I Aten’t Dead

I am torn between being disappointed at how poorly hospitals work and being amazed that they work at all.

There are two hundred different very specialized professions all trying to help the same set of people. As difficult as medicine is – and goodness knows it is difficult – maybe about half of the resources of hospitals and the people inside them are devoted to anything remotely medical, and the other half are devoted to the near-impossible enterprise of synchronizing these hundreds of different professions into providing something that looks vaguely like coordinated care.

Everyone’s time is so expensive that the system can’t afford to let them waste precious moments figuring out what they’re doing. So pretty much everyone looks at a computer system that tells them what they’re doing, does it, and then enters what they did into the computer system, along with what that implies for other people. The computer system then updates itself and tells other people to react to what the first group of people did.

This happens. A patient tells the nurse that he feels short of breath. The nurse places an order in the computer for a doctor to evaluate the patient. The doctor reads the computer system, evaluates the patient, and places an order for the nurse to draw blood to send to the lab. The nurse draws blood and places an order for the lab to test the blood. The lab tests the blood and places an order in the computer for a doctor to read the lab results. The doctor (who may be a totally different person from the first doctor in this story) reads the lab results, diagnoses pneumonia, and places an order for the pharmacy to send pneumonia medication. The pharmacist sends the pneumonia medication and places an order for the nurse to give it to the patient. The nurse (who, again, may be a totally different nurse) gives it to the patient, who tells the nurse he feels much better. The nurse places an order for a doctor to evaluate the patient. The doctor (who by this point may be a third doctor) says it looks like his pneumonia is gone and places an order for the case manager to discharge the patient. The case manager finds somewhere for the patient to go and places an order for big burly guys to wheel the patient to the door. The big burly guys wheel the patient to the door and place an order for an ambulance to come pick the patient up and bring him to the nursing home.

(because – and sorry for the interjection – it is always a nursing home. One of the first things I have learned is that, of the 1000 different places you can send patients when they improve, 999 are euphemisms for “nursing home”. If you are old, and a doctor tells you “Don’t worry, we’re not sending you to a nursing home, we’re sending you to a rehabiliation hospital/skilled care facility/group care institution/convalescent center/ANYTHING ELSE A DOCTOR SAYS TO AN ELDERLY PERSON”, be aware that these are just different ways of saying “nursing home”)

But getting back to the point – that’s ten orders just in this ludicrously simple example. At each of those steps, someone who has no idea who the patient is and might never have anything to do with him outside this single five minute interaction has total responsibility for patient care. At each of those steps, someone can use the computer wrong, place the order for the wrong patient, or accidentally forget the order and leave the patient sitting out in the corridor for twelve hours.

And every single one of those steps is a horrendously busy person who has received five orders at the same time, all of which are marked “HIGHEST PRIORITY” and who are operating on four hours sleep, and each of whom hates everyone at every other level because they keep giving them more work to do. And they are orbited by consultants, specialists, subspecialists, subsubspecialists, subsubsubspecialists, The Guy Who Knows Everything About The Protein Biochemistry Of One Tiny Part Of The Gall Bladder And Nothing About Anything Else, respiratory therapists, speech therapists, physical therapists, chaplains, Bessie The Adorable Pet Therapy Dog, social workers, People Whose Entire Job Is Sitting Next To Suicidal People And Making Sure They Don’t Kill Themselves, nurse assistants, nurse assistant assistants, nurse assistant assistant assistants, businessmen who overuse the phrase ‘patient-centered’, dieticians, pharmacists, and me.

My job as an intern is to navigate this bureaucracy. I’m with an attending – an experienced, prestigious doctor – who doesn’t want to waste any time. He just wants to go “Someone tell me what’s going on with the patient in room 824” and have someone answer “They have such and such a history and these lab results” so he can say “Yup, I use my massive medical expertise to diagnose that as Disease X, give them this and this and this intervention and then give them a repeat scan” and then move on to the next patient.

My job is to write down all the information he wants and get it for him, then write down all the stuff he wants done and do it for him. This generally involves entering orders into the computer, then begging people to do them, then calling them to see if they were done on time, then wailing and gnashing my teeth when they were not. It’s noticing that a patient who was supposed to have had a CT scan ten hours ago is sitting in the corridor looking lost and somewhat un-scanned and trying to figure out where something went wrong and how it can be corrected and if necessary threatening that I will have my attending yell at whoever is responsible.

Basically I am a secretary, but a secretary with enough medical knowledge that when my attending says “Order some piperacillin” I won’t spell it “pie bear on ceiling” or ask whether it is some kind of exotic fruit. Enough medical knowledge that if someone gets left out in front of a CT for ten hours, I know when to say “do the CT scan now because it’s the right thing to do” versus “do the CT scan now or she will probably die”.

Sometimes I get sent to take medical histories and examinations from people. They are never glad to see me. They usually say something like “I’m in constant pain and I can’t breathe and I just answered these exact same questions for the paramedics and the emergency room doctors, do I really have to do it again?” And I say “Yes” and then ask them How Long The Symptoms Have Lasted and Whether They Smoke Cigarettes because those are the rules.

If you are entering medical residency and want to prepare for it, practice reciting the following phrase: “I don’t know the answer to that question, but I will page my senior resident and he will get back to you.” I keep getting paged by nurses with questions like “Your patient in room 315 has critically low potassium, please advise.” And I went through medical school and I know stuff about low potassium and I have clever ideas for what to do and probably in over 80% of cases those ideas would not kill the patient. But “over 80%” is not enough so each time I have to find my senior, who is extremely busy and hates getting paged exactly as much as everyone else, and ask him a stupid question I already know the answer to. A lot of my job seems to be a totally useless middleman in between patients and nurses who have questions and senior doctors who have answers, but I’m learning a lot and one day I hope to bring my “ideas that will not kill the patient” ratio up to the 90% or so which is considered acceptable.

I have already helped, in a little tiny way, keep some people safe and healthy. It’s not always very dramatic. A few days ago I was looking at some numbers on a chart, and I was like “Hey, in medical school when I memorized this number, it was a much bigger number, and here on the chart it’s a very small number. That sounds like the sort of thing we should do something about.” The woman for whom that number represented the amount of blood cells in her body was probably happy I noticed. And today we had a Rapid Response, ie the kind of thing where everyone is running around waving defibrillator paddles and overusing the word “stat”, and I was yelled at to get some blood from the blood bank, and I successfully got some blood from the blood bank even though this required an entire phone call and two different operations on the computer.

And I have already made mistakes. I’m pretty sure I gave an elderly woman an unnecessary CT scan she had already had two or three days before, which probably cost a few hundred dollars. I came very close to ordering a medical procedure for the wrong person, although luckily it was caught beforehand. I made some mistake in ordering a guy’s coagulation status checked that made him stay in hospital an extra day until the check could be repeated.

And I’ve already had one patient die. He died today. It wasn’t my fault. He was brain-dead and hooked up to a ventilator, and the family chose my first week on the job to pull the plug. Palliative care patients are the easiest patients ever, and my job was limited to listening to his heart and lungs once a day or so and nodding sagely and telling the family that The End Was Getting Near. The last day I saw him, I leaned in to his chest to listen to his heart, and saw he was wearing a necklace that said “Whosoever Dies Wearing This Scapular Shall Not Suffer Eternal Fire – The Promise Of The Blessed Virgin”. Within about a second I had three major thoughts:

1. “And here I am, trying to cultivate virtue and avoid vice, LIKE A TOTAL CHUMP!”

2. “Is this, like, a legendary artifact? Should I be trying to steal it?”

3. “Wait, if people believe this works, why do they wait until someone’s on their death bed to put it on them? What if someone gets hit by a car? Struck by a meteorite? What kind of person has a necklace that saves them from eternal damnation, but only wears it on special occasions?”

And then after about ten seconds, during which I was trying to remain very solemn-looking, as if I found the patient’s heart sounds extremely interesting in a detached medical way, I thought “Wasn’t there something I used to do when I found something fascinating and bizarre like this? Somewhere I would record things back when I wasn’t working sixteen hour days, six to seven days a week? Didn’t I have some kind of a blog? I should find that and write about stuff there.”

But don’t expect too much more out of me in the near future.