Monday, April 06, 2009

The Skeptical OB

Wednesday, May 24, 2006

Hospital noise

At least one hospital appears to have gotten the message about noise:

The sound echoed throughout Montefiore Medical Center, like somebody pounding dozens of nails around the clock.

Wham! Wham! Wham!

The source was actually a pill banger, used to crush medications for geriatric patients who can't swallow whole pills.

The process occurred repeatedly each shift, disrupting sleeping patients and annoying employees. It was finally replaced by a pill grinder, more pepper mill than hammer, part of a noise-reduction campaign that includes rubber wheels on instrument carts, soft-soled shoes and posters reminding staff members, patients and visitors to pipe down.

Monday, May 22, 2006

I'm certainly not perfect

No one should conclude from my continuous ranting against the disrespectful behavior of doctors that I consider myself above such behavior. Far from it. I know how very easy it is to be disrespectful to patients, how the forces of contemporary medicine promote disrespectful behavior, and how there is very little condemnation of it within the profession.

Were I ever inclined to forget, I could just think back on the lowest moment of my internship.

There were certainly many low moments during my intership. In fact, one could argue that internship is a continuous year-long low moment. You'd think that it would be hard to mark the actual nadir. However, I'm quite confident that the lowest moment was the most personally embarrassing moment for me: at 3 AM on a dismal winter morning, I found myself on a medical floor screaming at a little old lady and threatening that I would break her arm.

I trained at the "House of God". It was pretty much at Samuel Shem described it; its medical floors were filled with elderly victims of dementia, suffering from various medical problems which we should not have been treating as aggressively as we were. You could walk down the hall and see a neat row of elderly women posied (tied) into reclining chairs staring into space, or repeating meaningless sounds, or talking but making no sense. They were all named Ida or Rose.

Like most obstetricians, I did a rotating internship which included 6 months of general medicine. I absolutely abhorred it. Taking call was the worst of all. You ran around like a crazy person all night, treating chest pain and various complications, all the while hoping that you would not get another "hit".

A "hit" was a new patient. Right away you can tell that we did not view a new patient as an opportunity to heal and learn. Far from it. In our sleep deprived, egocentric world, a new patient was admitted to the hospital to knock us down. The fact that she was actually sick just indicated her malevolence. Sure, she had been sick for days, but she had deviously chosen our night on call to show up at the hospital.

One winter evening, I was called to the ER with my resident to accept our latest "hit". Ida (of course) was an 88 year old, unpleasantly demented resident of a local nursing home. She had a bleeding gastic ulcer and was sent to the hospital for transfusions because of a very low hematocrit. When I got to the ER I saw that Ida was unaware that her hematocrit was barely compatible with life, and was scratching and spitting at the nurses while issuing a stream of invective.

Our first mission was to get IV access. Everyone who had tried in the ER had been unsuccessful. My resident and I assessed the situation and handled it in a way that seemed perfectly logical to us at the time. We tied Ida to the stretcher with rolls of Kling gauze. While the resident tried to keep the patient from spitting on me, I put in the IV after a great deal of difficulty. The red blood cells started running in.

My resident cautioned me that I should accompany Ida to the floor and supervise her placement in bed. The IV was extremely precious, and I should do whatever I needed to do to preserve it. That also seemed perfectly logical to me. I trailed behind the stretcher on the way up to the medical floor, and after the patient was placed in bed, I personally tied each of her limbs to the bedrail TWICE. I was taking no chances. At the time, I saw absolutely nothing wrong with what I was doing. Indeed, it seemed merely prudent.

I did not hear anything more about Ida throughout that evening. At about 3 AM, after managing another patient's chest pain, I happened to pass by Ida's room on the way back to my bed. Two bright eyes peered at me from the gloom. As my eyes adjusted to the darkness, I saw that Ida, clearly a protegee of Houdini, had managed to remove all four of her double restraints. She had pulled off the bandages covering her IV site and was holding the IV tubing in her hand in preparation to pulling it out.

That is when I uttered the fateful words in a voice so loud that nurses came running from up and down the floor:

"Ida," I shouted, "if you don't let go of that IV, I will break your arm!"

Ida, of course, smiled sweetly, pulled out the IV and spit on me for good measure. I turned to find a circle of nurses staring at me with mouths agape. I burst into tears, the one any only time during my entire residency. The nurses figured that I was too distraught to manage the situation, and called the resident to restrain Ida yet again, and replace the IV. Although people tried to console me, I was inconsolable. I just kept saying over and over again,

"What has happened to me? I threatened to break a little old lady's arm."

I don't remember what happened between then and morning rounds. I do recall that by the time of morning rounds, I was completely recovered and back to work again.

Saturday, May 20, 2006

The first time

The problem of medical staff failing to treat patients respectfully is a very old one. Eventually, I think, many doctors and nurses just get used to seeing it. However, the first time you see it, it can make a big impression on you. I can still remember the first such incident that I observed. It has stayed with me for more than 20 years.

I was in the first weeks of my general surgery rotation at a small suburban hospital. The chief of surgery used to take the medical students around to see the patients. There was a middle aged woman who was suffering severe complications from alcoholism (bleeding varices). She was schedule for surgery and the chief told us that the surgery was very complicated, the chances of survival were small, and the odds were high that she would become encephalopathic in the aftermath of surgery and never regain consciousness. I had this in mind when the resident called me to observe him putting in a central line prior to surgery.

I pressed myself into a corner where I would be out of the way. The central line placement was difficult and the resident struggled over and over again. He was sweating and everyone in the room was tense. I could not see the patient's face from where I stood. It seemed that she was incredibly stoic as she was stuck repeatedly. Eventually, her voice emerged from beneath the drapes,

"I'm sorry, but I have to pee."

The nurse looked at the resident, and the resident shook his head no. He was already frustrated and he did not want to stop to let the patient use the bedpan. So the nurse told the patient,

"Just pee in the bed. I'll clean it up later."

I was shocked and evidentially the patient was, too. Was it really that much trouble to take a few minutes to let her pee into the bedpan? The patient said she would try to wait.

Again the resident was unsuccessful and again the patient asked for the bedpan. This time she was pleading.

"Please, I don't want to pee in the bed. I've never had an accident before. Please, please just let me use the bedpan."

By this time, no one was interested in the patient's distress. She wept as she eventually peed into the bed.

"I am so embarrassed," she kept saying over and over again.

It only took a bit longer and her central line was finally placed. She was wheeled off to the operating room, weeping. The surgery did not go well. She survived, but she never regained consciousness and died a few days later. Her last conscious thought had been embarrassment, because no one could be bothered to give her a bedpan. She was going to her death. Everyone in the room knew it, but no one cared enough to let her preserve her last tiny shred of dignity before she died.

Friday, May 19, 2006

A doctor who understands the doctor patient relationship

Cancer Doc has a written a poignant description of the doctor patient relationship:

When you see someone continuously for three years, they become more than your patient. Not really a friend or family but something very distinct. Not the impersonal feeling of a brand new patient, but something akin to a comrade in arms. A fellow soldier. Someone you've humped through the bush, the desert, the bullshit for a couple years and now he's hit the goddamn landmine. Most of the time you just have talked shop, but that and the emotions involved are enough to bond you forever. Call it doctor-patient relationship. Whatever you want to call it. It's brutal.

Be sure to read the entire post. Cancer Doc shows what the doctor patient relationship can be.

Monday, May 15, 2006

BigMamaDoc is recovering

I am very happy to learn that BigMamaDoc, of the fabulous blog Fat Doctor, is recovering from the strokes she recently suffered. I was saddened, but not surprised, by some of what she had to endure during her treatment:

...Do you need to go to a hospital?" I agreed to go if Coworker, who took care of me during my last hospitalization, felt it was appropriate.

An hour later, we were at the ER, where the resident found my exam inconsistent. Sister insisted on an MRI. Resident sent me despite his hunch that I was faking.

In radiology, a very kind technician alerted the radiologist that I am a physician. Radiologist came to meet me, explained that they would do the MRI and look at my carotids only if they saw something on MRI. "Hold still," the tech said. Her voice, tinny and remote, came from a speaker somewhere near my head. I'm too fat for this machine, I thought again and again. The test seemed to last an eternity. I thought of Son. I thought of Husband. I thought of Job and Patients and Peers.

Technician came to reposition me for a carotid view. Oh no, they found something. "Did you find something?" I asked. She pretended not to hear me.

Radiologist never came back. As I was wheeled back to my ER room, Dr. Resident said, "Well, you've had several more strokes. I count at least 8 new lesions. Maybe more. This is very interesting. Let me repeat some of the physical exam. "

Oh, so who's the faker now, buddy?

A young woman with a history of thrombotic strokes presents to the ER with new symptoms. The resident doubts her, the technician is rude and the radiologist does not discuss the finding. Is this the way they would want to be treated?

She is almost certainly getting a higher level of care because they all know she is a physician, and this is the best they can do. Imagine if she were just a regular person.

By the way, when her sister insisted on the MRI, she was acting as a patient advocate.

Thursday, May 11, 2006

Gap widens in hospital patient satisfaction

Press Ganey Associates Inc., which measures healthcare satisfaction across thousands of healthcare delivery organizations has issued this press release about the widening gap in hospital patient satisfaction.

The American Consumer Satisfaction Index (ACSI) from the University of Michigan has shown that consumers' satisfaction with healthcare has decreased significantly over the past several years," says Melvin F. Hall, PhD, president and chief executive officer of Press Ganey...

Press Ganey data confirms what many healthcare policy experts have been saying about healthcare -- the landscape presents a lot of mediocrity with pockets of excellence and [pockets of] very poor care.