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Belly of the Beast #1: Musings on My Recent Hospitalization PDF Print E-mail
Written by John Weeks   

Belly of the Beast #1: Musings on My Recent Hospitalization

My contribution to the work in integrated health care stems from the breadth of my working relationships with the diverse stakeholders with a hand in the process. I've worked with leaders of hospitals, managed care companies, academic health centers, government agencies, venture capital groups, and complementary healthcare professional associations.

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The appendix - not a pretty sight
But until now, I hadn't had a significant, personal experience of the central stakeholder experience of Western medicine. From September 15-19, I entered the vault where most of medicine's attention and money is spent. I was a consumer of inpatient hospital service
s.

In truth, I'd experienced an overnight hospitalization in 1993 following a retinal re-attachment surgery needed following a basketball injury. The placement of a retinal buckle and later laser-tacking of the retina were straight-ahead miracles of modern medicine, for which I am daily grateful. This time was different. I had a concern which I presented, in the ER, as a gut ache and likely appendicitis. The surgeon took the appendix that night, gracias a Dios, and came back with a concern that I might have cancer of the appendix. He had me originally on a 5-7 day wait for the pathology report - which ended up, with patient pressure, taking just 3 days. Cancer?
Maybe I'd have to go under again, have a section of my colon removed, might need a colostomy bag, and what if they don't get it all out ... ?

Rumors of Death and the Gut Mortaring of Ballgame Peanuts and Kettlecorn
 


Peanuts,
kettlecorn ...

On September 13,

an afternoon
Mariners game,
I took my bowels
to the limit,
one more time.
 
I spent two days post-surgery fluctuating repeatedly to 104 temp. The staff has surprised by their inability to control it. Did they get all the infection out? Was the unusual temp related to a need to go under again, or something else going on?  I knew of such complications. Three of my five siblings have had their appendices removed - two had burst, like mine, and had nasty infections. (I was assured of no genetic link.)

These and other minor probabilities and major life and death potentialities floated about in my morphined and fevered state.

My conscious attention was not, typically, so focused on life's larger questions. I had made what I felt was a personal contribution
to the gut condition. I typically consume inordinate amounts of ballpark peanuts and kettlecorn at Seattle Mariners games. My wife has marveled at my "iron gut". On September 13, an afternoon game, I took my bowels to the limit, one more time. (My physicians stated without doubt that there was no linkage to the appendicitis, and thus they weren't too interested, though this was a major contributor to my experience through the whole ER and hospitalization process.) 

Image
Not officially implicated, but influential
For me, this set the incident up as potentially a case of self-inflicted constipation. By the afternoon of September 14th, my 55th birthday, I knew something was off.  However,
Mr. Iron Gut, I proceeded to mortar everything up with the rich foods of my birthday celebration. Bottom line - and we are talking about the bottom here - I spent 3 of the 4 hospital days dwelling in the swampland below Maslow's hierarchy of needs, at the infantile baseboard of the lowest Chakra, awaiting the passage of gas.  My 10 year old daughter high-fived me when the blessed relief finally came. My Kingdom for a fart!

All is well that ends well. I am thankful for the laparoscopic technology and my doctor's surgical skills. Beyond that, this was quite an experience. With this posting and a companion piece on cost, I offer you some of my musings from inside the belly of the beast.

Thumbs Up, Mostly, on the Human Care

My decision of when to go in for care - influenced by a $5000 deductible - I save for the companion piece, about costs.

Image
Bless the nurses - more international than this portait
Once I spiked a fever and my wife whooshed me off, I had, frankly, low expectations for the care I would receive. A family ER visit earlier in the year had put us face to face with a series of human drones, a stereotypically cool hospital experience. I could, with imagination, recognize that each of these humans, paid to take care of my family member, in that earlier visit, actually had human qualities of warmth, compassion, and  interest. None of this had been on display. Funny, you could tell they were decent souls. The humanity had just been drained out of them in the workplace. It hadn't been a pleasant experience.

So following my wife's strategy, we went to a different ER, about a mile away, of the same, sprawling, successful, dominant local hospital system. Less busy, we thought. Perhaps shorter waits and better care.

Bingo. The intake, and care from the nurse, the aide and the medical doctor were all personable, timely and forthcoming. The pattern mainly held in my in-patient experience. It was actually a wonderful United Nations of a hospital wing which boasted a nursing staff from six US states and 8 nations, speaking 16 languages. Two of my nurses, in particular, Michele and Jose, both Filipinos, were especially thoughtful and present.

One Hour of Physician Connection, Out of 90


I knew that nurses provide care in hospitals. I was surprised by how little contact, other than the surgery, I had with any physicians. The total time-tally over the roughly 90 hour stay is something like this:

  • 3 short visits with the surgeon (15 minutes or so)
  • 3 visits with a family practice resident doing a surgical rotation (15-20 minutes)
  • two visits with another resident (10 minutes).

Some may have checked my machines when I was sleeping. No complaints here, just interesting to observe. Does make me wonder how the American Medical Association has decided to take on the nurses as their chief enemy in the Scope of Practice Partnership. My experience was that 98% of my care, aside from the surgery itself, was pretty well already being handled by nurses.


... then Again, the Borg and "Process Errors"

The national debate and work on hospital safety, medical errors and medical deaths has lately been referring to a new kind of error. The error, neither human nor mechanical, is called a "process error."
The concept places fault squarely with the Borg, the modern sprawling, assimilating, impersonal health system. No human is tabbed with responsibility. Instead, we have a no fault scenario for which the patient pays, sometimes dearly.

Image
Process errors - the Borg did it
I had no significant negative outcomes from such process errors. But I could see where the seams of care might peel apart, especially had I been a more complicated case. It started at the beginning, in the ER. My spouse, with nearly 30 years in health care, wrote up an excellent, thorough history of my situation. The note did not follow me anywhere
. Not to the ER treatment room. Not to the surgeon. Both disrespect and loss of good information.

Then there was the "process" issue that came from the merger of the two hospitals
into the larger system. (We'd had the nasty ER experience in the dominant hospital.)  We learned, on diagnosis of appendicitis, that a health system executive decision had removed all surgery but cardiac to the other hospital. So I had to be transported via ambulance. While this did not effect my outcome, such an economically-justified efficiency could significantly influence the course of another's care. (The ER doc said to watch out for insurance forms for this $800-$1000 item since the hospital was responsible for paying it, due to the policy decision, but it would probably still be billed.)

Other surprises: Note-taking on my condition was frequently still done by nurses on scraps of paper. Did these make my file? My repeated sweating through of my gown and sheets, thus a need for a change, never seemed to make anyone's consciousness and certainly was not communicated across shifts. (Routine thigh-taping of the catheter tube would also have been nice, preventing a couple painful moments.) Tylenol to reduce fever and Percocet for pain were left by the bedside, with no clarity on the staff's part that I had, or would, take them. Three times I was, though in a pain-killer haze, asked to self-report on how many doses I had received. Uhhh ... lemme see ...

Then there was the business of temperature taking. One nurse routinely took it a second time "because it's always lower" the second reading. But everyone else's baseline is the first reading ... Twice aides didn't much care when I told them I'd just been sucking on ice, dropping my apparent orally-taken temp by degrees. Just wanted to square-check their charts.

Communication between shifts seemed faulty. Again, my case was pretty straight-forward. But how about the fellow next to me, with a dozen tubes running into his body?

On the Hospital's, In-Room Advertising of It's Desire to Offer "Excellence"

Pet peeve - borne of the internal and external "excellence" campaigns of many hospitals and health systems, frequently heard on radio and television. I woke from the surgery and saw, on the far wall, next to the white board on which my nurse and aide were to write their names when they came on shift, a sign which read:

We want you to Experience Excellence

Please let us know how we can meet your needs

From inside the pain and haze I thought: Experience excellence? One thinks about "excellence." This is an appeal to the rational mind, a kind of adding of columns and comparative measures. Not ready for that. It doesn't compute. What I want is to experience the warmth and care of human beings. How about:

We want you to Experience the Warmth of Human Caring

while we seek to provide you the very best in medical treatment.
Let us know how we can meet your needs

The hospital marketeers would probably say that such caring is an assumed part of "excellence". From my perspective, in recovery, "excellence" should have been positioned as an assumed part of "caring." The sign seemed to be the hospital talking to itself.

Meantime, a simple place to work on both human care and excellence was the white board itself. Batting .333 is great in baseball. But this is a failing mark as a percentage of personnel who actually made a point, when coming on shift, of writing their names on the white board so I could know who was serving me. A good first step to shift our relationship from "appendix by the window" and "nurse." I routinely had to remind them that it was meaningful to me that they write down what their names were.

Complementary Treatments .. Not! - Except from a Friend and Family

My hospital did not offer me a menu of complementary services that might have been to my liking. In fact, I thought it best to pretty well keep quiet about my own background and work so that my care would not be shifted by the defensiveness that the mention of complementary care quickly stimulates in some medical personnel. Occupation: Writer/organizer.

Image
A little complementary care ... from friends
That said, on the third day a friend came in and offered a foot-massage and reflexology treatment which immediately began to create percolations in my until then nearly dormant gut. Happily for her, the real action did not begin until that evening when my spouse and daughter took a foot apiece and repeated the process, to similar GI activity. I'd also been served up a little homeopathic Lycopodium, 30c, toward the same end. Ten minutes later, during a walk, my daughter gave me her post-fart high-five.

Were this a small, rural hospital, I might judge the institution differently. But this is a wealthy hospital which serves a Seattle-area population known for its interest in health and use of complementary and alternative treatments. Failure event, here, on the "excellence" campaign.

The Food, the Gawd-Awful Food ... and Missed Teaching Opportunity

Now this is reprehensible. With all the breakthroughs in medicine in the last half century, this hospital's food sense was straight Campbell's soup 1950s. How a healthcare institution in 2006 can claim to have any relationship to "excellence" while still promoting these nasty foods to people in much more challenged healing processes than I, is infuriating. One thinks, at these times of the strategy used by Mao in the Chinese Cultural Revolution: the executives responsible for the selection, and the food service companies with which they contract, need to be sent to the countryside for "reeducation." Have none ever heard of Hippocrates' teaching to let your food be your medicine and your medicine your food?

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Campbell's: Best of the dismal hospital fare
Is it time go from IV hydration to the "Full Liquid Diet"? Campbells soups. Jellos. Sugary custards and puddings. Do we really want to promote coffee drinking, Pepsi, espresso shakes and milkshakes in those moments of a person's healing? I chose what seemed to be most promising, a "Fruit Smoothie of the Day". How could I have imagined there would be real fruit involved? Some cherry sugary syrup whipped with ice. Time to go from liquid to the full diet? Lasagna, pizzas, nachos and cheeseburgers. To be fair, there was a salad or two. Think iceberg lettuce and raddish slivers. It is long past time that hospitals use their engagement with patients to promote the eating of decent, healthy foods, to let them know about choices that may be better and easier for all aspects of their healing processes, and for digestion, and good living.

I began eating foods at home with two excellent vegetable and chicken soups, one cooked by a sister-in-law, another by my spouse, and a great gazpacho made by a good friend from tomatoes from her own garden. When will we routinely have such choices in hospitals? I also came home to an email from a friend with a link to an Associated Press article entitled "Hospitals Go Organic for Patients' Sake," about changes in Good Samaritan Hospital in Portland, Oregon. It can be done.

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Hippocrates - needed on the hospital lecture circuit
And Overall ...


...  I am thankful for the surgery, for laparoscopic technology which will, above all, help me keep my figure, and for the care from the nursing staff.  I am glad I had family around, and  especially for the guidance of my spouse, Jeana, who also helped out by doing the internet search work in the time we had questions.

Finally, I have increased desire that Donald Berwick, MD, and his Institute for Health Improvement  (see related Integrator article) have the vision to take up the banner of patient-centered, person-centered care which has been recommended to them. With a patient-centered perspective, the good care I received would have been backed by good, smart use of food, the option of healing therapies and the certainty that the names, on the white board, were those of the human beings who were caring for me.

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