Adventures in qualityland.

Several years ago, my aortic valve had to be replaced, and my wife insisted that I find a doctor near our retirement home. I searched around and finally settled on a nationally known clinic that had just opened an outpost not too far from our town. Let's call it the Mustard Clinic.

Recently, the cardiologist at Mustard decided that I should have a transesophageal echo of my artificial valve, and so, after a few questions, I agreed to have the procedure scheduled. A few months before, while having a routine echocardiogram, the technician asked why I was not having a transesophageal echo, and went on to describe the new tube they were using. "No bigger than an N-G tube", she said, and that sounded acceptable to me. I knew that I would need SBE prophylaxis, but nothing else was mentioned about preparation except that I should be fasting. As a matter of fact, I went through the scheduling and instruction phase at Mustard twice, because my first appointment had to be canceled.

The day before the appointment, the clinic called to ask if I could come early, as they "had to squeeze in" another case that morning. I agreed, arrived on time, and was called the usual 30 minutes after I arrived. The IV gentamicin and ampicillin was started but was run in half the usual time, because "we are behind schedule."

When the proceduralist came in to introduce himself and his resident, I told him that I had a rather hyperactive gag reflex. He said that was okay, because they would use a small amount of IV sedation and then my wife could drive me home. My wife happened to be 2,000 miles away visiting her mother. I said that I could not wait for her, and, anyway, I had a car parked outside. He said, "That's okay. Just hang around for a few hours, and you should be okay."

I told him, "Sorry, but |should be' is not good enough." I did not want my life endangered when I drove home. So he gave me two squirts of topical anesthetic and started the procedure. You can image my surprise when the "N-G tube" turned out to be a standard diameter gastroscope, which looked to me like the diameter of the Holland Tunnel. Upon insertion, I gagged uncontrollably. Two more squirts of topical, and, with one hand in my mouth and the other guiding the scope, he started again. I was still gagging, but I was told to "take a few deep breaths." Now, I know that line. I was taught it in the bad old days of medicine, when patients had to endure more than necessary pain or discomfort. It's like "I'm sorry you feel that way" when used by a physician manager.

Of course, the proceduralist had not read the entire chart and was unaware of the fact that I had some urologic surgery at Mustard five years ago that left me with a little stress incontinence. So the more he pushed the scope down, the more I gagged and the more wet I became. Finally, I freed a hand and waved him off.

He was angry to have a perfectly fine procedure stopped, and I was lying there feeling raped. My pants were soaked with urine, so I had to walk out of the clinic with a dark stain covering my crotch. No one offered me a pair of scrub pants to wear home instead of my urine-soaked chinos, nor, for that matter, had they thought to offer the use of scrub pants for the procedure.

The physician's note, of course, just reflected that I had stopped the procedure, not that I had received inadequate instructions or anesthesia, or that my kidneys may have lost a nephron or two from a rapid gentamicin infusion.

The following day, I filed an incident report with the patient representative and, in a letter, informed the clinic that I wasn't about to have my insurance company pay for that kind of treatment.

The next day, my cardiologist called to say he was sorry I had trouble with the procedure and that my pro-time was way off. I had better increase my Coumadin. But that's another story.

Another Story

I was surprised to hear that my pro-time had fallen to 14.5 seconds. The measurement had been 22 seconds six weeks ago, but, as I thought about it, I just assumed that Coumadin is a very unpredictable drug.

Of course, I had been taking Coumadin since installation of the replacement aortic valve eight years ago and had, for the most part, managed my own anticoagulation. About two months before, the cardiologist at Mustard Clinic had decided he wanted to manage the coagulants and began to adjust the dose. We had started with a pro-time of 22 seconds, and he wanted it about 18 seconds. I had been using the new normalization ratio, which, for you noninternists, adjusts the results to compensate for variables in the substrates used in the prothrombin determination. I was shooting to 3.0, and I thought that the original 22 seconds was probably above the 3.0 level I was using.

Anyway, the dose was dropped, and, two weeks later, the new pro-time was reported as 22 seconds. I asked the nurse who called with the results and the doctor's new dosage schedule what the ratio was, and she said emphatically, "We don't use those here." I hadn't heard that tone since I was an intem dealing with a very senior nurse. I guessed they had standardized their thromboplastin, or whatever the substrate was. (Like most of you, I never could remember the clotting mechanism.) I thought the new dose was too low and said that, when using that dose in the past, I had become under-coagulated. The nurse assured me that the doctor knew what he was doing, so I went along.

The truth of the matter became clear when a friend of mine in the surgical division gave me my lab results. Even if "they didn't use those ratios," the lab reported them. The second 22-second pro-time was reported with a normalization ratio that had fallen significantly from the first 22-second pro-time. I was actually borderline under-coagulated when the dose was reduced the second time.

Even if the new ratios weren't the final determinant of dose, at least they should have been used as a warning that my pro-time was lower than it looked. The second reduction in dose should have been more cautious, or some one should have listened to the patient.

Now that I had been un-anticoagulated, I decided that I could do a better job and took over management of my anticoagulants, along with my other duties.