Saturday Morning

I should be practicing for my Grand Rounds Presentation in Late February.

But I am here, writing to the void...

A lady on McClure 5 was just having a lot of trouble breathing... they called a code.. even thought she was responsive, breathing on her own, pulse jogging along... I went up the stairs from 2 to 5 in a matter of moments.. arrived in my own sort of shortness of breath. They were waiting for me: "We need someone here to intubate her!" So I gently brush by the 15 people in the door to get in there, and get to the head of the bed.. She's awake, breathing, doing not-so-good.. My attending for the day is starting a case down in the OR, and by some chance, the attending from SICU comes over- who is one of the anesthesiologists... He recommends Bipap.. and the lady begins to do better... But in the waiting game that we were playing, he asked if I was okay- if I felt like I could intubate on my own if I needed to-he would be leaving. It was a defining moment- because I do. So we waited. And she got relatively better. She looked like "she was getting a little better." It's funny how almost everything in medicine is in relative terms. There are few things that are concrete and definitive. I think what I like about anesthesia is that intubating the trachea is a definitive act- and it is life saving or could be life threatening if done at all wrong. I can't think of many other things in medicine that are for sure, 100% right or wrong. Of course, there are many things that are 100% wrong.. but it is astonishing how many of them could be argued "a little bit right" in certain circumstances...

Which brings me to my next latest and greatest idea.

Kyler and Dan and Max live off a road with two nursing homes. At least 3 times a week, I have to pull over for an ambulance or fire truck which is rushing past to get to Birchwood or Starr Farm. Nursing Home Lane it should be called. It's kind of nuts to me that as a taxpayer, I am paying for these visits, tri or quad-weekly at minimum (lets not even address the ones that I don't see). They are unnecessary visits from paramedics and I'm not sure they are doing anyone any good.

So the ladies and gentleman that live at these lovely homes are by nature, impaired mentally, physically, possibly emotionally. They are more likely to get sick, stay sick, die, lose function of some bodily process they formerly had control over. That is the baseline population. The wonderful folks (don't you just hate that word- folks?) who take care of the ladies and gents are not necessarily nurses or doctors- although there probably is A Nurse on staff at all times I would hope. So lets just say that Mr. Potato Head gets a urinary tract infection and a fever and tachycardia. They call 911. It costs $1000. for the ambulance, At the very least $1000 for the ER visit, likely $30,000 for a visit in the hospital for like 3-5 days.. and what does Mr. Potato Head need? An antibiotic, tylenol and some fluids. All things that with one nurse on site, they could provide..

So the cost is one thing. But what does Mr Potato Head get out of this experience? He gets all of the above medical necessities at a highly inflated cost of what it could be, but as a bonus, maybe he gets some delerium! Confusion! Where am I? Why am I here? Where's Marge? Where's the Waiter? (I had a patient at the VA in West Haven who would scream for the waiter all the time. He was hilarious) And then he has to stay for a few more days to let the delerium be completely worked up, stuck with more needles, awoken at 11:30 pm for those all important midnight vitals, awoken at 4 am for those all important pre-round vitals.. and so he's sleep deprived, in a foreign environment, and getting painful procedures. He probably will end up with a catheter in his bladder, too, despite the infection, because he wets the bed and the nurses don't have enough time to clean him up, so it's either - catheter or diaper rash. You pick. Mr. P probably then screams that he has go all the time because it's hurting in there... And then the delerium lifts, 30,000 dollars later. He is sent back to his room at Starr Farm. Marge looks for him and he's a little off still. He isn't hungry because of the antibiotics, so he doesn' t eat. The nurse (who is overworked and trying to provide primary care to 100 residents) considers calling 911 again for "malaise and anorexia." She did last week for Mr. Broccoli Shoot and he was taken to the hospital for a few days, and she didn't have to clean the poo from his ears. What a relief. But she doesn't. Mr. P takes a few more days to adjust back to his life... He enjoys his days to the extent he can, does the activities, goes on walks, visits with Marge.... only to get diarrhea a few weeks later and poor Nursey-Nurse has to think about what would be best. There are probably parameters like, heart rate over such and such. And blood pressure below such and such. Temperature not normal. Three of the above abnormal vital signs, call 911. Nursey Nurse doesn't want to be responsible to the family. She probably knows it's gonna be more work in the end to call 911...

But she does, to avoid litigation. And gets his medical chart ready, and the last time they gave him his Flomax, and the last time he had a BM and how much assistance he requires for eating and the seven phone numbers of the family members in four states that want to be called in descending order, directly from any treating physician. And she writes it all diligently down and waits for Bob and Joe from Station Four Fire department, whom she knows so well.

It's a system problem. I guess the world needs Geriatricians to be "on call" for these places and they should be called when Mr. BS gets his "anorexia" with abnormal vitals.

It's also a problem of our society- don't you love that- I'm getting all high and mighty about society now.. but lets be honest here- no one wants to be the bad guy saying- if you get sick, I don't want you to go to the hospital. But it needs to be said. Hospitals are dangerous, sick, disgusting places. There's a fine line between going there to get well and getting worse. I personally think most of the calls that the good ol' Burlington Fire Department gets are for people that the hospital is just a more disgusting place than they already might be. I don't mean of course that Birchwood and Starr Farm or Any Nursing Home of Your Choice is a disgusting place per se different from any other. But a hundred people living in close proximity who don't have full faculties of their bodily functions is a recipe for disaster. The Army knows that even healthy people who live in close proximity are exponentially more likely to get all kinds of disgusting bugs.. thats why they vaccinate the crap out of soldiers.

So lets all decide that when we get into our Nursing homes, (I for one will be the one streaking down the hallway, as I don't mind nudity) that we do not want to go to the hospital unless it requires surgery or a tube in the throat. And actually, I don't even want those. I will have DNR tattooed on my chest. I'll have to add DNI. Maybe each breast will have DNR (right) and DNI (left) over them. The doctors would have to put the electrodes on before shocking me- so this would eliminate any confusion.

And by the way, if I get any kind of brain damage- take me off the life support right away.