Guest blog by Laura Nathanson, MD, FAAP.
Author of What You Don't Know Can Kill You: A Physician’s Radical Guide to Conquering the Obstacles to Excellent Medical Care
We’re going through a sticky patch in hospital care. Patients and their loved ones often feel that there are too many doctors (and you rarely see the same one twice) and too few nurses (and it’s hard to get their attention). Worse: it’s hard to figure out just who is in charge -- or whether anyone is. Here’s why:
· Too many doctors:
Many hospitals are Teaching Hospitals. That means that medical students, young MD’s not yet licensed to practice, (Residents), and practicing doctors who are earning a Subspecialty degree (Fellows) all contribute to patient care. And all of them work under the supervision of a fully qualified Specialist or Subspecialist. Many patients have complicated conditions and a resulting profusion of doctors in various stages of training.
All these doctors may appear at your bedside, individually or en masse. They rotate in shifts that are shorter than they used to be; your daytime doctor is unlikely to be your nighttime doctor. And they change crews as often as week to week.
· Nobody in charge:
If you have only two doctors, they need to communicate only with you and with each other. If you have three doctors, there are six crosspaths for communication. If you have six doctors, there are potentially 720 types of doctor-doctor communication. Nobody checks that every such communication takes place and is accurate.
Medical specialists often vie with each other for decision-making power. Who decides if the lung abscess needs antibiotics, or surgical drainage? The lung doctors, the surgeons, or the infectious disease specialist?
Just to top it off, many hospitals now employ their own Hospitalists -- physicians who are charged with being the final decision maker at the patient’s overpopulated bedside, able to overrule a Specialist’s and or a Primary Care Doctor’s recommendations.
· Too few nurses:
We are coping as a nation with a severe nursing shortage. Even if lots more people were eager to become nurses, there are fewer and fewer expert Registered Nurses around willing and able to teach them.
So nurses may not only be few and far between, but exhausted by longer shifts, higher patient loads, the paperwork demanded by Managed Care and the Joint Commission, (a private, non-profit watchdog for hospital standards,) and the rapid development of new skills for them to master.
What can be done?
The fall out from these developments can be serious: errors and delay in diagnosis, dangerous glitches with medication and care techniques, and oversights in ordinary patient safety.
Here are my suggestions for staying safe in the hospital:
1. Ensure that a competent adult stays at the patient’s bedside, and goes along on trips requiring wheelchair or gurney, as close to 24/7 as possible.
2. That adult should serve as a Sentinel, alert to obvious deviations in care (food being given to a patient who is supposed to have nothing by mouth, for instance); ominous changes in the patient’s condition unnoticed by the staff (increased trouble breathing, poor color, incoherence); and situations that are dangerous, such as an unconscious patient who is vomiting and in danger of aspirating the vomitus.
3. The Sentinel should be prepared to perform tasks that free up the nurse for more sophisticated patient care. Offer to empty basins and bedpans, sponge-bathe the patient, tidy the bed, know where vomit basins, bedpans, towels etc. are located, and how to help the patient put on a hospital gown. The Sentinel also may have to call for, or even administer, emergency treatment, such as suctioning the vomiting patient.
4. Ask every caregiver not only their name, but their exact title. If you don’t know what the title means (“I’m a first year fellow in Invasive Radiology,” for instance) then ask (“What is a Fellow? What is Invasive Radiology?”).
5. Ask for the training credentials of the Hospitalist. “Hospitalism” is not a specialty in itself; there are no required credentials, no Board Certification in Hospitalism. Your Hospitalist should be a Board Certified Specialist in the kind of condition the patient has. If not, or if you’re not sure, call your own Primary Care Physician.
6. Every student, resident, and fellow works under the supervision of a senior, board-certified physician. Ask each one who their supervisor is and the nature of his or her credentials. If a surgeon-in-training appears at the bedside to perform a procedure, make sure that the senior surgeon knows about it and agrees to it beforehand (unless it is a truly urgent situation.)
7. The potentially most dangerous area of the hospital is the MRI suite. It contains an extremely powerful magnet that acts on every magnetizable object in the room. Metal devices or fragments inside the body can shift and damage tissue. Loose objects in the room, such as an oxygen tank, will “home in” on the magnet at great speed, regardless of what is in the way -- such as your head. Make sure your technician has checked on all possible dangers. There are no “national” guidelines for MRI safety.
8. Every study or lab test performed is ordered to answer a specific medical question. For instance, Is the bone broken? Is the pneumonia improving? Has the heart suffered damage? If you don’t know why a test has been ordered, clarify it and write it down. Once the test is performed, make sure that the physician who “read” the results actually answers the question.
9. Wear a shrill whistle on a chain around your neck, hidden under your top, to use ONLY in the case of a true desperate emergency.
10. As soon as possible after discharge, obtain and review the records of the stay with an eye towards accuracy, logic, and the credentials of the physicians. Make sure the reports of studies answer the medical question that was asked, and that the reports of students and doctors in training have been annotated and co-signed by the supervisor.
If this all sounds daunting, well, it is. But after thirty years as a physician, and sixty-seven days and nights with my husband in four different hospitals, I can’t honestly offer less intimidating guidance.
It is likely to be decades before we get medical care under better control, and in the meantime it is up to us, the Sentinels of our loved ones, to become the crucial missing member of the Health Care Team: that is, the person ultimately in charge.
Copyright © 2007 Laura Nathanson