The following sections will walk you through how to be a patient in the hospital by introducing you to hospital culture and illustrating ways to maximize the good and mitigate the bad. Their goal is to allay common concerns as you prepare to enter the hub of the medical world.
Think of a sheet of paper with your breakfast order, gliding along the ticket rail at a diner. Though the arrival of toast and eggs is far preferable to that of a chipper phlebotomist and their blue elastic bands, every unit of action that takes place in a hospital—from the delivery of an Alka-Seltzer to a physical therapy consult—happens through a similar, albeit more regimented, fashion.
The order is the main unit in the hospital’s system of checks and balances. It ensures 1) that you, and not Jane Smith, are getting the unit of red blood cells and 2) that everyone from the pharmacist to the nurse agrees that it’s the right type and that it’s indicated for your condition.
At hospitals, there is a hive of activity going on around you that you can’t see and a host of exchanges you aren’t privy to. For example, if you’re recovering from surgery and experiencing breakthrough pain, you might decide that you urgently need something stronger. Unsure when the surgeon will come by and visit on rounds (Do I wait to ask them? Tell the nurse? Call room service?), you settle on asking the nurse. He explains that he’s used all the PRN medications available for your pain but that he will contact the surgeon to request an order for a stronger dose of Dilaudid. You hang on to your bed rails, anticipating that the process will involve a quick phone call or page—about the amount of time it takes you to bring Tylenol to your partner when they have the flu.
If the stars align, it could happen within ten minutes, but realistically it could take several hours. The order for your pain medication is not as simple as nurse-to-cabinet-to-bedside: Once the ticket is on the rail, it enters a veritable minefield of potential stalls.
Your nurse might have to tend to another acutely ill patient before they can get back to the nurses’ station and put in a request to the provider. (Add twenty minutes.) When the surgeon receives the page, they might be in the middle of operating. If it’s after-hours, the page might go to an on-call attending who’s not familiar with your case and needs to read up before they can enter the order. (Add an hour, give or take). Once they determine it’s sound to increase the Dilaudid, they enter an order into the electronic MAR (Medical Administration Record) for the new pain med, indicating dose and frequency.
From here, the order is kicked back to the pharmacist, who ensures that this new dose is appropriate and safe, given your other medications and your health status. They are a second pair of eyes to the ordering provider’s. Once they approve the order, the MAR is updated to show that the new order of Dilaudid is approved. The pharmacist also has to set things in motion for the specific dose of Dilaudid to be delivered to the floor and placed in a mechanized cabinet called a Pyxis or Omnicell. This humming machine (something like the love child of a vault in Gringotts Wizarding Bank and a tarantula) talks to the electronic MAR, so when your nurse signs in with their thumbprint, the machine will alert them that the Dilaudid is approved and ready to pull. (Add another hour, give or take, from pharmacy to machine.)
Two hours and twenty minutes have now elapsed. A nurse can check the order’s status at various points throughout this interval, going repeatedly to the med room to try to pull the pills, but they can’t do much to speed it up.
This system is, understandably, headache inducing. We need the Dilaudid! But if you can grasp it, you can use it to your advantage and spare yourself as much waiting as possible.
If you anticipate needing a medication while you’re in the hospital, something over-the-counter you take at home, such as milk of magnesia or Benadryl for allergies, note them down before going to the hospital. During admission, ask the provider or nursing team to ensure they will be available to you if you need them. They will become authorized orders and available medications, even if you don’t end up needing them. (See “Take as Needed: The PRN.”)
If you are experiencing discomfort, especially pain, don’t wait until it becomes unbearable to speak up about it. Discuss it at its earliest signs and find out what options you have to address it. (See here for language to talk about pain.) Of course, you can’t always anticipate discomfort, and the onset might be sudden. In these cases, remember to treat your nurse like a team member—don’t channel your frustration at them. I say this because they are truly your best partner on this one, and they can and will insert themselves into the process to speed it up or sleuth out the holdup. For example, they can call the pharmacy and alert them to the order that’s yet to be approved—waiting on the phone until they see the red PENDING sign disappear on the MAR in front of them.
Whenever you check into the ER or have a hospital stay, operate on the assumption that you’ll get more tests than you need. You’ll be poked, prodded, whisked off to radiology, and stickered up for electrocardiograms a dozen ways to Sunday. Infuriatingly, much of it may be unnecessary. Tests are often used with wild abandon, a habit that in today’s medical world is born of practitioner survival. Sometimes it’s done to appease insistent patients, sometimes because providers conclude the risk of missing something outweighs the time/money/risk associated with testing.
“Furor medicus” describes an intense cycle of misdirected medical activity at the patient’s expense. It usually happens because a provider feels they must do something, but are unsure what. Excessive testing can fill in for substandard assessment and diagnostic skills, and providers operating within a frantic, inefficient system often have to resort to this practice.
In a system that’s created the eight- to ten-minute appointment, tests are a way to ensure a better standard of care when providers can’t take the time to collect a proper history, look at the case holistically, and pursue all avenues to make a proper diagnosis. Excessive testing is also a $200 billion peril on a national scale, the fiscal waste reflected in your own medical bills.
Still, tests are essential diagnostic tools, and receiving an onslaught of them can provide a sense of comfort. It’s a relief to sense that everyone is on it, ruling things out and honing in on a diagnosis. The idea of something peering into our insides to see things we can’t feel is reassuring!
But testing is not a net neutral when it comes to your health. They can prime you for anxiety, to think, If I’m getting test A, I must have condition A. They can also lead to overdiagnosis, or overly aggressive interventions for a disease that might never cause you problems. They can create noise around the diagnostic process, adding information that can distract from the larger picture or divert attention away to things of lesser importance. And more, they can affect your long-term health: A study by the National Cancer Institute estimated that cancer diagnoses in the United States will see an uptick from excessive CT scans alone.
Settings for Excessive Testing
Teaching hospitals can be hotbeds of excessive testing. When new students get their training wheels taken off, that learning curve is steep (it’s fodder for lots of laughs in the nurses’ station). They have to learn somehow, and many are excellent from the get-go, but in the meantime you’re their guinea pig.
Next, each time you go to the ER, you’re signing up for an extensive and wide-reaching battery of tests. Be as specific as possible about your symptoms, and be extra inquisitive about the necessity of X-rays and scans they’d like to run. This is particularly true for abdominal pain of unknown origin, the most common complaint that brings people into this setting.
When you’re admitted to the hospital, namely for a procedure, providers often order a standard set of tests. They might even be automatically generated orders. This is the time to talk with your providers and ensure that each test is absolutely necessary. If you just had an electrocardiogram (EKG) at an outpatient clinic the week prior, is another one necessary? If you had X-rays taken last month, can they call your PCP and request them? Go over each test and ask these questions, as paying for something unnecessary or exposing yourself to radiation twice just as a matter of policy is wasteful and detrimental. Before any test, ask:
Do I definitely need it?
Are there safer options?
How much will it cost?
What are the risks?
How will it impact things if I don’t do it?
Choosing Wisely (http://www.choosingwisely.org), a campaign started for patients by the American Board of Internal Medicine, has information about overused and harmful tests and treatments. It’s my best resource for determining the necessity of any given test, and I recommend it to friends and family. The site provides recommendations on tests and treatments to avoid for dozens of acute and chronic conditions, and advises on situations in which you should ask more questions before proceeding.
There are multiple entry points to the chain of command in a medical setting, and you should choose based on the nature of the situation you need resolved. For instance, contacting a provider to inform them of poor nursing care might seem logical, but other staff can address this issue with more immediacy. Below are select links in the chain of command that will be most useful during hospital stays.
CHARGE NURSE
A charge nurse is responsible for overseeing care and staffing for a given shift, assigning nurses to patients, and keeping watch over the general flow of the unit. Your assigned nurse will be your number one, but you should turn to the charge nurse for issues impacting your stay outside of direct nursing care, such as a request to switch rooms, or a request to work with the same nurse when they return.
HOUSE SUPERVISOR
House supervisors are administrative leaders who oversee the general flow of departments and entire hospitals. They sometimes run the ship during off hours, weekends, and holidays. They are the go-to source for an issue between the ER and the hospital—if you’re trying to transfer, be admitted, or be released from the hospital when no one is available to help and you’re running into red tape.
NURSE MANAGER
Nurse managers staff and manage different units in the hospital, ensuring quality of nursing care, adequate staffing, and effective policy for handling issues on the unit. Turn to one if your issue is ongoing and relates to quality of care or communication issues.
ATTENDING PHYSICIAN
Attending physicians are at the top of the hierarchy of medical professionals who come in and out of your room. You may not have one directly assigned to your case, but every resident reports to an attending, so this is where to turn if you have an issue with your provider and your provider is a resident.
OMBUDSMAN OR PATIENT RIGHTS ADVOCATE
If the above sources fail you or you’re dealing with an ethical issue, call the hospital’s ombudsman or patient rights advocate. They’ll help you navigate the issue and provide other resources.
Hospital-speak is rife with acronyms, and it’s easy to give up trying to decode them, but there’s one important one that every hospital patient should know: PRN.
In Latin—the matriarch of medical language—pro re nata (PRN) means “as the thing is needed.” In the context of medical care, it means there’s a host of medications the provider has ordered to have on hand for you if symptoms arise. PRNs exist to control anything that might bring you discomfort during the hospital stay: pain, nausea, anxiety, GI distress, or insomnia, to name a few.
Effective PRN use depends on communication with your nurse, who can dispense them at select intervals (for example, every six hours) to stay on top of your symptoms. Because these medications are not scheduled, they depend on you speaking up. Let your nurse know when a symptom is causing you discomfort. Let your provider know if there’s a medication you take from time to time at home (melatonin, Prilosec) that you’d like to have available to you. There’s no such thing as “over the counter” in a hospital. The team needs to know about anything you’re taking because it could interact negatively with something they’re prescribing.
For the best hospital stay, it’s important to understand how shifts work, especially nursing shifts. With few exceptions, shifts are usually twelve hours; 7 a.m. and 7 p.m. mark transitional periods when the floor’s contained little universe is handed over to a new round of staff. The charge nurse will be replaced, and each staff nurse will hand their patients over to someone new in a ritual called the hand-off report. Practiced effectively, the hand-off report is a chance for three parties (the patient, the departing nurse, and the incoming nurse) to get on the same page, review relevant changes or significant issues, and outline the plan for the next twelve hours.
On a bad day or a less organized unit, however, the hand-off report can devolve into kvetching outside the patient’s door—about their bad attitude, indolent provider, or insufferable family member. Nursing, like most medical professions, exacts a specific toll. The stress has to be metabolized—sometimes via collective commiseration after a long day (we all do this this, no matter our occupation!)—but it shouldn’t preclude the hand-off report, which research consistently demonstrates is one of the most critical processes in patient care.
An effective transition can support patient safety and reduce medical error. It’s an essential part of your hospital stay, and you should request that it happen at your bedside and/or in the presence of an advocate. At the beginning of your stay, indicate that you would like to touch base with nurses during hand-off reports. Use these as an opportunity to get a sense of the twelve hours ahead and to locate yourself in the universe that will be rotating at full speed around your hospital bed.
Be yourself. The world worships the original.
—INGRID BERGMAN
When you’re forced to be in the hospital for any period of time, your world becomes small. It atrophies in a literal sense, as it becomes confined to the four corners of a room, and the circumstances can invite you to shut down and be passive. Amid the narrowing, however, patients also talk about the ways their world expands during this time. Where it shrinks in navigable space, it grows in other, unexpected ways.
During this time you can become a shell of your former self, or you can hold court—and I recommend the latter.
Your individuality gets whittled down from the time you’re admitted. You hand over your clothes and valuables. You get into a bed, in a room identical to all the other rooms on the floor, and it’s possible that slowly you become distinguishable from their inhabitants only by diseases and symptoms.
Here, the power of narrative discussed in chapter 7, “How to Talk to Providers,” is at play again. Share stories when they’re relevant, introduce family and friends when staff come and go, add to conversations information that gives you context, and allude to the people, places, and things outside the hospital that give your life meaning.
Put photos up. If you love to cook, write down favorite recipes to share. If you’re a gardener, brag about your tomatoes! If you love reading, recommend a favorite book or pass on one you’ve just finished.
These small acts might seem indulgent or out of place in the medical setting. This isn’t How to Win Friends and Influence People, after all. But these things make you human—they’re a vessel for relating and the scaffolding for empathy. If nothing else, they preserve a space for human connection, a commodity in short supply in the world of modern medicine, where we don’t slow down enough to let it come about organically.
Nothing incites cheer like hearing the word “discharge” after an extended hospital stay. You might be in such a rush toward the double doors, your dog, and your own bed that when the team comes in to discharge you, you toss the paperwork in your bag and don’t look back.
We don’t blame you—especially after the trials of patience we put you through in the time between sharing the happy news and then getting everything done on our end before we can actually let you leave. It’s proper torture to do this to patients!
Being antsy and excited is not the best state in which to properly plan your discharge. It’s like trying to listen to the teacher two minutes before class ends, or attempting to do your best work the afternoon before a vacation. It’s not the best time to think of questions. It’s easy to think, I can call about that if it comes up, and even easier to think this when you’re repeatedly told during discharge, Just call if this comes up.
I propose going about discharges in a new way. Early in your stay, talk to friends or family about anything you’re concerned may be an obstacle to recovering. Nervous about the stairs in your house? Concerned about how you’ll get refills on medications prescribed in the hospital? Want to know if your insurance will continue to cover physical therapy?
Once you have a list, ask to meet with the hospital social worker or case manager. Do this early in your stay, to address your concerns and ensure that your transition out of the hospital will be as smooth as possible. If you schedule ahead, you can have your advocate present at this meeting.
Consider the following topics and prompts to come up with questions relevant to you:
What kinds of bills should you expect?
Will you have follow-up appointments? Can you get to them?
Picture a full twenty-four hours of your day-to-day routine. Will anything be newly difficult?
Do you have concerns about anything going wrong or unmanaged at home? What are they?
Do you need support services, such as occupational therapy or home health? If so, who will coordinate these services—you or the hospital?