. Stroke worldwide is now the second commonest cause of death, behind heart disease, and ahead of cancers, infections, and trauma. The most cost-effective way of reducing this number is what we call primary prevention: preventing strokes in people who are not already known to be unwell, mainly through lifestyle measures. Next is secondary prevention: preventing strokes in people who already have a disease, such as high blood pressure or heart disease. Possibly the most effective secondary prevention is directed at preventing further strokes in people who have already had a temporary or completed stroke and have to some extent recovered.
Most of the hospital care after a stroke can be described as tertiary prevention: preventing complications. There is a long list, including lung, skin and bladder infections, clots in the leg veins, limb contractures, and avoidable disability. This work is carried out by an organised multidisciplinary team: nurses, physiotherapists, occupational therapists, speech language therapists, doctors, radiographers, social workers, dietitians, psychologists and others. Care of this type, when required, produces better outcomes in designated stroke units, which are usually in the bigger cities. In our smaller hospitals, we try to manage stroke services in a manner that adheres as closely as possible to the criteria for stroke unit care.
I had a busy week at home. My mother, who herself has had a stroke in the past, is in respite care after an injury, and is probably looking at permanent rest home placement. We have been supporting her with her decision. The flowers on her bedside table had dried out, so I decided to pick the last roses from our garden to take into her. I may have stood on a rose thorn at that time, or on something else a few days earlier, because I had an uncomfortable black lump on the sole of my foot. I asked my wife to have a look at it, and I had a go at it myself, but neither of us had the time to deal with it properly.
Monday. I woke up at work in Dunstan Hospital. I couldn’t be in Wellington Hospital that day because I worked nights at the weekend. I was not busy, except for dealing with one new patient who had turned up just prior to handover. I left the lady’s continuing care to the daytime doctors and drove home. We went early to the airport—you never know when and for how long the road will be closed for roadworks. The plan was for my wife to drop me off, then return home and fly up herself on Thursday to stay with me and take a road trip at the weekend with our daughter, who was living and working in Wellington at the time, to visit a relative in Hawkes Bay.
It was a fine day. I had booked a window seat on the left so I could see the mountains. Over the years, I have flown out of Queenstown dozens of times. I never tire of the views. I took a taxi to my hotel, which was an unnecessarily comfortable place in the middle of the city. Most of the places away from the city centre, which are cheaper and are more accessible by car, were full, probably because of disruptions to the Cook Strait ferry sailings.
Tuesday. I walked up to the hospital, through the centre of the city, through the Basin Reserve, the scene of a dramatic last-ball test cricket win over the English a few days earlier, up the slight rise to Newtown and into the hospital main entrance. I was completely unsure of where to go. I walked to the stroke ward; they were not expecting me. I had a name: Martin, the lead stroke doctor. We had been communicating by email. I was directed to his office, in the Neurology outpatient clinic. He was not there. Nor was the administrator, who was supposed to arrange for me to get a name badge and door swipe, but was working in private that day.
Another neurologist was in the office. She told me she was on for acute stroke calls that day and took my phone number in case she needed to call me. She found me some relevant journal articles to read. I was happy to sit and wait; I found it helpful to put my sore foot up. Martin arrived, as expected, after dropping his kids off at school, a more complicated process these days as the parents go with the children in a “walking school bus” then have to make the short journey on foot back to the house. Martin told me about the stroke service, made a few phone calls, got me started. I returned to the ward.
The first patient was a large Māori lady who had complete weakness of her right side and was unable to speak. Ironically, she had been flown to Auckland and back for clot retrieval, because there was no interventional radiologist on in Wellington at the time she presented. She had a bleed at some point and remained severely disabled. She communicated with the staff via a picture board. When asked about her concerns, she indicated she was unhappy with the meals. Even the aphasic patients were complaining about the food.
The other patients included a man in his 50s who had suffered an unlikely stroke, affecting his balance, as a complication of a clot in his leg. There must have been a communication between his right and left atrium, and the neurologists were arranging a bubble ECHO test to confirm it, recommended by the cardiologists, but I never got a chance to find out the result. The medical staff on the ward also had to consult with the vascular team about treating the clot in the leg, possibly inserting a filter into the inferior vena cava to prevent spread to the lungs, and the haematologists about starting anticoagulants in the presence of a stroke. Luckily, he never had a clot in his lungs, or they would have needed to consult a respiratory physician as well.
The neurologists were also being consulted about patients on other wards in the hospital. I went with the registrar to see a man in the secure mental health ward. He seemed a nice guy, looked like one of the people I had seen on other trips sleeping in Courtenay Place. At least in hospital, I thought, he would be able to get a feed. The night before, he had been found wandering around naked after taking some drugs, was arrested, heavily sedated, and locked up. Sometime after arrival, he had suffered a seizure. It had happened once before under similar circumstances and he had some investigations then. The registrar decided the man didn’t need to start on anticonvulsant treatment, and we returned to the relative peace and quiet of the stroke ward.
I attended the multi-disciplinary team meeting, similar to the ones we have in Dunstan, except I didn’t know most of the patients, and they all suffered a stroke. One we discussed at length was a Chinese citizen who had a stroke while visiting family in Wellington, was not well enough to return to China on a commercial flight, did not have enough money for a charter flight, and was fast losing what little he had paying for his care on the Stroke Unit. None of the other wards, and none of the rest homes, would take him. The meeting centred on finding some way of supporting the family to care for him in their homes.
At the end of the afternoon, the registrar told me, there was an acute stroke call to room A3 in ED. Without my name badge, I had to go outside, in through the front door, and explain to the receptionists, whom I got to know better during the next few days, who I was and what I wanted. I was directed to the correct cubicle, but it was occupied by a family group, none of whom appeared to be a stroke patient. I asked directions from the nurse in charge, who was as unhelpful as possible, treating me like an intruder, regarding me as she might have regarded the naked man from earlier in the afternoon. Later, I discovered the stroke call had been a mistake. I made my way out of the hospital.
For dinner, I met my daughter at an Indian restaurant across the road. She arrived by bus and was planning to take another bus back into town. I was happy to join her on the bus. My foot was troubling me and I didn’t want to make it worse by walking a long distance downhill.
Wednesday. It turned out to be a long walk up the hill to the hospital. I often walk a similar distance at home, but not on a hard surface. I have a pair of Rockports, which are designed as walking shoes, although they are made of leather and rubber, and are usually very comfortable, but today they were not. Being optimistic by nature, I was pleased to imagine I was developing some sort of inflammatory reaction around the foreign body in the sole of my foot and it would soon be expelled. I sat in a little office adjacent to the ward with my foot up, waiting for the medical team to arrive.
I had a talk with the Stroke Nurse Specialist, who had led the multidisciplinary team meeting the day before, is involved in organising early supported discharge, and gets to follow up stroke patients in clinic. She is impressed with the technological outcomes, but says often the patients are not. They are already dealing with their loss of health and find the process itself is disabling. Even the outcome measures we use, such as the Rankin Scale, are designed to measure the need to provide care, rather than the subjective experience of the person who has suffered the stroke.
My foot was getting worse. I explained I had a medical problem of my own, not something a neurologist, or even the students and junior staff, who have more general skills, could deal with. At 10am, I left the ward, and walked carefully down to the Urgent Care Clinic up from the Basin Reserve, as the doctors on the ward had advised, pointing out I would be seen more quickly than at ED. They were right. I filled out a form and was seen within a few minutes by the triage nurse. At 11am I saw their doctor. By that time, I was developing a small collection on the side of my foot, which I had been unaware of. It was classified on the ACC form as a reaction to a “biological foreign body.”
The doctor said she “didn’t have the skills to drain it.” She phoned the surgical registrar at the hospital, who answered immediately and said it was not his department. She phoned the orthopaedic registrar who eventually answered, but on an unclear line, and agreed to phone back. I returned to the waiting room, waiting to find out the plan. The doctor came out with a letter to the hospital, who had agreed to take me. I tried harder, said “I hoped you would do it,” but the answer was the same, and more: she “didn’t have the skills” and “didn’t have the equipment.” I’m not sure she had ever handled anything with a sharp end. She offered me some pain relief, which I had not taken up till then, and declined. I wanted to get it fixed. I paid for my assessment, topping up the money from ACC with my credit card.
I hobbled back up the hill and arrived at ED around midday. I gave them my letter, my details, including my wife’s phone number as an “emergency contact.” But I asked them not to phone her unless they needed to as she didn’t know I was here. They reassured me about that. At 12.30 I saw the triage nurse. Then I started the first of my long waits, for which I was unprepared, had brought nothing with me. My bag was back in Martin’s office. I was feeling sick and fortunately not hungry. I have never formally learned to meditate, but I enjoy sitting quietly doing nothing, concentrating on my own thoughts, if I get the chance, so I did that, for two hours.
At 2.30, I met the orthopaedic registrar. I don’t remember her name. She was polite and friendly, looked tidy in scrubs, but from the little I saw of her, and I’m sure she was also busy with other patients, I could not accuse her of being efficient, and in the end did not show herself to be either caring or helpful. She insisted she would need to do a blood test, an X-ray, and an ultrasound, before she would know what to do. Over the course of the afternoon, she organised these tests. All three. One at a time.
A trainee intern came in to take my blood. He reassured me he had done it before, and would have only two attempts before handing over to someone else. I told him I would be easy. He asked me what I did for a living. His confidence did not increase when he learned I was a rural hospital doctor. He did his job well, got some blood, and went away happy, saying I was the easiest one he had done for a while, and revealing he had missed the last few. The registrar came back with the results, said my inflammatory markers were slightly raised, and filled out a form for an X-ray. I found my way round to Radiology.
The room contained only a handful of patients. I was encouraged when after only a few minutes they called my name, but they only wanted to clarify which foot was sore, left or right, as it was unclear on the form. I realised there was another door, which opened intermittently, admitting large numbers other sicker patients from the main ED area, which still looked chaotic. I didn’t see the intimidating charge nurse from the day before. The radiographer eventually took me through to the machine and did six views, loudly and effusively praising me for keeping my foot still, as if I had completed some complicated gymnastic manoeuvre. The registrar came and looked at my X-rays too. They were normal.
The doctor tried to arrange a formal ultrasound—she didn’t offer to do an ultrasound herself, as we would have done in the hospital where I work. There were no appointments left for that day. I asked the doctor if she would drain my collection, to relieve the pain, to look for the foreign body. She insisted she couldn’t do this without the ultrasound. She gave me a prescription for an antibiotic; Flucloxacillin. She said I would get an appointment for an ultrasound tomorrow or the next day. I asked her if she would phone me with a time. She told me Radiology would do that. I took a taxi back to the hotel. My daughter picked up my prescription and bought me a takeaway and a drink.
Thursday. Nothing. The egg-shaped swelling on the side of my foot persisted, though the species I felt had laid the egg evolved from an ant to a thrush to a small hen, and felt like an ostrich. I was developing, in spite of the Flucloxacillin, a worrying red warm area on the top of my foot, which hurt whenever I put it down or stood up. I was struggling to walk, even to the toilet, was unable to go back to the ward, unlikely to learn any more about stroke care. I went nowhere. I texted Martin to explain my problem and advised I would pick up my bag when I came in for my ultrasound. Except no-one phoned me with an appointment. I made a plan to return to the ED tomorrow and put myself in front of them. Perhaps by then I would need an ambulance. I lay with my foot up, listening to podcasts, taking my Flucloxacillin, also some Paracetamol and Ibuprofen, not wanting anyone to blame me for causing my own sore foot by not taking pain relief.
Friday. My wife, who had arrived by then, received a call on her cell phone. Radiology had been phoning me on the wrong number. I don’t know if they had booked an ultrasound for yesterday. They wanted me today. 1pm. They agreed I should present myself first to ED, later that morning, so someone would know I needed to be followed up after the scan. My wife and daughter dropped me at ED at 11.30 on their way out of town. I asked the ED reception staff to correct my phone number. They didn’t need to. They had the right number already.
I was seen by a lovely triage nurse, whose name I’ve forgotten, who showed what seemed to be a genuine concern for the fact I had received no real treatment, and my foot had got worse. She told me to wait where I was, explained that ultrasound was in a different part of the hospital, and an orderly would take me there in a wheel chair. She would phone orthopaedics when I got back and ask them to look at the scan. I sat with my few items in a New World shopping bag. Martin, the neurologist, kindly dropped round my own bag, which contained mainly my jacket, and some writing material, from his office.
The orderly appeared a few minutes before the time for the scan. He noticed the swelling on my foot, which he described as “a big blood blister”. He said if it were him, he would have burst it with a pocket knife and asked me “why did you come here?” There was no adequate response I could make. The orderly pushed me in a wheelchair to the other end of the hospital, using his swipe card to open at least three of the doors. He called a friendly greeting to the ultrasound staff, confirmed he would come back for me, and left me sitting in their waiting room.
A young woman appeared who said she was the radiology registrar. She was learning to do ultrasounds because they have to do them after hours when the ultrasonographers are not available. She took me through and had a tentative look at my foot, along with the ultrasonographer on for that day. They both said they were being careful, worried about bursting the blister. Neither could see a foreign body. Both could see an extensive collection. My favourite line about ultrasound is from Bob Dylan’s “Subterranean Homesick Blues”: “you don’t need a weatherman to know which way the wind blows.” The orderly returned and took me back to the ED waiting room.
Past first base; I had completed my investigations. The anonymous triage nurse noticed I had returned, made sure I was comfortable, promised to phone orthopaedics to look at the scan. I settled in for a long wait. The nurse returned, said she had phoned orthopaedics, they had looked at the scan, had decided it didn’t look too bad, and I could see one of the ED doctors. My wait would be longer. There were seven patients in front of me, my nurse told me, but I could see a steady stream of others being brought in by ambulance who would probably receive a higher priority.
I commandeered an extra chair to put my foot up, checking from time-to-time to see there wasn’t anyone else who needed it. The woman beside me, who had been waiting about the same time, told me it was fine to use the chair. “That’s a gnarly looking foot,” she said. “Yes,” I said proudly, “but they’re going to fix it soon.” I was better prepared. I had a bottle of squeezed orange juice, which I sipped on intermittently, quenching my thirst and providing a bit of energy. I had a copy of the Listener in my bag, along with my shoes. I had plenty of time to do the crosswords. I couldn’t complete the Quizword because I didn’t know the name of New York’s oldest independent bookstore (Argosy) or another name for Firethorn (Pyracantha). The cryptic crossword was easier.
There was an article on stroke, which I read with interest. An English doctor, who has done research in New Zealand, was reported to be questioning the value of current methods of treatment and rehabilitation. Patients often find them disempowering, focused on the goals of the professionals. He wants to set up an alternative programme where stoke survivors take charge, deciding from the outset what is important for them, working on the whole person, not just the “damaged part.” The therapists are trained to listen, not talk, to work with the patient’s aspirations, not restricted by the professional’s more limited goals for them. Whether the programme is introduced in this country or not, I hope we can all learn from the doctor’s ideas.
In general practice training, we teach about this stuff. Following George Engel, from 1977, we are encouraged to take a biopsychosocial approach to care. Following Eric Cassell, from 1982, one of the goals of medicine is to explore the nature of the patient’s suffering. We are taught to practise patient-centred medicine, treating people receiving healthcare with dignity and respect and involving them in all decisions about their health. We may have many patient-centred doctors and nurses, and people who are grateful for their care, but we do not appear to have a patient-centred health system.
Time passed. Slowly. A few people went off for assessment or treatment, disappeared from the queue, appeared to be getting something done, to be replaced by others. There was a change in the nursing shift. My anonymous lovely triage nurse was no longer there. There was another nurse, who I’m sure was equally lovely, and I didn’t know her name either, but she didn’t meet me and had nothing to do with me, or for me. When you notice all the patients are changing, it’s encouraging. When all the staff are changing, it’s bad.
A nervous, untidily-dressed woman was sitting at the end of my row. As the waiting-room filled she became more agitated. She launched into a long rambling speech consisting mainly of the adjective “fucking”—fucking this, fucking that—with a sparse collection of nouns and verbs. There were a few other words, which to my understanding included information about having to wait for a brain scan, her car being moved on from where she had tried to park it, and not having enough fuel to get home. Understandably, no-one took any notice, tried to ignore her. The woman approached the reception desk in a threatening manner. Five beefy black-uniformed security guards appeared miraculously, as if from out of the walls, a doctor came along to talk with her, and the woman, surrounded by her new friends, moved off to another part of the hospital, possibly to be locked up with the naked man from earlier in the week.
A doctor came and rescued me from the ED waiting room. I will call her Lucy, because that was the name on her badge, and she told me her name was Lucy, and also told me the name of the small town in New Zealand she came from, which I’d never heard of (that is the true test, the best definition, of a rural small town: no-one has ever heard of it). I thought she was an ED trainee, but she told me she was doing orthopaedics, that if I had to wait for the ED doctors I would have waited even longer. Perhaps the anonymous lovely triage nurse felt sorry for me and referred me back to orthopaedics before she went off.
Lucy knew my history, had seen by blood test results, X-rays and scans. The good news, she said, there was no evidence of infection. It should clear up on the antibiotics, though she suggested I change from Flucloxacillin to Augmentin to cover a wider range of bacteria, and gave me a prescription. No infection? Antibiotics? Orthopaedic specialists are legendary for their lack of interest in non-bony parts of the body, but they are not usually known for completely illogical thinking. Perhaps she meant there was no bone infection.
I was in the home straight. After three long days, seeing three receptionists, three nurses, four doctors, a radiographer, an ultrasonographer, my friend the orderly, potentially the neurologists and junior staff and medical students on the ward, after having a blood test, an X-ray and an ultrasound scan, I was looking forward to having some treatment. I asked Lucy what she was going to do. Once she worked out what the question meant, she explained carefully the details of her plan: nothing. She was going to do nothing.
I was heartbroken, not bone-broken, but looking disappointed enough to move even an orthopaedic specialist. I asked Lucy to do something, please, to drain some fluid from the bottom edge of the blister. She agreed to do it. Using an 18-guage needle, like we use for taking blood off a big vein, and a 30ml syringe, she skilfully drew off 20ml of straw-coloured fluid with a bit of blood in it, but no pus, as she pointed out, and applied a dressing. We walked back out to the ED waiting room, which was much easier for me with the fluid drained and my shoe and sock on, back to the other patients, who had become lifelong friends and were pleased to see me restored, Lucy apologised for the long delays. Something to do with lack of resources, she said.
I took a taxi back to the hotel. My foot felt better. As Lucy would have predicted, most of the fluid re-accumulated after a walk to the bookshop. But I still felt better after my placebo surgery. The Augmentin did kill off a wider range of bacteria, mainly the helpful ones in my gut, and I developed diarrhoea, an inconvenient side-effect when travelling away from home, and I will probably join the list of people who mention it as an intolerance when asked about allergies, but my foot and my non-infection eventually cleared up.
Lucy kindly gave me an extra dressing, which I used when the first one soaked through, and kept on for as long as possible, allowing me to walk, but after my return to work it was coming off and needed to be replaced. The charge nurse on the ward at Dunstan removed it, cleaned my wound, and applied another dressing, all in 360 seconds, beating Wellington’s record by seven hours and fifty-four minutes.
As expected, I learned some new things in Wellington about stroke care and big-hospital neurology, well worth the effort, a surprising amount in a-day-and-a-bit. Unfortunately, I learned more than I ever wanted to know about the efficiencies of tertiary hospital medicine.