Thursday, May 27, 2010

How to survive hip surgery at Ellis and learn to enjoy it

(from the NAMI Schenectady newsletter, May-June 2010)
It's 8:40 am. They've had me in pre-op two hours already, taken my clothes and wallet and glasses and dressed me in a johnny shirt. Abruptly, someone grabs my bed and pushes me roughly into the hall, zigzagging along as I study the ceiling tiles flashing by overhead. They come to a plain door in the hall and it opens and they wheel me into bright lights. What a disappointing little room with a few scattered people flitting by and a few tables for apparatus. Imagine—this is the core of the hospital—the grand operating theatre, where people survive or die at the hands of skilled surgeons while nurses watch the blips of electronic machines and liquids in translucent bags flow silently into the body to keep vital life signs going. Like we see on the hospital shows on TV. The eerie aura of life and death hanging in the balance is in there and it's unsettling unless you put it out of mind and take as comfort that you are in the hands of the best people we have,the best trained, the best team, the latest equipment. I say to myself: Brother, I trust. I feel special in the center of the room. They've whisked me out of my bed onto a narrow bench or table. I could almost fall off of this it's so small. Is that the best they can do? I thought. They whisper hello. I think it's the anesthetist who now greets me. They're assuming positions around me. He clamps a plastic mask over my nose and mouth, lifts it off and says, you'll be out in a few seconds. I'm not out right then, but the mask comes down again and I'm off in dreamland.

Next—it seemed an eternity later--I woke up in post-op, with a head full of cuddly dreams and imaginings of stars and moons. How are you feeling? Someone asked, the same question I would receive umpteen times a day from now on. I felt like I'd been away a long time. They took me by gurney to my room on A-3, post-surgery and somehow slipped me into my bed where I slept for hours. Then hospital life begins: the first night or two they wake you just about every hour to take vital signs--blood pressure, pulse, and temperature (the last is done by machine with a swipe of your forehead—no more thermometer under the tongue. Someone from the hospital lab comes in at 5 or 6 am to wake you and draw your blood, every day. The nurses and student nurses who crowded into my room ask me questions and have to write everything down. They check my dressing. My hip surgery went well—the incision is clean and untroubled with a cross hatching of dark staples down its length, like repair after a shark's bite. The housekeeper even woke me at 6 one morning to introduce herself. The day nurses streamed in and out, 18 or 20 separate visits the first day, inquiring, soothing, wordlessly doing their chores. They push a console with a laptop computer on it and spend awhile pushing the screen to record my vital signs and assess my condition. Out in the hall they're doing more of that, nurses studying their computer screens and punching keys. That's modern nursing.

My bed is wide and comfortable and above my head is a line of switches for them to turn lights on or off. They can elevate or lower my bed's upper half. I have a phone to order my meals and a remote control for the thin-screen high-def tv on the wall. This must be the queen suite in Ellis Hospital, armed to the teeth with modern technology. I'm hooked up to an intravenous line with a fluid bag hanging overhead on a metal tree with an electronic contraption blinking out red or green numbers on its face. Then there's the pump. It's ingenious, a small plastic grip with a button on it in bed alongside your hip which you press whenever you feel pain. Well, every body knows after getting part of you removed you're going to feel pain and so you push that pump pretty darn often. The line from the pump goes up to an overhead bag with liquid dilaudid, an opiate narcotic that Ellis chooses to use as its main pain mollifier, in place of pills and other injections that have been used in the past. Imagine—no pills, just push the pump and feel instant relief. It invites odious comparisons with the appeal for instant gratification that junkies must feel with their drugs on the outside. This is more humane, of course, to comfort us, to let us know our every tremor and ache can nevertheless bring peace of mind. (Oh, to have the drug maker's contract with hospitals that issue this magical drug.)

As the days grow and I begin to feel less pain and more like a human being, they talk of discharging me, first to Sunnyview and then home. But there's a catch—my MVP Gold insurance doesn't cover rehab at Sunnyview for some reason so they cant get me in there even though the head discharge nurse says, we're going to take you down there Saturday morning and roll you through the gates. They were stopped before they started. So Ellis goofed here, they suggested I go home only three days after my surgery and that wouldn't work. Why should someone at home do the rehab and close care that's needed so soon after? Rehab is part of the process of getting better—daily exercise and attention to each step of the way. And you don't dump people back home right away. The compromise,which suited me, was to have a home-duty visiting nurse-physical therapist come to our house several times after I finally left the hospital after the weekend. She put me through my paces and this worked well, thanks to Visiting Nurse Service (bless them for what they do).

Now, it's much later when I write this, three weeks after the big event. I can sit up and type on the computer and answer the phone, even with the last of the aches and pains coming from my rump. Oh, still I long for the pleasures of the Ellis pump, the assurance it gave each of us, the lofty, dreamy feelings it created. I remember I couldn't read the first few days in hospital while taking that stuff. My mind wouldn't concentrate, my eyes wouldn't focus on the page, they ran off to other lines of text. I thought it was me but it was the drug. Anyway, if you're thinking of surgery at Ellis, you'll have the chance to enter dreamland like I did and you'll make it through, thanks to the pump. (Roy Neville, April 30)

Why hospital care costs so much--the expansion of medical records

It's always been the business of doctors, nurses and health care givers of all kinds in hospitals, nursing homes, doctors offices, clinics and the like to keep close and detailed patient records. Depending on the circumstances these range from a folder your doctor keeps that contain his handwritten notes about your complaints and condition, test results, his analysis or assessment, treatment recommendations and prescriptions ordered. If you're hospitalized you might have a more detailed health history taken, plus data sheets and charts, progress notes of those taking care of you, results of lab tests and the analysis and diagnoses of various practitioners who have had a whack at you. That's my guess. It's simply taken as truth that the doctors and clinics and other health care practitioners who take responsibility for your care will review these records and rely on them when they next evaluate you. And they will plan for your continued care and what role others might play, on the basis of what is written down in your records.

As sensible and eternal as this system has been for everybody serving in an office or clinic or hospital, modern corporate medicine has made big changes in medical record keeping in the last decade. The changeover to electronic records is still going on, with ever more complex and extensive kinds of data gathering and analysis required. This creates an amazing burden on nurses (as well as the Ellis mental health clinicians downtown) who are the primary record keepers. I've recently witnessed the fact that nurses spend more than half of their time on the orthopedic floor at Ellis at their computer workstations in the patient's room and out in the hall. They're not talking to the patient, or observing or doing treatments or giving out medicine, which are the things that nurses do.

They take vital signs (blood pressure, pulse and temperature) at your bedside in seconds, then retreat to their consoles to record everything that the computer program calls for including such inanities, I'm told, as whether the bed rails are up or down. And I suppose, they assess whether you look bright this morning, if you're eating and sleeping and have had a proper bowel movement. And they will do this type reporting over and over, filling in boxes on the computer screen using different codes and shorthand that some computer whiz has designed for them.
It's enough to make nurses turn away from the profession. The student nurses I had at my bedside during my recent recovery from hip surgery at Ellis in April said they spent several hours a day at their computer. One said they had to assess what my condition meant, not just the physical signs. That means using their imagination. It's done so that supervisors can see what they've done, every shift, every day.

Do they want to do this? Not at all. They told me they disliked it, it kept them away from direct patient care and their reason for becoming a nurse. They were asked to put down far more detail than needed. My professional home-care physical therapist said when she went into nursing 27 years ago she did it to be close to patients, to make a difference in their recovery. Now she works on a laptop in my house for part of her time with me and spends more time on it at night—all to satisfy federal rules for her position.

Why do they do it? The nurse said it's required by federal Medicare regulations. That governs Medicaid and private insurance companies as well. The hospital has to do it to be reimbursed. They also do it because the hospital wants to be protected in the event of lawsuits over the treatment someone has received or a medical malpractice claim, for instance. That's why we knuckle under to these outrageous claims on the time and energy of our doctors and nurses.

While electronic records are touted as cost-saving, critics say this is not demonstratedly so. Instead, the price tag to switch over to these systems has cost hospitals and the public millions of dollars. There's an extreme concern in the hospital about sharing and safeguarding the extensive system of electronic records, which adds to cost. They must protect both patient and physician confidentiality under federal and state laws. So the sharing and access is likely missing. The visiting nurse's computer record on me cant be shared with my surgeon, who ordered her care, nor the hospital, both of which have systems incompatible with hers. And time spent at the computer console is certainly a consideration. Nurses can't be assigned more patients than now, just as the Ellis mental health clinicians can't take on more patients, leading to the backlog in appointments the past few years.

While computerized records are all the rage, and have clear benefits for storage and versatility of use over the handwritten ones, hospitals and clinics and doctors offices still must rely on longhand notes for many applications. For one thing, it's simpler to write down what the patient says when face to face. These are the customary progress notes and charting that nurses are trained to do. Why should they recapitulate the record on a computer screen? For whom are the records kept, after all, if not the immediate patient? Instead, the computer records seem destined for data banks that serve the institutional purposes of regulators and insurance companies and research entities. I don't think my hospital records have much value to anyone else, except for somebody's studies and we shouldn't have to pay for that.

By the way, NY State is about to implement a multi-million dollar computer network to store and manage our medical records, called eHealth. It's like a data bank for each of us so doctors and other care providers can access information about us when we need them to. The information would come from hospitals, physicians, pharmacies, clinical labs, health insurers, and the Medicaid program. It can pave the way for safer, more convenient health care,say the people touting eHealth. It will tell others if we've changed doctors, seen a specialist, visited a clinic, or checked into a hospital and much more. I call it invasive and super-expensive, not needed or wanted. The state will receive federal surplus money through ARRA, the Recovery and Reinvestment Act to pay for it. It's also called SHIN-NY and you'll be hearing about it soon, as
hospital costs keep rising, and you wonder why. (Roy Neville)