Wednesday, July 13, 2011

Hospital Politics at the Lower Levels

I watch "House" religiously, while my dad endeavors with equal religious devotion to reinforce to me that what I'm seeing is not in any way a realistic portrayal of any facet of a functioning hospital. What my dad says about Dr. House's dream team of diagnosticians is absolutely true. Even the wrold-renowned Mayo clinic, famous for its collective diagnostic capabilities, could never afford to have an eccentric but Einstein-like disostician with a merry contingent of followers only a few IQ points below that of of their boss, all of whom akulk around avoiding clinic duty while waiting for a patient to show up with a sensational and mysterious illness, the diagnosis of which is typically elusive until the end of the hour-long program. I wish such really were the case. Wouldn't everyone who's ever been seriously ill love to believe that a group of sub-specialists also specializing in diagnostic medicine (I'm not sure there is such a specialization; I think that's ordinarily what specialists in internal medicine do) ia on his or her case in just the way maggots are on the food my brother leaves in his room if my mom is not careful to insist that he clean it and carry his dishes to the kitchen on occasion?

On occasion, hospital politics are shown. Those shown are usually the ones happening at the higher level of hospital operation; the board and hospital director meet periodiclly, In almot every case someone important either threatens to quit or threatens to be fired. That sort of thing may or my not happen; it's so far removed from anything that i see that I ould have no way of commenting intelligently on the degree of reality depicted in that aspect of "House." The political activity I see is more likely to be between doctors and other doctors, or between various therapists, interns, nurses, and others endeavor to do their jobs or to do as little as possible of their jobs while forcing the bulk of their duties upon someone else. the politcs I'm seeing now revlove mostly around doctors and nurses. Doctors are clearly considered superior to nurses in the chain of command. They've had more schooling and have a higher levdl of certification. They give the orders. It is up to the nurses to see that the orders are carried out. The chain of command at times becomes a bit blurry or ambiguous, particularly at a certain time of the year - right npw -- whena new class of first-year residents is ontroduced and takes up the spots formely held by the newly promoted second-tear residents. First-year residents, with few exceptions, are considered pond scum -- the lowest of the low -- and have to prove their mettle even to those who are theuretically beneath them on the chain of command. This practice is both pejorative and dangerous, but it is what it is. To quote a a portion of an old Protestant liturgy, "As it was in the beginning, is now, amd ever shall be." No one knws why it is tis way. Doctors know they went through it and that each upcoming batch of doctors will wade his or her wy through the same muck when the time comes.

My Uncle Scott came by my hotel room to check on me because I've been sick. My dad, who would ordinarily check on me, is working in northern California. My Uncle Scott didn't like the way my lungs sounded and wanted me to go to the hospital. I tried to to convince him that my mom could take me there before and after my classes for repiratory therapy and that I could even have intravenoua antibiotics as an outpatient. I suggested that he could call in a change of my antibiotics that night, and that my mom would drive me to the hospital so I could receive an injection. My Uncle Scott didn't like any of my ideas, so I'm in the hospital tonight. My Uncle Scotr and the attending physician both said if things go really well I may be released as earliy as Thursday.

Since it's the same hospital that houes the loony bin, I asked if I could be admitted to the isolation unit of the loony bin. The doctor said no because I need more regular monitoring and care than I would receive there. As much as I am loathe to admit that he is correct, the nght staff there probably wouldn't do much for me. They're maybe good for a Klonopin or an Ativan in a pinch, but that's about it. Right now I really don't need either Klonopin or Ativan.

Because of doctor's prders I was able to bypass most of the usual admittance procedure. I had a respiratory treatment right away. The treatment usually involves having stuff puffed into one's lungs and also forcing one to breathe to a certain level of strength as measured by an instrument. I must admit that I really don't know as much as I should about this procedure because I'm seldom coherent when it happens to me. After an IV bag with a different antibiotic than the one I've been given by injection, I'm somewhat awake and feeling vaguely human. For now the hurses are letting me stay up, but they say if I'm still up in an hour, after my next breathing treatment, I may have to have something that will make me sleepy.

I'm concerned about my classes because, being summer-term courses, they're extremely short, and attendance is mandatory. My doctor told me he would speaa to the preofessors and set up skyping sessions, although he's not certain if I'll be up to participating much, depending upon my state of pharmaceuticalization, if there is such a word. Reggardless, I'm sure any readers understandss the intended meaning.

My mom is here with me. My dad is coming here tomorrow. Their policy is that we, meaning my brother and I, do not spend nights in the hospital without at least one parent present. If they're both out of the country when one of us is hopitalized, the person or persons acting in loco parentis stays in the hsopital with the one of us who is admitted to a hospital. This is especially true, my dad says, at any teaching hospital in the month of July, when much treatment is handled by very green rookie first-year residents who are also very exhausted. My dad knows this for an absolute fact because he was once a very green and exhausted resident ohysician. Tired and inexperienced physicians, my dad says, are a perfect equation for major and potentitally life-threatening medical errors. My dad would prefer to be here, but since he can't, my mom looks at every medication and the dosage, then calls my dad for an OK before it is given to me. Dr. Jeff offered to come in and spend the night in my hospital room as well. Pulmonology is pretty far removed from his specialty oif pediatric psychiatry, but he has kids, so he's had to learn about such things. All MDs have a very basic background in every aspect of medicine, but ib general, one with chidren has leanred a good deal about anything condition that has ever affected any one of his children. Still, to be treated by someone within his or her speciality is the optimal situation for a patient.

I've been assigned to a female first-year resident who is spending the night at the hospital. This is better than if she were at home and being woken up by phone calls about me every hour or so, At that point, physicians, whether interns or fully certified specialists, become overly tired and irritated about being disturbed too frequently. This can lead either to the physician making an error or the nurse on call becoming afriad to call a physician even when the call is warranted. At times the nurse even calls the physician when a call is not necessary simply to irk him or her, which can led to a situation much like "The Boy who Cried Wolf." this is why it's better to be assigned for now to a doctor who iS already here.

The doctor is nervous about caring for me because she has been told my father is important in medical circles. Uncle Scott tried to reassure her that it's a routine case and that I'm only here as a precaution, and that, furthermore, she can call him at home in addition to calling the attending physician if anything at all about my condition makes her nervous. Beyond that, she is free to call my dad or my Uncle Steve.

One thing I've noticed is that there seems to be friction between the first-year residents and the nursing staff. It seems to exist mostly in the form of a power struggle. Many of the nurses feel that they've been at their jobs long enough that they know more than the first-year residents, In some cases this is conceivably true. On the other hand, the doctors, first-year residents or not, are ultimatly in charge of making decisions regarding patient care. Sometimes the nursing staff disagrees with the deisions made by doctors. If a doctor makes a decision that could result in serious medical harm to a patient, as I see it, the nurse has a few options. The dirst and most obvious is to attempt to calmly discuss it with the first-year resident. If the nurse is confident that she is correct and that the first-year resident is wrong, the next option would be to appeal to a higher authority -- one with an MD following his name, and not another nurse. If both of these fail, the nurse can appeal once more to another MD with more authority of either of the others already consulted -- and these important MDs are hard to come by in the wee hours of the morning. That failing or that option not available, the nurse has little choice but to document that her conerns were duly noted, follow the doctor's orders, and be prepared with a crash cart in the event that she was correct in her original assessment.

How frequently these conflicts occur depends both on the nurse and the first-year resident involved. Personalities often get in the way. In some cases it is a first-year nurse who is at odds with a first-year resident, which is a usually a clear idication of a problem between the physicians and the nurses at a given hospital. Even though doctors -- especially first-year residents -- ar human and, as such, fallible, in no case should a first-year registered nurse, who typically possesses either an associate's degree or a bachelor's degree along with her nursing certifiction, presume to have greater knowledge than a physician, resident or otherwise, who must complete, as a bare minimum, a bachelor's degree and a four-year course of study at an accredited colleg of medicine. It is only through many year's of experience that a nurse should ever presume to know more than a doctor about anything related to medical treatment. A rookie nurse is lower on the food chain than is the lowliest first-year resident. Even if he is wrong, in absence of doctors to whom to appeal, it is the firt year nurse's obligation to follow orders and to be prepared to take action if the orders given were wrong.

The nurse assigned to my case is a first-year-nurse. If I had't otherwie known it, the lack of skill she demonstrated in inserting my IV would have made her lack of experience and expertise perfectly clear. My Uncle Scott took the iV kit away from the rookie nurse -- against her protestations -- and inserted it himself. As it is, I'll have bruises on my arms for weeks in the regions of various veins she tried unsuccessfully access. If Uncle Scott hadn't intervened, she's still be looking for veins and i'd be bleeding internally or externally.

the rookie nurse has attitude. She's giving my forst-year resident all sorts of shir, unaware that most of the orders my first year resident id giving are coming directly from either my pulmonologist or my dad. my Uncle Scott has shown up a few time to overrrule her. he's a male, so she grants him slightly more respect despite his own shade of greennes when it comes to the profession. The rN tried to blcok my most recent repiratory therapy, which my dad and the pulmonologist had ordered. If she weren't sucj a complete bitch, my Uncle Scott or the other first-year resident might have clued her in on whom I am related to nd who is giving the order tht she;s ignoring. It appears that the remander of the nursing staff doesn't think all tht highly of her, either, s most of them have some clue that my father is influential , but no one is telling her. She tried to gove me a steroid injection that was contraindicated by what I had inhaled and wasn't ordered by any doctor charged with managing my case. My mother had to physically precent her from giving me the injection. I hate to see someone new blow it so horribly, but I fear that this nurse will be called in by personnel tomorrow morning and relieved of her duties at this hospital.

Dr. Jeff has come into my room. He's concerned that my mom won't get any rest with the status quo. My mom is resting on the extra bed in the room. The nurse had told her to get off of it because it is for sick people, but Dr. Jeff told her to get back on it. He has banned the rookie nure from my room.

Now tht I've finished another repiratory therpy treatment, I'm finally getting sleepy. I'll check in with everyone tomorrow.

P. S. Regarding hospital politics, nurses can only hope to precail against any doctor unless he or she is truly incompetent and/or if they presnet a united from. Neither i the case here. The nurse is Toast.


  1. Yikes, it sounds like that nurse is a total twit!

    I hope you feel better soon!!!

    As for missing classes, in the whole grand scheme of things, it's not the end of the world or even critical. The only thing here that matters is your health. You are still young that even if you *had* to re-take some classes, it won't really put you behind, especially since you're already ahead of 99.9% of kids your age. Don't stress about it, it's not worth it.

  2. I go back and forth on residents (mainly interns). The majority of the time they drive us crazy. But, I've noticed that they are a lot more sensitive than attendings and more... real. It was a resident's idea to do the bone marrow biopsy that diagnosed me with HLH, so I guess sometimes being fresh out of med school is a good thing. But most of the time they're just plain... I don't know, for lack of a better word, stupid. But then again, so is everyone at one time or another, and it's not like any of our mistakes have the power to kill anyone. Well, at least, not as much the probability. So, they’re probably scared out of their mind.

    Sometimes I wish one of my parents became a doctor. Maybe it would've saved me time and suffering if they would've had the same medical understanding as a physcian.

    Sorry you're in the hospital. I hope the breathing treatments help and you're out of there before it gets too mind numbing. Are you on a C-Pap type breathing treatment? Feel better soon!

  3. Same in UK hospitals, too.