Saturday, September 25, 2010

How To Be A Pain In the Ass In the Hospital

So here’s a fascinating little tidbit from CBS News: How Not to Die in the Hospital. As a critical care nurse, I feel especially qualified to comment on the hilarity that ensues with the perusal of this article when compared to real life.  Let’s discuss each recommendation step by step, shall we?

The first two pages discuss the terrible possibility that you may die if you’re in the hospital. This is true. I’ve seen patients die unnecessarily myself. No arguments here. The vast majority of complications from hospital stays, however, do not involve death. Most patients have pain or vomiting or diarrhea, at worst. They may have a bad hospital experience, but in the end, they get better. Sorry for the un-fun visit, but you’re better. Mission accomplished.

Page three talks about hand washing. “If you do not see your clinician wash their hands, ask,” Dr. Pronovost recommends. Very good idea, Doc. In all my years as a clinician, I have had exactly two patients bother to ask if I had washed my hands. I had, but was happy to do so again right in front of them. In both cases, the patients who were so concerned with my hands didn’t give a hoot about their family members who came to visit them and touched not only their skin, but the IV’s, central lines, wound dressings and whatever else was attached to them. Big signs that say “CONTACT PRECAUTIONS - DO NOT ENTER THIS ROOM WITHOUT A GOWN AND GLOVES”  and protective equipment located right outside a patient’s room are summarily ignored by the dozens of visitors encrusted in God-knows-what filth they’ve brought from the outside world. Patients don't mind if their visitors slobber all over them after they've just arrived from a cholera party, but God forbid if a staff member didn't wash their hands for the three hundredth time that shift.

On page four of the article I find it hysterical that patients are encouraged to ask if they still need the breathing tube (speaking is a physical impossibility with one). But their point is the possible route of infection from catheters and other invasive devices. Here’s the thing: old people are more likely to be in the hospital. When they get that catheter, it’s like a godsend to them. They don’t have to get out bed to pee, they’re dry & comfy. They beg for the catheter to remain. If the mean ol’ nurse has the nerve to remove said catheter, they still don’t want to get out of bed and pee all over themselves and get bedsores from the constant moisture. So you’re damned if you do, damned if you don’t.

Page five recommends you stay at least at a thirty degree angle if you’re on a ventilator. Agreed, this is very necessary to prevent pneumonia! Can you please explain that to the family members that go all willy-nilly with the bed positioning controls and keep laying their loved ones flat “because it doesn’t seem real comfortable sitting up like that”? 

On page six, they recommend easing anxiety or pain without being sedated. Um, you DO realize that ALL anti-anxiety medications have sedative properties, right? And, um, except for Tylenol and NSAIDS, all narcotic pain meds are sedating to some degree, ya know? Further, rare is the patient who does NOT want the absolute strongest medications in their highest possible dose. Most patients with “chronic pain” have already hardened their nervous systems with constant prescription narcotics at home so that even ridiculous doses that would tranquilize a stampeding elephant have no effect on them. We could shoot uncut heroin directly into their brains and they’d beg for more.

Page seven - the “specialist” page! Lemme tell ya - if you’re in the ICU, you have a specialist. In fact, you probably have so many specialists, that the doctors and nurses aren’t sure whom to call if there’s a question about your care. Did you have a stroke, but now you have an infection? The conversation outside of your room probably goes like this: “Hi, Doctor Smith? The stroke patient in room 6 also has the flu. What do you want to do? Call the Infectious Disease specialist? OK. *Ring* Hello, Dr. Brown, the stroke patient in room 6 has the flu and Dr. Smith asked that I call you... You’re not a stroke specialist? I know...but... what? Call the patient’s primary care doctor? Well, you see, his doctor is in Bumfuck, Egypt and... *Click*... hello? Hello?” Also, with the chronic shortage of beds and staff in hospitals, you may be in the ICU simply because they had an open bed, not because you need intensive care, and with the staffing problems facing hospitals, your nurse (or doctor[s]) may well be right out of school, ink still drying on their diploma. So good luck with that.

Page eight deals with central line infections. Dunno what to tell you about that. Lots of folks have central lines and despite best practices, they still can get infected. Roll the dice.

Page nine and ten are two of my favorite pages. “The Deadly Blood Clot”! Yes they can kill or create a stroke or heart attack. TED stockings and SCD’s (sequential compression devices) help prevent them. Interestingly, about five minutes after the nurse fits the stockings over the patient’s legs and applies the SCD’s, the patient usually starts complaining that they don’t like them and take them off and it makes my legs feel hot and can you take these off... and so on. Explaining their use and the horrible consequences that they prevent falls on deaf or at least unimaginative ears. The theoretical killer blood clod seems far less important than the tight stockings and swooshing SCD’s. If they relent and leave the things on while the nurse is in the room, you can bet your bottom dollar that they’ll take them off as soon as the nurse leaves. If a visiting family member gets wind of it, they’ll hustle to take the things off themselves, then file a complaint that the nurse “wouldn’t listen” to the patient. Interestingly, the patients who don’t even need the TED’s and SCD’s, those folks who are fully mobile and reasonably healthy, are the ones most likely to keep them on.

Page eleven deals with “Drugs Gone Wrong.” Yep, it happens. One of the problems is when nurses and pharmacists have to translate SCJsjdhyt^*%nv[f written in doctor handwriting hieroglyphics into actual words. Think computerized charting will help? Guess again. The patched-together ad hoc code that most medical charting software is written in frequently crashes or inserts errors into medication names or dosages, or medications may suddenly simply disappear from your chart. Thank your nurses, who are diligent to spot errors and excel at doing so, that you actually get the medications to help you get better. So cut them a little slack if you miss a dose of brain heroin.

The last recommendation talks about communication. Ask questions, express your thoughts, get involved, blah blah blah. You want to know what most patients think of as “communication”? “I need more pain meds!” “Why can’t I have some food?” “Nurse! I just shit all over the bed!” "You guys suck!" If you carefully explain why the patient is not due for any more pain meds five minutes after heroin was injected into his brain, or why the patient whose intestines are rotting from the inside cannot have food, the response will be “But ‘they’ said I could have fried chicken/a narcotic fountain/cases of Dom Perignon. You just don’t want to be bothered with me.”

Sometimes, we don’t. We just suck.