Today had lots of very nice little parts. Work was good; a couple of the patients had happy surprises for me. Then I got to have coffee with Jeanne-Marie who I hadn't seen in ages and who seems to be doing stellarly. To round out my afternoon, Ellie told me the entire plot of the most recent book she's read which involves a girl and her crush time traveling to pre-Civil War times in the U.S. It's funny how sometimes pre-teeners really don't want to talk at all and sometimes they can keep going with breaks only to inhale for twenty minutes.
There isn't a whole lot to report on today, just nice normal normalness so let me point out a couple of nice articles in the 1/24/13 NEJM. There is a nice viewpoint which they summarize as "Awaiting surgery for a malignant pleural effusion, the man is in pain
and looks much older than his 50 years. The medical oncologist thinks
he's dying. But the surgeon believes the procedure will help, and
medical hierarchy discourages questioning of such decisions." I think I have played the part of everyone in this tableau (except the patient, hopefully). Go read it; it's worth the ten or fifteen minutes it takes. One of the things he doesn't talk about that I think is operative in this case is the "herd mentality" where the more people involved in a patient's care, the less likely any particular one is to speak up about things that seem to be going astray. I've had the experience myself where I feel like the patient has five specialists involved in their care and they all evidently think this is OK so why should I, the lowly generalist, make my differing opinion known. There are times I have wished that I had made my lowly opinion known and times it was just as good I hadn't. I try now not to be swayed and to make sure that things make sense to me in any case I'm involved in, but sometimes it's tough. Now that I think about it, I've had that experience most frequently as a hospitalist. I wonder if that is a typical hospitalist feeling or if I'm just special that way. When I've been in the office, I really feel like the internal medicine slogan of "internists: doctors who specialize in you" is true; that I may not be as expert in any medical field as the five specialists this patient is seeing, but chances are I know the patient better than any of their specialists and often I am the only person who understands what all the specialists have to say.
Yesterday, when I ran into some of my old pals, one of them is a specialist who has sent me a few patients all of whom I was very attached to. As we talked about them, I felt a real sense of sadness and real missing of my old primary care practice.
Back to the NEJM. There are a couple of nice articles on smoking, too. This one is on the hazards of smoking and benefits of cessation and has lots of cool statistics for the U.S. like this: "smokers lose at least one decade of life expectancy, as compared with those hwo have never smoked. Cessation before the age of 40 years reduces the risk of death associated with continued smoking by about 90%." Check out figure 2 which shows the survival curves of never smokers versus current smokers. At age 80, it's 70% versus 18%. Whoa, huh? There's also a nice "clinical practice" article about alcohol use. The CPC is a good one and, I am embarrassed to say, one that I should have figured out pretty early on and completely missed. A good reminder to me about that particular disease. (I don't want to say anything more in case you're going to read it; I don't want to spoil it for you.)
Tomorrow is planned to be another really lovely normal normal day. I'm all for it.
I'm going to hope for continued pleasant normalness for me and for you, I will hope that you are having pleasant normalness and that it continues. If not, I will hope that you are able to get to pleasant normalness.
Showing posts with label hospital systems. Show all posts
Showing posts with label hospital systems. Show all posts
Tuesday, February 5, 2013
Monday, December 10, 2012
Day 177 - Ana and Accountability
The original plan for today was a visit to Ana with Maggie so we could all go on a walk and then the humans could go to lunch. When I woke up this morning and saw the rain, I immediately began backpedalling. We decided to still have lunch which was delicious at Golden Bowl, a Vietnamese restaurant that Ana had been introduced to by a Vietnamese doc at Dartmouth. I had vegetarian pho which I thought was delicious. Ana had these crispy noodles with chicken and vegetables in a light sauce that somehow had been infused with just a slight hint of a smokey flavor. I enjoyed mine, but maybe wish I had gotten the noodles. Next time.
After grocery shopping, there was not a whole lot of time left for interesting activities besides a little more weaving and some reading, still Marty Makary's "Unaccountable." I was thinking about what I read yesterday in the setting of the hypothetical procedure of toe reversal. My patients don't need this done very often; I have sent one patient to get a toe reversed, to Dr. A and have had patients get toes reversed with Dr. B, C and D before I met them. None of these patients have had problems with their toes since I've known them so I conclude that probably Dr B, C and D all do a good job.
I have had a couple of patients who have had their toes reversed by Dr. F in the past or who have had the related procedure of toe inversion by Dr. F. Dr. F works in a hospital a few towns over from me. I have never actually even seen the hospital he works in. I have seen maybe three instances of his work. In one instance, the reversed toe, spontaneously re-reversed itself; in another the inverted toe, partially de-inverted and was left as a huge mess and in the third, the toe became infected and had scarred in a not very pretty fashion. Toe inversion is a tough operation, however, with a high fail rate for anyone, although I have not seen any complications with Drs B through D. Remember, however, that my sample size is very small. I have seen probably less than 1% of Dr. F's work and maybe I just got a skewed sample. Dr. F is in a different hospital than me, perhaps the patients who have bad experiences with him get so frustrated they leave that hospital and come to me whereas the happy ones stay there. Maybe it's just random chance and the next patient of his I see will have a perfectly reversed toe or maybe a whole foot of them. Alternatively, maybe Dr F really is not a good toe reverser.
What should I do in this situation? If a patient were to tell me they wanted Dr. F to do their toe reversal, what should I do? Dr F certainly has a right to be free from being slandered by me and with so little evidence. I could not tell a patient to avoid Dr F and to potentially harm Dr F's reputation. I would be speaking based on three bad toes. And yet, I don't really want my patient to go to Dr F. People don't get their toes reversed unless their feet are in desperate straights and no one who is considering toe reversal would be able to use the foot afterwards if it goes wrong. There is not room for a "margin of error" and I want to spare my patients the possibility of a nonusable foot after surgery if I can. How can I balance my need to help keep my patients safe with my need not to libel Dr F? If my husband told me he was considering Dr F for toe reversal, I would say, "please don't." My patients deserve this same level of information from me, don't they? If a patient thought that I let them go to someone I felt was a substandard specialist, they would not be happy with me. I wouldn't be happy with myself under that circumstance.
OTOH, maybe it's not my job to keep patients away from Dr F. He has privileges at a hospital that is supposed to be monitoring his skill level, that has access to all his outcomes, not just three. Maybe I should just relax and trust that the system is working.
If I were at a conference, would I raise my hand saying that Dr F was a "menace"? Certainly, his results are much worse than anyone else I've seen, but I have seen such a small set of his results, maybe what I've seen is not representative. I don't think it's fair to say "menace," but exactly where would one draw the line? What if I had seen six of his toe jobs and they all had complications? What if I had seen one with a really really bad complication--a "never" event, like reversing the wrong toe? Or what if I thought he reversed toes that didn't really need reversing, that he did procedures that didn't need to be done?
Fortunately, it is hypothetical, as I hope was emphasized by the crazy procedure I made up. The next few chapters of the book describe what happened in New York after they made hospital's mortality rates for CABG public as well as some horror stories from Dr. Makary's own training years. It is good reading, thought provoking and I'd encourage you to pick it up. When I'm done, I'll lend it to you if you'd like.
For tonight, for me, I'm going to wish for continued good fortune in excellent colleagues. For you, I'll wish that you are able to get high quality medical care when you need it.
After grocery shopping, there was not a whole lot of time left for interesting activities besides a little more weaving and some reading, still Marty Makary's "Unaccountable." I was thinking about what I read yesterday in the setting of the hypothetical procedure of toe reversal. My patients don't need this done very often; I have sent one patient to get a toe reversed, to Dr. A and have had patients get toes reversed with Dr. B, C and D before I met them. None of these patients have had problems with their toes since I've known them so I conclude that probably Dr B, C and D all do a good job.
I have had a couple of patients who have had their toes reversed by Dr. F in the past or who have had the related procedure of toe inversion by Dr. F. Dr. F works in a hospital a few towns over from me. I have never actually even seen the hospital he works in. I have seen maybe three instances of his work. In one instance, the reversed toe, spontaneously re-reversed itself; in another the inverted toe, partially de-inverted and was left as a huge mess and in the third, the toe became infected and had scarred in a not very pretty fashion. Toe inversion is a tough operation, however, with a high fail rate for anyone, although I have not seen any complications with Drs B through D. Remember, however, that my sample size is very small. I have seen probably less than 1% of Dr. F's work and maybe I just got a skewed sample. Dr. F is in a different hospital than me, perhaps the patients who have bad experiences with him get so frustrated they leave that hospital and come to me whereas the happy ones stay there. Maybe it's just random chance and the next patient of his I see will have a perfectly reversed toe or maybe a whole foot of them. Alternatively, maybe Dr F really is not a good toe reverser.
What should I do in this situation? If a patient were to tell me they wanted Dr. F to do their toe reversal, what should I do? Dr F certainly has a right to be free from being slandered by me and with so little evidence. I could not tell a patient to avoid Dr F and to potentially harm Dr F's reputation. I would be speaking based on three bad toes. And yet, I don't really want my patient to go to Dr F. People don't get their toes reversed unless their feet are in desperate straights and no one who is considering toe reversal would be able to use the foot afterwards if it goes wrong. There is not room for a "margin of error" and I want to spare my patients the possibility of a nonusable foot after surgery if I can. How can I balance my need to help keep my patients safe with my need not to libel Dr F? If my husband told me he was considering Dr F for toe reversal, I would say, "please don't." My patients deserve this same level of information from me, don't they? If a patient thought that I let them go to someone I felt was a substandard specialist, they would not be happy with me. I wouldn't be happy with myself under that circumstance.
OTOH, maybe it's not my job to keep patients away from Dr F. He has privileges at a hospital that is supposed to be monitoring his skill level, that has access to all his outcomes, not just three. Maybe I should just relax and trust that the system is working.
If I were at a conference, would I raise my hand saying that Dr F was a "menace"? Certainly, his results are much worse than anyone else I've seen, but I have seen such a small set of his results, maybe what I've seen is not representative. I don't think it's fair to say "menace," but exactly where would one draw the line? What if I had seen six of his toe jobs and they all had complications? What if I had seen one with a really really bad complication--a "never" event, like reversing the wrong toe? Or what if I thought he reversed toes that didn't really need reversing, that he did procedures that didn't need to be done?
Fortunately, it is hypothetical, as I hope was emphasized by the crazy procedure I made up. The next few chapters of the book describe what happened in New York after they made hospital's mortality rates for CABG public as well as some horror stories from Dr. Makary's own training years. It is good reading, thought provoking and I'd encourage you to pick it up. When I'm done, I'll lend it to you if you'd like.
For tonight, for me, I'm going to wish for continued good fortune in excellent colleagues. For you, I'll wish that you are able to get high quality medical care when you need it.
Wednesday, September 19, 2012
Day 95 - home again, home again!
Here are my statistics for this consolidation:
doses of chemo: 6
visitors (counted only once/person):6
meals I ordered delivered correctly by hospital staff: 8/13
meals I ordered delivered correctly by commercial take out staff: 1/1
how happy I am to be home now: infinity
Compared to consolidation #1, this one was much easier. I feel completely "with it" now (remember I was quite "without it" after my last one); I am a little tired, but not overwhelmingly so. It was harder at the beginning, however, I think, because I had five weeks off instead of the previous measly four so I was starting to see that I could feel normal if I just kept off the poisons. I was not quite so willing to get back on them as I had been the first time.
Another difference is that this time (as is highlighted above) the food service was sending in random meals at some points. I was not all that excited about eating all the time anyway (one of the LNAs said to "eat like it's medicine" and I often have to) and to have something I wouldn't like under good circumstances show up is not that helpful. On the other hand, it became a little funny eventually to see what ridiculous things might show up on the tray. Vegetarian chili? No, sorry, pork roast. Entertainment is always welcome even if random foodstuff is not. Anyway, I'm home now and had Green Bean gorgonzola salad and pesto/mozzarella/tomato sandwich for dinner. I'm stuffed and it clearly made up for several of the "medicine meals" eaten at the hospital.
A second difference is that I expanded my walks a bit. I had previously seen the signs for the "Albert Schweitzer" trail, but had never followed them because I think I felt a little fragile and didn't want to potentially stray that far from the hospital. This visit I was feeling a little more self-confident and stronger and crossed the road (after googling the trails and memorizing their routes). It turns out the trails are completely on hospital land and are about one million times nicer than the circumferential hospital trail (like, they are real woods trails that go up and down and have old trees around and roots across the path and everything). This was good for morale, too.
A final difference was that this time I officially became too uninteresting for the residents' team and was followed by the nurse practitioner. Whether or not I'm interesting is somewhat debatable, of course. I am able to grant immediately that medically I am the dullest patient on the floor (happily!), but I think by virtue of the fact that I'm a practicing doc myself I have a thing or two to offer to residents that is actually hard to get in other ways. On the other hand, they may have gotten a lot of that in their first day with me (who knows what the heart absorbs when?).
Be that as it may, initially, no one explained to me that being on the nurse practitioner's service meant that the attending would still be seeing me. This was a fairly reasonable assumption because my first day on the NP team, the attending did not round on me (the fellow had and that counts for administrative purposes and I was spending a lot of time on the afore-mentioned trail so he couldn't find me, but didn't leave a note or call so I didn't know). I thought it meant that all the faces I had grown accustomed to would evaporate and I was feeling quite abandoned. (note the recurrent problem: goodbye not said) But guess what happened that was really, really nice? The intern who had been to busy to do more than the minimum in the morning had promised to come back to chat and he did. He was under absolutely no obligation to. I was no longer his patient. He could easily have stuck his head in and said something perfunctory or he could have come in and had a short chat with me, but he stayed for a long while--asked questions he didn't have to, answered questions of me he didn't have to. I was touched and impressed. I am quite sure he's going to be really good. Then this morning, I went for a walk (to get the coffee that I have discovered I can stand) and I saw the intern again. He said hi and remembered that I was leaving today. Then a while later I saw the fellow; same thing. I have had many a non-recognizing experience in the common area of the hospital; it made me feel noticed, appreciated. I liked it. I'm not sure what the difference was this admission, but it's good.
Now, after a non-eventful ride, I'm home. I took the dog for a walk, helped a little with homework, walked downtown to get dinner, ate too much and have read one of the semi-junk journals that get sent to us. About once/year I get hooked by an interesting title or two and always waste more time than it's worth. Anyway, a meta-analysis of 300,000+ primary and secondary MI prevention shows that about 50% of primary prevention patients and 67% of secondary prevention patients being adherent to their meds (having the med on hand 75% of the time is their definition). Yikes! Beta blockers are the secondary prevention med people are most likely to skip and diuretics and beta blockers are the primary prevention med people are most likely to skip. Food for thought.
I'm tired now and going to go to bed. I am happy to have felt appreciated and noticed today by the house staff (that's the technical term for residents and fellows). I hope you are feeling appreciated and noticed. I am even happier to be home. I hope you are right where you want to be tonight.
doses of chemo: 6
visitors (counted only once/person):6
meals I ordered delivered correctly by hospital staff: 8/13
meals I ordered delivered correctly by commercial take out staff: 1/1
how happy I am to be home now: infinity
Compared to consolidation #1, this one was much easier. I feel completely "with it" now (remember I was quite "without it" after my last one); I am a little tired, but not overwhelmingly so. It was harder at the beginning, however, I think, because I had five weeks off instead of the previous measly four so I was starting to see that I could feel normal if I just kept off the poisons. I was not quite so willing to get back on them as I had been the first time.
Another difference is that this time (as is highlighted above) the food service was sending in random meals at some points. I was not all that excited about eating all the time anyway (one of the LNAs said to "eat like it's medicine" and I often have to) and to have something I wouldn't like under good circumstances show up is not that helpful. On the other hand, it became a little funny eventually to see what ridiculous things might show up on the tray. Vegetarian chili? No, sorry, pork roast. Entertainment is always welcome even if random foodstuff is not. Anyway, I'm home now and had Green Bean gorgonzola salad and pesto/mozzarella/tomato sandwich for dinner. I'm stuffed and it clearly made up for several of the "medicine meals" eaten at the hospital.
A second difference is that I expanded my walks a bit. I had previously seen the signs for the "Albert Schweitzer" trail, but had never followed them because I think I felt a little fragile and didn't want to potentially stray that far from the hospital. This visit I was feeling a little more self-confident and stronger and crossed the road (after googling the trails and memorizing their routes). It turns out the trails are completely on hospital land and are about one million times nicer than the circumferential hospital trail (like, they are real woods trails that go up and down and have old trees around and roots across the path and everything). This was good for morale, too.
A final difference was that this time I officially became too uninteresting for the residents' team and was followed by the nurse practitioner. Whether or not I'm interesting is somewhat debatable, of course. I am able to grant immediately that medically I am the dullest patient on the floor (happily!), but I think by virtue of the fact that I'm a practicing doc myself I have a thing or two to offer to residents that is actually hard to get in other ways. On the other hand, they may have gotten a lot of that in their first day with me (who knows what the heart absorbs when?).
Be that as it may, initially, no one explained to me that being on the nurse practitioner's service meant that the attending would still be seeing me. This was a fairly reasonable assumption because my first day on the NP team, the attending did not round on me (the fellow had and that counts for administrative purposes and I was spending a lot of time on the afore-mentioned trail so he couldn't find me, but didn't leave a note or call so I didn't know). I thought it meant that all the faces I had grown accustomed to would evaporate and I was feeling quite abandoned. (note the recurrent problem: goodbye not said) But guess what happened that was really, really nice? The intern who had been to busy to do more than the minimum in the morning had promised to come back to chat and he did. He was under absolutely no obligation to. I was no longer his patient. He could easily have stuck his head in and said something perfunctory or he could have come in and had a short chat with me, but he stayed for a long while--asked questions he didn't have to, answered questions of me he didn't have to. I was touched and impressed. I am quite sure he's going to be really good. Then this morning, I went for a walk (to get the coffee that I have discovered I can stand) and I saw the intern again. He said hi and remembered that I was leaving today. Then a while later I saw the fellow; same thing. I have had many a non-recognizing experience in the common area of the hospital; it made me feel noticed, appreciated. I liked it. I'm not sure what the difference was this admission, but it's good.
Now, after a non-eventful ride, I'm home. I took the dog for a walk, helped a little with homework, walked downtown to get dinner, ate too much and have read one of the semi-junk journals that get sent to us. About once/year I get hooked by an interesting title or two and always waste more time than it's worth. Anyway, a meta-analysis of 300,000+ primary and secondary MI prevention shows that about 50% of primary prevention patients and 67% of secondary prevention patients being adherent to their meds (having the med on hand 75% of the time is their definition). Yikes! Beta blockers are the secondary prevention med people are most likely to skip and diuretics and beta blockers are the primary prevention med people are most likely to skip. Food for thought.
I'm tired now and going to go to bed. I am happy to have felt appreciated and noticed today by the house staff (that's the technical term for residents and fellows). I hope you are feeling appreciated and noticed. I am even happier to be home. I hope you are right where you want to be tonight.
Sunday, September 16, 2012
Day 92 - ordinary ordinariness at MHMC
The weather was absolutely perfect New England fall up here. The sun was out, there was a nice breeze. At first, I needed my jacket and sweater and then after I got walking, I could take off my jacket, keep the sweater. There were lots of birds and squirrels out, making all kinds of cute little noises. There were no other people out because the campus empties out on weekends, especially Sundays. I enjoyed my walk very much which was good because I had to work for it a bit.
I woke this morning, beautifully rested. One of my doctors evidently took pity on me and wrote an order for vitals while awake only so I slept through without interruption, then napped when I woke up. Yum! Eight hours of uninterrupted sleep with a two hour nap tacked on, what a dream. I am not sure how to write up the rest of today without making it sound like complaining (especially whining) which I really don't want to do. I mean it to be observation.
So, I woke and ate breakfast. (The nutrition people gave me a default breakfast because for some reason they couldn't get my order straight. I didn't want to waste perfectly good food so I ate it; I don't really like french toast when I'm feeling well and it's good french toast. Ah, well, live and learn--perhaps.) Then I wanted to take a shower and go for a walk. I couldn't take my shower until my port was taped up. Wait for the aid to have some spare time. Shower. Dress.
Ready to go on walk, but Dr. Meehan is rounding. I'm not sure how long he'll be here and don't want to inconvenience him so I wait a while. Then the nurses tell me he seems to have disappeared so I go for my walk. Halfway through I get called back because he's back on the floor. He evidently told them that he would be here for hours and they didn't have to call me which they interpretted as he was leaving imminently and I should come back pretty soon. So I did. Lunch was here (what I ordered--tasty portobello mushroom stuffed with barley). Ate, was rounded upon--I'm doing fine. Talked on phone with Terry, dietary person comes in for tomorrow's choices (unless I want french toast again, I better talk with him--I asked him to return in 5 minutes so I could finish talking with Terry, he returned in 15). Finally, I get to finish my walk which was worth the wait because it had warmed up beautifully and I could take off my jacket after a few minutes and bring it in.
These are not really complaints, but the point is that I am so dependent on other people here that I cannot go for a walk without a half dozen stays and interruptions. I am probably one of the most independent patients in the hospital. I wonder what it is like for the ones who are bedbound, very disabled, have more than one wound that needs to be tended to, multiple doctors who need to round on them, etc. Yikes! Of course, the people who work here have their jobs and are probably just as frustrated by the intersecting needs of the other disciplines and the patients as I am. As a worker, however, I have several tasks to do and if patient one is not available, I can move on to patient two and then circle back to patient one so it's not quite the same as for a patient who really just has one agenda.
Speaking of agendas, for a while today, I thought of nothing but the peanut butter cookies at Au Bon Pain. I was positive they would taste great despite the fact that nothing sweet has tasted great in months. I bought one and, guess what? not delicious. We did stop at the coop on the way in Friday and bought a big bag of salted roasted nuts. These still taste delicious.
Other activities for today have been sudoku, email, reading and chatting on the phone. That's about it for today. Chemo tonight and tomorrow morning.
I hope your interruptions and delays turn out to be useful today and that you have perfect weather for whatever you are wanting to be doing.
I woke this morning, beautifully rested. One of my doctors evidently took pity on me and wrote an order for vitals while awake only so I slept through without interruption, then napped when I woke up. Yum! Eight hours of uninterrupted sleep with a two hour nap tacked on, what a dream. I am not sure how to write up the rest of today without making it sound like complaining (especially whining) which I really don't want to do. I mean it to be observation.
So, I woke and ate breakfast. (The nutrition people gave me a default breakfast because for some reason they couldn't get my order straight. I didn't want to waste perfectly good food so I ate it; I don't really like french toast when I'm feeling well and it's good french toast. Ah, well, live and learn--perhaps.) Then I wanted to take a shower and go for a walk. I couldn't take my shower until my port was taped up. Wait for the aid to have some spare time. Shower. Dress.
Ready to go on walk, but Dr. Meehan is rounding. I'm not sure how long he'll be here and don't want to inconvenience him so I wait a while. Then the nurses tell me he seems to have disappeared so I go for my walk. Halfway through I get called back because he's back on the floor. He evidently told them that he would be here for hours and they didn't have to call me which they interpretted as he was leaving imminently and I should come back pretty soon. So I did. Lunch was here (what I ordered--tasty portobello mushroom stuffed with barley). Ate, was rounded upon--I'm doing fine. Talked on phone with Terry, dietary person comes in for tomorrow's choices (unless I want french toast again, I better talk with him--I asked him to return in 5 minutes so I could finish talking with Terry, he returned in 15). Finally, I get to finish my walk which was worth the wait because it had warmed up beautifully and I could take off my jacket after a few minutes and bring it in.
These are not really complaints, but the point is that I am so dependent on other people here that I cannot go for a walk without a half dozen stays and interruptions. I am probably one of the most independent patients in the hospital. I wonder what it is like for the ones who are bedbound, very disabled, have more than one wound that needs to be tended to, multiple doctors who need to round on them, etc. Yikes! Of course, the people who work here have their jobs and are probably just as frustrated by the intersecting needs of the other disciplines and the patients as I am. As a worker, however, I have several tasks to do and if patient one is not available, I can move on to patient two and then circle back to patient one so it's not quite the same as for a patient who really just has one agenda.
Speaking of agendas, for a while today, I thought of nothing but the peanut butter cookies at Au Bon Pain. I was positive they would taste great despite the fact that nothing sweet has tasted great in months. I bought one and, guess what? not delicious. We did stop at the coop on the way in Friday and bought a big bag of salted roasted nuts. These still taste delicious.
Other activities for today have been sudoku, email, reading and chatting on the phone. That's about it for today. Chemo tonight and tomorrow morning.
I hope your interruptions and delays turn out to be useful today and that you have perfect weather for whatever you are wanting to be doing.
Saturday, September 15, 2012
Day 91 - brief note on room design
Again, my roommate was very nice, and even with a nice roommate, there were some things about the design of our double room which would have made it a real trial for me to have to stay there. (maybe I would have gotten used to them? doubt it).
The first is the afore-mentioned bathroom right by my bed. At CMC, the door to the bathroom is rotated 90 degrees away from both beds, essentially, you walk by the bathroom door as you walk into the room. I think this is a much better solution.
Second, and I don't know that there is a solution to this, the nice armchair is in the window and there seemed to be only one of them in the room. This means that it was impossible for me to use it unless the roommate was out getting a long procedure without having to be stuck on her side of the curtain with her in bed, either wanting to talk with me, talking on the phone with her family or trying to sleep. This situation obviously was not going to work for me and means that I would have been stuck in bed the entire time I was in my room. It would not hurt me to spend hours in other part of the hospital, but I'm glad I was put back into a single. I'm not sure what kind of improvements would have made the chair situation better. I just don't think the room is big enough for two armchairs and the person who gets the window, gets the window.
I know the trend in well-funded hospitals as they remodel is to make every room a single which I think is an excellent plan. I know however, that some hospitals are so crowded they have, even worse, hall patients. If I thought being in a double was terrible, how much would I have enjoyed being a hall patient in one of the over crowded city hospitals?
The first is the afore-mentioned bathroom right by my bed. At CMC, the door to the bathroom is rotated 90 degrees away from both beds, essentially, you walk by the bathroom door as you walk into the room. I think this is a much better solution.
Second, and I don't know that there is a solution to this, the nice armchair is in the window and there seemed to be only one of them in the room. This means that it was impossible for me to use it unless the roommate was out getting a long procedure without having to be stuck on her side of the curtain with her in bed, either wanting to talk with me, talking on the phone with her family or trying to sleep. This situation obviously was not going to work for me and means that I would have been stuck in bed the entire time I was in my room. It would not hurt me to spend hours in other part of the hospital, but I'm glad I was put back into a single. I'm not sure what kind of improvements would have made the chair situation better. I just don't think the room is big enough for two armchairs and the person who gets the window, gets the window.
I know the trend in well-funded hospitals as they remodel is to make every room a single which I think is an excellent plan. I know however, that some hospitals are so crowded they have, even worse, hall patients. If I thought being in a double was terrible, how much would I have enjoyed being a hall patient in one of the over crowded city hospitals?
Tuesday, August 28, 2012
Day 73 - more on coordination of care
I felt so horrible yesterday that all I could think about was my virus. I completely neglected to update everyone on Ellie's first day of sixth grade. She is at the middle school now. The way our school district works is grades K-5 are each done in the towns and grade 6-8 (middle school) and 9-12 (high school) have kids from 5 surrounding towns. This means there is a huge influx of new kids for Ellie this year which should be nice. Some of the towns have like 40 kids to a grade so the middle school will probably be a bit of a shock for those kids. The Lincoln Street School where Ellie was last year has (I think) like 200 kids to a grade so the 120 kids in her 6 classroom "team" is not overwhelming at all. She knows a few of them already and should do fine at getting to know more. She was happy with her back to school outfits both yesterday and today and had a little bit of homework both days. I think it will be a good year. She likes her homeroom teacher so that's a good start.
The other news of my life is that today Emily left for college. She drove her Subaru station wagon to Amherst, MA all by herself and moved into her room all by herself. She is getting to move in early because of her job and her roommate is still on vacation in Maine so she had to arrange the furniture all by herself. Last year when she moved in, we all drove up with her and helped move furniture, carry boxes up the stairs, etc. In fact, Ellie got to miss a day of school to do it. This year, she just backs down the driveway and is gone. She called to let me know she got there safely which was much appreciated.
Otherwise, today was another largely quiet and uneventful day. I tried to do last Friday's NYT puzzle on my own and it just wasn't any darned fun. I found out yesterday that Will Shortz shares my birthday. He is a little bit older than I am, but was also born in the MidWest.
I wanted to talk a little bit about coordination of care. You will easily draw the conclusion, but let me tell you the story. So, on Monday, my labs were really good (it turns out I misread my lab results and my ANC is actually almost 4,000--so that's normal). I asked if I should keep taking my anti-fungal, anti-bacterial and anti-viral. Dr. Manno told me he thought yes, but that I should ask Dr. Hill. I called up and by the time they got back to me, it was today. They said no more anti-this, that and the other and that I didn't need any more labs until my next visit to start chemo jail on September 14. Then about 40 minutes later Dr. Manno's office called me and asked me to come in next week for labs and a visit with him. They pointed out (rightly) that my platelets and hemoglobin are not normal yet and that they would like to follow them to normal. Of course, it's all a matter of what one worries about; there really is no reason my hemoglobin and platelets should not continue towards and into the normal range, but it's always nice to witness and prove these things.
The conclusion, which I think is pretty self-evident, is that NCCC in the north and south would end up looking a lot more smooth and coordinated if they shared their plans with each other. It is kind of awkward to have two fully independent hematologists. They are well coordinated in that Dr. Manno is clear that he defers to Dr. Hill in my case on all things directly related to the treatment and I have been impressed with how well they do that piece, but it would look so much nicer if the little auxillary pieces were in place. I don't feel my care is compromised in any way, just the elegance and style.
I spoke with my friend Linda from Minnesota today and we reminisced about when Ellie was born. Her family were our first visitors in the hospital and she agreed that it was so nice to have a loving, happy thing in their life at that point. I think Ellie had not even had her first bath at that point and was a little less than pristine, but, o, so cute!
My cold is about the same. Last night I woke up with a stuffy nose and whenever I wasn't blowing my nose or sneezing, I could hear Emily coughing. What a contageous household we have here.
I am hoping for a day without excessive mucous for myself tomorrow. That is a fairly prosaic wish, but I will wish it for you, too.
The other news of my life is that today Emily left for college. She drove her Subaru station wagon to Amherst, MA all by herself and moved into her room all by herself. She is getting to move in early because of her job and her roommate is still on vacation in Maine so she had to arrange the furniture all by herself. Last year when she moved in, we all drove up with her and helped move furniture, carry boxes up the stairs, etc. In fact, Ellie got to miss a day of school to do it. This year, she just backs down the driveway and is gone. She called to let me know she got there safely which was much appreciated.
Otherwise, today was another largely quiet and uneventful day. I tried to do last Friday's NYT puzzle on my own and it just wasn't any darned fun. I found out yesterday that Will Shortz shares my birthday. He is a little bit older than I am, but was also born in the MidWest.
I wanted to talk a little bit about coordination of care. You will easily draw the conclusion, but let me tell you the story. So, on Monday, my labs were really good (it turns out I misread my lab results and my ANC is actually almost 4,000--so that's normal). I asked if I should keep taking my anti-fungal, anti-bacterial and anti-viral. Dr. Manno told me he thought yes, but that I should ask Dr. Hill. I called up and by the time they got back to me, it was today. They said no more anti-this, that and the other and that I didn't need any more labs until my next visit to start chemo jail on September 14. Then about 40 minutes later Dr. Manno's office called me and asked me to come in next week for labs and a visit with him. They pointed out (rightly) that my platelets and hemoglobin are not normal yet and that they would like to follow them to normal. Of course, it's all a matter of what one worries about; there really is no reason my hemoglobin and platelets should not continue towards and into the normal range, but it's always nice to witness and prove these things.
The conclusion, which I think is pretty self-evident, is that NCCC in the north and south would end up looking a lot more smooth and coordinated if they shared their plans with each other. It is kind of awkward to have two fully independent hematologists. They are well coordinated in that Dr. Manno is clear that he defers to Dr. Hill in my case on all things directly related to the treatment and I have been impressed with how well they do that piece, but it would look so much nicer if the little auxillary pieces were in place. I don't feel my care is compromised in any way, just the elegance and style.
I spoke with my friend Linda from Minnesota today and we reminisced about when Ellie was born. Her family were our first visitors in the hospital and she agreed that it was so nice to have a loving, happy thing in their life at that point. I think Ellie had not even had her first bath at that point and was a little less than pristine, but, o, so cute!
My cold is about the same. Last night I woke up with a stuffy nose and whenever I wasn't blowing my nose or sneezing, I could hear Emily coughing. What a contageous household we have here.
I am hoping for a day without excessive mucous for myself tomorrow. That is a fairly prosaic wish, but I will wish it for you, too.
Thursday, August 23, 2012
Day 68 - discharging patients
Holy buckets! Today was a packed day! It started with the smoke detector going off at 01:55 this morning and my debating for about one minute if I really wanted to wake Gary and Barbara as they said to. Before I finished debating, it had stopped so I went back to bed and then told them in the morning. Ultimately, Gary took the heater for the boiler apart and there was a piece of fire board (or something) that had crumbled on one end and he thinks that is where it was leaking. We now have our basement open to keep the exhaust from building up. This is a little worrisome because Terry is allergic to cats, the cat they have already is a poor mouser and we already have problems with mice every winter. Hopefully nothing larger will decide our basement looks comfy. There are raccoons, skunks, 'possums and woodchucks in our neighborhood.
The next activity was dog barf and I won't dwell on this more than to say I was worried at this point that the day was going to be really lousy! Fortunately, it turned around once I got to Manchester and got my labs. My platelets were 53 (which is higher than the 20 transfusion threshold so no transfusion), my white count was 1.05 with an ANC of 130 (too low for real food, but clearly higher than the previous 10 so next time!) and my hemoglobin was 9.0 (transfuse at 8.0 so no transfusion here either). This is tremendously good news because it meant that I could spend the day having fun with Emily instead of sleeping while she read. The other funny thing about my labs is that I drank a ton of water on the way in so that my veins would be as plump as possible. This diluted my potassium, hemoglobin, albumin and BUN. I have to figure out how to be well plumped but not too well plumped.
Emily and I then went to the Currier and then lunch with Eva at the Bridge Cafe (soup and a grilled cheese for me--soon one of their fabulous salads) and then I took Emily home and went to therapy. I had set myself up to see my therapist when I was in marrow failure depression mode, but decided it is not a bad thing for people with leukemia to talk with their therapists regularly so I kept the appointment even though I had recovered my marrow and my mood. It was nice to see her and she always has lots of practical ideas so I appreciated talking with her.
On my way home, Terry called to say that he had to go to the ED so I accompanied him there. He's fine, and says that I can tell you the story.
All his life, Terry has had horrible veins and last spring he got some pretty extensive vein surgery which really improved things. Then he got an infected clot in early June and some of you may know that one week prior to my diagnosis, Terry spent a few days at CMC getting IV antibiotics and hoping to avoid more vascular surgery (it worked). He recently took a driving trip to Nova Scotia and returned with a superficial clot and a unilateral swollen leg. His vascular surgeon's nurse told him to go to the ED and make sure he didn't have a DVT. He didn't, they gave him antibiotics and sent him home.
Which finally gets us to the part of the story I wanted to talk with you about. What happened is the nurse told him he could leave, he got dressed and we awkwardly walked out of the ED, nobody particularly said "goodbye" to us or thanked us for coming in or did the very tiniest ritual that would make us feel like the ED visit was over. It was as though we went to some one's house and said "good night" and they walked out of the room, leaving us to find our coats and the way to the door. I had exactly the same experience when I left Leb as well that the nurse pulled my PICC and I finished getting dressed. We picked up my stuff and wandered off. I felt like there was no official closure from the hospital staff. It felt as though once I was discharged, they lost interest in me. I know from being on the other side that hospital discharges are somewhat awkward experiences for the doctors; I always feel afraid to spend much time with the patient I expect to discharge because I worry I will turn up other reasons they need to stay. I wish there was some sort of tiny ritual we could do to make a clear transition between now you are a patient here and now you are out in the world.
In the clinic, it is so much easier; I say "thank you for coming in today; I'll see you in [time period]; please take this up to the secretaries and they'll set up your appointments" and gesture invitingly to the front desk. I think it is awkward in the hospital because patients may get dressed in their own clothes at the very last step just before they leave (I did in case I bled when they pulled my line). The nurse has probably already given the patient their prescriptions, paperwork, appointments, etc. and to have the nurse wait around to re-interact with the patient for a nicety rather than a necessity must feel like a waste of time. And yet. There was probably a time when discharge instructions felt like a nicety and not necessary.
Patients who are non-ambulatory get wheeled to their ride and thus get an official goodbye. I wonder if having the nurse come in and look around the room with the ambulatory patient quickly while saying the "thank you for coming in" phrase would be helpful or not. Or perhaps the nurse could return and say thank you while directing the patient to the exit.
I wonder if anyone else has this unbalanced sense at the time of discharge or if it is only me. Please let me know your experiences.
Well, I'm off to a happy platelet, go marrow, go! bedtime. I hope tomorrow is a good day for all of us.
The next activity was dog barf and I won't dwell on this more than to say I was worried at this point that the day was going to be really lousy! Fortunately, it turned around once I got to Manchester and got my labs. My platelets were 53 (which is higher than the 20 transfusion threshold so no transfusion), my white count was 1.05 with an ANC of 130 (too low for real food, but clearly higher than the previous 10 so next time!) and my hemoglobin was 9.0 (transfuse at 8.0 so no transfusion here either). This is tremendously good news because it meant that I could spend the day having fun with Emily instead of sleeping while she read. The other funny thing about my labs is that I drank a ton of water on the way in so that my veins would be as plump as possible. This diluted my potassium, hemoglobin, albumin and BUN. I have to figure out how to be well plumped but not too well plumped.
Emily and I then went to the Currier and then lunch with Eva at the Bridge Cafe (soup and a grilled cheese for me--soon one of their fabulous salads) and then I took Emily home and went to therapy. I had set myself up to see my therapist when I was in marrow failure depression mode, but decided it is not a bad thing for people with leukemia to talk with their therapists regularly so I kept the appointment even though I had recovered my marrow and my mood. It was nice to see her and she always has lots of practical ideas so I appreciated talking with her.
On my way home, Terry called to say that he had to go to the ED so I accompanied him there. He's fine, and says that I can tell you the story.
All his life, Terry has had horrible veins and last spring he got some pretty extensive vein surgery which really improved things. Then he got an infected clot in early June and some of you may know that one week prior to my diagnosis, Terry spent a few days at CMC getting IV antibiotics and hoping to avoid more vascular surgery (it worked). He recently took a driving trip to Nova Scotia and returned with a superficial clot and a unilateral swollen leg. His vascular surgeon's nurse told him to go to the ED and make sure he didn't have a DVT. He didn't, they gave him antibiotics and sent him home.
Which finally gets us to the part of the story I wanted to talk with you about. What happened is the nurse told him he could leave, he got dressed and we awkwardly walked out of the ED, nobody particularly said "goodbye" to us or thanked us for coming in or did the very tiniest ritual that would make us feel like the ED visit was over. It was as though we went to some one's house and said "good night" and they walked out of the room, leaving us to find our coats and the way to the door. I had exactly the same experience when I left Leb as well that the nurse pulled my PICC and I finished getting dressed. We picked up my stuff and wandered off. I felt like there was no official closure from the hospital staff. It felt as though once I was discharged, they lost interest in me. I know from being on the other side that hospital discharges are somewhat awkward experiences for the doctors; I always feel afraid to spend much time with the patient I expect to discharge because I worry I will turn up other reasons they need to stay. I wish there was some sort of tiny ritual we could do to make a clear transition between now you are a patient here and now you are out in the world.
In the clinic, it is so much easier; I say "thank you for coming in today; I'll see you in [time period]; please take this up to the secretaries and they'll set up your appointments" and gesture invitingly to the front desk. I think it is awkward in the hospital because patients may get dressed in their own clothes at the very last step just before they leave (I did in case I bled when they pulled my line). The nurse has probably already given the patient their prescriptions, paperwork, appointments, etc. and to have the nurse wait around to re-interact with the patient for a nicety rather than a necessity must feel like a waste of time. And yet. There was probably a time when discharge instructions felt like a nicety and not necessary.
Patients who are non-ambulatory get wheeled to their ride and thus get an official goodbye. I wonder if having the nurse come in and look around the room with the ambulatory patient quickly while saying the "thank you for coming in" phrase would be helpful or not. Or perhaps the nurse could return and say thank you while directing the patient to the exit.
I wonder if anyone else has this unbalanced sense at the time of discharge or if it is only me. Please let me know your experiences.
Well, I'm off to a happy platelet, go marrow, go! bedtime. I hope tomorrow is a good day for all of us.
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