Wednesday, September 5, 2012

Epilogue: Case Study Ellen—Good Policy is Not Enough

These last few months have been so intense.  I have seen health care providers who struggle as they try to care for patients while others acted as if caring for a patient was a burden.  It was at the point of patient care that I saw the greatest variability in how someone was treated.  

I remember the nurse in the step-down unit who had said that the IV should be changed every 72 to 96 hours and became annoyed that after 96 hours I asked how come the IV had not been changed.  Her response was that she was dealing with more pressing patients and she would get around to it.  It was clear that the needs of the individual had become either dominated or subservient to some benchmark or target. This is not the health care any of us want or deserve.

As all this occurred I contacted the leadership at Georgetown University Hospital and they were responsive to my many concerns.  They  made it clear that the policies they had developed had not been followed.  All were apologetic and all apologies were accepted but the bottom line is that the patient suffered and died.

Saturday, September 1, 2012

Part IV: Case Study Ellen— Another Trip to the ER

I returned to DC on Monday and my intention was to visit Ellen at the Rehab Center and see how she was doing.  The plan was that she would be there for a while to regain her mobility and then go home.  As I was driving I decided to call Ellen's daughter to see how things were going.  

She let me know that the Rehab Center wanted to call 911 and have an ambulance take  Ellen to Suburban Hospital.  Ellen's white blood cell count was high and they felt she needed to be taken there even though her primary doctor was affiliated with Georgetown University Hospital (GUH).  We were told that the Montgomery County ambulance would not take her to GUH which is located in Washington, D.C.  The only way Ellen could get to GUH was by hiring a private ambulance. And so we did.

So once again Ellen, her daughter, and I were on our way back to the ER.  This time I  let the Georgetown staff know we were coming ahead of time.  We were glad that Ellen was put in the same area designated as Fast Track B. We chuckled about what "Fast Track" means.  

This time Ellen had a wonderful nurse (Jason) who did all he could to make her comfortable.  The 4th year resident (Bobby) had a good disposition and was very patient with her. Ellen had blood drawn, ultrasound of a swollen leg, chest x-ray, and answered many questions. The physician on duty told us that her white blood cell count should not have been alarming as that may have occurred because of some of the medicines she was taking.

In the end they released her to go back to the Rehab Center.  There was nothing wrong with her or perhaps more accurately there was nothing found that could be fixed. Consequently, at 2:20am on Tuesday Ellen was transported back to the Rehab Center by the regular ambulance service.  On Thursday at 1:45pm Ellen died.

Monday, August 27, 2012

Part III: Case Study Ellen— Shades of Patient Dumping

Ellen's daughter, Ann, had been told that Ellen would be moved on Monday to a Rehab facility and so Ann had gone to visit other family members in Delaware to discuss the situation with them. Ann felt that her mother was in a safe place--- Georgetown University Hospital.

Saturday at about 6pm I was called by a representative of Georgetown University Hospital (they meant to call Ann) and was informed that Ellen would be moved that evening to the Rehab facility.  I told the woman that I was the friend and not the daughter and thought it was a terrible idea to move her.   It seemed that now that the insurance had been approved that they were going to move Ellen to the Rehab facility. I let the person who called me know that the person she needed to talk to was Ann (Ellen's daughter) and gave her the correct number to call.  

How had this situation come about?  It seems that Saturday during the afternoon a physician called Ann to confirm the DNR that Ellen wanted and Ann said yes she understood that is what her mother wanted. There was no mention that she was going to be moved that evening.

The move on Saturday was totally unexpected and far from good or responsible care.  Ellen was weak, fragile, and readying to go to sleep when she was disrupted with the news that she would be moved.  A person too weak to go home and yet moved on a Saturday night. One can only imagine the enormous amount of stress this put on Ellen.

Is this patient dumping.  How could anyone have allowed that?  This is not the way that patients or their families should be treated.  

Monday, August 20, 2012

Hispanics and the Undocumented.

A few months ago I presented at a conference at the National Institutes of Health (NIH) and was reminded by the comments that people make that too often what people think about Hispanics is framed by their perception of undocumented people.   The assumption is that all undocumented persons are Hispanics and if there are alot of is probably because they are undocumented and shouldn't be getting services anyway.

The numbers are pretty straight forward.  We know that there are 313 million people in the U.S. and about 55 million are Hispanic.  Of the estimated 11 million people in the U.S. that are undocumented fewer than 8 million are Hispanic.  This means that assuming every undocumented person is included in the count of 55 million Hispanics that 47 million Hispanics are in the U.S. legally. But people like having myths and scapegoats.

One of the proposed reasons for the rise in health care costs is that "all those" undocumented persons are using health resources.  The facts according to the Pew Hispanic Center indicate that 41% of undocumented persons have health insurance and those that do not have health insurance either pay out of pocket or tend to avoid the health care system.  The goal of undocumented workers is to work and not be noticed.  That is why going for any type of health service, especially any which may require an interface with a government agency, is avoided.

So do we have a health crisis in the U.S.?  Most definitely.  But don't blame it on persons who are undocumented.

Part II: Case Study Ellen— Water, nutrition, and the right mattress

My 83 year old friend Ellen was admitted to the hospital because she was dehydrated and very weak.  While in the ER I was told that she also had the beginnings of a bedsore. And while I was glad that she was admitted there were some observations that raised concerns:
  • Just like in the ER health care professionals end up spending more time in front of a screen than in direct patient care.
  • On Day One Ellen was given a large container of ice water with a straw so she could drink water.  The person who brought it did not realize she was too weak to either lift the container or suck from the straw.  I asked that she be given water in a cup and it was written on the board.  When I came back on Day 2 there was a pitcher of warm water that she could not lift and the glass. I got her ice water and filled her cup.  During the time I was there she drank 8 ozs of water.  I told the nurse how much she had to drink but I don't think anyone was really monitoring her intake even though the reason she was admitted was dehydration.
  • Ellen had asked for tissues and while I was gone they left her two boxes---unopened.  I had to open one for her the next day when I returned.
  • Since Ellen is very weak she is not able to eat very much.  I asked if they had Ensure and they said yes. I asked that she be given chocolate Ensure because she will usually drink it.  She was given vanilla.  When I inquired I was told, "... they send what they have."  It was not till Day four that she finally got the Chocolate Ensure.
  • Although the beginning of a bedsore was pointed out to me while in the ER, Ellen was not given the special mattress to decrease the likelihood of the bedsore getting worse. 
  • The care team is supposed to write their name but the only ones who did so were the nurses.
Better than most, I understand the stressors in health care, but some small low cost actions ( water, edible food, the right mattress) would definitely make the patient experience one conducive to getting better.

Part I: Case Study Ellen— If It is Weds. Night I Am in the ER

Over the past four weeks I have spent three Weds evenings in the ER with a friend (two times with Ellen and one time with David). One time at Sibley Memorial Hospital (part of Johns Hopkins Medicine) and twice at MedStar Georgetown University Hospital.  I wish that I could say that one experience was better than the other but the reality is that neither ER was what I had hoped.  They both shared some concerning similarities:

  • Both had staff who spent more time in front of a screen than with patients.
  • It was hard to know who could answer questions.
  • Getting admitted into a room required waiting, and waiting, and waiting.
  • There was no privacy...everyone hears all the HIPPA stuff seems irrelevant.
  • Cleanliness did not seem a priority.
  • Getting a glass of water was challenging.
  • The transition from the ER to a hospital room took too long.
The major takeaway is that people go to the ER when they do not know what to do or when there are no other systems to take care of them.  That certainly was the case for the patients who's assessment I could hear through the curtain that separated us: the person who had a problem with alcoholism and was recurring visitor to the ER, the person who would go to a psychiatric unit because she said she had no place to get her  medication, as well as the person who was in a nursing home and prone to falling.  

Everyone waited patiently because it was clear that the ER needed help. 

Tuesday, March 27, 2012

Gastric Surgery for Diabetes

Type 2 diabetes is a complex condition that we are only beginning to understand, type 1 diabetes is an autoimmune disease, and type 1.5 is a new condition that we are beginning to study. Nevertheless, the media has latched on to two new medical studies and named gastric bypass surgery the new diabetes cure for type 2 diabetes.
I understand that people want quick solutions. I also know that one's relationship with their weight and stomach is complex. But your stomach is not just part of your "beauty" or "physique" nor is it just about digestion. Your stomach is the home for the many good microbes you need that help control your endocrine and immune systems.
Keep in mind that your body has 10 trillion cells and 100 trillion microbes that all work to keep you healthy. How exactly these microbes work is part of an evolving science. Some good information on the microbiome was provided in a recent Wired magazine. You can also learn about the brain in your gut by viewing the TED presentation by Heribert Watzke: The brain in your gut.
So anyone who encourages the cutting out of parts of the stomach as the answer does not understand the relationship between the stomach and health. The surgeons who advocate cutting do not address what happens to your microbiome, i.e., the healthy bacteria in your gut, that we are now learning are so important to our endocrine and immune systems.
Gastric surgery is not the answer.