Thursday, June 4, 2009

Survive a short hospital stay (at Duke University Hospital)

I want to take a step back and review how we keep patients (especially elderly patients) safe and alive during a hospital stay.

IMHO, summers are probably the worst time to undergo surgery at a teaching hospital. There are a new (and largely untested) crop of young doctor wannabees. Experienced physicians and surgeons will provide these wannabees the opportunity to care for the surgical patients.

But the over-tired, over-egotistical and under-professional young doctors are desperately trying to exert their importance. These young doctors are often too insecure to ask important questions. Oh, a bad sign. That makes the environment ripe for accidents and errors.

Mark E. Easley, MD (Duke orthopedic surgery) performed a life changing and foot saving surgery on my 76 year old dad on Monday June 1, 2009. Dr. Easley recognizes that my dad (and my dad's daughter and wife) dislike Duke University Hospital. Knowing that mental attitude is essential for the patient to succeed, Dr. Easley arranged for dad to have the surgery performed at a comfortable setting (the outpatient Duke Ambulatory Surgery Center). Great place.

But then dad was transferred to Duke University Hospital to spend one (repeat one) overnight.

As an advocate, you must:

1. Speak with the actual surgeon after the surgery. Ask questions. Make certain that you understand the surgeon's orders regarding weight bearing status (if the surgery was on the lower extremity) and make sure you understand the surgeon's expectations.

Dr. Easley was clear that my dad was non-weight bearing and would only have to spend one night in patient at DUH.

2. The surgeon is tired and is going to leave after he or she knows the patient is stable. And I waved good-bye to Dr. Easley.

Dr. Easley undoubtedly expected that the hospital staff member/orthopedic surgical resident would have correctly heard Dr. Easley's orders or, at a minimum, contacted Dr. Easley if he had questions. A question would surely occur if he patient's family disagreed with the orthopedic surgical resident's recollection of Dr. Easley's orders.

As an advocate, you have every right and responsibility to challenge the young doctor if he tells you something you know to be untrue. This is particularly true if the "something" has the probability of damaging the health or safety of the patient.

3. If necessary, you should contact the surgeon (in my case, Dr. Easley) yourself and nip the conflict in the bud. That is precisely what I did. And since by the next morning the young orthopedic surgical resident still thought my dad was full weight bearing, the email response from Dr. Easley was instructive to the young doctor wannabee.

4. If your patient is on Medicare then there is just a plethora of tests and consults that the hospital can order to make money! And this could take days. If your elderly patient is anything like my dad, being in a hospital is a horrible, scary experience.

As an advocate, you have every right and responsibility to contact the surgeon's nurse or PA directly to discuss discharge plans. You should inform that office that you certainly do not want to be disrespectful to the surgeon. However, unless the surgeon indicates a medically necessary reason or need for your patient to be in the hospital, then you intend to have your patient discharged.

It is important and respectful to communicate with the surgeon's office. That physician knows the patient's condition. That need to communicate must to weighed against the mental and emotional damage to your elderly loved one every moment that he or she is unnecessarily in the hospital.

IMHO, one of the reason health care costs are so high is that Medicare (i.e. in Obama-speak, "the public insurance option") has very little administrative costs on the front end, where claims are readily approved with little investigation. A hospitalist (or in the orthopedic resident situation, "hospital staff") tends to suck the life blood out of the Medicare system by requesting consults that are just plain a waste.

Due to DUH's failure to notice my dad's serious foot infection in August 2008, I have been successfully transferring my dad from chair to commode and chair to bed numerous times. I have taken dad to Duke physical therapy since September 2007. And, unless dad is in the DUH, I take dad multiple times a week.

My dad's safety has been my priority since he was diagnosed with cancer in April 2007.

I was frankly offended that the orthopedic surgical resident required that I demonstrate my competence to care for my dad before the resident would allow a discharge. And IMHO, requesting such unnecessary consults perpetuates Medicare waste.

BTW, I would have left DUH Tuesday afternoon irrespective of whether the orthopedic surgical resident was satisfied that I could car for my dad properly. If Dr. Easley wanted dad to remain under hospital care, I would have arranged an ambulance to transport dad to Duke Hospital (in Raleigh).

And, I can help but believe that the occupational therapy, physical therapy and wound management consult were part of the orthopedic surgical resident's mandate from DUH to get as much money from Medicare and supplemental insurance as possible.

PLEASE remember that the patient is the most important person in the hospital setting. Be polite. Try (your best) not to raise your voice. But, use your gut instinct and best memory of what the surgeon told you to ensure that the vulnerable patient is receiving proper medical care.

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