Reimbursement over the Atlantic

Two unrelated issues came to mind as I reflected on a recent harrowing experience. One was the heated debate over the imbalance in financial reward between medical-surgical procedures and so-called cognitive activity or (forgive me) non-procedures. The second was the solid foundation of traditional Western medical education on which I was fortunate enough to capitalize.

It seems that in medicine we have developed a curriculum that is effective, even for those of us who only practice part-time and cannot be on the cutting edge of technology with its latest generation of cephalosporins. It is a credit to traditional medical education that when occasionally challenged by friends, family, and the few patients for whom I take responsibility, I can draw on the strong foundation of fundamentals available in every U.S. medical school. This method does not require enormous amounts of detail close at hand, but simply a logical sequence of steps to organize symptoms and signs, focus on a few potential organ systems, and then make a diagnosis. This leaves the obscure and the incurable for textbooks and keener minds.

Now, having said this, I must quickly admit that I do not have the same confidence when it comes to medical emergencies. I have willingly stepped aside for the eager emergency medical technicians in public places where my interim help as a physician was sought. Frankly, I was glad to yield as I barked a few officious platitudes so that all present might have no doubt as to who was in charge. A once-proud knight in white cotton pants who could cannulate any orifice in an emergency, I now secretly hope none of my middle-aged golf partners suffer a medical catastrophe over a 2-foot putt.

This introduction will explain why I was less than eager to respond when an announcement requesting a physician came over the intercom 1 hour into my transatlantic flight to Berlin and Warsaw. I should declare here and now that there were other reasons for my reluctance, not the least of which was the Scotch and champagne before takeoff. Despite my concerns, I could never deny my profession. Yet, I am more than happy to defer to some young buck eager to make an impression. My preferred role is always sage advisor and arch second-guesser. I have a healthy respect for the obstacle that teamwork presents to a couple of unacquainted physicians.

You guessed it. Nobody responded. There was another sandbagger on the flight. We met as we passed through the galley. After the usual preliminary questions about specialty he quickly begged off. He was retired, he said, and would prefer not to get involved. His guilt was palpable. This provoked a fleeting thought on my part about malpractice coverage in international skies. But I was committed now and not to be deterred. After all, this was what it was all about. My mother had announced to me early on, just following her decision that I become a physician, “Make sure you choose a specialty so that you can stand up at the country club when they call for a doctor.” I never have been sure to which specialty she was referring, but I blame her that I am not a dermatologist today.

The supervising stewardess informed me that one of her flight attendants was “unresponsive.” This sounded like a medical emergency to me. I was surprised at how calmly she proclaimed this. I attributed it to the kind of grace under pressure that one expects from the folks in the wild blue yonder. Trying to emulate her demeanor, I followed her to a perfectly normal-appearing uniformed attendant whom I recognized as the first person to serve me when I boarded the flight. She now appeared about the same, except that she seemed unwilling to speak. She had, I was told, gradually reached this condition over the period of an hour. She had become forgetful and slow and would do nothing but lean against the center divider with her arms folded across her chest. She appeared alert, had no gross evidence of a neurologic deficit, and was certainly in no distress. Still, there she was. I had to do something.

The Captain suggested that she might have suffered a stroke. The thought had not occurred to me. I quickly assured everyone that I had already eliminated that diagnosis. She was too young. too attractive. I prayed they would see logic where I could not. Nor did I know anything about this woman. It seems flight crews are not necessarily permanent teams but are often thrown together at the last moment; her colleagues could not help with any history. So here I stood, all eyes on me, and all ears hanging on every brilliant utterance (I was reminded of the old E.F. Hutton ad). I felt enormous pressure to say something profound. I asked her name. “Helga,” I was told. After a few insipid questions to which I received nothing but Helga's icy stare, I decided I needed some time away from my audience to pull my thoughts together. I pronounced to the Captain that this was as close to veterinary medicine as I had been since forced to care for screaming children during a stint in the military. Helga had a look about her that reminded me of panic. Hers or my own, I cannot say. I informed the Captain that this appeared to be a stable situation and a more thorough examination risked the exposure of this potential panic I feared. “Then,” I warned the Captain, “we'll have to tie her to the seat for 7 hours.” The Captain quickly agreed; Helga was led quietly to her seat and strapped in. I mumbled something about the possibility of drugs or a psychological disorder and uneasily returned to my cold dinner.

Although I was assured by my retired colleague that my judgment was sound, I struggled with the problem and could think of nothing else for the next hour or so. I spotted one of the most helpful of the female attendants coming my way. It occurred to me to ask her if we could go through Helga's luggage. She was ahead of me. She came, she said, to show me Helga's purse. Imagine my little heart when we discovered the bottles and bottles of injectable insulin. I paused to allow my professional life to pass quickly before my eyes and commanded the attendant to direct me to my patient.

There was my Helga, the same bright stare, the cute smirk, but now in all its glory, the early stages of decerebrate rigidity. Just so that you have a clear vision of the situation, I should point out that I had a choice as I ministered to my patient. I could have sat next to her like a companion or I could be her physician and place myself in front of her. I bravely chose the latter. In order to accomplish that, I found myself kneeling on the floor in front of her. It was from this position that I made a pitiful effort to feed her orange juice, managing only to soak her blouse with the life-saving liquid. It was during the next few minutes as I was trying to work out the mechanics for an emergency orange juice enema that my stewardess/nurse/angel asked whether I was interested in reviewing the standard emergency medical kit. “I was just about to ask for such a kit,” I said archly, and asked that she fetch it immediately. I felt my stewardess/nurse's confidence in me grow as I proceeded two steps behind her.

The emergency kit had an inventory printed on the case. The available light in our cubby did not allow my presbyopic eyes to read the print, but again my able assistant served me well. I could comment on the comprehensiveness of the kit, but our time would be better spent describing my mixture of feelings when the angel of the air uttered the precious words “50% dextrose and water.” On the one hand, I was pleased that the cure for my patient was available. On the other hand, I must admit that my pleasure quickly turned to semi-panic as my thoughts raced to the certain confrontation I would soon have to face with that old devil, the venipuncture.

I must say I was once considered quite adept with the manual procedures one learns as a trainee, and later in my career was the procedurist of choice for those few procedures necessary to a nephrologist. Venipuncture is one thing, venipuncture on one's hands and knees, in a moving aircraft, done by a slightly rusty physician is quite another. My final delight came when I reviewed the package and found a 50-cc syringe with the needle connection dead in the center of the barrel. Now, in addition to my other concerns, I would have to forego the luxury of steadying the barrel on the limb, and would have to attack at about 35 degrees and at a moving target. I wanted to be someplace else.

The sweet, sterile liquid was drawn up, the tourniquet in place on the rigid left arm, a small vein palpable and visible just lateral to the antecubital fossa. At exactly this critical moment the pilot made the familiar announcement: “Ladies and gentlemen, we will experience a bit of turbulence for a few minutes.” All of this in the usual reassuring drawl with which frequent fliers are so familiar. I hope the picture is clear.

Who is it that said, “I'd rather be lucky than good”? The needle found its way in very nicely. I aspirated a puff of the most gorgeous red blood I have ever seen and experienced euphoria. Now I carefully injected the glucose solution. No swelling appeared around the puncture site! At about the 35-cc mark I looked at Helga. How was she feeling, I asked. “I'm fine,” she responded. The response of the hypoglycemic patient to intravenous glucose remains one of the most dramatic events in medicine. She was, in a matter of moments, virtually recovered.

It is a peripheral issue certainly, but of interest, that she denied taking any insulin, denied being a diabetic, and, in fact, was quite indignant when asked why she had insulin in her handbag. She insisted on returning to her station and even rejected German medical attention when they boarded the plane in Berlin. At my suggestion, the Captain arranged for her to be removed from the flight and to be observed by a physician in Berlin until she was out of danger.

I must say I enjoyed hero status for the balance of the flight and the acclaim has still not totally subsided, even today. During the check-in for my return flight I was flagged, placed in the VIP lounge, and humbly asked if I would accept first-class accommodations. In Berlin, the regional vice-president boarded the plane and presented me with an expensive bottle of Moet Chandon, at the same time informing me that I would be hearing soon from corporate headquarters. Those who know me well will have no difficulty envisioning how graciously I accepted the praise and recognition. You and I know I don't deserve it, but I have had some tribulation in the past few years, and I didn't deserve that either. And I was beginning to learn how surgeons must feel and why their services are reimbursed as they are.

The irony is not subtle. Had this patient been brought to any emergency ward in the United States, she would have been given some intravenous glucose with no downside risk. Certainly the noble ER physician would not have received any recognition, unless of course he or she had not performed the simple but mandatory drill. The cognitive trick here is the review of the conditions that could be the cause of bizarre behavior, with special attention to those that are treatable. But I was being praised for successfully performing a simple procedure that was almost too late because I had missed the diagnosis. I blew the hard part and no one noticed.

My clearest thought in the aftermath was that this whole episode was a fascinating microcosm of the physician reimbursement debate. The airline personnel had emphatically come down on the side of the procedure. They were not the least bit concerned about my diagnostic prowess … or lack thereof. Rather, they were thrilled that I had successfully performed a procedure so simple that several people on the flight might have done it as well.

We are fascinated with the procedure. Praise to the person who can invade! Why no enthusiasm for making a diagnosis? I have a theory. Compare the audience for public television's William F. Buckley program with some other events the American audience might select. How about a heavyweight championship prizefight? The Superbowl? The Indianapolis 500? We are an action-oriented society. Forget about thinking. The children of Plato now want blood. And they are willing to pay for it.

• Copyright ©2004 by the American College of Physicians