Ten Tips For A
by Laura Nathanson, MD, FAAP
Author of What You Don't Know Can Kill You
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
Author
Dr. Laura Nathanson is the
author of What You Don't Know Can Kill You (Published by Collins; May
2007; $15.95US/$19.95CAN; 978-0-06-114582-7) and The Portable Pediatrician,
as well as several other books. She has practiced pediatrics for more than
thirty years, is board certified in pediatrics and peri-neonatology,
and has been consistently listed in The Best Doctors in
For more information, please visit http://www.lauranathansonmd.com.