Saturday 24th December, Christmas Eve, 2011.
This is a story of two hypothetical John Smiths; one who lives in the US, and another in the UK. They both fall ill on Christmas Eve 2011.
Scenario 1: New York, USA | Veterans Health Admistration (VA)
John Smith is a 77 yr old navy veteran visiting his son Steve’s family in New York having travelled all the way from San Francisco, a 2500 mile journey. This is a particularly poignant Christmas as John suffered a major heart attack earlier in the year.
This morning, Steve found his father sweaty and disorientated. John was taken to the Emergency Department of the local VA Hospital. John was diagnosed with an infected ulcer in the right leg. The infection has spread to his blood stream. They looked up his electronic health record on the VA’s VistA system and instantly they had access to his whole medical record in San Francisco. They found out that in addition his recent heart attack, John also suffered from diet-controlled diabetes, kidney disease and high blood pressure. Indeed, John’s diabetic control has been poor; he has not collected his last 2 prescriptions and has been an inconsistent attender at outpatient clinics. His blood pressure has been difficult to control and his last recorded blood pressure (BP) was 165/85 mmHg.
John was not looking great. He look dehydrated and he was confused. His BP was 110/60 mmHg, pulse 110 bpm, Temp 38.5 C and his blood sugar was very high. He needed antibiotics right away. Steve said that he thinks that his father might have a penicillin allergy but cannot be sure. Thankfully, his doctors were able to confirm on the VistA system that this was untrue as he has been prescribed a course of penicillin earlier in the year for a mild chest infection and responded well to it.
To make a decision on which antibiotic to use, John’s doctor consulted their local antibiotic guidelines. After that, they looked back at John’s microbiological history on the Vista computer system. To their surprise, they found that a highly resistant strain of bacteria was found in John’s bloodstream earlier in the year when John had a similar infection. On the very same report, alternative antibiotics that can kill this bacteria was listed. The microbiologist on-call was consulted over the phone. Sitting at her home computer and using VistA, she recommended an alternative course of penicillin-related antibiotics tailored to John’s current illness.
These were commenced intravenously. John was transferred to the high dependency unit as even-though his blood pressure was ‘normal’, this was significantly lower than his usually high blood pressure. Over the next 24 hours, John slowly but surely improved. The blood test results from the day before confirmed the presence of the highly resistant strain of bacteria.
John did end up spending Christmas in the hospital but his family all visited. He was discharged on boxing day back to his son’s house. The intravenous course of antibiotics was continued at home by the community nurses. His doctors remotely monitored his treatment from the hospital using the Vista computer system. They also made minor adjustments to his diabetic medications.
Meanwhile in San Francisco, Dr Johnston, John’s primary care doctor has already been in contact with his colleagues in New York having been alerted by the VistA system that John has been admitted to hospital 2600 miles away. What John’s family did not realise was that John has also made a prior decision that in the event of his heart or breathing stopping, he did not want to be resuscitated. This was clearly documented on the VistA system with John’s signature electronically recorded. Thankfully, this document never needed to be consulted on this occasion.
Scenario 2: London, England, United Kingdom | NHS – National Health Service
John lives in the Newcastle, situated in north of England but is visiting his son’s family in London in the south. When Steve noticed his father was unwell, an ambulance was called and he was promptly admitted into of one of London’s most prestigious teaching hospitals.
Once again, a diagnosis of an infection in an ulcer spreading to the blood stream was promptly made.
As Steve thinks that his father is allergic to penicillin, a second choice antibiotic was used as recommended by the local antibiotic guidelines. Even though John’s blood pressure was much lower than his usual, the doctors did not have this information at hand; a blood pressure of 110/60 is the normal range for the general population. John received care on the standard medical ward.
Anti-diabetic treatment also commenced. The doctors did not know what medication John was usually on and his general practitioner (primary care practitioner) would not be open until 4 days later given the long Christmas weekend.
Over the next 24 hours, John deteriorated. His blood pressure continued to drop and he stopped passing urine. Appropriately, he was transferred to the high dependency unit. His blood results confirmed that he has an infection in his blood. Based on preliminary investigations, the antibiotics he is on should be effective. It was just too early to expect a response.
John continues to deteriorate. His is now in complete kidney failure. Fluid starts to accumulate in his lungs, depriving oxygen from vital organs such as his brain. He is transferred to intensive care unit (ICU) where his is put on a dialysis machine to take over the role of his kidneys and a breathing machine to oxygenate his blood. Blood results then revealed the highly resistant strain bacterial. His antibiotics was promptly changed. It is now 48 hours after his admission to hospital.
John suffers a cardiac arrest and after 10 mins of CPR and 3 cracked ribs later, the doctors successfully resuscitate him. Unfortunately his organs has taken another severe insult. The decreased blood supply to his brain has caused a stroke.
Over time, John starts to make a slow but steady improvement as the antibiotics start working. He spends a total of 10 days in intensive care. He lost 30% of his body weight and a lot of his muscle mass. He is in constant pain from his rib fractures. After discharge from ICU he was to spend another 30 days in hospital.
He finally felt to have recovered enough to be discharged back home to Newcastle in a wheelchair, carers 3 times a day, 20% lighter and a broken man psychologically. Dr Johnston, his GP, had no idea that John has been in hospital for the past 40 days until he was phoned up as part of the discharge process. When Dr Johnston visited John at home, he could hardly recognise him.
So, what are the differences and similarities between the two scenarios?
Both scenarios took place in publicly funded heath systems in first world countries.
Both employ salaried and highly trained healthcare professionals doing the best they can for their patients.
Both encourage the use of locally agreed protocols and patient safety initiatives.
Vista – the VA’s fully integrated Electronic Patient Record.
A patient with his health and dignity intact.
Find out more: http://nhsvista.net/
About the author
Dr Wai Keong Wong is a Haematologist in Training in London. Wai Keong is fellow on the NHS Medical Director Leadership and Management Scheme. He hopes to acquire skills that would allow him to drive up quality by aligning systems and processes which will remove barriers to safe, effective and personal healthcare – something he believes all patients deserve. He believes passionately that a fully integrated clinicians driven electronic patient record based on open standards is central to achieving this vision. He recently had the opportunity to visit a VA hospital whilst he was in the United States.