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We
are pleased to present the following
excerpt from the book
What You Don't
Know Can Kill You: A Physician's Radical
Guide to Conquering the Obstacles to
Excellent Medical Care
by Laura W. Nathanson, MD
Collins - May
2007
Ten
Tips For A Safe Hospital
Stay
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. Published
with permission.
Dr.
Laura Nathanson is the author of 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 America. For more information,
please visit www.lauranathansonmd.com.
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