The High Cost of Cure

How a hospital bill grows 17 feet long
Day 9

Blood cultures now revealed growth of a gramnegative bacillus, identified as bacteroides, probably of bowel origin. The patient was sufficiently improved that he could be questioned about toxins, drugs, mushrooms, work exposure, and possible ingestions of heavy metals; there was no evidence for any of these. He was seen again by the surgeons, who concluded that his abdomen was soft, with normal bowel sounds.

Day 10

He was seen by the neurological consults, who observed mild proximal muscle weakness and suggested study of the electrical activity of the muscles, by electromyography. He was also noted to have mushy swelling of his extremities.

Day 11

The patient's mental condition continued to improve. A repeat kidney X ray was read as normal.

Day 12

There was continued improvement. Enzymes had dropped to near-normal levels. He had no temperature.

Day 13

Bariuim enema was repeated, in the search for diverticulitis or other source of infection. None was seen.

Day 14

Electromyography was normal. It was decided to discontinue his chloramphenicol antibiotic and see if he remained without fever.

Day 15

Chloramphenicol was stopped. The patient did well, taking liquids by mouth.

Day 16

On his second day off antibiotics, his temperature fluctuated in the range of 101° to 100° F.

Day 17

The patient had an upper gastrointestinal series of X rays, which were normal. On his third day off antibiotics, the temperature began to spike again, to 102°. Tenderness and guarding of the right upper abdomen reappeared.

Day 18

The surgeons concluded that the patient had cholecystitis, or infection of the gallbladder, which had probably begun initially as cholangitis, infection of the bile system. They also wondered, however, whether he might have a liver abscess. The patient was restarted on antibiotics.

Day 19

Mr. O'Connor was transferred from the medical service to the surgical service as a preoperative candidate for exploratory abdominal surgery. His mental state continued to clear slowly.

Day 20

The neurological consult saw him and agreed that his mental status was improving. The surgeons, however, found that his abdominal tenderness had disappeared with the antibiotics. X rays of the gallbladder showed no filling of the bladder sac, but the films were of poor quality. Radioactive scans of the liver and spleen were negative.

Day 21

Scheduled operation was canceled in order to allow time for further preoperative studies. A repeated gallbladder X ray definitely showed no filling, although this time the films were of good quality. A celiac angiogram was scheduled.

Day 22 and Day 23

The weekend. Specialized procedures such as celiac angiography could not be done, and further work on the patient was postponed until Monday.

Day 24

Celiac angiography was performed. Under 1ocal anesthetic, a thin, flexible catheter was passed up the femoral artery in the leg, to the aorta, and finally to the celiac axis, a network of arteries coming off the aorta to supply blood to all the upper abdominal organs. A dye opaque to X rays was injected, and the vessels studied. No space-occupying lesion (tumor) was found, and the vessels were normal in appearance. The patient made a good recovery from the procedure.

Day 25

The abdomen was soft and nontender. The patient felt well. He was still on chloramphenicol antibiotic. Enzymes were, by now, fully normal.

Day 26

The patient had no fever and felt well. The surgical staff decided to stop antibiotics, and see if fever and symptoms recurred.

Day 27

He was taken off antibiotics. Temperature and white-cell count remained normal. The patient himself was in good spirits.

Day 28

There was no demonstrable worsening of the patient's condition on his second day off antibiotics. His wife expressed the opinion that his mental state was entirely normal once more.

Day 29

His condition remained stable on the third day. He said he felt well. He had no fever and no elevation in white count.

Day 30

His condition was still good; his abdomen was soft without tenderness. He said he felt well. It was now clear that he was not an operative candidate. Plans were made for his discharge the next day.

Day 31

Discharged. His discharge diagnosis was fever of unknown origin with bacteroides septicemia. The opinion of the house staff remained that this patient had probably had bile-collecting-system infection.

Five days after discharge, he was seen in the surgical clinic by Dr. Monchik, who scheduled another set of gallbladder X rays for the future, and noted that if the patient had further trouble with infection, it would probably be necessary to remove the gallbladder. For the moment, however the patient was fully well.

"To do nothing," said Hippocrates, "is some times a good remedy."

On the surface, Mr. O'Connor's hospital course seems proof of this ancient dictum of "watchful waiting. But this is not really so: had Mr. O'Connor received no treatment, he would almost certainly have died within twenty-four hours. He received vital symptomatic therapy (lowering his fever) as well as acute support of vital functions (assisted respiration). He was closely monitored by teams of physicians who were prepared to intercede on his behalf, supplying more assistance should his body require it.

He also received a vigorous diagnostic work-up, which did not produce as much information as one might like. His therapy was successful, but no physician at the hospital could claim, at discharge, that they really knew what was going on in his case. A diagnosis of cholangitis and cholecystitis was likely, but never demonstrated.

His hospital bill for a month of care was $6172.55 This is just a few dollars less than Mr. O'Connor's annual salary. But he did not have to worry about it; unlike that of most patients with some form of health insurance, Mr. O'Connor's coverage was essentially complete. His personal bill amounted to $357.00.

In this, as in many other things, Mr. O'Connor was a very lucky man.

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