Map of life expectancy at birth from Global Education Project.

Thursday, October 27, 2011

The last place you want to be when you're sick . . .

is in a hospital. Hospitals are very dangerous places for several reasons. The most obvious is that there are a lot of debilitated people there with tubes going into their orifices, and often extra holes with extra tubes, that are full of all kinds of nasty bugs that eat antibiotics for breakfast, and then eat people for lunch.

But that's not the only reason. I'll pass briefly over the risk entailed by being in the clutches of doctors who are often overeager to do really radical stuff to you, although I happen to think that's quite dangerous. As Covinsky and colleagues discuss in JAMA, an extraordinarily high percentage of older folks who are hospitalized for one reason or another leave the hospital with brand new disabilities having nothing specifically to do with the original reason for hospitalization. Quite often, they never make it home again. Among the reasons:

Excessive confinement to bed. This can happen due to inappropriate bed rest orders, or because they are essentially tied to the bed by a urinary catheter or IV line. If you can walk, dress yourself, make it to the toilet, etc. when you enter the hospital, you should insist on keeping on doing it. When people who are already frail become inactive for even a couple of days, they often can't get their strength back.

Poor nutrition. Again, people may be placed on restrictive diets inappropriately, but they also may just find it very hard to eat the swill placed in front of them. And, as with the above, when you lose strength due to a bout of malnutrition, if you're getting on in years, it may be hard to get it back.

Falls. The hospital is an unfamiliar environment and believe it or not, regular hospital wards aren't necessarily set up so as to be safe for people prone to falling -- there's a lot of weird furniture on rollers, slippery floors, often the odd piece of paper or linen lying on the floor, not necessarily railings where they should be, etc.

Delirium. The environment is bizarre, noisy, chaotic. People may be drugged or sleep deprived. The result is often loss of contact with reality. Sometimes people never fully recover their cognitive chops.

So . . .

A) Try not to go there, and deal with issues on an outpatient basis if at all possible.

B) If you do have to go there, as I say, be feisty and a pain in the ass and insist on getting out of bed, getting dressed, getting yourself to the loo, keeping to your usual routine of newspapers and crosswords or whatever, as much as you possibly can. Eat. Don't take any crap.

C) The people who run hospitals need to learn how to do it better.

That is all.


robin andrea said...

There is a common mantra in hospitals that patients shouldn't let pain get ahead of them. But it occurred to me, watching my mother become seriously mentally unstable after being overly medicated on Percoset, that hospitals really really like sedated patients. I think the real mantra is, as long as the patient is quiet, all is well.

Daniel said...

Is my recent experience unusual?

I've been in a hospital twice, at birth and earlier this month for 11 days with a brain bleed. The first 2.5 days I was on heavy pain meds via IVs, along with anti seizure meds, calcium channel blockers, etc.

On the 3rd day PT got me out of bed and walking under guidance. They came by twice the next day but by then I could walk slowly on my own and do laps around the ward. This was especially encouraged by the neuro-surgeon who said it was the best thing I could do and to stay out of bed. Every day I walked, sat up in a chair etc. and stayed out of bed. Everyone encouraged this.

A dietitian came by and said it was noted I wasn't eating all of my meals, I explained I usually eat a vegan diet. All my subsequent salads etc. were amazing, couldn't have done better at home.

I was absolutely eager to leave, but I was really impressed by the quality of care I received. I'd classify it as always good to excellent from specialists, hospitalists, nurses, CNA, etc.

The day after I was released, and under orders to slowly get back to a regular routine, I got a letter from the insurance company stating that the hospital stay was too long and they were not obligated to pay the entire bill.

Oh well....

Cervantes said...

Yes Daniel, post-surgical care nowadays -- and for a while actually -- has encouraged ambulation. There's a lot of evidence that the sooner you get people up and walking around, the better. The problem is mostly with older folks, who doctors are apparently afraid to allow to walk around. The vast majority of these hospitalizations do not involve surgery, or only relatively minor procedures. Often it's to get IV antibiotics, an orthopedic injury, rectal bleeding, something like that.

That's great news about the food - I think many hospitals are getting better at that. (Emeril Lagasse's brother, BTW, is the Executive Chef at Tufts Medical Center. Fun fact for your next cocktail party.)

As for the insurance company, if the doctors didn't want you to leave, and obviously you didn't know the payer would try to make you pony up for the difference - well, I'd tell them to go pound sand. Either the insurance company pays, or they don't get paid. It's not your problem.

Robin, you are right about them overmedicating people to some extent for the convenience of staff. People are a lot easier to deal with when they are zonked out. And your mother's experience, as I believe I mentioned in the post, is common.

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