I just got back from the hospital. My wife was admitted with acute appendicitis
and is scheduled for an appendectomy in the morning. That sounds like a routine
occurrence. There are after all about a quarter
of a million appendectomies done in the US every year. I had a complicated case myself at age 18
with a perforated appendix, sepsis, and a weeklong stay in the hospital with a
drain in my side. It was one of the sickest episodes in my life – even after
the appendix was removed, I could barely talk with my friends who came to visit
due to the pain and intense malaise – but mostly the malaise -an intense
feeling like you have the flu but many times worse.
The problem started at about 2PM today when she noticed some
nausea and abdominal pain. She thought it
started after drinking some coffee at her health club along with a protein
drink. Over the next hour she became
intensely nauseated and started to get increasing pain. She asked me to examine her and she had
tenderness with some slight rebound tenderness in the right lower quadrant but
no abdominal wall rigidity. I suggested
we go to the emergency department to get assessed for appendicitis. She declined because she knew the process
would take hours. She preferred Urgent
Care – but I reminded her it was the place of no urgent lab results and over
penetrated x-rays. There was nothing
urgent about any of the Urgent Cares we had been to in our health plan. I finally convinced her that the ED was the
only place where things get done and I was worried that she had an acute
abdomen that would only get worse.
That is exactly what happened over the next two hours – increasing pain and nausea. She was eventually vomiting continuously and in severe pain. So, we headed down to the ED and got there at about 7:10 PM. The check-in was excruciating slow. An RN asked her about 50 questions while she could barely sit in the chair. She kept saying that she had to lay down. The nurse finally said – “I wish we had a bed to offer you but we don’t. You can lay down over there on the waiting room chairs.” The chair she referred to were in the triage area. My wife laid across two normal sized chairs and covered herself with a blanket we brought from home. We were interrupted by a nurse who took her down the hallway gave her medication for nausea (Zofran) and pain (hydromorphone). She came back to those chairs but we were eventually asked to go to the general waiting area. I took this picture of her laying across a larger bench style chair that was too short for her to lay flat..
By 3 hours she was finally given a bed in the ED low acuity
area and more Zofran and hydromorphone.
That stopped working a lot sooner.
She was sent for a CT scan of the abdomen at the 3 ½ hour mark. That was preceded by a visit by an ED
resident and later the attending physician. We got the final CT result about 1
½ hours later when I went out to report she was continuing to get worse and the
medications did not seem to be doing anything.
The Zofran was changed to Compazine and more hydromorphone was given. Eventually a new ED physician came in and
explained that surgeons had been called and that an appendectomy would probably
be recommended.
At that point it was after midnight and I discussed me going
home after I had said me piece with the surgeons. I had two specific concerns about antibiotic
coverage. My wife was out of it by then
but whispered: “Just behave yourself.”
When you have been married as long as we have - that snappy repartee
develops.
On the long drive home, I had time to reflect on a number of
things. First, I was an intern at this
hospital in 1982 and at that time we had a trauma wing and a non-acute
wing. Interns would rotate from one side
to the other every other night. The attendings
on each side wanted to get people in and out as quickly as possible and they
emphasized that point to us. There were
no bottlenecks and people were triaged based on acuity. There was a sign there tonight saying that
was still the rule. Of the 30 or so
people in the ED waiting room are, there was possibly 2 other people as ill as
she was. They were all laying on waiting
room chairs. Second, the pace was
leisurely with a lot of down time. I still don’t understand why it takes 6
hours to get a diagnosis of acute appendicitis when I could do it as an intern
in 15 or 20 minutes without a CT scan (we were told the CT scan results took 30
minutes to get back.) Third, if EDs are
that inefficient why not offload some of the front-end work to Urgent
Cares. That would entail making an
Urgent Care urgent – a place where you can get a rapid assessment and the
necessary tests and (hopefully) get directly admitted to a hospital and
treated. Fourth, the bottleneck suggests
to me that beds are being rationed at some point. We were in the second busiest ED in the Twin
Cities. At some point – ED demand has been well defined and it should be
accommodated. Fifth, the place is run
down. When I was there the argument could be made that it was worse, but this
is a brand-new addition to the front of a brand-new addition to an old
hospital. It had the gestalt of a bus
depot. People were milling about coughing and sneezing around the people laying
on chairs waiting to get a bed. Not a
good look for either patient satisfaction or infection control.
All things considered it is an ongoing suboptimal experience. Nausea
and pain were tolerated far too long with little follow up on the initial
results. It highlighted to me the need
for an advocate when you go into a hospital these days – not just to prevent
major problems but also to troubleshoot around routine decisions like: “Should
I press this call light because not only does the medicine not seem to be
working but I feel a lot worse.” Or “Maybe you should ask that doctor again if
they have the CT results – it has been an hour.” And of course, if you know additional
history as an advocate that is valuable information.
Were there bright spots?
Both the ED and surgical residents had a great interpersonal style. They gathered all the relevant information,
were personable, and the surgery resident did a great job with the informed
consent for the surgery. That’s about it.
It took 5 hours to get to the two physicians who could do something and
then another hour to do it. I told the
surgeon I was in the same ED as an intern and then went into psychiatry. She said that her experience on psychiatry
was “heartbreaking” and she thanked me for my service. Not the first time that has happened.
That is all I know at this point other than the fact that my heart rate was up the entire time I was part of this process – probably by 30 or 40 beats per minute. I got home at about 1:45 AM and got about 4 hours of sleep. A call to her nurse this morning for an update resulted in me finding out that she is still in the ED at 9 AM. She is now getting IV fluids, antibiotics, anti-nausea medication, and pain medication. Her surgery is not scheduled until 3:45 PM today. The nurse reassures me that she will be in a hospital bed after the surgery and may be able to go home the same day.
This is state of the art health care in the US. After 40 years of micromanaged health care by
managed care organizations we have a system that is less efficient and patient centered than the one
I was trained in back in the 1980s. The only real innovation has been the use of CT scanning for the diagnosis and that was scientific innovation rather than business management. Despite all the patient satisfaction surveys
we have a system that no patient should be satisfied with.
George Dawson, MD, DFAPA
Supplementary 1: Will post an update later. I need to get some sleep before going back to the hospital.
