Cracked: Putting Broken Lives Together Again - Drew Pinsky, Todd Gold (2004)
NOT EVERYONE GETS a break.
I’m examining Amber. She should be feeling stronger than she seems to be, and so I’m looking for clues.
“Breathe in,” I say. “Deep.”
That sounds clear. I move the stethoscope slightly across Amber’s back.
“Now breathe normally.”
Believe it or not, performing this basic procedure on a survivor of sexual abuse makes me feel awkward. I’m extremely conscious of my movements. Amber is oblivious. She has no idea of my concerns. Still, the slightest misattunement on my part can activate the rage of victimization. Sometimes I behave much more cautiously than required, because I’m especially sympathetic to her pain.
The exam starts out as routinely as the others I’ve given her over the past three weeks. Nothing out of the ordinary. Then, however, I hear a sound between S1 and S2. It’s a faint whoosh, the sound of a mid-systolic heart murmur. Hmmm. I ask her to take a few more breaths while I double-and triple-check myself. The sound is unmistakable.
After telling Amber to pull the back of her shirt down, I step around so I’m facing her. She has yet to come out of her shell, but there’s something about her now, something I can sense, that lets me know life is returning to her. It is in her eyes. Dante wrote about this, the phenomenon of seeing God reflected in the eyes of Beatrice. To me it’s a matter of light and dark, life and death.
Does that sound corny? So what? What’s supposed to nourish my soul and sense of purpose more than reaching across the divide and connecting with another human being who hasn’t been able to do it alone? What’s more satisfying than this flash, this vision, this warm glimpse at the unknowable?
I stare at Amber. For all I saw and felt in that fiery moment, I’m no better than I was before. Neither is she. In fact Amber might be in more precarious territory.
“Has anyone ever said anything to you about a heart murmur?” I ask.
“What?” she asks.
“A heart murmur. Has anyone ever mentioned that? Or mitral valve prolapse?”
“No.” She shakes her head slowly.
I see the concern in her face. That’s a problem. She’s unable to deal with such anxiety. Her brain is sending messages that overwhelm her. Even though she’s shrinking right before my eyes, I have to keep going. My job is to steady and stabilize her, as I continue to ask unsettling questions.
“Well, I do get these things in my chest,” she adds.
My first thought is, No, that’s not what I mean. I’m talking about a sound that I hear. But then I remind myself that she’s a cocaine addict. She’s done a lot of coke. It wouldn’t be the first time I’ve seen a young person with heart damage from cocaine. Coke restricts the blood supply to the heart, dissolving the cordlike fibers that tack down the valves. If the cords break, the valves flap.
“Have you ever had chest pain?” I ask.
“Sometimes. When I’d do a lot of coke, sometimes I would feel like my heart was going to explode inside my chest.”
Every addict who’s done stimulants has felt that at one time or another. That isn’t helping me.
“I’m hearing a turbulent blood flow in your heart,” I say. “It doesn’t necessarily mean anything. You were a little anemic when you came here. Sometimes anemia can cause a murmur. Many other common conditions can cause murmurs. I don’t want you to worry. But I want to look into it further.”
She seems to accept this. I order an electrocardiogram for Amber, and I also want to get an echocardiogram. One of these tests looks at how the heart muscle conducts electricity; the other uses sound waves to take an actual picture of the heart. Together they should answer my questions.
I have still another one, though. I don’t like the look in Amber’s eyes—the glaze, the lifelessness, the cold, opaque appearance that’s the opposite of the sparkle of connection. I try making a little light conversation as a way of gently taking her emotional temperature, and this seems slowly to draw her out. Finally she admits, “I keep having these damn panic attacks. Everyone keeps telling me that I’m doing good, but it’s too hard. I feel like shit. Nothing’s working.”
“You need to stay open to the staff and your peers,” I say. “That’s the only way you’ll be able to start managing your feelings.”
I leave Alexi in Amber’s room to watch for any signs of a postexam panic attack. There’s no telling how much more anxious Amber might become once she’s left alone. I’m worried, too, and I want those tests scheduled as soon as possible. I ask Julie, the utilization and review nurse in charge of negotiating coverage with insurance companies, to get approval for Amber’s electro-and echocardiograms. Already over-burdened, Julie rolls her eyes as if to say, “Sure, I’ll get right on it—as soon as I take care of the other ten million problems on my desk.”
A few hours later, I find Julie in hell. Actually, she’s in her office, but she’s got two phone lines going and she’s writing furiously on a legal pad. Seeing me in the doorway, she shakes her head no. The poor woman. She has a frustrating, thankless, and absolutely vital job dealing with insurance companies, unraveling red tape, and persuading nurses and clerks two thousand miles away that patients are really sick and need more treatment. It happens with nearly every patient.
She looks relieved when I ask her about Amber. The brightness in her eyes tell me she has an answer, and I’m right. But it’s not good news.
“They’re going to cover her, but only for two more days,” she says.
From her look, I know I’m supposed to infer that she fought for the best coverage she could, and that this is their final response. I find that infuriating. Julie apologizes. It’s not her fault, I know. She’s as fiercely committed to the patients as anyone. She gets to know all of them and feels terrible when she can’t get the responses I want. But she doesn’t make the decisions. Nor do I. What we think the patients need has little to do with the reality of what the patients can get.
That falls to the system.
The reviewers she speaks to are generally hostile, hurried, and unsympathetic to the human side of medicine. They want patients in and out as inexpensively as possible.
I know how the conversation went between Julie and the carrier.
Is she eating?
Is she walking?
Blood pressure okay?
What medication is she on? Does she have a place to go? Fine, she’s got two more days.
They ignore the fact that she’s fragmented, suffering flashbacks and panic attacks, so fragile she knows she’ll never make it after she returns to her abusive husband.
But the doctor wants to keep her, argues Julie.
Well, he’ll have to talk about that with our doctor.
Nine times out of ten, the results are unchanged. Their decisions are couched in jargon and euphemisms: “Unless you can provide us with more information to substantiate continued inpatient hospitalization,” we hear time and again, “we’ll be unable to certify any further inpatient days based on our clinical criteria for continued inpatient treatment.”
Most insurance policies allow for thirty days of inpatient coverage for chemical dependency, but customers don’t know that their carriers sell the policies to review agencies, businesses that make their money by limiting access to coverage. In other words, the less money spent on treating a patient, the more money made by the review agency. What’s the motivation for giving someone the best care? Or the care they need? Not as much as one would like to believe.
One day I got a call from a carrier telling me to get rid of a patient who’d been in the unit just three days. A tall, nice-looking black man, he was a severe cocaine addict. After years of addiction, he’d finally checked himself into rehab. It was the first time he’d sought help. Though his withdrawal was very difficult and he was overwhelmed by anxiety and cravings, he really wanted to be there. He’d lost his home, his wife, his job—everything but the thirty days of coverage he had left on his plan.
Then he lost that, too. According to his carrier, there was nothing wrong with him. It didn’t matter how vehemently Julie argued. Having already declared him medically stable, they’d made a decision. They wanted him moved to a residential facility they had on a list. They went so far as to arrange the transfer for the next morning.
That pushed me over the edge. It was the equivalent of me calling another hospital and changing the treatment for a surgical patient without speaking to the surgeon. They also missed another, more subtle issue. This patient was emotionally fragile, with no support system outside the hospital to turn to. He’d made a connection with us. Dismissal at that point would be just another abandonment for him. He might start using again as a result. Or he might decide that no one was worth trusting, which would make it that much more difficult to enroll him in treatment.
It was the most unethical behavior I had witnessed. I called the California State Insurance Commissioner, intending to launch a complaint. Instead I was literally overwhelmed by all the different ways they had for customers to lodge complaints against their HMOs, doctors, nurses, hospitals, and so on. In the process, though, I discovered that they had no protocol for a practitioner who wanted to file a complaint against an insurance company. After hours on the phone, a sympathetic clerk suggested I call my congressman.
In the end, I wrangled another day out of the carrier, a miracle that allowed me to prepare the patient for his transfer, but I never heard from him again.
Unless Julie is able to do something, I fear the same will happen with Amber. She is likely to start using again soon after discharge. I ask Julie to go back and request additional tests, the echo especially. I need that test. Maybe a psychiatric consultation, too. See if they’ll agree to that, and prolonged care. I have to keep Amber from leaving.
Julie lets me go through all my explanations without saying a word. She gets it. I know. She does this all day long.
“I’ll try,” she says. “But don’t get your hopes up.”
“You don’t have to beg me. I’m not the problem.”
A while later Julie stands before me, perfectly still, with defeat etched across her face. The tests aren’t going to happen. Neither is the consult.
I kick my toe into the floor out of frustration. “This woman needs those tests as soon as possible,” I say.
“I talked to the reviewer, and they want her out,” she says. “According to them, her detox is completed. Her vitals are stable. She needs to step down to outpatient, and then she can see her primary care provider. He can order the echo and the electrocardiogram.”
“Listen, she’s a cocaine addict,” I say. “She’s got a new murmur. And I have a funny feeling about it.”
Julie shakes her head and says, “You’re going to have to give me more than a funny feeling before I can call them back.”
It’s maddening. Here I know exactly what to do as a doctor, and yet I’m being told I can’t do it. I’m left fluttering in the wind, feeling as out of control and powerless as my patients. But as much I’m disturbed, I handle it. That’s the difference. I stay focused on work and devote time to my family. In fact, on days like this, it’s a relief to drive away and coach my sons’ sports teams.
I need that replenishment. Oddly, I don’t share much about work with my wife. I’m able to compartmentalize the different parts of my day. I also know that Susan’s response to the tales of frustration I’d bring to the dinner table nightly would be to ask, “Why do you care so much? Does anyone else put themselves out that way?”
I can’t help but care. I wouldn’t know how to hold myself back. My patients are struggling for their very survival, confronting core issues like abuse, neglect, pain, self-esteem, and the absence of love. If I can be their bridge over all that, I’m doing my job. Even if I fail, at least I’m trying. This is why I get so crazed when insurance companies make decisions based on actuarial tables rather than sound, practical medicine.
Early the next day I ask Julie to arrange a doctor-to-doctor review, which is a call between the carrier’s physician and me. By their nature, such conversations are rarely pleasant. Nor are they often fruitful. Usually they mean speaking to a doctor in an office in Connecticut for whom revising a decision would mean taking heat from the insurance company, who employs him to get patients out while minimizing any exposure to liability. Translation: They want the patient out ASAP, without making them look bad if something should go wrong.
We never tell a patient their insurance company wants them out. If the carrier heard a hint of that, they’d refer their business elsewhere. We end up using the same stupid euphemisms as the carrier: “Your resources have been exhausted, and we have to find another way to optimize those resources your insurance company has available.”
It’s a tricky dance that almost always makes me uncomfortable. The few times awful things have happened as a result, I have had insurance companies defend their decisions by saying, “Well, Doctor, it’s your signature on the chart discharging the patient. We don’t practice medicine.”
I don’t want to go through that with Amber.
While worrying about her, I’m confronted by someone who doesn’t appear to have any worries: Mitch, the alcoholic. He is back. Not only has he risen from the dead, he’s taken over the groups, dominating them with his self-absorbed commentary and savvy about the program from having been through rehab enough times.
“He holds court like some sort of senior statesman,” says Alexi.
“It’s all a defense to deflect anyone from focusing on his issues,” I say.
“You should’ve heard this last meeting,” she says. “This young woman, Zona—she’s in the outpatient program and still in Sober Living—”
“Yeah, I remember her. Married to a cop. Sexual abuse in her background.”
“Right. In group, she was complaining that her husband had become abusive on the phone. He complained about the stress of managing their house and two children without her.”
“Obviously he senses that she’s growing away from him as she grows in the program, and he was lashing out,” I interject.
“Mitch immediately stood up and launched into a diatribe about the importance of making sobriety a priority in one’s life. He told her, ‘Your husband needs to support your sobriety. That’s it right now.’ And then he said, ‘All of us love you. The Big Book says the codependent is sicker than us. My girlfriend tried to get me to change my sponsor because she didn’t like him.’ And he just went on and on. It was always about him, full of all those twisted references to the Big Book. He sounds like one of those wild TV evangelists.”
At that point, Julie bolts into the nursing station and interrupts our conversation. She has the doctor from Amber’s insurance company on the phone. She rolls her eyes. That tells me two things: The doctor isn’t pleasant, so don’t count on anything, and also don’t keep him waiting. I don’t waste a second.
“This is Dr. Green,” he says.
We exchange a couple quick pleasantries, and then I get into the case.
“This is a poly-drug-addicted female in her late twenties with a new cardiac murmur,” I say. “She was anemic on admitting labs, but I don’t think that explains what I’m hearing. The quality of the murmur suggests to me the possibility of a blown mitral leaflet.”
“We’re not the medical carrier,” he interrupts. “If this is a medical problem, it will have to be referred to her primary care provider.”
“I understand,” I say. “But this woman needs further inpatient treatment for her chemical dependency. She’s extremely labile. She’s having intense cravings. She’s suffering flashbacks. She’s a trauma survivor with profound PTSD. She needs a very high degree of structure, supervision, and support. At this moment, her relapse potential has to approach one hundred percent. In spite of the severity of her condition, she’s shown remarkable progress in treatment. I’m convinced that sending her to a medical facility at this point in her treatment would be destabilizing.”
He asks for more facts. I describe her vitals, and list the medication we’ve given her. After a brief silence, he says she sounds stable, and asks me for the basis of continued inpatient treatment. Hasn’t he heard what I’ve said? It doesn’t sound like he has. It’s very discouraging. Actually, it’s worse.
“Dr. Pinsky, we base the need for continued inpatient hospitalization on the published guidelines of the American Society of Addiction Medicine. Your patient does not meet any of our criteria for continued inpatient treatment.”
Great. I’m talking about a living, breathing, suffering, pain-riddled human being down the hall who wants to get better but needs help, and he’s looking at published guidelines that are open to interpretation. A body versus a black-and-white chart: Where would you go looking for the truth? I remember the first conversation I ever had with such a reviewer. He was a physician for a new local managed care company. He called after one of his “lives,” as he referred to her, had checked into our program for the third time in two months. He wanted her out in three days. When I argued that the patient would relapse and lose her job, he said that was precisely his point. She’d lose her job—and her insurance. Then she was no longer their concern.
The rest of our conversation was chilling.
“She might also lose her life,” I said.
“I’m an insurance administrator, not a social agency,” he replied. “I can’t tell you whether that’s good or bad.”
Now, with Dr. Green, I’m getting the same feeling again. My expertise means nothing. Forget about proper medicine. What about simply helping a human being?
“I’m sorry, Doctor,” he says with a tone of condescension. “If you could provide more information, it might be different. But based on what you’ve told me so far, I can’t certify any more inpatient days. She’ll need to step down to intensive outpatient.”
“Does she have coverage for Sober Living?” I ask.
“I can’t tell you that,” he says. “I don’t have any information about her insurance policy. We’re just the review agency.”
That’s it. After hanging up, I take a walk outside to cool off. When I return to the unit, I still need to vent. I find Alexi, who’s discussing something with Finley. Both shake their heads as I recount the conversation. All three of us know a bad decision’s been made, and yet we can’t do a thing about it. Such is reality. Life is often a series of problems. You get bad news, and then you deal with it.
“She’s going to be gone in a day and a half,” I say finally. “I’d love to see what’s going on before she leaves. Can we at least call Medical Services and see if they can get in touch with her PCP and get approval for the echo and the EKG?”
“They did the EKG about forty-five minutes ago,” says Alexi.
“Who ordered it?” I ask.
“I don’t know,” she says with a wink.
A moment later, I get the results from her chart. They indicate a fast pulse, a slight widening of the QRS complex, and some very wide premature beats that still look atrial, nonspecific changes of the ST/T segments that could represent a restriction of blood to the heart muscle, but don’t necessarily. Nothing that specifically suggests trouble. So what about the damn murmur?
I start to second-guess myself. Did I really hear that whoosh?
Wait a minute. I look at the EKG results again, and notice something else: Her QT interval might be a little prolonged. It’s subtle. Although the computer readout says it corrects to normal, it definitely appears longish. I won’t rule out anything. Having recently read a report that raised questions about a possible relationship between the new antipsychotics like Seroquel and QT prolongation with sudden cardiac death, this could be an issue.
I close the folder and turn to Alexi. Her eyes ask, “Well?”
“I don’t know,” I say. “All this does is continue to worry me.”