What’s Wrong with Health Care?

A Burger King hamburger sesame seed bun, as se...

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Customer service.

We’ve turned taking care of the sick and injured into fucking Burger King. Everyone wants it “their” way. Sorry folks, life isn’t like that especially in my house. When we turn patients into consumers, they begin to expect to treated like customers and hence have no skin in the game. This leads to unrealistic expectations and our administrative “leaders” play up that we are in the business of providing customer service instead of healing. That then becomes our problems on the floors and our “customers” think that “their” way is the only way.

Yes, I will be disturbing you at midnight to check your vitals and then doing it again at 4am.

Yes, you will have blood drawn, probably several times through the day and night.

No, you can’t have your hydrmorphodemerolepam every hour, even if that’s how you take it at home – which is probably what got you here in the first place.

No, burger and fries are not part of your heart healthy diet to help treat your congestive heart failure.

Yes, lasix makes you pee. And, yes, I will be giving you a dose tonight, as the doctor ordered, every 8 hours so that you can breath and not have a hugely swollen scrotum.

Yes, it would be nice for your family to come in to learn wound care techniques so they can care for you at home.

No, not all of them can stay the night with you in a double room.

No, you can’t go out to smoke, even just for a minute. And I’m definitely not giving you an oxygen tank and wheelchair to do it.

Yes, you are more than welcome to leave AMA because we’re all racist assholes who won’t give you IV narcotics every hour, please just sign this form.

No, you don’t get a cab voucher, discharge prescriptions or fresh clothes if you do leave AMA. Sorry.

Yes, Dr. First-Year Intern, they just left AMA after threatening the entire staff, but you might catch them by the ED if you hurry. I’d bring Security with you though.

I will be polite and respectful, but I will not fawn over ingrates, feed into those with unreasonable expectations or take the crap from the dis-respectful. I refuse to be turned into a cashier clerk at the local fast food joint or a Pez dispenser of Oxycontin. There is difference between customer service and letting the public run wild in our house.

It’s time to take it back.

To set expectations.

To educate our patients.

To let the world know that we are not there to be exploited, abused and disrespected.

It’s a long journey, but it starts with a single step, for nurses and other health-care providers to stand up and say, “NO MORE!” and start to expect our patients to be active and involved, to care about their health, to put some skin in the game and start behaving like responsible adults.

But that will never happen. Sad.

Wasting Money at the End of Life?

Movin’ Meat: Are End-of-Life costs avoidable?.

Yes.  docs need to learn to say, “No.”

Case in point…a 90-something year old patient, recently had a pacemaker implanted for mild tachy-brady syndrome.  They had some occasional mild tachycardia and rare episodes of bradycardia which were non-symptomatic for a big reason: they were never out of bed or chair.  Yes, this lovely patient was completely dependent upon others for every aspect of their care, not to mention completely demented.  If your idea of quality of life is being 100% dependent on your family and having absolutely no meaningful interaction with them, then this is great.

I can understand doing procedures on folks with whom it will make a positive outcome – like the 80-something year old CABG mentioned in the above link.  It makes sense.  But to do these kinds of procedures on those with poor quality of life is just cruel.  It only delays the inevitable.

In this case, the family convinced the doc to do the procedure.  What makes my blood boil more though is that this same family had another member in and out of our facility spending nearly half of the last year of their life in the hospital in multiple lengthy admissions.  They would not accept that this family member was dying and insisted on all measures being done.  And now that there is a new one heading down this same road, it will probably be the same.

End of life costs are avoidable if we as society realize the death is a natural part of life and accept it.  Instead we claw and fight to eke out the last painful years many have, enduring lives of bed sores, PEG tubes, nursing homes and hospital admissions.  For what, a couple more years?  Years that can’t even be enjoyed because of the multitude of illnesses?  It doesn’t make any sense to me.

Is Protecting Yourself a Joint Commission Violation? | WhiteCoat’s Call Room

When are you guys going to learn? When a patient is choking the life out of you, you HAVE to offer them milk and cookies then tell them to go to a secluded room before you try to defend yourself. Those are the rules. If they have their hands around your windpipe and you can’t breathe, then just point emphatically to the secluded area.

via Is Protecting Yourself a Joint Commission Violation? | WhiteCoat’s Call Room.

Yes.  Yes it is.

This is the inherent problem of large regulatory bodies like the Joint Commission:  they do not operate in reality.  They exist in a perfect fantasy land where falls never happen, infections are impossible and ED (and all patients) are well behaved.  They do NOT understand the complex and dangerous reality that is modern health care.  Like managers, they should be required to spend an amount, say a week a year, of time where they are the primary surveyors.  Your primary survey (management) area is ED?  You get to spend a week in the trenches.   The people who are writing the rules NEED to be intimately familiar with the true consequences of their actions.  Handing down edicts from on high isn’t as easy when you know what it means to the actual providers.

Of course that is just a fantasy because like most bureaucrats, they got into this line of work to avoid (or couldn’t hack it) just this sort of thing.  Actual patient contact?  Ewww.

Falling Down

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Anyone who has read “The House of God” knows Fat Man’s Second Law:  Gomers Go to Ground.  It’s harshly worded and blunt beyond our politically correct society can accept, but it is true.  People, especially the elderly, fall.

And why not?  The elder with dementia that doesn’t understand their own limitations, the folks we pump full of beta blockers, diuretics, narcotics and anti-psychotics, and the TBIs and CHIs that can’t grasp their clumsiness are all part of the hospital (and in greater society) milieu.  They fall.  For multiple reasons.  If you do a quick search of the literature, I’m beyond positive that you will find hundreds, if not thousands of pieces of information of falls, causes, risks, sequelae, outcomes and the like.  And the chorus is the same:  falls are bad.  Falls that result in injury are bad.  Elder folks falling is bad.  Our friends of the Borg, er, The Joint (smoking) Commission have decreed that, Falls Shall Never Happen! Oh, and by the way, if they do pipes up CMS, we ain’t going to pay for the care costs related to the fall.  Go to ground and break your hip?  Hospital eats it as no one (even private insurers are starting to follow this trend), is going to pay for your care.

This fear of non-payment has created a flurry of activity.  Fall programs, rounding programs to ensure falls don’t happen by addressing all the things that cause folks to fall (pain, potty, position…), new special booties that both identify the wearer as a high fall risk and provide excellent grip and with all of this loads upon truck loads of new paperwork and charting.  So where does this leave us?  Stuck charting and paperworking instead of providing patient care.

OK, now what do we do about it?  Simple:  accept the fact that people fall.  Don’t point fingers in a blame game or penalize institutions when it happens, accept the simple fact that this will happen.  Then start operating under the assumption that everyone is a fall risk in the hospital.  Actually reduce the paperwork and charting so we can be present and available to prevent falls.  But always know that it will happen.

It’s not an easy fix as say preventing BSIs or CA-UTIs where checklists and proper technique will prevent many if not all infections.  Falls are too dynamic to be placed on a rigid checklist.  For example, a certain patient on my floor was incredibly unsteady, but was strong enough to be “mobile”.  Even though we rounded on them, they were close to the desk, minimized meds that could alter their mentation (worse than it was), they could have fallen in an instant.  Many times, even though they were mere feet away from my typical charting spot, they were up and in the bathroom before I could get to the room after the bed alarm sounded.  There was the patient that threw themselves over the bedrails opposite of their hemiparesis, of the one who suffered cardiac arrest while up walking.  These things happen.  We can never stop them all.

I know why we do all the excessive charting and paper trails besides the whole, “Look we’re doing something about it!”  It’s a way of (hopefully) reducing our liability in court.  So we can say, “Look at all the things we did.  We should be paid (or not have to pay)  Aren’t we good?  Forms in triplicate and fall assessments every 4 hours!  We did everything!”  If we had the assumption that people were going to fall and the rational expectations of this, none of that would be necessary.  But there is no such thing as rational expectations in health care anymore so we all suffer.

The best thing though is when asked where you were while the patient fell would be to reply, “I was charting their fall assessment!”

Cheap vs. Inexpensive

Do cheaper doctors provide inferior care? – By Brian Palmer – Slate Magazine.

To most patients it really doesn’t matter.  They’re not choosing a doctor because they are cheap, they are choosing them because they have to.  Constrained by the limits of their insurance plans they go for the doc who can get the in the office or sees them in the ED.  It’s not like they go out calling around to get quotes like they are buying a car.  But here’s the kicker, in spite of all the work we do to improve our outcomes, reams of data available to help patients choose their hospital it comes down to this more often than not:

Studies have shown that patients’ hospital preferences are more responsive to improvements in amenities like wireless Internet and on-demand video than the likelihood that the hospital will help them get well.

Who cares if the hospital will cure your nasty case of I’ve-abused-myself-for-too-long, because if they don’t have cable, gourmet food and staff fawning over you they’re not going.  To the average public it’s all about fluff.  There are exceptions to this.  There are those who seek out the very best doctors to help cure the rare childhood cancers, referral centers for LVAD therapies and transplant, exceptions do exist, but they better have wireless and food on-call!

Makes One’s Head Spin

The hue and cry throughout the land over health care reform usually ends with the same admonition:  read the bill.

Sorry.  Not going to happen.  Much like any other carefully crafted piece of legislation, this vaunted bill carries a ton of bureaucratic legalese that makes as much sense as Ancient Latin.  For example:

(a) Medicare-

(1) IN GENERAL- Section 1861 of the Social Security Act (42 U.S.C. 1395x) is amended

(A) in subsection (s)(2)—

(i) by striking `and’ at the end of subparagraph (DD);

(ii) by adding `and’ at the end of subparagraph (EE); and

(iii) by adding at the end the following new subparagraph:`(FF) advance care planning consultation (as defined in subsection (hhh)(1));’; and (B) by adding at the end the following new subsection:  h/t Junkfood Science

Yes folks, this how it is written, full of additions, striking, subparagraphs, subsections and enough misdirection and confusion to employ a cadre of lawyers full-time for the next millennium (maybe that’s the point…).  My point being this:  it does no good to read something if it makes no sense.

I know that I’m probably oversimplifying things, but again, a quote:

(hhh)(1) Subject to paragraphs (3) and (4), the term `advance care planning consultation’ means a consultation between the individual and a practitioner described in paragraph (2) regarding advance care planning, if, subject to paragraph (3), the individual involved has not had such a consultation within the last 5 years. Such consultation shall include the following:

`(A) An explanation by the practitioner of advance care planning, including key questions and considerations, important steps, and suggested people to talk to./p>

`(B) An explanation by the practitioner of advance directives, including living wills and durable powers of attorney, and their uses./p>

`(C) An explanation by the practitioner of the role and responsibilities of a health care proxy./p> (JFS again)

Sure, this is a little clearer, unless defined by paragraph 2, subsection 2, which refers to chart 23a for those referred to in subparagraph 2, section 3.  Those in subparagraph 3, section 2a, please use chart 84-4b.

Sorry, got carried away for a second.  The pundits wonder why our representatives don’t read bills (remember, no one really read the Patriot Act either as it was full of the same crap, and there wasn’t “enough time” to do so.)  It’s simple, this is why.  Understanding biochemistry is easier than reading Congressional legislation.  It’s no longer as simple as “I’m Just A Bill” of Schoolhouse Rock fame.  The concept is the same, but the ideas contained therein are a little more complex.

The argument goes that to encompass such a wide swath of American life, it needs to be complex.  But it is the very complexity that makes it unwieldy and administratively top-heavy.  Like the tax code, this too will spawn, or at least encourage the cottage industry of interpretation due to the mostly vague nature of the act itself.  We can’t have our decisions made by committee or by the elite, especially when it comes to our health.  That is something between a doc and his patient.  If the doctor is not the Primary Provider, see Section 21a, paragraph 5, subsection 4.  But I think you get my point.

I have no answer to this problem.  Wish I did.  I don’t think socialized medicine is the answer, nor do I think our current system has any life left in it.  We obviously can’t continue on the same path we’re on.  And yes, there is going to be some pretty bitter pills to swallow in the coming months and years.  But I know one thing:  I don’t want the government running my health care.

And now for some levity:

Dr. Wes: An Open Letter…

Dr. Wes: An Open Letter To Patients Regarding Health Reform.

“Now, in the unfortunate circumstance where you might become sick, you will need to develop symptoms that follow a few simple rules. Do not, under any circumstances, develop symptoms that fall outside federal protocols developed based on comparative effectiveness research data. If you do, your doctors will face pay cuts, litigation, limited resources due to lack of funding for cost-ineffective technologies, and the scourge of discharge planners. Does the term “leper colony” mean anything to you?”

Classic.  With just the right amount of snark.