Lost on the Floor

I saw this story titled: "Hospitals Designed to Heal" on line this morning as I awoke from the slumber of a man exhausted (this is the last time I stay up all-day after the night shift...family first though). While I agree in concept that hospitals are places to heal and that they should provide a healing environment, there are limits to that.

"Southwest Washington Medical Center in Vancouver built its new hospital tower with many design features as comforting as you'd find at a resort hotel." I found the words "resort hotel" particularly ominous. In creating a resort, you place in the patient mind set that this is a vacation, thus they should be served hand and foot, as if they were on vacation. Granted, not all patients will feel this way, but many, and their families will. I am a believer in the active participation of the patient in their health care, if able. That's why I will try to get patients to do things for themselves. Yes, I will be by their side every step of the way, but I will make them do it themselves, again, if able. As an example: we post-CABG patients 2-3 days our of surgery on our floor. These folks need to start moving soon after surgery to reduce any number of complications. We push them, yes, but when they go home, we will not be there to do everything for them. We want to get them out quickly to reduce the risk of obtaining a nosocomial infection or other nosocomial complication. Coddle we don't do. Nurse them, we do. We encourage active participation. If you're on vacation, do you really want to work?

I do understand the importance of quality design and eye-pleasing decor especially when faced with research like that done by Roger Ulrich where he "compared abdominal surgery patients assigned to rooms identical except for the window view: Half overlooked a grove of trees; the other half faced a brick wall. Patients with the tree view recovered sooner, suffered fewer complications and needed less pain medication than wall-view patients." There should be limits though. Do we need to spend millions and millions of dollars to draw patients to one particular hospital? How about when that money is at the expense of current facilities? One colleague related to me a story of the expansion of the Legacy system in Portland into nearby Vancouver, WA. He related how the project for the Salmon Creek hospital went way over budget and how the system diverted money from where it could to make up the shortfall. It meant no extra shifts, reduced staffing, no sitters unless absolutely needed, no new equipment, reduced availability of working equipment, all to create this Valhalla-esque hospital with Italian tile floors in the main lobby. Sure, they operated within acceptable limits, but bare-bones. While he may have had an axe to grind, it made a point to me.

One thing I do believe a great deal in is private rooms. At one point during my time in Arizona, my wife ended up in a hospital and there shared a room with 3 other women. Yes, 4 post-partum women per room. Not cool. Not even close to peaceful, much less anywhere near private. HIPAA was non-existent on this ward. We heard all about how one roommate had Hepatitis C and gang bangers coming after her. A private room would have solved this problem. Semi-privates do work, but still you have to basically live with someone else while in the hospital. What if the roommate has an overbearing or overly large family? Or is a moaner/groaner/screamer/yeller? Not exactly a peaceful healing environment.

Finally though, it comes down to money. Like so many things in life. If the hospital presents a pleasing face, more people will choose to have care there, which equals more money for the hospital. Elective surgeries are where the money is in our health care environment. If you don't get that business, you don't stay in business. Considering that one drug-eluting stent costs around $4,500 not to mention the cath lab, the post-procedure room, nursing and ancillary staff and of course the doc, you can see how it can add up quickly. And this is a simple stent. What about a total hip or knee? Yep, big money.

Contained in the article, although along a different train of thought, was this gem of a thought:

"A study last year by Randall Pozdena, an economist with consulting firm EcoNorthwest, estimated that the metro area has about 1,500 surplus beds. Considering projects planned or under way, the economist projected that unused capacity will expand to 2,208 beds by 2025. That's assuming the addition of 2.2 million residents and a doubling of residents older than 65."

I'd love to know how they figured this one. When we're full nearly every night, it is hard to fathom. I know that is metro wide and that we're not the only floor at my hospital, but it seems very often we have the last bed in the joint and it gets filled quick. Maybe it's all about location, but I don't know. It's an interesting idea to chew on.

Is there an answer? Not really. What would I love to see? Let me show you:
I see a place where it is nice, but not like a resort hotel, more like a 2-star one. Nice, with the necessary amenities, good TVs, internet, decent food. We have plenty of staff and working modern equipment. The patients are polite and pleasant as are the families. We don't have to fluff pillows or pick things off the floor for capable patients. The nurses have a 3:1 patient to nurse ratio, CNAs that do their jobs, colleagues that don't call off for no reason, plenty of staff parking and a coffee cart open all night.

A guy can dream can't he?

According a new article published by the New Scientist on Monday, a new group of enzymes have been found that effectively remove the cellular antigens that are the basis for blood typing. In easy words, they turn any blood type to Type O, which anyone can receive.

Sure this is not going to solve the problem faced in health care due to a lack of blood and blood products, but it should make an impact. The arena where this will probably be seen the most will be in the field of trauma resuscitation where it is not uncommon to burn through tens of units of blood, if not more, in a trauma situation. I think the most blood I've been on-hand to see given when in an ICU as a student where we gave 6 units of PRBCs plus a six-pack of platelets during the 6 hours I was on the unit...which really is nothing. Most I gave in a shift was only 3 units, over a whole 12 hour shift.

The other flip side is that it does nothing to address problems of plasma and platelets, two other common forms of blood products typically given in the in-hospital setting. But, it is progress.

It's like the ubiquitous order of a Diet Coke after the "Double Quarter-Pounder Meal."

The other night started off like any other. Got my assignment, looked...OK, at least everyone is A & O and mostly independent. "So far so good." I thought to myself. It's funny, I no longer look to see what the actual reason they are admitted for anymore, just if they are going to either:

a. curse me out
b. try to get out of bed and go boom
c. yank at their lines
d. all of the above (usually the most popular.)

Good nursing practice? Maybe a little judgmental, yes, but this is tempered by experience. I figure, more than likely, I can deal with their admitting diagnosis, but if they are demented or delirious or just plain psychotic, that task just became a whole lot harder. But I digress.

So I was going along, and everything was actually OK. Then someone mentioned the "q" word. A chill swept over the nurses station as we all looked at them and in near unison said, "Did you just say the "q" word?" Mentioning the "q" word in the medical world is akin to mentioning "MacBeth" to a stage actor. Not sure what else we could say, for sure the alternative for the actor is far worse. Who really goes on a nursing unit and tells someone to "break a leg?" No one in their right mind. But it brought me back to the time that I had used it.

I was a senior nursing student doing my senior preceptorship in the ER of a smallish rural hospital. On the night shift. At the beginning of the month. During a full moon. Surrounded by black cats and broken mirrors ( OK the last part wasn't quite true.) But there I was. It had been a slow night, nothing too crazy. So I said it. the "q" word. No more than 30 seconds later we heard the tones come over the radio,

"Rural ER, this is unit 55, how do you copy?"

The nurse sitting there, "We copy, over:"

"55 y/o male, found down in apartment, in full arrest, we're coming code 3."

I looked over at my preceptor, she said, "You're on compressions, OK?"

As the thought ran through the back of my head that this was all my fault for saying that dreaded word, I said, "OK." Lead vest on, shoe covers, gown and mask, gloves and goggles. We had just barely gotten the trauma bay ready when we heard the sirens outside in the bay. They piled out of the unit, one in front, one in back, one surfing the gurney performing compressions. Rolled them into the trauma room, stopped compressions only to transfer to the table.

Now it was on me. I started, feeling the ribs grate under my hands, just keeping my mind on the rhythm, 80 a minute. I heard report in the background.

History of esophageal varices and alcoholism. Found down in apartment after wife had called it in after the patient had passed out while talking on the phone to her. 80 a minute.

1 and 2 and 3 and 4 and...keep the rhythm.

7 french ET tube, 21 at the lips. Left and right EJ IVs, got 3 liters in the field. RT is standing to my left bagging as I do compressions. The doc holds compressions for a moment to find the femoral vein. Then back at it. 1, 2, 3, 4,...

I'm hearing orders being given, rapid infuser, get 6 units of blood ready, continue NS until the blood's ready, get me an ultrasound machine. The doc calls out again to hold compressions. Has the femoral line. Compressions resumed.

I'm getting tired now, starting to look around for someone to spell me. Arms feel like lead. Now I look down and see with every compression fluid spurting out of the ET tube, a pink mix of blood and saline. But I keep going. As a student I can't do much, but I can do this.

The monitor shows asystole. The doc halts again, uses the ultrasound to see if the heart is doing anything. Nothing, just a little bit of movement. Finally, I switch out with another nurse. I can't feel my arms, sweat runs down my back and face. And then it is over. The doc calls it. I look at the clock, 7 minutes since they arrived in the ER. Then I nearly lose it. I run out the door to the ambulance bay, into the cold night air overwhelmed by the fact that we couldn't save him. Someone's father, husband, son. In spite of our best efforts, we couldn't save him.

That wasn't the worst. That came when his wife showed up. He came in covered in blood, I mean caked on. The police had said the scene looked like a murder scene there had been so much blood. So we cleaned him up as best we could. Cleaned his hands, his head, his hair. Made him presentable so that his wife could come and say good-bye. My nurse gave me the rest of the night only giving me the easiest cases. As we sat down and talked about it I asked,

"Does it ever get easier?" To which she replied, "Not really. You just forget to feel it anymore."

I knew she meant that you insulate yourself as you get exposed to it frequently, but it sounded a little cold, but I understand it much better now. Rationally, I know that even though I said, "quiet" that didn't cause this to happen, it was bound to happen regardless, sometime. It just happened when I was there. So I never say, "It's kind of quiet tonight." Not anymore.

Oh that other night? It went just fine.

As I was walking down the hall on the unit doing midnight rounds I heard it. Faint at first, just enough to prick my ears up, then more distinct, "let me out! Let me out!" in an ongoing chant. I knew that it wasn't anyone on my end of the unit, it had to be coming from the other side, 40-50 yards down the hallway. When I got back to the nurses station, it started again. Someone jokingly said, "sounds like a nurse!" We all laughed.

Later that night, I heard what it was all about. It was one of our patients, screaming out about being kept in the room. Guess she liked to wander. (Later heard that day shift had found her half-way down the fire escape at one point.) In the course of all of this, the nursing supervisor cam by and asked why the door had been closed, y'know, against JCAHO regs and all. They simply told her that the woman's yelling and abuse had finally gotten too much, so they closed the door for a little bit of quiet...maybe to let the other patients sleep.

"Well," she said, "I'll go and see what is going on." She walked over to the door and opened it, stuck her head inside.

The patient looked up and said. "What the f*ck do you want?!" Then began cussing her out, using more four-letter words than the proverbial sailor. The supervisor, quickly exited, closed the door and without another word about it, went on her way. Just smiled and nodded.

I wonder what JCAHO would really have us do in this situation? I know that closing the door is probably not the best thing, but it was what we had to do. (She was being checked on frequently and sitting in a geri-chair, so she was safe at the time.) Really, there is the ideal world that the surveyors and policy makers inhabit, way up in the ivory tower of administration and then there is the reality of life on an acute nursing care floor. Considering the new report out that nearly 5 million adults in the US has Alzheimer's, we better figure this out, or else instead of being greeted warmly by our patients, we'll be asked "what the f*ck" do we want on a more regular basis.

The Basics:
The Health Insurance Portability and Accountability Act is a group of legislation designed to make it easier to share your health information between providers, i.e. insurance companies, health professionals, while securing that information. It also has provisions regarding insurance coverage, pre-existing conditions and quite a bit more. It is also the genesis for a whole new industry of consultants and companies focused on implementation of its regulations.

How it applies here:
While I couldn't seem to find anything that prohibits medical blogging, within the framework of HIPAA, certain guides need to be followed. Like anywhere, confidentiality of a person's personal health information is to be guarded at all costs. This makes it difficult, especially for newer clinicians or those without a flair for fiction, to accurately present their topics without disclosing too much about the patient.

The Bottom Line:
Names, dates, locations, genders etc. are all modified to ensure patient confidentiality. It is not my goal here to point fingers, talk about people behind their backs, snicker and generally speak ill of those who are ailing, it is a chance for education and a glimpse into the life of a floor nurse in a busy metropolitan hospital. I am trying my best to sanitize each and every account to ensure patient confidentiality, to eliminate things where the reader may say, "I know who he is talking about." With the exception of diagnoses, any relation to persons real or imagined has been identified and eliminated. This is fiction, flavored with fact. The ideas and stories are real, the people are not. The patients are an amalgam of patients done well enough that even their family members would not know it was them.

Thank you for your discretion and ability to understand this.


Addendum - July 11, 2007
With the recent furor over medical bloggers and HIPAA, privacy and all of that, let me add a couple of things.
1. "The other night" means just that. Could be last night, a week ago, a year ago. I have a very long view of time and use that as a way to identify that it happened. Just not when.
2. I try not to identify gender, but when I do, it is usually wrong. Granted that gives me 50/50, but hopefully it takes away further ID.
3. Age. There's old, older and pre-historic. No dates or ages associated...infer as you will.
4. Finally, I know that it is pretty easy to track people down via the interwebs, so my anonymity isn't iron-clad. I'm OK with that. Hopefully you can respect that.

New day, new location, new name. As I lay thinking about writing about work, I realized that it ws probably a good idea to keep my personal blog and work blog separate. If nothing more than to ensure privacy and comply with HIPAA, than to present with a greater degree of freedom than previously.