Tuesday, May 01, 2007
Reflections on Heart Surgery
My Mom had unexpected heart surgery yesterday in Nearby State, so I made the drive there and back for moral support. (That's why my voice was absent from the comments yesterday.)
Having been relatively lucky in medical terms thus far, I came to the cardiac ward as a newbie.
It's a weird mix of futuristic and backwards.
The technology now, of course, is amazing. The entire surgery took just over an hour, and she was conscious and very much herself – if a bit tired – immediately after. The doctor's entire report to me consisted of “she did great!,” which is really all I wanted to hear anyway. Pacemaker technology has apparently improved tremendously. I remember the warnings about microwave ovens and suchlike; now, they pretty much say “don't arc weld” and send you home. Mom has made it this far without arc welding, so I like her chances.
They even have rolling x-ray carts, so they can do x-rays without moving patients. Pretty cool.
What they don't have, though, is a handle on the logistics of what they're doing.
For example: why would a hospital serve patients nothing but a steady diet of red meat in gravy? Didn't they get the memo? The only fruit Mom got was smuggled in. This strikes me as perverse. You'd think a hospital, of all places, would serve healthy food.
But that's trivial compared to the really basic information the doctors and nurses apparently didn't relay to each other.
With every new medical person in the room – and it was a cast of thousands over the course of the day – the same litany of questions was repeated. Mom got to repeat her weight to several different people, even though she was weighed in when she was admitted. You'd think someone would have written it down. Each new one would ask whether she was diabetic, whether she's right-handed or left-handed, whether she had arthritis, etc. I wouldn't expect any of those answers to change after the first time they're asked on any given day.
At one point, an aide came in to check Mom's blood sugar, until the nurse at the station bellowed that Mom isn't diabetic. The aide shrugged, smiled sheepishly, and left. This did not inspire confidence.
When they rolled in the x-ray cart, I actually had to volunteer to leave the room. Had I not volunteered, it looked like they would have just fired off a few anyway.
When the wheeled Mom's stretcher from the first waiting area to the next waiting area – and wow, do they have waiting areas – the little automatic door-opener didn't work. It was almost slapstick.
I was amazed at the amount of “hurry up and wait.” It sort of felt like sitting on the tarmac when your plane is 8th in line for takeoff. You're strapped in, you're committed, and you're not moving. They don't tell you much, and what they do tell you is weirdly cryptic. (True example: “take her stuff, because she won't be coming back here.” Okay, where will she be going?) It doesn't seem to be malicious so much as structural – they don't communicate with each other, either.
The contrast between incredibly sophisticated technology and a staff that seemed to have only the faintest grasp on what was going on was striking. What little information that was written down was written on paper, which was stacked hither and yon. Apparently, PDA technology hasn't quite hit there yet. Sure, they can implant a microchip that decides whether you live or die, but a PalmPilot is beyond them. I don't get it.
I'm all for the cool lifesaving gadgetry, but it's only as good as the system behind it. Surely they have access to cutting-edge communications technology. I know this isn't my usual topic, but does anybody out there know why they're still using paper files, and re-asking the same questions over and over again?
The VA has and it's revolutionized health care there. The VA is now (once you're actually in the system) out-performing every single private health-care plan/system and doing it for less money.
If you read Kevin Drum (www.washingtonmonthly.com) he's on the topic with some frequency and his archives have links to a slew of comments/studies/articles.
As for the communication, I would agree that the infrastructure for communicating info is terrible. I have to agree that VA has done a better job of implementing 21st century technology. However, their mandate is not profit, but cost savings. Those who are in the savings business know you have to front some dough and time to get there. Profiteers are "what have you done for me lately" people.
This just reinforces the idea that you or your family need a family member as advocate on hand in the hospital. Someone has to chase the nurses when you can't, challenge the doctors when you are groggy, and act as a backstop when the decisions are being made under duress. The hospital is a scary place, and it's easy to speak to a patient in a way that removes reason from the process and nearly compels the answer the professionals want you to give.
Be prepared to be a hero in the neighborhood where mom lives. My mom had her hip replaced in November, so I went back to neighboring state every other weekend. Well, the nosy neighbors took notice and now mom has the greatest son in the world. DD, love your folks while you can and visit more than you want to. It wtill won't be enough.
That said, since you asked about the logistics... I would like to point out that much of what you discussed isn't logistics (in the strict "what business and academia define as logistics" sense.)
That said, I want to deal with a comment from Vinny who wrote "However, their mandate is not profit, but cost savings."
Obviously, I agree that there is a difference between the two (profit being what's left over after subtracting the costs from the revenue) but there is certainly a direct link. In the logistics arena, where much of what we do is seen as a "cost center" rather than a "profit center" we have had to consistently remind folks that one dollar of cost driven out of the system is one dollar of profit immediately added to the bottom line. ONE for ONE swap. try that with increasing revenue. If the "profit margin" is 1% (about right for hospitals), what would be required to get the same one dollar of profit? Revenue has to increase $100 to add $1 to the bottom line!
It certainly is more profitable to drive out costs than it is to increase revenue. The problem is people seem incapable of making this rather simple argument. Perhaps it's not as "glitzy" as increasing the number of patients, or adding a (costly) new capability to the hospital.
Somebody earlier mentioned the lucidity issue of re-asking questions. That's part of it. The other part is that patients often forget their medical histories, or lie about their weight, or all sorts of things--so it's a way to make sure that the physicians and nurses have all of the correct information. They are looking at the charts, but they ask over and over to make sure. Much better that than for a patient to get something wrong with the only person who asks questions and then be administered medication based on the wrong information.
Best wishes for your mom.
This habit of asking the same question over and over even though the information is in the chart seems common in medical practice. It happens at my primary care office. I particularly dislike being asked my age and height. Hey, it's not like I'm growing at age 40.
Just to see if anyone was paying attention, I started lying about those two items. One visit I'd say 5'9" and 37, the next 5'10" and 36, the one after that 5'6" and 39. No one ever noticed. Scary, isn't it?
I'm accounting as fast as I can
1. Hospitals serve unhealthy food to encourage repeat business.
2. i'm not sure why they're not using PDAs. When my mother had surgery 7 years ago, all the doctors had a PDA. In our medical pre-professional program, all the students are using PDAs. Maybe we're getting close to saturation, but not quite there yet.
To folks who tell fibs about age/height/weight just to see if anyone notices...
Yes, we should all be terribly concerned if people don't notice, but it's a terrible risk to take just to prove a point. After all, medications can be safe for one age-group but potentially deadly for another (aspirin, for example, ought never to be given to anyone under 18 -- to be on the safe side of Reye's Syndrome risk). And blood sugars generally sky-rocket following surgical trauma, so it isn't a bad idea to take the blood sugar readings of all patients following trauma, not just the diabetic ones. And as for heights and weights... well, especially with those who are medically frail, one does not want to be messing with those measures because they can influence dosing. If 5 charts have 5 different weights/heights/ages... and you get dosed incorrectly as a result, well that's both tragic and stupid, but locating the source of the stupidity would be no simple matter.
Medical records are not an innocent and neutral record of a patient's status and care; they do not simply record a history, but have a mandate to structure information according to institutional rules. Sometimes those rules and categories are offensive, and reductive, and deeply troubling... but I'd challenge the narrative in care notes if I were going to challenge anything about histories in patient charts (I have spent 14 years reading patient charts in my research area, and this is exactly what I do).
I am not, however, about to lie about my weight or height when I am admitted to an ER with a potentially life-threatening allergic reaction [or with my primary care physician either for that matter -- in case my pharmacist needs to check a script, for example], and I'm not going to play around with my child's information just to see if anyone is paying attention. The stakes are just too damnably high.
Two reasons they keep asking the same questions - sometimes things like weight will change in a short period of time and they want to make sure they get the most current info, not just what's on the chart. Second, if there has been a clerical error, it won't precipitate other errors because the information is being collected again. The more critical the process, the more redundant they will be in collecting info so as to avoid clerical errors and bad outcomes.
That said, I vote for the patient advocate. You cannot get by without one.
The worst part about the whole thing was that they actually asked me about my reactions to anesthesia. I said I wasn't allergic, but they the two times I'd had any kind of anesthesia, I'd gotten really sick afterwards. Since it had been a while, like 10 years, they didn't take me seriously and so didn't include anti-nausea drugs as part of the cocktail they gave me. And what happened post-op? Tossed all my cookies . . . over and over. By then, they had to go through several different drugs--apparently harder to combat nausea once it starts--and keep in mind, I had stitches in my throat. I could go on . . .