Being hospitalized is a truly scary experience, even beyond the obvious fear from the issue causing the hospitalization itself. As you are admitted, you realize that the people taking care of you are not actually superheroes; instead, they are normal people doing a work-a-day job just like you. You realize that errors made on the lowest level of the medical food chain may be the ones that get you killed. A registration clerk can accidentally miss a keystroke that changes your middle initial, leading to the wrong blood type being administered to you or the wrong patient’s medication being delivered to your room. You begin to think about how your own motivation and job performance wanes after fighting with your spouse or yelling at the kids before dropping them off at school. With everyone you encounter, from the registration clerk to the lab tech, your assigned nurse, and the doctors in charge of your care, you hope against all odds that they are all having a good day.
As you worry about these things, you are simultaneously reluctant to verbalize your fears to those caring for you: you don’t want to piss off the lady who is about to draw your labs or the young man about to start your IV. Instead, you vow to be very vigilant and watch them all like a hawk. However, you realize two things. First, this is a very foreign environment, and you have no idea what is being done to you or the nuances of the technology involved in doing it. Second, you are sick or injured! You may feel too poorly or be in too much pain to focus on the details of your care. You may be forced to concede your vulnerability and simply hope and trust that everyone cares enough to do his or her best job.
Your hospitalization represents one of the biggest events of your life. Yet to those who are caring for you, you may be the 40th patient of the day. Your surgery may be the third that morning after two emergency cases that kept your surgeon awake all night. To you, it is frightening to think that your crisis may be mundane to your health care team. At the same time, you want them to be experienced enough so that treating you is mundane, from their perspective.
Members of your health care team have to walk an emotional tight-rope where they are able to demonstrate care and compassion, yet not experience so much empathy that they develop “compassion fatigue.” Compassion fatigue is a real risk for doctors and nurses who empathize too deeply with patients. They eventually become unable to absorb one more tragic story or handhold one more patient through a personal crisis. Even if a provider does not over-empathize, an excess volume of work or expectations can overwhelm the capability to care. I remember secretly confessing to my fellow medical students and residents that I had at times wished a patient would die so I could just get some sleep. I was shocked to find that all of the people I confided in admitted to having similar thoughts at some point in their training or careers. Even now, almost daily, an ambulance will get called out for a cardiac arrest, and when the paramedics arrive and call back a “signal 9” (indicating a patient dead too long to resuscitate), the entire ER work station will erupt in a cheer.
I realize these statements may alarm some readers, but they are the truth, and I want you to trust that I am telling the full story. We are dropping a lot of “cold hard reality” on you in this book, telling you many things you probably don’t want to hear, but at the very least I hope we are conveying the sincerity of our claims. While my anecdotes about medical school and life in the ER surely seem incredibly calloused to someone outside the field, it is in fact a normal defense mechanism for those who work in a “pressure cooker,” where the stakes are life-and-death and the acceptable error rate is nothing short of zero.
This stress and pressure is exacerbated in situations where the demand for services greatly exceeds the ability to supply them. For reasons we discussed in the earlier parts of this book, there are many flawed policies that led to exactly this situation. As if the stress of taking care of critically sick and injured people were not enough, modern health care workers are now burdened with a truckload of government mandates, many of them contradictory. They are required to use a cumbersome system of electronic medical records (EMRs) for all order entries and documentation. Of all the things I hear patients comment negatively on, the most common is the fact that their nurses, technicians, and doctors seem to spend most of their time at a computer screen and very little time at the bedside. Ironically, the “patient safety movement” has created so many redundant mandates that patient care is actually being compromised.
Despite all of these downsides, hospitals perform incredibly well and are very vigilant. Nowhere else do you find such good outcomes where the odds are so stacked against those engaged in a challenging endeavor. We must remember that the majority of people in this country die in the hospital—60 to 70 percent, depending on the source. It is very common for patients who are in hospice to end up in the ER near the moment of death because families are not familiar or comfortable with the death process. At least a couple of times per month I am placed in the position of shepherding the family of a hospice patient through the dying process. This is now such a prevalent part of emergency medicine that it is becoming a subspecialty interest for some emergency physicians.
I bring up these realities to point out that hospitals are filled with sick and dying patients. Most of the patients there have multiple medical illnesses and have been in decline for a long time. As we discussed in Chapter 2 with the concept of NNT, drugs never have just a single effect. When you have a patient with multiple illnesses, it is very likely that you will worsen one disease process through the act of treating another. As a patient becomes sicker and sicker, the attempt to treat one problem may disproportionately worsen another, producing the appearance of medical error. Ultimately, in hospitals across the country, patients will die and they will do so in proximity to some sort of medical intervention. When these sorts of things happen it is very easy to interpret them as medical errors that caused injury or even death. This is somewhat akin to storming the beaches at Normandy expecting that no one will be injured or killed. Just because people are dying in hospitals does not mean that hospitals are killing people.
I don’t mean to belittle the dangers of medical errors or suggest that a hospital is a safe place to be, as there are real dangers. However, becoming overly freaked out, or overstating a danger, actually makes it harder for patients and their health care providers to be vigilant against dangerous mistakes. The patient safety movement, while well intentioned and important, has created new dangers.
THE ALARMS THAT CRIED WOLF
“The constant beeping of medical devices in hospitals is causing “alarm fatigue” and putting patients’ lives at risk.
Hospital workers have become desensitized to the noise, which sometimes causes them to ignore the alarms, and has resulted in at least two dozen deaths each year, according to a new report by the Joint Commission, the national organization that accredits hospitals.”1
To understand how to rationally address your risks while in the hospital, we need to understand how we became so concerned about risk that we have impeded our ability to mitigate it. To understand this phenomenon we have to go to the source: the Institute of Medicine.
In 1999, the Institute of Medicine published a report on the scope and nature of medical errors, along with suggestions for decreasing their risk.2 One of the laudable aspects of the report was the focus on systems errors rather than blaming individual actions.
Even so, the report’s preamble contained the shocking statement that “at least 44,000 people, and perhaps as many as 98,000 people, die in hospitals that could have been prevented…. [P]reventable medical errors in hospitals exceed attributable deaths to such feared threats as motor-vehicle wrecks, breast cancer and AIDS.” You can probably guess that the media focused on this part of the report, rather than the nuanced treatment of systems errors versus individual mistakes. It is this statistic that has been used repeatedly by journalists and others to represent patients being killed as the equivalent of a jumbo jet loaded with passengers crashing every day for a year.
The result of this report over the past 15 years has been a bonanza of patient safety initiatives and activity. An entire cottage industry has sprung up around this report, and now hospitals have entire floors of wall-to-wall cubicles of ex-nurses, social workers, and administrative types entirely devoted to patient safety initiatives.
Let me give two examples of the well-intentioned but ultimately counterproductive outgrowths of this report. First, there was a national movement to label all liquids on a procedure tray. This was in response to a single case report of a surgeon who accidentally injected epinephrine instead of saline from cups placed on the surgical tray. As a result, I now have to label betadine (a brown cleaning solution) that is in a cup and lidocaine (a clear liquid) that is in a syringe on every suturing procedure I perform. Failing to do so is a firing offense, even though it is impossible to mix up the intended purposes of a brown liquid in a cup and a clear liquid in a syringe. It is also extremely difficult to accomplish under sterile conditions. The solution has been the production of kits with pre-made labels at enormous expense when calculated on a nation-wide basis.
The other example I’ll give of an inappropriate application of rules that do not truly promote safety is the expansion of the “time out” procedure. This was born from the experience of wrong site or wrong patient surgeries. The “time out” has been a ritual amongst the best surgeons for a very long time; this was not something that was recently invented. The way it works is that you identify the patient appropriately, and if there is to be a surgery on any paired limb or body part, you write “yes” on the limb or part that has the procedure and “no” on the incorrect side. Before you begin the procedure, you take a “time out” to confirm the patient identity and surgical site. However, since the IOM report came out in 1999, the “time out” ritual has been applied to every single procedure imaginable, even those cases where common sense dictates it is not necessary. For instance, time outs for laceration repair in a non-paired body site are patently ridiculous. Even when the body site is paired, it is pretty easy to see which side needs the laceration repair. Nonetheless, the ritual must be performed—and most important, documented—to satisfy an arbitrary rule that does not serve the original intent.
Do not misunderstand me: I can fully appreciate the public’s horror at the idea of waking up and realizing your surgeon amputated the wrong leg! It is entirely appropriate that hospitals adopt procedures to make sure this type of outrage is exceedingly rare. (Many readers would have wanted me to say “impossible” rather than “exceedingly rare,” but that would only be true if we stopped amputations, period. Is that the right solution?) What I am saying is that we have to use our heads when devising the safety protocols. It makes perfect sense to insist on a “time out” when it comes to leg amputations, but it does not make sense to do so for stitching up a gash in the neck. The sad effect of over-applying a great idea to inappropriate situations is a gradual desensitization to the process in general. It is the same phenomenon we discussed in Chapter 2 regarding the FDA’s rules on advertising. When it comes to things that can significantly affect your health, you want the safety rules to be as crisp and sensible as possible; ironically, this is the worst area to cast too wide of a net.
Let me be clear: I do want to emphasize that medical error is a real problem, and that those convened to address the problem are in fact well-meaning people doing important work. Further, actual improvements have occurred since the advent of the IOM report. It is important to create a culture where error analysis can be done openly. Different lines of work carry different risks when an employee has a bad day: a birthday cake may have a misspelled name, a steak may be undercooked, or an investor may lose money. A bad day at the hospital means someone’s child can die.
However, there is a downside with anything you do, and as we have learned, those downsides are magnified when you implement change in a top-down fashion. One of the biggest problems with this campaign is that things are not as bad as the 1999 report made them out to be. A hospital is a place where critically ill and dying patients are cared for. A medication or procedural error can occur with a critically ill or dying patient. If you retrospectively go back and discover such an error in a patient who has died, it is very easy to attribute the death to the error. This is especially true if you have been commissioned to write a report on the problem of medical errors. In some cases, off-protocol treatments given as a last-ditch effort in a dying patient may have been scored as an error.
Overstating dangers can also create real dangers. Being too quick to sound the alarm—crying wolf—makes us not respond to the alarm any more. There are so many safety procedures and precautions in hospitals nowadays that it actually impedes patient care and exhausts the ability to be truly vigilant. When safety measures are feared or resented, they will not make you safer. When the ER doctor and nurse have to go through an arduous “time out” ritual and documentation to relocate your obviously dislocated right index finger, then safety has actually suffered.
To make sure I’m not losing any readers, let’s make a quick detour into the “real world” that you all know: flying on a plane. How many readers carefully listen to the stewardess before the plane takes off, as she explains how to operate the seat belt? This is exactly the kind of thing I am talking about in this section. The government—in this case, the FAA—mandates absolutely absurd “safety protocols” that the airlines must obey, or else they go out of business. Flying passengers can sense that these drills are patently absurd, and so tune them out. Now, does this mean flying carries no risks? Of course not; the whole plane can crash into the Pacific Ocean—that’s pretty dangerous! My point is that slapping on a bunch of nonsense regulations so that we feel we’re “doing something about safety” is not only silly, but it actually crowds out possibly meaningful information that the flight attendants could give during those announcements.
The patient safety movement has spawned numerous private agencies that rate hospitals on their safety. In principle this sounds great, but in practice it too produces unintended consequences. For example, every region has smaller community hospitals that boast on their billboards some safety award from one of these agencies, while regional referral centers are lambasted in the papers for their safety record. But consider that when patients are too sick or unstable for the community hospital, they end up being transferred to the referral center. When you take sicker patients, who have been hospitalized multiple times and who have had multiple rounds of antibiotics at the community hospital, then your infection rates are going to be higher than other centers, and you may have to administer treatments that do not fall into “best practices” parameters.
As our new safety culture unfolds, we are seeing truly excellent surgeons who have unfavorable safety statistics because they are willing to take on the sicker and more challenging cases. People of lower socioeconomic status are more likely to be such sicker patients. How many specialists are dropping off ER call to avoid uncompensated care of patients who might damage their safety profile? How long can a referral center withstand the bad press that is their only reward for serving as backup for a community hospital? The biggest danger emerging from the patient safety movement that the sicker you are, the less anyone in the medical profession will want to associate with you.
In contrast to the often-exaggerated dangers, in this section I want to focus on the real things you should worry about if you must be hospitalized:
• Your doctor does not work for you. Your doctor is not paid by you. His treatment of you is based on protocols and “best practices” that are required by the government, third-party payers, and hospital administrators. These protocols may contradict the type and extent of treatment that you desire or that you and your doctor think are best. If your doctor deviates from protocol—even when it is per your desires—he may not be paid, could be financially punished, or could even face firing or loss of privileges. Your doctor may be faced with a tough choice between your wishes and practice standards. This is even truer of the hospital. There are ever-tightening criteria for what constitutes a “legitimate” hospitalization and what will be paid for. Even when you are hospitalized, the hospital will only be reimbursed for a certain number of days or a fixed amount. This creates immense pressure to treat and discharge you within the allotted time frame. An army of case managers is continually looking over the shoulders of inpatient doctors in attempt to discharge patients “in a timely manner.”
• The patients are sicker than ever. Most of the patients will (hopefully) be sicker than you. The sickest patients have chronic diseases of civilization and have been dying slowly for decades. This creates an environment that expects patients to just be tuned up until their next hospitalization. The idea of treating and curing an acutely ill person is becoming more and more foreign. Because the staff is used to dealing with people with much poorer protoplasm, you face the risk of over-treatment, and because the staff is used to sending patients home who are still experiencing signs of illness, you face the risk of premature discharge. As patients have gotten sicker and resources more scarce, the acceptable criteria for admission have become more stringent (you have to be sicker) and the criteria for discharge have become more lax (you can be sent home less well). The presence of these sicker patients means that they may distract care from patients who do not come from a background of chronic illness and may appear to be lower risk. Finally, patients who are in and out of the hospital become colonized with multi-drug resistant organisms—organisms that you will be exposed to during your hospitalization.
• The system is overburdened with patients. Overcrowding combined with reduced funding results in understaffing relative to the demands. Your caretakers will be pushed to the limits of their attention and coping ability at all times. They are constantly just one small surge in volume away from tipping into disaster mode. Fatigue combined with frenzy puts you in real jeopardy.
• The system is overburdened with rules and regulations. As if mountains of chronically ill patients are not enough, there are also endless regulations and requirements to be met in the process of caring for this tsunami of sickness. Irrelevant documentation requirements have been set in place to try to deny payment to hospitals, meaning the hospitals must insist on following the requirements if they want to get compensated for their work. This leads staff to ask a patient who is having a heart attack about ringing in the ears, or a history of domestic abuse; or asking a person with a laceration about smokers in the family, seatbelt usage, or presence of guns in the house. The time staff spends doing these sorts of things translates to attention diverted away from your real problem.
• EMRs (electronic medical records) have crippled efficiency. As we discussed previously, the government has pushed EMRs down the throats of providers without any evidence of improved efficacy. The result has been cumbersome systems that have all but ground clinical care to a halt. If you are ever hospitalized, take note of how much time your doctors and nurses spend tapping a screen. These inefficient systems and government mandates have turned these professionals into the highest paid data entry clerks in the world. EMRs also increase the risk of improper data or simple data entry errors being populated forward with each new encounter. Worst of all, the system is fragile. One power outage, computer outage, or sunspot event could bring an entire hospital to its knees. All of which poses a danger to you.
• Doctors and patients have both been made fungible. The third-party payment system has subverted any true price system where value is objectively calculated. A top-notch orthopedic surgeon who has done thousands of hip replacements gets reimbursed the same amount as an orthopedist just out of residency who has to read the product insert of the prosthesis and be guided by the product rep. Payment for your illness as a patient will be based on your diagnosis, regardless of how complex your case may have been. The fact that both you and your doctor have been made into interchangeable cogs means that you have little means of detecting the best health care providers, and you run the risk of being the square peg that gets rammed through a round hole.
• You have been made the enemy. As is inevitable with price controls, there is resentment between the provider and the consumer. To the provider of inpatient care, you essentially represent an overwhelming risk of financial loss. You also represent medico-legal risk, as well as potential fraud allegations from a government that does not want to pay out what it has promised—and that has created a web of impossible-to-follow laws that reclaim paid-out funds and levy fines so that the system can limp along.
Finally, after laying all of this groundwork to dispel some of the hysteria surrounding the IOM report, as well as making you aware of the dangers no one has previously informed you of, we can now discuss some specific measures you can take to protect yourself in the unfortunate event that you, or a loved one, are hospitalized.
This is first and foremost. If you are hospitalized, you want someone who is familiar with your health, personality, and wishes at the helm. Ideally, this will be a doctor who still admits his or her own patients to the hospital. When your own doctor is writing admission orders and doing daily rounds, you will have a greater chance of influencing care. Hopefully, this will be predicated on having selected your physician by the criteria we discussed in Chapter 10. When this is the case, your prior discussions and meetings will be in your doctor’s consciousness, and will make their way into your treatment plan. It is quite uncommon for primary care doctors to admit their own patients for reasons we have covered previously. Even if your doctor does not do his own admissions, the fact that you have a doctor will positively influence those providing your inpatient care. Your doctor’s practice style and philosophy will be known and this will influence your care in a positive way. Your doctor provides referrals to the specialists who may be called in on your case, and these specialists will be more responsive and will operate in a way that keeps your doctor happy.
The ideal circumstance is that you have a primary care doctor who participates in a cash-only plan or concierge practice, has opted out of Medicare and Medicaid, and does not file directly with insurance. This means you will have to pay your doctor out of pocket and get reimbursed by your insurance. In some cases, these doctors avoid all the hassle by having an agreement with their patients that they will not bill for inpatient services. In this case, you will have someone at the helm of your care that can be more resistant to government-mandated treatment protocols and length-of-stay requirements.
The best way to avoid the dangers of hospitalization is to avoid being admitted in the first place. For instance, if the reason for admission is the need for IV antibiotics, then try to accomplish this on an outpatient basis at an infusion center. If you have a blood clot in your calf or thigh and need anticoagulation, see if you can be self-taught how to administer your Lovenox (blood thinner) injection at home. If you have a respiratory illness that requires breathing treatments and oxygen by nasal cannula, see if this can be set up through a home health agency. Many times hospitalization occurs only because of technical issues with treatment. If there is no difference between treatment in the hospital versus similar treatment administered at home or at an outpatient facility, then you should not be hospitalized. Before agreeing to hospitalization, make sure there is something that is going to be done to you in the hospital that cannot be done elsewhere.
Which is the better route? The answer is: it depends. If your admission is elective or for the performance of an inpatient procedure, and you are stable, then direct admission is the way to go. You can be seen at your admitting doctor’s office and your doctor can make arrangements for you to go directly to an inpatient room with his admission orders in hand (or transmitted electronically). If, however, you are acutely ill, unexpectedly ill or injured, or unstable in any way, then it is best to be admitted through the ER. In some cases, you may have to go directly to the ER and your doctor will become aware of your illness after the fact. In other cases, your doctor may send you to the ER for stabilizing treatment and workup. In such situations, the ER can carry out treatments quickly that cannot be accomplished on the floors. Lab tests, x-rays, and other tests can be acquired in a much more expedited fashion, and their interpretation by the emergency physician can guide your treatment and determine the setting to which you should be admitted. Advance notice from your doctor before your arrival at the ER can help represent the acuity of your situation, so that you are triaged appropriately and your evaluation is expedited. ERs around the country are bursting at the seams, but if you are unstable or acutely ill, it is where you need to be.
This is where developing the strong social connections implicit in a primal lifestyle will come in handy. You need to have established the sort of close personal relationships that ensure a support system will rally around you when you are hospitalized. You really want to have a close friend or family member with you throughout your hospitalization. Not merely for the moral support, but also to help look out for your best interests. If the person(s) staying with you have a medical background, all the better. Your advocate needs to be very defensive of you, and unafraid to ask questions on your behalf. Your advocate can be a watchdog who makes certain that the people who care for you have washed their hands and properly identified you before administering treatment. Your advocate can be on point when you are too tired or ill to concentrate fully. Your advocate can help communicate your wishes when you feel too vulnerable to assert yourself. Just the mere presence of someone who looks intelligent and interested will be enough to make the people involved in your care bring their “A” game. Ideally, your advocate(s) will be with you at all times, even if this means friends and family are working in shifts. If this cannot be achieved, then try to have your advocate present for the medical team’s morning and afternoon rounds, where scarce time should be applied. If you are hospitalized away from home, or are otherwise unable to have such a support system, ask the nurse in charge of your care if the hospital is able to assign a patient advocate to you.
Make sure you bring (or have been brought by someone else) your cell phone, tablet, and/or laptop, along with their respective chargers. These are your connections to the outside world. If you have selected the right doctor, he will also be your connection to the person in charge of your care. He will likewise be a source of entertainment during the long boring stretches. You can look up issues related to your treatment on the Internet, investigate any potential drug-drug interactions, or check out websites like thennt.com. Also, do not forget other “stuff” like your toiletries, a change of clothes for when you are discharged, and your favorite pillow and comforter.
I highly suggest preparing ahead of time a “fact sheet” to bring with you to your hospital admission. This is a sheet that you can hand to anyone filling in information on your chart. All of this information is required for documentation in the medical record. Some of it is incredibly important, while some is utterly ridiculous. All of it is mind-numb-ingly tedious for whoever is stuck entering this data. The fact that it is such an agonizing part of your admission makes it error prone, and like an early mistake on a trigonometry test, its impact will be passed forward throughout this—and possibly any future—hospitalizations. Your admitting nurse or doctor will be incredibly pleased if you hand over a document with the following information:
• Full name
• Birthdate/current age
• Social Security number
• Race (it can actually be relevant)
• Gender
• Religion (if any)
• Your primary language
• Marital status
• Occupation
• Allergies (medication, food, or anything else); include the nature of the reaction (extremely relevant)
• Prior exposure to general anesthesia and if there were any problems
• Your current weight in kilograms (your weight in pounds divided by 2.2)
• Your current height in inches and centimeters (multiply inches by 2.54)
• If you use tobacco or alcohol. Specify type and amount (can be relevant). Include exposure to second hand smoke
• If you have been subject to domestic violence in the past two years (only if you wish to disclose)
• If you have firearms in the household (only if you wish to disclose)
• Your last tetanus booster
• If you have had this season’s flu or pneumonia vaccine
• Your preferred emergency contact and medical power of attorney if you become incapacitated
• If you have a living will or advanced directive
• Your preferences for resuscitation status (full code, CPR, ventilator, do not resuscitate)
• Organ donation status/preferences
• Your insurance and policy number
• Your family doctor and his office phone number
If you can hand a sheet like this to the person doing your intake documentation, he or she may fall down and kiss your feet.
Be sure to bring the worksheet you composed if and when you were trying to come off medications. This should include all of your medications with both trade and generic names. Include the dose, how taken (oral, transdermal, etc.), and the dosing interval. Also include all supplements that you take, even those you fear might make you look odd. For example, fish oil may postpone an invasive procedure because of its blood thinning properties. Vitamin K may be relevant if you are going to receive prophylactic therapy for deep vein thrombosis, and olive leaf extract has calcium channel blocking properties. The possible interactions are extensive, so list all of your supplements. Any medications that will be continued in the hospital, along with the medications that are ordered during your admission, will be combined on a “medication reconciliation form.” Make certain that a hard copy of this is kept in your paper chart. Also request a hard copy you can keep on your person. If the hospital’s computer portal or EMR crashes, a hard copy of this form can be a real life saver. At the time of discharge, you should receive another medication reconciliation form that includes your prior medications and any new medicines you will be sent home with, along with how long you will be on these new medications. Make sure you have such a form to take home at discharge. Use it to update your medication worksheet.
Whenever someone enters your room to do anything for you or to you, demand that they confirm your full name and birthdate. Do not let this slide, even if your nurse has seen you 20 times that day. Remember he or she is overburdened and likely does not remember your name. Every so often, give them a fake birthdate or wrong middle name and make sure they catch it. If they do, just give them an “I was just testing you” tease and then provide the proper information. If they let it slip by, let them know they screwed up and that you don’t want it to happen again. If you are blown off, request the charge nurse or hospital administrator.
“My full name is Denzel Washington.”
Some readers may not be the “pushy” type, and may think the suggestion to quiz every nurse and doctor on your name and birth-date is just too awkward. But consider this: the mere fact that you ask this type of thing will keep everyone on his or her toes when dealing with you. That is exactly what you want. If the nurses all chuckle and roll their eyes behind your back, it means they are thinking about your case even after they’ve left the room. The following statement is critical to understand: if something bad (and preventable) happens to you in the hospital, it’s not going to be due to a malicious intent to hurt you. Rather, it will be caused by an honest mistake due to fatigue or overwork. The best way to prevent that from happening to you is to make yourself stand out from the moment you show up. This is one of the rare situations where yes indeed, you want to be “that guy” (or lady).
If your condition permits it, make certain to get out of bed and walk around the ward or hospital at least two times per day. Every two hours that you are awake, practice coughing and deep breathing. The walking helps to prevent venous blood from pooling in your legs where it could form a blood clot or deep venous thrombosis. The walking, along with the coughing and deep breathing, prevents a condition called atalectasis. When you lie in bed for a prolonged time and do not breath deeply enough, the lower segments of your lungs do not ventilate fully. As a result, the tiny air sacs do not expand and will fill with fluid. When this happens, you can develop a fever that can create confusion about your condition. Even worse, the fluid can colonize with bacteria from the hospital environment and actually develop into pneumonia. Hospital-acquired pneumonias tend to be more virulent and difficult to treat than community-acquired pneumonias and represent one of the greatest dangers of hospitalization.
On the wall of your room, right by the door, should be a dispenser of an alcohol-based instant hand sanitizer. Anyone who enters your room should hit that dispenser before touching you or anything in your room. If they fail to do so, immediately offer them a hit of your hand gel before they touch you, the bed rail, or the computer keyboard. The last thing you want is some MRSA or multi-drug resistant bacteria from your neighbor down the hall deposited on you or on any surface in your room.
You may only be able to communicate with your doctor or team of doctors once or twice per day. This is the time where discussion about tests, procedures, and treatments will occur. It is your sole opportunity to be prepared for what is going to happen, and to bring your preferences into the equation. As such, make sure you discuss with your doctor when to expect rounds to occur. Let your nurse know this information as well, and make sure that it is confirmed by his or her experience. Let your nurse know that you want to have a heads-up about rounds, and under no circumstances should you be allowed to sleep through rounds or be off the floor when they occur.
When the team comes to your room, you need to have all of your questions and concerns prepared. Rounds are performed in a rapid-fire fashion and can be over before you know it. Make sure you get the opportunity to have all of your questions answered and for the next stage of your hospitalization to be clearly laid out. Ask if you can use your smart phone to record the discussion so you will have it for future reference. Also, make sure your advocate(s) are present for rounds. The presence of articulate and well-dressed friends and family will put everyone on notice that all involved need to be on their toes.
Hospital food is almost universally horrible. It is generally straight out of the ADA guidelines, minus any hope for palatability. Ask your doctor if you can have your own food brought in for you. Your advocate(s) can keep you on an optimal primal diet that will help speed your healing and recovery. If you must eat hospital food, specify a gluten-free diet and then pick around with primal principles in mind.
As important as the admission process is, the discharge process can be even more important. Unfortunately, many patients’ experience of discharge planning is having a nurse walk into the room to announce “congratulations, you are being discharged.” The next thing you know, you are in a wheelchair on the way to the front entrance of the hospital while you frantically dial your cell phone for a ride home.
One of the reasons for this is the extreme push to get patients out of the hospital as quickly as possible: the inpatient payment formulas only allow payment for a certain number of days for a given diagnosis. Therefore, make certain that you are truly ready for discharge. You may simply still feel ill, or you may not have been able to make the appropriate social arrangements at home. When you check in for admission, you will sign a form acknowledging your right to block any discharge that you feel inappropriate—which is based on Medicare law, but is often given to all patients. If you state that you do not feel ready, and yet you are still pushed to leave, then tell your nurse, doctor, and discharge planner that you wish to exert your right to appeal the discharge. This will usually buy you more time. If this fails, bring the issue to the hospital administrator.
In general, though, you should be happy to be discharged at the soonest possible time. Even so, you need to leave with a clean and well-planned transition. Your discharge medications and home instructions for self care, as well as exact dates, places, and times for follow-up, should all be provided in an easy to read (legible) format. A specific discharge time, arrangements to gather all of your belongings, and a way home should all be in place the day before (or the morning of) your discharge. Again, make sure all of your questions and concerns are addressed before leaving. Once everything is in order, grab your bag of belongings along with your get-well balloons and climb into the wheelchair for your ride to the front awning.
Congratulations! You survived.
