On Breaking One's Neck
January 19, 2014 11:29 PM   Subscribe

On Breaking One's Neck. Dr. Arnold Relman, former Editor in Chief of the New England Journal of Medicine, gives a first-hand account of a catastrophic accident, intensive care, and rehabilitation--as a patient. I am a senior physician with over six decades of experience who has observed his share of critical illness--but only from the doctor's perspective. That changed suddenly and disastrously on the morning of June 27, 2013, ten days after my ninetieth birthday, when I fell down the stairs in my home, broke my neck, and very nearly died. Since then, I have made an astonishing recovery, in the course of which I learned how it feels to be a helpless patient close to death. I also learned some things about the US medical care system that I had never fully appreciated, even though this is a subject that I have studied and written about for many years.
posted by russilwvong (22 comments total) 32 users marked this as a favorite

 
I had never before understood how much good nursing care contributes to patients’ safety and comfort, especially when they are very sick or disabled. This is a lesson all physicians and hospital administrators should learn. When nursing is not optimal, patient care is never good.
He's realizing this now? Wow.
posted by benito.strauss at 11:36 PM on January 19 [41 favorites]


Sort of dickish to openly bad-mouth the hospital where he spent the latter part of his treatment -- don't shit where you eat from a tube inserted into your stomach through your nose or abdomen, as they say.
posted by serif at 12:36 AM on January 20 [2 favorites]


Great article, thanks for posting. I agree with all of it.

I had never before understood how much good nursing care contributes to patients’ safety and comfort, especially when they are very sick or disabled. This is a lesson all physicians and hospital administrators should learn. When nursing is not optimal, patient care is never good.

As a nurse: lulz.

And when I would occasionally doze off, I was soon awakened by someone coming to check my blood pressure, or by noise in the hall outside my room.

This sort of thing drives me nuts. One thing that consistently drives me nuts about nursing care in the USA is that nurses are far less empowered to use their clinical discretion. If a patient is awake at 2 am asking to go to the bathroom, logic dictates that you would do things like take your vitals at the same time to avoid awakening them again, yes? But nurses are so handcuffed by needing to cover their own ass, that if you are expected to take vitals Q4, and that's not due til 4 am, then guess what buddy you're likely to be woken up again in a couple hours. Ludicrous. Especially since a good nights sleep is so important to recovery.
posted by supercrayon at 1:06 AM on January 20 [21 favorites]


In a similar vein, George Orwell describes the sensation of being shot in the neck by a sniper in the Spanish Civil War.
posted by Quilford at 1:41 AM on January 20 [2 favorites]


I don't think this is a dick-ish article at all, he had an observation about the nature of his care. This guy is in his nineties, vital, interested, and observant, and with the perspective of decades of experience. To me, the idea that our world loses this kind of human capital continuously, to nothing more than age, is a shame.
posted by C.A.S. at 2:04 AM on January 20 [15 favorites]


OK, that is a terrifying injury. I know at least two people who have died breaking their necks, one in a pretty mundane household accident.

I am kind of surprised that he got up and took the cab to the hospital - everything about his description of the accident screams "DON'T MOVE ME."
posted by louche mustachio at 2:16 AM on January 20 [1 favorite]


$300k+ in care charges is a hell of a lot to spend on a 90+ year old.
I get that he is smart and lucid and enjoying quality of life, but there are plenty of other instances where the money is spent to keep somebody alive in recurring pain, with limited lucidity and poor quality of life.
But we don't have a way of making decisions about the worth of medical care.
posted by bystander at 2:20 AM on January 20


bystander: "$300k+ in care charges is a hell of a lot to spend on a 90+ year old.
I get that he is smart and lucid and enjoying quality of life, but there are plenty of other instances where the money is spent to keep somebody alive in recurring pain, with limited lucidity and poor quality of life.
But we don't have a way of making decisions about the worth of medical care.
"

I think that the article answers this question best:

"Medicare’s rising costs are a serious drain on the federal budget, and very elderly beneficiaries like me are responsible for a major part of that expense. Given the limited life expectancy of someone my age, is it justified to spend hundreds of thousands of dollars to extend a nonagenarian’s life a little longer? That is a question needing more discussion than I can undertake here. I would hardly be an unbiased voice, since it was my life that was at stake, and I was very glad it was saved. Of course, in our health system, charges may have little relation to true costs, making such a discussion still more difficult to pursue."

Can you really pursue the question of costs without addressing the issue that the costs of the American health care system are artificially high? Also, the system is inhumane enough already; I can't imagine introducing the question of whether it's worth caring for people in a system that denies routine care to those who need it. It's not like if the money is taken from cases like these it'll then be spent increasing welfare overall.

And on moving him, I suppose with the shock of the injury he wouldn't have been able to make the call. The article doesn't mention whether the son that helped him to the cab is one of the doctors or one of the lawyers in the family of three of each (wow). On the other hand, as my mother the nurse would testify to, having once been overridden at the scene of an accident she came upon by a doctor who insisted on moving a patient with suspected spinal injury, doctors can sometimes be pretty bad at emergency response.
posted by lookoutbelow at 3:23 AM on January 20 [5 favorites]


Good for Dr Reiman. I think all doctors should be treated like typical patients as part of their training.
posted by claptrap at 5:01 AM on January 20 [7 favorites]


I don't know the statistics but one real lesson for older folks is *do not fall* it does not take a fall down stairs, just a tip over.
posted by sammyo at 5:47 AM on January 20


I can't imagine introducing the question of whether it's worth caring for people in a system that denies routine care to those who need it.

If you even try to imagine that some people should have higher priority access you are an advocate of instituting death panels. One can't even imagine cases where providing care is an injustice to others who need it more. I've seen it cited often that half of a person's medical expenses occur in the last six months of life. As morbid as it sounds, much of this could be put to better use, but...

It's not like if the money is taken from cases like these it'll then be spent increasing welfare overall.

Sadly, I agree and wish I knew how to solve that one.
posted by dgran at 6:31 AM on January 20


*sigh*

Another "Sick Like Me", wide-eyed account by a doctor who realizes that patients are people too, and that the medical care system (and doctors) can generate an additional level of suffering during a time of crisis.

The first half-dozen times I read these, framed in this way ("I have come back from the wilderness to report back what it's really like!"), I thought it was great. Now I'm wishing that we--and these doctors--would have just been willing to observe and listen to and learn from patients (and families) themselves. There are a lot more of us than them, and we've been telling them these stories for a very long time now.

Sick Like Me.
posted by blue suede stockings at 6:34 AM on January 20 [12 favorites]


My nights in Spaulding were terrible, just as they were in the MGH ICU. One of the great risks to very ill, immobilized patients is infection—mainly pneumonia, which is most likely in heavily sedated patients. Because of that risk, I was unwilling to take sedatives or sleep medication, so I lay awake most of the time watching the clock, sometimes waiting much too long for responses to my calls for help in getting up to urinate. And when I would occasionally doze off, I was soon awakened by someone coming to check my blood pressure, or by noise in the hall outside my room.

That was for me one of the most shocking things about being in the hospital for the first time. I'm well aware of how important sleep is for healing and the immune system. And how noise and especially lights prevent good sleep. Despite being an infamously heavy sleeper, I really struggled to get much sleep at all between the constant lights, the door being kept open (you weren't allowed to close it), and my "roommate" crying. In the two days I was there I probably got two hours sleep.
posted by melissam at 7:03 AM on January 20 [1 favorite]


Sort of dickish to openly bad-mouth the hospital where he spent the latter part of his treatment -- don't shit where you eat from a tube inserted into your stomach through your nose or abdomen, as they say.

I know other people who have spent time at that hospital. Based on their experiences, anything more positive than what he wrote would be neither truthful nor just.
posted by Diablevert at 7:08 AM on January 20 [4 favorites]


Quilford: "In a similar vein, George Orwell describes the sensation of being shot in the neck by a sniper in the Spanish Civil War."

In a similar vein, Werner Herzog describes what it's like to be shot in the groin. "It's nothing..."
posted by symbioid at 7:28 AM on January 20


Sort of dickish to openly bad-mouth the hospital where he spent the latter part of his treatment

I think it'd be worse to sugar-coat things just because he happened to spend time there. I mean, if a 90-year-old physician, who presumably has very limited plans on ever going back to that hospital, can't tell things like they are ... who is going to?

Anyway, I found the article interesting and the author seems like a great guy. While certainly there seem to be enough similar pieces written by people in the medical establishment who suddenly become patients, I don't think that means that we need to stop writing them any time soon. Maybe the collective weight of all those experiences will move things forward.

His article Obamacare: How It Should Be Fixed, which he apparently proofread while in the ICU with his neck injury, is interesting reading if you have a NYRB login. (And if you don't, it seems to be available here.) Some of the introductory paragraphs have been overcome by events since publication, but the general points still seem very valid. (tl;dr: He's in favor of single-payer.)

It's particularly cool because there is something of a stereotype of older doctors not being on board with evidence-based approaches and cost control to the same extent that younger doctors are, but here's some guy who's 90 years old with 60+ years in the field saying that it sucks and it's broken and we need to stop diddling around at the edges with payment mechanisms and control costs and look at outcomes. Granted, I could imagine some ad hominem objections on the basis that he's retired and has already made his living in the field, probably went to med school when it didn't involve crippling debt, etc., etc.

I am kind of surprised that he got up and took the cab to the hospital - everything about his description of the accident screams "DON'T MOVE ME."

It is classicly very much a "don't move me" injury. But — and this is one of those things that is somewhat controversial — there's a very defensive-medicine aspect to all the cervical-collar + backboard stuff. The traditional way of viewing spinal immobilization is "can't hurt, might help" in the sense that it prevents further injury (catastrophic further injury, in some cases) and the downsides are minor, so do it. However, there's some evidence that there are downsides, particularly in older patients — being backboarded doesn't make breathing any easier, which raises the chances that you'll end up getting intubated (bad), and if there's a significant transport time it's pretty uncomfortable, raising the chances that you'll end up getting drugs for pain control (might seem nice at the time, but bad), and I've heard anecdotally that it can lead to increased risk of bedsores if you're going to spend significant time in the hospital once you get there (also bad) — so the actual calculus isn't as clear as many people believe it is, or as conventional training may assume. (I strongly suspect that in the next 10 years or so, we'll be bringing in far fewer people to the hospital on backboards. In some very progressive jurisdictions this has already started to happen.) So anyway, while I wouldn't ever want to say that not calling an ambulance for a broken neck was the right decision, it's entirely possible that Relman ran the numbers in his head and decided, for whatever reason, that the risk of self-transporting to the hospital was reasonable.

Or maybe he's just stubborn and wanted to be hardcore by walking into the ED with a broken neck under his own power. That happens too.
posted by Kadin2048 at 8:54 AM on January 20 [2 favorites]


To be fair, if you feel you have to do something life threatening stupid just to be hardcore sometime in your life, 90 is a lot better age to do it than 20.
posted by Zalzidrax at 9:43 AM on January 20 [4 favorites]


Well, I assume he also didn't know for sure his neck was broken till he got to the hospital, whereas he did know for sure he'd cracked his head off the floor and that there was a cab waiting at the door that instant. Calling an ambulance, even with rapid response, probably takes an extra 15 or 20 minutes to get them there, get him strapped to the board and loaded into the bus. If he starts to choke from the swelling before he gets to the hospital...
posted by Diablevert at 10:27 AM on January 20 [1 favorite]


If you have been a physician for 60 years and it's just now--as a patient yourself--that you are realizing how important good nursing care is to a person's recovery--your nurses over the years have probably thought you were a gigantic dick.
posted by Kokopuff at 12:29 PM on January 20 [11 favorites]


Sort of dickish to openly bad-mouth the hospital where he spent the latter part of his treatment -- don't shit where you eat from a tube inserted into your stomach through your nose or abdomen, as they say.

Kadin2048: I know other people who have spent time at that hospital. Based on their experiences, anything more positive than what he wrote would be neither truthful nor just.

I don't doubt that he had a shitty time in Spaulding hospital, and I'm sure he identified real problems at Spaulding, but to openly criticize that hospital when he surely has private, professional channels for his complaints struck me as inappropriate.
posted by serif at 6:56 PM on January 20


For the record, the quote attributed to me by Serif was actually Diablevert's. I have no experience with any of the hospitals in question.
posted by Kadin2048 at 8:03 PM on January 20


Oops! Sorry about the misattribution.
posted by serif at 8:06 PM on January 20


« Older Paramount has ceased releasing films on 35mm film ...  |  Contempt of Cop... Newer »


This thread has been archived and is closed to new comments