[HN Gopher] Things I've noticed while visiting the ICU
___________________________________________________________________
Things I've noticed while visiting the ICU
Author : exolymph
Score : 310 points
Date : 2022-11-18 20:21 UTC (1 days ago)
(HTM) web link (trevorklee.substack.com)
(TXT) w3m dump (trevorklee.substack.com)
| HEmanZ wrote:
| These threads always have lots of people jumping on doctors and
| their decisions/callousness/lack-of-reason/etc.etc.etc. My wife
| is a physician (OBGYN) at a major city hospital that primarily
| serves a very poor population. I'd like to share her schedule,
| and see if you think what kind of care you could perform under
| these circumstances:
|
| Monday - Friday - Wake up at 4:30 AM - Get to hospital by 5AM to
| start rounding on patients - Sometimes work inpatient all day
| sometimes clinic thrown in, but usually not done working until 7
| PM, without even a 15 min break or a chance to eat a meal (15
| hour day) - Come home and do about an hour of notes - At least
| once per week, wake up in the middle of the night to deliver a
| patient who asked for that kind of continuity of care.
|
| Saturday: - Wake up around 5am to be in by 6am to start the day -
| Work inpatient, usually without time for a 15min break for food,
| until 10AM SUNDAY (28 hours shift)
|
| Repeat 49 weeks/year (days of 24/hr shift can vary and she
| usually gets one weekend off/month). Her average time at the
| hospital last year was 96 hours/week.
|
| How much confidence do you have that you'd be able to take care
| of a complicated pregnancy at the end of a 28 hour shift, having
| not eaten for more than 24 hours, having 10 other patients on
| your mind, and having had only a couple of hours sleep the night
| before? It's no wonder to me anymore to me birth outcomes are so
| bad in understaffed hospitals in poor areas...
| thfuran wrote:
| That sounds illegal.
| HEmanZ wrote:
| Nope, not where we live.
|
| I have seen administration do some blatantly illegal shit
| around physicians with COVID, but I don't want to write that
| up here.
| rscho wrote:
| Doctors answer: yes. And?
| gus_massa wrote:
| That is insane. For some reason, airplane pilots have very
| strict rules about how long they can be in the cabin, how much
| they must rest, and similar stuff. (Also, they have checklists,
| plenty of checklist, but medical doctors don't like
| checklists.)
|
| Even bus and truck drivers have a more sane maximal shifts
| restrictions.
| chips_n_fries wrote:
| And she is not a resident or in a training/certification
| program?
| HEmanZ wrote:
| Not anymore, but she's only two years out. Her hours are
| actually worse than most of residency these last two years.
| jmt_ wrote:
| It's kind of amazing anyone chooses to go into healthcare
| having to work like this. It's the absolute last field I would
| ever want to go into, even as an engineer who wouldn't need to
| actually practice medicine. Seems like you need to practically
| give up your life to save countless others. Your wife, and
| those like her, are truly performing an innately critical job
| at an absurd cost to themselves - God bless.
| jmcgough wrote:
| It depends a lot on the specialty. Obgyn is particularly
| hellish.
|
| But yeah, there's a good reason why suicide rates are so high
| for doctors...
| rednerrus wrote:
| The AAMC should increase the number of students they admit. The
| average medical school is turning away 95% of applicants. The
| top 10 schools in America are excepting <2.5%.
| [deleted]
| late2part wrote:
| excepting?
| cfu28 wrote:
| Doing this would make the problem worse by increasing the
| amount of unemployable newly graduated doctors that can't
| practice because they can't match into a residency program.
| Medical schools have exploded in number the past few decades
| compared to the actual amount of residency spots that have
| been opened.
|
| The limiting factor isn't medical school admissions, it's
| residency spots. We'd need to increase medicare funding if we
| want more residency spots.
| triceratops wrote:
| Why does medicare alone have to fund residency spots?
| cfu28 wrote:
| Conceptually, I'd agree with you. I don't think medicare
| alone needs to fund residency spots (its just currently
| tied to the amount of spots last I checked). I'm more
| concerned about the total number of residency spots.
| hef19898 wrote:
| Wow, that first paragraph is as _cynical_ as it gets: " The ICU
| is filled with old people." It ends with people now knowing why
| it tales so long to get doctors appointments, and saying the
| author is not sure whether ir nit this is a good thing, that we
| (the articlee is about the US but is pretty much the same
| everywhere) spend so much of our health care resources on the
| old. _While his dad, also not in his twenties, was cared for in
| the same ICU_. Maybe he should visit an ICU for infants and
| babies next time...
|
| Staffing. Well, what can I say. Patients are there 24/7, staff is
| obviously not. That staff works in shifts, great realization. I
| am almost surprised that the author wasn't surprised ICU staff
| has vacation and sick days.
|
| And finally "The ICU is a good place to not die, but a bad place
| to recover.". No shit, Sherlock, tgat is basically what an ICU
| does, stabilizing patients enough to transfer them to a "normal"
| station for recovery, or, worst case, to a paliative unit if
| death is the only possible outcome.
|
| Oh, not to forget: "It really makes me think about how the
| hospital might be organized differently. If the hospital focused
| less on pure survival, might their patients recover faster?" What
| makes a emotionally involved amateur think that the people
| running ICUs, after sometimes years if nit decades of training in
| that _exact_ field, don 't think about this question constantly?
| And tgat the current state of ICU care represents the _current_
| optimal solution?
|
| I am so fed up with articles from people judging things by
| looking at them from the outside. Mind you, the articke in
| question here is one of the better ones.
| dtgriscom wrote:
| What's cynical about stating the truth? Are you disagreeing
| with his observations, or just hoping he'd have the good taste
| to keep them to himself?
| hef19898 wrote:
| Saying ICU are overproportionally occupied by the lederly,
| abd very young also if this a different ICU, is a fact.
| Continuing to say that is reason "you" have to wait for
| getting a slot and asking whether or not the observed
| sotuation is actually hood is cynical.
| ozzythecat wrote:
| I'm a layman with no knowledge of how ICUs work, because
| (thank God), I've never had to visit one.
|
| I found this article informative, and not cynical at all.
| No system is perfect, and so with all of the significant
| benefits they provide, ICUs have some things they aren't
| best for.
|
| > Continuing to say that is reason "you" have to wait for
| getting a slot and asking whether or not the observed
| sotuation is actually hood is cynical.
|
| I see you bashing the author, but you haven't made a
| coherent argument at all. In fact, I'm not sure if this is
| even English.
|
| If there's something op got wrong, help us understand and
| make it a teaching moment. Just bashing them isn't
| productive.
| newsclues wrote:
| The observations of the comment about old people does however
| match the demographic data, and it shouldn't be simply
| dismissed this context is important and was not made clear
| during the COVID-19 pandemic.
| fedeb95 wrote:
| Exactly my thoughts. I don't know anything about medicine, so
| my ultimate opinion is "I don't know". If I were to guess, the
| article just describes a well functioning medical structure and
| the author has some problem with people paying taxes.
| hef19898 wrote:
| I really wished "I don't know" would be the default position
| of otherwise smart, educated and exeperienced people once
| they step out of their fileds of expertiece. There is only so
| much that easily transfers from one domain to another, or
| from one industry to another.
| throwaway2037 wrote:
| Related, interesting anecdote: I was recently talking to a
| co-worker. We are both "third-country", so we can compare
| and contrast our current healthcare system versus "home".
| My co-worker made an interesting point: In their home
| country, patients are much more involved in their care, and
| doctors are willing to engage with well-prepared,
| intelligent patients. As a point of comparison: Our current
| country, not at all.
|
| My point of this anecdote vis-a-vis high-agency healthcare
| systems: I like when I can ask questions to a doctor about
| their diagnosis and proposed treatment. Yes, I understand
| they are busy and there is a reasonable limit. I am equally
| annoyed when this is viewed (in the extreme) as an assault
| on their authority!
| derbOac wrote:
| I've worked in ICUs; this is mostly accurate except for a few
| things.
|
| Older individuals do probably occupy most ICU beds but this
| really depends on the ICU. Some are dominated by acute traumatic
| injuries which can actually skew younger.
|
| The observation about attendings is accurate, but as one of those
| psychiatry and neurology consults, the gripes can go both ways.
| ICU physicians have a reputation for ignoring long term
| consequences of decisions. So you end up with a lot of "can they
| go off a ventilator? then they're fine" stuff. This is reasonable
| in some ways but sometimes there are patients who will probably
| predictably be ok and attending more to consequences 10 years
| later makes a huge difference in the rest of the life of the
| patient.
|
| Also, some ICUs are actually very neuro heavy depending on
| patient populations.
| DoingIsLearning wrote:
| > So, when it comes to prescribing (...) Giving psychiatric
| medicine "as needed"? Go wild.
|
| This implies a lack of duty of care which is painfully unfair.
|
| As a counter story to this I have a friend of mine who is a
| _former_ ICU nurse with a gigantic scar on her forearm.
|
| I much later in our relation found out that the scar is from a
| patient who basically ripped her forearm biting down on it while
| she was trying to stop him from tearing out a central line in his
| own neck.
|
| It's ironic that in trying to stop a patient from having a
| massive central line bleeding she ended up bleeding herself.
|
| Outside hospitals we fail to realize how disoriented and
| irrational patients can get when coming out of anesthesia or with
| certain diseases.
|
| So yeah 'as needed' is absolutely right because everyone is
| entitled to work in a safe environment.
| duffpkg wrote:
| Author of Hacking Health for O'Reilly, managed operating
| companies for hundreds of hospital facilities, etc...
|
| One widely under realized aspect to healthcare costs in the US
| (there are many) is the very high number of ICU beds per capita,
| ~35 per 100,000 people. While it gets a little complicated to
| compare apples to apples, a reasonable person could say we have
| 30% more than germany which is the only european contry that is
| close and double to triple most other nations we are typically
| compared against like the UK and Canada.
|
| ICU beds are extremely expensive to both build and operate. Also
| for the lay person the term "bed" has a specific regulatory
| meaning and does not refer to just the physical existence of the
| room and bed but means that it is operational with highly
| regulated amounts of staffing, services and equipment. Each "bed"
| has costs in the millions to build and equip and operating costs
| are typically in the neighbood of $10k to $40k per "bed" per day,
| occupied or not, a large portion being labor.
| throwaway2037 wrote:
| I am going to repeat myself here.
|
| Quick Google search for "icu beds per capita" finds:
| https://www.oecd.org/coronavirus/en/data-insights/intensive-...
|
| US: 25.8 / 100K population
|
| Germany: 33.9 / 100K
| Blammar wrote:
| Can you explain why one ICU room costs millions, and why they
| cost 10k a day even if no one is in them? Neither makes sense
| to me. I can imagine say 100k in monitoring equipment in a
| room.
|
| Maybe it's the hospital inflation applied to equipment?
| duffpkg wrote:
| An ICU unit isn't exactly a single room. There are different
| configurations but they typically involve some sort of
| centralized monitoring station and 5-20 ICU "beds". Total
| cost of that / number of beds. Everything in hospital
| construction is expensive, ICUs are at the extreme end of
| that. Huge power requirements, medical gas lines, fixturing
| and surfaces needs to be able to be disinfected, special air,
| special water, on and on. It has requirements very similar to
| an operating theatre.
|
| The reason they cost so much even if no one is in them is
| because of what a "bed" means. It isn't the literal bed, it
| is a unit a treatable/treating capacity. Requiements vary
| somewhat by jurisdiction but it's going to mean 24/7/365
| nursing and attending doctor staff. You can't just call them
| in when a patient shows up, they need to be scheduled and
| available. Then ICUs will also need a large cadre of oncall
| specialists, neurologists, cardiac, laboratory testing staff,
| and on an on to cover a huge range of possible patient needs.
| Stocked blood units, stocked medicine units. All those things
| have costs whether a patient in in the bed or not. Hospitals
| to a large extent spend an incredible amount of money on
| capacity. No wants wants to end up in a hospital to have them
| say, "oops, we didn't expect your spleen to rupture today,
| Dr. Bob won't be in till next tuesday so you are out of luck,
| sorry"
| lostlogin wrote:
| To add to this, the costs the one area I understand are
| huge.
|
| Radiology generally needs to have a CT ready to go when
| there is an ICU. It likely needs an MR too, and staff for
| running after hours. Portable X-ray and ultrasound, a PACS,
| a RIS, services contracts and a load of other smaller
| costs.
|
| That's several million in hardware costs.
|
| The running cost is huge with MR service contracts alone
| into the hundreds of thousands per year.
|
| Staffing utterly dwarfs that expense and getting skilled
| people to work out of hours requires a lot of money, and
| additional cover for when they sleep.
|
| Staff need to be kept competent with courses and training,
| certificates and leave to get to these sessions. More
| money.
|
| The consumables are silly expensive and expire fairly
| rapidly. Everything needs to be available and a few spares
| should be present.
|
| Radiology can be a cash cow for day to day operations in a
| private clinic. But having staffing and equipment that can
| run 24 hours a day with 100% uptime is a massive cost
| multiplier.
| throwaway892238 wrote:
| So, they're complicated, they're expensive, they're
| necessary... why don't we have the state pay for them? We
| spend 720 Billion dollars on the military. Would it be
| useful to send a couple of those billion to make ICUs less
| expensive?
| NegativeLatency wrote:
| Yes it would, but in the US we have a for profit medical
| system so this is a natural result of that.
| xyzzyz wrote:
| Where do you think state money comes from? Even if it's
| the government that foots the bill for ICUs, in the end
| it will still be paid collectively by all of us regular
| people.
| ThePadawan wrote:
| Well good thing regular people don't ever need to use
| ICUs.
| MichaelZuo wrote:
| Did you reply to the wrong comment?
| ThePadawan wrote:
| No.
|
| In case it was unclear, I was being sarcastic in my reply
| and pointing out the hypocrisy of being offended that
| "regular people" would have to foot the bill for ICUs -
| as if they weren't the ones relying on their existence.
| relaxing wrote:
| Where do you think the for-profit money goes? (HINT: it's
| in the name.)
| xyzzyz wrote:
| Most hospitals in the US actually are non-profits, but
| that's really beside the point. Just because something is
| for profit or non profit does not allow you to
| immediately conclude anything about its cost. For
| example, the government in my city built a 3 stall public
| restroom at a cost of $638,000. At this price, if I
| wanted to have a restroom built on my behalf, I'd rather
| hire a for-profit contractor to do it instead of the
| putatively non profit state.
| Dma54rhs wrote:
| For one American medical workers earn absolute insane wages
| compared to their European counterparts.
| db48x wrote:
| Most of the cost is people. It's not much use calling it an
| ICU room unless there are doctors and nurses and
| anesthesiologists and other specialists on call to actually
| care for people intensively. Plus a janitor or two.
| zeagle wrote:
| My impression as a Canadian resident was the bar seemed a lot
| lower to get into the ICU in the US. Unless they needed a tube
| to secure an airway, pressors, or CRRT we managed COPD with
| BiPAP, pretty profound hyponatremia, cirrhosis with& bleeds,
| DKA/HHS on the ward pretty regularly just as examples of
| repatriated patients I remember. I always figured it was due to
| an overly litigious culture and a money maker for the hospital.
| To be clear I didn't practice in the US.
| haldujai wrote:
| It's probably because we don't have enough ICU (or step down
| beds) in Canadian hospitals than the fear of litigation in
| the US. Canada's capacity is amongst the least in G20
| nations.
|
| A lot of patients we manage on the ward or step downs (i.e.
| pressors on step down, I'm unaware of any ward that will let
| you run these, very few tolerate central lines) really should
| be in a full ICU, or at least a high level step down unit
| like D4ICU at KGH (rather than the hilariously awful AMA
| units at TOH).
| throwaway2037 wrote:
| I am going to repeat myself here. You wrote: <<Canada's
| capacity is amongst the least in G20 nations.>>
|
| Not even close.
|
| Quick Google search for "icu beds per capita" finds:
| https://www.oecd.org/coronavirus/en/data-
| insights/intensive-...
|
| Canada: 12.9 / 100K population (slightly higher than OECD
| average)
|
| For the record, it is usually better to quote "OECD" than
| "G20". G20 just means _total_ GDP is large, but GDP per
| capita can be very low, like India, Indonesia, and China.
| OECD is always (democratic and) high-income -- high GDP per
| capita. For example: Nederlands, Norway, and Switzerland
| are all OECD, but none G20. All are very high income and
| high human development.
| haldujai wrote:
| This number includes level 2/step-down ICUs inclusive of
| regional/community hospital.
|
| This is not the bed count of units capable of having
| cardiac support or prolonged ventilation.
|
| I can't readily find the OECD figure but if you look at
| ventilator capable beds in Canada the number drops to
| ~9.7, again inclusive of community/regional hospitals
| mostly staffed by non-ICU trained physicians which are
| only equipped for short term ventilation.
|
| Which center in Canada have you trained at where there
| isn't constant pressure to offload ICU patients to the
| ward due to a lack of beds?
| conductr wrote:
| This is a practical reality of the "we keep old people alive
| too long" category.
| [deleted]
| Cipater wrote:
| How old should people be allowed to get? Why are the old less
| valuable to you? A life is a life, is it not?
| MichaelZuo wrote:
| Well traditionally, nobody allowed old people anything,
| except what their own family or checkbook could provide.
| lostlogin wrote:
| It had never been this simple. A child dying is pretty
| universally seen as worse than an 85 year old dying.
| hackeraccount wrote:
| I feel like the greatest tragedy of them all is a 53 year
| old person dying.
|
| Why 53?
|
| No reason. No reason at all. I may change my view on this
| in a few months however.
| conductr wrote:
| It's more about health and quality of life vs our
| capabilities to delay the inevitable. If you're unfamiliar
| with the topic there's plenty of information out there
| about how much money is spent and now low quality of life
| is commonly enough in the final few years.
| incone123 wrote:
| I'm not old but I have an Advance Directive on my file that
| essentially says if I'm fucked then they should let me go.
| (And I'm in the UK where treatment is free at point of use).
| throwaway2037 wrote:
| Wow, this is a great post. I never knew about this NHS
| programme. I wish I had the same where I live.
|
| https://www.nhs.uk/conditions/end-of-life-care/advance-
| decis...
|
| https://www.nhs.uk/conditions/end-of-life-care/advance-
| state...
|
| At the risk of sharing some PII, are you willing to share
| some of the conditions that you set?
| DanBC wrote:
| Compassion in Dying have some advice about advance
| decision making.
|
| https://compassionindying.org.uk/making-decisions-and-
| planni...
|
| It's important to get the right balance around
| specificity. You need to include some
| tomcam wrote:
| I'm old and statements like this are... interesting
| conductr wrote:
| We all will be old one day, if lucky. My comment was not
| about _you_ because you happen to be old right now. But are
| you unfamiliar with typical end of life care in the US?
| Where the last few years is a constant stream of
| hospitalizations, rehabilitation, etc with no quality of
| life and no tangible benefit but a very substantial cost? I
| find that concept... interesting... as in, I don't like
| paying the cost and I don't intend on participating in it
| when my time comes. I think this feeling is growing with
| younger generations because we've witnessed what older
| generations are subjecting themselves and their families
| to.
| tomcam wrote:
| I'm familiar with all those issues and have been for
| years. Have taken both parents through agonizing deaths.
| Doesn't make comments like yours less unsettling.
| samanator wrote:
| Something I've learned about the ICU and hospitals in general
| when my brother was passing away is that they are not designed
| for large families. I have 10 siblings (9 now?) and the hospital
| would only allow for 3 guests at a time. The head nurse in the
| ICU would only allow for 2 guests at a time, parents included.
|
| We had to fight, trick, and sneak in order for all of us to be
| together with him in his last days (e.g. we would loiter outside
| the hospital picking up discarded guest stickers and pass
| ourselves off as other people).
|
| What I learned from this is that I do _not_ want to die in a
| hospital.
| maxerickson wrote:
| The solution to difficulty booking doctors isn't to pontificate
| on how to allocate their time, the solution to difficulty booking
| doctors is to make more doctors.
|
| There's lots of levers that could be pulled in the US. Cut down
| on undergraduate requirements, incentivize large health systems
| to fund more training (people like to complain that the federal
| government only funds a fixed number of residency slots, as if a
| trillion dollar industry is just absolutely helpless to do
| anything).
|
| Medical care suffers under the bizarre idea that central planning
| and capacity management will control costs. Meanwhile, costs are
| spiraling up and up and up. Train more doctors and all the stupid
| games being played to optimize their utilization start to go
| away, because it is less worth it when demand is less than
| supply.
| chromatin wrote:
| Although I agree with you on a distaste for the foolishness of
| central planning, lLet me provide an alternative perspective.
|
| A huge proportion of US physicians are already mediocre; a
| shocking number are bad. (Source: I am a physician.) Given
| this, I am concerned that further relaxation of standards in an
| effort to train more doctors won't lead to better outcomes.
| triceratops wrote:
| Not making American doctors do 4-years of an undergraduate
| "premed" degree will not meaningfully lower standards. Nor
| will creating more residency slots.
|
| We don't need better outcomes. We will happily take the
| existing outcomes but cheaper.
| cfu28 wrote:
| Is the point you're making here that removing the "premed"
| undergraduate degree (which doesn't exist) will somehow
| lead to reduced healthcare costs?
| intelVISA wrote:
| "But I want my doc to have a degree from medical school not
| some 3 month anatomy bootcamp..."
| toast0 wrote:
| > Given this, I am concerned that further relaxation of
| standards in an effort to train more doctors won't lead to
| better outcomes.
|
| The high standards certainly prevent people who are unable to
| meet the standars from practicing medicine, but they also
| prevent people who are able to but see the standards as
| unreasonably onerous and pursue something else. Some of those
| could have been great doctors but looked at the steps and
| said nope, I'm not going to go to med school, then hope I can
| get a residency, in which case I get to have a hellish
| schedule and little autonomy for at least three years, and
| then probably a hellish schedule and little autonomy for many
| more years.
| spfzero wrote:
| I get what you're saying, but I don't think more doctors is the
| answer. Hospitals will only hire the absolute minimum number of
| doctors they can possibly get away with, other than the ones
| who actually bring in new business.
|
| This is the reason: as soon as the medical industry has
| established a consensus price for some procedure or other item
| of care, the hospital administration starts to work on figuring
| out how to do it for the least possible cost. The price has
| been set in stone, no need for further justification. Medicare
| or whoever WILL pay that much. The price is fixed so the only
| knob left to turn is cost, and cost will be reduced all the way
| down, until service is just above a level so poor that patients
| would decide to stay home.
| NegativeLatency wrote:
| Possibly part of the problem then is having a for profit
| medical system?
| natosaichek wrote:
| Totally agree. Also, let people open more medical care
| facilities. Right now "Certificate of Need" legislation is
| killing lots of viable options for care _outside_ hospitals.
| kudu wrote:
| > people like to complain that the federal government only
| funds a fixed number of residency slots, as if a trillion
| dollar industry is just absolutely helpless to do anything
|
| Agreed, but I would go further and say that if demand by
| students for the training provided by residency exceeds the
| demand by hospitals for the work provided by residents, I don't
| see why residents couldn't pay for their training just as they
| do for medical school. The whole "residency funding" thing
| seems like a red herring as an explanation.
|
| To be clear, I'm not saying that medical graduates should have
| to take on more debt to pay for residency, but rather that the
| reason this doesn't happen is not obvious according to typical
| economic reasoning.
| oaktrout wrote:
| If you've spent on average ~200K for medical school, how
| willing will you be to pay to work for 3 to 8 more years
| before you get a paycheck? Resident doctors already make less
| than nurses with 4 year undergraduate degrees.
| barry-cotter wrote:
| So? People really, really want the prestige that goes with
| being a doctor. If they could pay for it they would.
| Physician compensation is heavily weighted towards middle
| and late career as it is and that hasn't stopped people
| beating down the doors to get into medical school. Half the
| people who currently apply to medical school could look at
| how crap it is and decide not to and there would still be
| intense competition.
|
| The below article on how awful medicine and medical school
| are was written a decade ago and nothing has gotten better.
| People really like social status.
|
| https://jakeseliger.com/2012/10/20/why-you-should-become-
| a-n...
| [deleted]
| e40 wrote:
| On why there are too few doctors:
|
| https://www.theatlantic.com/ideas/archive/2022/02/why-does-t...
| ntonozzi wrote:
| .
| maxerickson wrote:
| It's not illegal for other entities to fund residencies!
|
| I anticipated your argument in my other comment...
| NegativeLatency wrote:
| Just getting accepted to a medical school is pretty hard unless
| you're amazing/very good at the tests.
|
| Had a cousin and a friend (both I would characterize as smart
| and hard working) take several years after undergrad and
| eventually "settle" for physicians assistant schools.
| j-bos wrote:
| I personally want my doctors to be amazing and very good. For
| now tests are a fair proxy, it's the 8 years that seem
| ridiculous, esp when looking at non US countries.
| ncallaway wrote:
| > For now tests a a fair proxy for that
|
| Is it? Is there a study demonstrating the correlation to
| pre med test scores to patient outcomes?
| j-bos wrote:
| Personal intuition, feel free to dismiss.
| NegativeLatency wrote:
| I agree with your sentiment however it reminds me a lot
| of the leet code style interviews and all their
| downsides.
| ncallaway wrote:
| Makes sense, and seems like a sensible prior.
|
| It just strikes me as something that wouldn't be
| particularly hard to answer with a detailed study, and
| probably is a pretty high value question to answer, so I
| wouldn't be surprised if there was a study.
|
| Maybe I'll poke around this weekend
| lofatdairy wrote:
| I would argue that having onerous tests are not a great
| proxy. Not only do they not necessarily measure how good a
| physician a student would be, but it also encourages
| undergraduates to intentionally enter easier/less rigorous
| coursework to focus more on the exam aspect (though GPA
| plays a large role as well). I'm sure a psych major may
| make a fine physician, but I don't want doctors to only be
| educated in a rather dubious field. If undergraduate
| education is only a stepping stone towards medicine, then
| just integrate medical education with undergraduate
| studies, rather than adding a ritualized acquisition of a
| bachelor's degree.
| jmcgough wrote:
| Everyone takes the same premed courses though, and you
| need to be able to teach yourself any MCAT content that
| wasn't covered by coursework. Sure people will game it,
| but it's your science GPA that counts, and having people
| from a diversity of backgrounds is a good thing.
| [deleted]
| dogmatism wrote:
| Nah, doesn't matter. There are still the pre-med
| requirements (organic chem etc -- recall recent bruhaha
| about that at ?NYU) that can't be sidestepped for easier
| courses
| jasongi wrote:
| RE: the amount of people over 70. This isn't just ICU, this is
| all of healthcare.
|
| Both culturally and legally humanity seems incapable of accepting
| death. The threshold for the amount of intervention we'll do for
| a human dying is way too much. Sure, you can say DNR, but
| voluntary euthanasia laws are restrictive and the default from
| the medical and broader community is almost always try to survive
| at all costs.
| stordoff wrote:
| I spent about ten days in a UK ICU with Covid-19, so figured I'd
| share a few comments based on my experience. I was in a room for
| one person, so I've no idea who else was in there. I didn't
| suffer any delusions/hallucinations, other than my memories of
| the first night being a little hazy (which can probably be put
| down to being moved at 3am unexpectedly and possible hypoxia).
| However, after I discharged, I felt like I could still hear the
| <90% SpO2 alarm going off in my head constantly for _weeks_ (I
| spent most of the ten days struggling to maintain 90% SpO2, so it
| was a noise I became very familiar with).
|
| > There are many consults, but the ICU attending is king (or
| queen) / Sometimes nurses are the footsoldiers of the ICU regent,
| and sometimes they're governors
|
| It's hard to say specifically was making the calls, particularly
| as the PPE made it a little difficult to recognise people, but it
| definitely felt like there was continuity of care - treatment
| plans were discussed well in advance, and usually didn't change
| unexpectedly. The recommendations from the physiotherapist and
| nutritionist (my appetite was virtually non-existent), as well as
| my own requests, were followed by all of the staff involved as
| far as I could tell.
|
| > Everyone agrees that sleep is important, but nobody has any
| idea beyond that
|
| I couldn't sleep for the first two nights, but beyond that, I
| didn't find this to be an issue. I'd go to bed around 10:30, and
| wasn't disturbed until about 8 o'clock the next morning. As I
| understand it, HR/BP/O2 monitors could be checked from an
| adjacent room, and most of the non-critical alarms were muted (I
| believe they were still audible to staff outside of my room).
| There were a few times staff came in to check/adjust something,
| but never more than once a night (that I noticed at least).
|
| > The ICU is a good place to not die, but a bad place to recover
|
| I'm not sure I can agree with this. I was moved back to a ward
| for a few days before I was discharged, and felt that I would
| have recovered better had I stayed in the ICU (though I
| understand why that's not practical). The room of eight had two
| dementia patients who would yell out for most of the night. Obs
| were taken about every three hours, which woke me every time (BP
| was taken with a pressure cuff rather than the arterial line
| which was used in the ICU, and I wasn't routinely wearing a
| finger sensor). As a result, I got very little sleep until I was
| discharged. It was also much more difficult to get the attention
| of staff at times.
| ericmcer wrote:
| His observation that the ICU is full of the elderly reminded me
| of the Obamacare debates when I was younger.
|
| I always felt like I was taking crazy pills when I would leave my
| conservative elder parents who hated the idea of universal
| healthcare, and go to my younger liberal friends who were all for
| it. It was such a clear case of peoples ideology running directly
| against their self-interest. Young people being against paying
| for old peoples healthcare (while the elderly control a much
| larger share of the wealth) made sense to me, old people wanting
| more reassurance that they would always have healthcare made
| sense, but the two groups essentially wanting to self-sabotage
| was always confusing.
| crooked-v wrote:
| Fox News & co have spent decades training their target
| demographic to hate and fear anything that Democrats even
| pretend to like. There's nothing particularly age-inherent
| about it other than said demographic being both wealthier and
| less educated and thus a better group to target with the
| associated nonsense grifting.
| anon291 wrote:
| A lot of old people have made peace with death. Not all, but
| many
| JamesianP wrote:
| If you abandon your ideals when it conflicts with your own
| self-interest, it is not ideology at all, just self-interest.
| You are criticizing integrity here. such as it is..
| prenevikdale wrote:
| I would hope that liberal young people (and we millennials)
| wouldn't be against paying for old people's health insurance at
| all. The hardest part of believing in a principle is doing so
| when you aren't benefitting from it.
|
| While I have little patience for Fox News lemmings of any age,
| I have noticed that the relative lack of older folks in our
| daily "internet trenches" has caused the digital zeitgeist to
| take on a distinct anti-elderly tone. From lighter- hearted
| mockery, to blaming a nebulous organized "boomer" class for
| birthing every modern sin of civilization, and everything in
| between.
|
| In any event, as more internet literate adults experience the
| full lifespan, it may create a corrective trend.
|
| By the way, nearly every reply in this thread has been more
| informative and thought-provoking than the original article on
| Substack. A really interesting thread to follow, thanks to the
| contributors.
| ncrmro wrote:
| I woke up in the ICU after getting hit on my motorcycle with a
| brain bleed and ton of other damage and all I can say it I'm
| super grateful for everything they did.
| Ensorceled wrote:
| I noticed a lot of the same things when my dad was in the ICU.
| Some additional thoughts:
|
| 1. "Almost every patient has delusions and nightmares" I
| personally felt "off" when visiting my father. The sounds,
| smells, lights and constant buzz of activity all contributed to a
| feeling of being in a surreal dreamworld. Lack of sleep
| contributes. I can't imagine what my father experiencing.
|
| 2. Food was HORRIBLE. One meal was a low quality hamburger on a
| plain, white bread bun with a slice of "american cheese", fries,
| iceberg lettuce salad with a couple of slices of cucumber and a
| single slice of tomato, a container of apple sauce and glass of
| milk. Lots of salad dressing and ketchup. They wouldn't let us
| bring better food into the ICU and my dad didn't want to "make
| waves".
|
| 3. Family is critical. My father got better care because I, or my
| brother, was there to act on his behalf. Having obnoxious family
| members is worse than having none from what I saw.
| etrautmann wrote:
| Yes - my wife is a physician and she routinely describes how
| well meaning family members make care harder for their loved
| ones by trying too hard in the wrong ways. Requesting more care
| doesn't get you better care - "squeaky wheel gets the grease"
| doesn't really apply in many situations.
| throwaway2037 wrote:
| I have heard an equal number of stories that are exactly
| opposite. Only through aggressive, pushy "squeaky wheel"
| behaviour was someone able to get the correct care.
| Ensorceled wrote:
| I certainly saw that. The issue we had was my sister grilling
| everyone who came into the room, or even walked by, often the
| same questions that she already asked that person earlier. I
| could see everyone starting to dread seeing her. The "squeaky
| wheel gets the grease" doesn't apply if people are avoiding
| the patients room.
|
| My father's cardiologist was explaining the procedure he was
| about to perform and my sister and mother were so upset they
| just flooded him with irrelevant questions and questions that
| he had already answered. I kept trying to get them to stop
| talking over top the surgeon and actually listen to the
| answers he was giving. He finally asked me if I could
| "socialize this with your family" so he could return to the
| operating room.
| amatecha wrote:
| I had a family member who wasn't even in ICU, and still
| experienced delusions simply from being sick and being in the
| hospital for a few days. He thought there was a group of family
| members around the corner waiting to jump out and surprise him
| and was insistent that I tell them not to disturb the other
| patients. I had to argue with him to get him to accept that,
| no, there is not a random group of family members waiting to
| jump out. He insisted he heard them talking and stuff. It was
| pretty disconcerting for me actually because he has always been
| a psychologically-bulletproof person. Definitely an eye-opening
| moment for me.
| cwillu wrote:
| Now thinking about how this applies to the acute mental
| health wing.
| tomcam wrote:
| Very well thought out article, but I promise your life will
| improve if all you do is read the caption on the first image.
| parker_mountain wrote:
| This is not a picture of a real hospital. This is a picture of
| Mystic Falls hospital, from the CW show "The Vampire Diaries".
| If I remember correctly, the guy on the left is an evil vampire
| hunter (the vampires in the show are mostly heroes, except when
| they're evil and trying to take over the world), and the doctor
| on the right is maybe a vampire? Or she might just be friends
| with a vampire but not realize it. Or she gets killed by a
| vampire. I forget and refuse to look it up. It's a really
| stupid show.
| bombcar wrote:
| I suspect it IS a real hospital, depending on if the show was
| set in a hospital or not. If they only needed it for a few
| scenes, you just rent out a hospital or something that looks
| similar enough.
| bbarnett wrote:
| No, it's a real hospital, and a real scene, but they're all
| reverse vampires.
| bombcar wrote:
| Isn't a reverse vampire just a blood infusion doctor?
| tomcam wrote:
| Thank you
| oifjsidjf wrote:
| A bit offtopic but an interesting book:
|
| Confessions Of A Medical Heretic - Robert S. Mendelsohn M.D.
|
| https://archive.org/details/confessions-of-a-medical-heretic...
| a_shovel wrote:
| I don't have much personal experience with hospitals, but there's
| a trend I've noticed across several articles now where the
| medical system is characterized by an unpredictable and frequent
| alternation between extreme competence and extreme incompetence.
|
| The author's dad was being seen by a variety of highly trained
| specialists all working to treat him, but "people need to sleep"
| seems to be a recent discovery in the ICU world, and if his
| family hadn't been there to help, every new nurse would have
| tried to give him the same medication that gave him a bad
| reaction, over and over, just because there wasn't an established
| place to write that (obviously important) information down.
|
| I've read that food with better nutrition than regular hospital
| food may reduce mortality rates by as much as _half_ [0]. That 's
| such a huge effect that it's shocking that hospital food is just
| expected to be bad. Everyone says nutrition is vital for health,
| but hospitals don't seem to care.
|
| I think the root problem is cost-cutting. Management cuts costs
| until the brink of disaster, and tries to hold it there for as
| long as possible. This is not a system that strives for the best
| outcome for patients within reasonable limits of the resources
| available; this is a system that attempts to extract as much
| value as possible from the patients, and patient death is only
| prevented as a means to that ends.
|
| [0]
| https://www.sciencedirect.com/science/article/pii/S073510972...
| blue039 wrote:
| tunap wrote:
| >"people need to sleep"
|
| Sleep is almost impossible with regular check-ups... 30 min or
| 60 min, don't remember. Excepting the comatose and most
| medicated(maybe not?), a person's sleep cycle is unable to
| reach REM when a stranger approaches and fiddles on regular
| intervals. I would think monitoring from afar(sensors, cameras)
| would be more beneficial, but I was informed the liability
| factors preclude such remote monitoring.
|
| edit: to add context, I slept in the room on separate occasions
| with 2 family members. While tests were not performed, the
| regular checks were mandated. I was exhausted after my shifts
| ended.
| ThePadawan wrote:
| More than 10 years ago now, I was in the ICU for myocarditis,
| leading to bradycardia, a very slow heart rate.
|
| During the night, it would drop to 40 (which is still fine),
| but sometimes below 30, at which point my heart monitor would
| blare an alarm, waking me up and scaring the absolute bejesus
| out of me, raising my heart rate immensely. A nurse would
| walk in, see that I was fine, and leave again.
|
| This occurred nightly for a few days.
| throwaway2037 wrote:
| I don't understand this post. It reads like "have your cake
| and eat it too". The the heart monitor did not blare an
| alarm, maybe you died. Which one do you want?
| ThePadawan wrote:
| The alarm to go off in the nurses' station so they could
| investigate.
| QuercusMax wrote:
| Last time I was in the hospital (in 2016 with a broken arm)
| it was very difficult to sleep because the bed had some
| device that pokes you every so often to make sure you don't
| develop bedsores from lying too still.
|
| This makes sense for someone who might be in there for weeks,
| but I was barely there overnight!
| tomcam wrote:
| Nightmarish yet darkly comical. Sort of torture adjacent...
| cactus2093 wrote:
| From reading the abstract you are completely mischaracterizing
| this study.
|
| For the average person healthy food usually means food with
| fewer calories and more micro-nutrients, like eating more
| broccoli and less white bread.
|
| This study is about malnourished patients who need more
| calories than they can even digest from an average meal so they
| need specialized high-calorie foods that are customized for
| their own metabolism. It's essentially exactly the opposite of
| what "healthy food" means in any other context.
|
| So it has nothing to do with any narrative about cost cutting
| and the quality of ingredients used in hospital cafeterias.
| cco wrote:
| A closer reading of the intervention shows that it wasn't
| _just_ "more calories".
|
| But I think that is missing the forest for the trees, what
| this study showed is that when a patient is left on their
| own, they consume an inadequate diet that _puts their health
| at risk_ in a hospital. By a big margin!
|
| I would imagine, though the study didn't show this, that the
| primary factor in recovery here was having a human
| (dietician) actually paying attention to your recovery. On
| intake they put together a plan, and followed up routinely to
| ensure that the patient has consuming their diet.
|
| The GP's point is valid, hospitals are missing out on a 50%
| increase in health outcomes because they're letting patients
| fend for themselves with regard to nutrition. You're right
| that it isn't as easy as spending $6 per meal vs $3 to buy
| "better" food. But what it means is that hospitals are
| failing their patients because they aren't thinking and
| acting with a holistic eye towards patient outcomes.
| Negitivefrags wrote:
| I don't think the problem is cost cutting. I think the problem
| is just the same problem that every human enterprise has.
|
| Most people just don't give a shit outside thier immediate
| responsibility.
|
| Looking at the global view and actually making changes that
| require persuading other people is a hard and often thankless
| task.
|
| Many people who do give a shit get this crushed out of them
| early in their career by the negativity you will face if you
| try.
|
| Much easier to just accept the status quo.
|
| Occasionally you get a group of people who really care and come
| together determined not to let things be crappy and they can
| form an organisation that is significantly more effective for a
| time. But once the rot of "We can't fix things" sets in, it's
| really really hard to turn things around.
| msrenee wrote:
| Cost cutting is definitely to blame for how understaffed
| hospitals are. Then Covid happened and it got even worse.
| It's definitely not all due to Covid though. Even the "not-
| for-profit" medical group in my area has been pushing doctors
| and PAs to take more and more patients, well past what
| they're comfortable with. Nursing staff has been cut down to
| nothing compared to 10 years ago. Wages haven't gone up to
| match the increase in workload.
|
| Again, this started before Covid, the pandemic just
| highlighted how much these cuts screwed over both healthcare
| professionals and patients.
| rscho wrote:
| I work in a hospital, and occasionally in ICUs. You're wrong.
| Most workers are very much jaded, but they do care. Problem
| is, the system crushes you to death if you don't set pretty
| harsh limits to protect yourself. In a lot of cases, that
| means de-humanizing your work, put your feelings aside and
| work like a machine. Good little machines are just what
| management wants, right? Now higher management... wow, those
| people really don't give a hoot about anything that's not
| themselves!
|
| A second major contributor to inertia, is that the
| initiatives from lower echelons are usually set for failure
| by the intricacies of bureaucracy. And said bureaucrats are
| completely unimaginative about what they could do to fix
| things, because they never leave their office to see what's
| really happening in the trenches. So yes, in fine the problem
| is the extreme stupidity stemming from human collective
| behaviour. Complain, and suddenly _you_ are the problem!
| gowings97 wrote:
| What percent of patients have a medical need to be woken up
| every few hours then?
| rscho wrote:
| You'd be surprised to see what happens to staff going
| against waking up patients all night. You get the
| "dangerous sloth" sticker on your forehead real quick on
| the morning grand rounds.
| gowings97 wrote:
| With all the focus on EHR and billing, they can't have
| all the machines taking vitals hooked up and in a ready
| only state thats sent to the nursing station?
|
| This is the type of stuff I have a gripe with. Sinecure
| and fiefdoms of power.
| rscho wrote:
| Silencing monitors is actually forbidden by law in many
| places. Staff is supposed to be near the patient at all
| times => monitors beeping. That's certainly a bad state
| of things, but not a "fiefdom of power". It's so
| ingrained in our education that most staff don't even
| think about it but would certainly agree if asked whether
| the patient would sleep better without it.
| gowings97 wrote:
| Not saying monitors should be silenced. You can monitor
| someone without waking them up.
|
| Fiefdoms of power - nursing union not wanting to give up
| the night shift premium pay when the job description
| changes to monitoring a screen and half the physical
| workload vs. day shift.
| haldujai wrote:
| I'm not sure where you're getting this from. I / my
| nurses silence alarms at literally every hospital I've
| ever worked at (granted they're temporary silences by
| design so you have to hit silence q1h/q30mins depending
| on the alarm).
|
| Stanford Healthcare recently installed a system where all
| alarms/notifications get sent to a hospital assigned
| device the nurse carries rather blasting in the sleeping
| patients room as 90%+ are false alarms (aka IV or SpO2
| sensors).
|
| The real issue is that hospital technology is outdated
| and most places don't have the option for this level of
| telemetry.
|
| I've never been told / instructed my staff to "be near
| the patient at all times".
|
| In fact, most places have 1:8 nursing coverage on the
| ward...
| rscho wrote:
| You're right that silencing alarms is strictly forbidden
| in anesthetic territory only, not ICU. I'm biased bc I'm
| in Switzerland, and here the coverage ratio is usually
| 1:1. The country is so rich, that many things are
| different here... they really are near the patient at all
| times. To give you an idea: the day COVID really hit, we
| received 180 shiny new Hamilton respirators complete with
| additional staff overnight, in an ICU that's usually ~30
| beds. And you can't order "your nurses" around, because
| they've got a lot more power. Yes, in most places it's
| different and I should have mentioned that.
| haldujai wrote:
| I want to clarify two points given the language used in
| your response:
|
| 1. I used the possessive "my" in reference to nursing
| staff for simplicity in writing and clarity to the reader
| rather than to indicate ownership, we are on a team. This
| is akin to saying "my goalkeeper wears Nike soccer
| cleats".
|
| 2. I do not "order nurses around." I verbally communicate
| and leave medical orders in the chart that nurses act on.
| It is not about a power struggle, we are all trying to do
| our jobs and do what's right by the patient. I'm grateful
| when nurses question my medical orders (as long as it's a
| positive/educational discussion, which it is 99% of the
| time) as they catch my mistakes and we all learn
| together.
|
| If you are concerned that you can't order nurses around,
| I strongly suggest reflecting on whether this leadership
| style is the most conducive to providing quality patient
| care as this can increase barriers and hostilities in the
| workplace resulting in communication breakdown and
| adverse events.
| barry-cotter wrote:
| Any doctor who says they treat nurses as valued
| professional colleagues should be presumed to be lying
| unless you have seen it yourself, in person. Doctors
| treating nurses like shit is the norm, not the exception.
| How badly varies a lot.
| rscho wrote:
| Thanks for the lesson, mate. I'll be strongly reflecting
| over the past 15 years of clinical practice and see the
| errors in my ways.
| ghufran_syed wrote:
| pretty much _every_ patient in the intensive care unit -
| that's kind of what the "intensive" is referring to.
|
| If nothing else, you either take the blood pressure the
| normal way with a pressure cuff, which is _going_ to wake
| you up. Or you put an intra arterial catheter, which
| reads continuously without bothering the patient, but has
| a small risk of damage to the vessel, infection etc
| halpmeh wrote:
| Everything you said is spot-on, but, brining things full
| circle, the lack of "shit giving" could be due to cost
| cutting. People don't have an incentive to care. The end
| result, vis-a-vis their personal situation, is unchanged
| whether or not they go the extra mile. Part of this is
| because they exist in a rigid corporate structure hyper-
| focused on value extraction and not at all focused on the
| development of human capital.
| lazyasciiart wrote:
| I don't know why the haldol reaction didn't go in his chart,
| but the whiteboard in the room (which is present in every high
| level hospital room I've been in) is _exactly_ where the TV
| information and other patient preferences should be, and is the
| second best place after the chart to put a drug reaction. Cost
| cutting has nothing to do with "nobody wrote it on the place
| for writing it".
| colechristensen wrote:
| >The author's dad was being seen by a variety of highly trained
| specialists all working to treat him
|
| The training doesn't really matter. Context is very important
| as is caring about doing a good job. You'll find a severe lack
| of both in hospitals. You eventually have to stand up and
| defend yourself against bad healthcare... or search endlessly
| for good healthcare which is terribly difficult to find.
| citilife wrote:
| For point #4 (about sleep) and point #5 (about delusions) - these
| are probably related. If you don't get enough sleep you get
| rather paranoid.
|
| Having been in the ICU with various family members I notice they
| check on you A LOT and that often will wake you up. This lack of
| consistent sleep (either from injury, illness or checks) make
| people rather paranoid. Further, sitting still and waiting often
| makes people a bit stir crazy.
| ivraatiems wrote:
| My wife is a physician who works in a critical care setting. She
| did not read or approve this post; these are my thoughts as
| someone who hears a lot about the other side of this environment:
|
| For the most part this seems like a sensible and reasonable
| article communicating what must have been an extremely difficult
| situation for the author. In case the author reads this: I'm
| really glad your dad got better and I know everybody working in
| the hospital appreciated the amount of patience and restraint it
| seems like you showed in helping him without being that patient
| family member who goes off the handle about everything. (There
| are so many of those.)
|
| Many of the issues the author points out are very real -
| constantly-rotating doctors, attending disregarding consults once
| the consult leaves the room, the ICU not being set up for
| anything but bare survival - all of that is totally true from
| what I understand. I think, if anything, the author fails to
| understand how systematic and critical those issues are when he
| says things like this:
|
| > So, digestive issues, hormonal issues, and mental issues all
| get short shrift. Basically, if there's an obvious symptom, a
| consult will come in to try to treat the symptom. Then they'll
| take another test in a day or so, see what happens, and go from
| there. There's no sense of a scientific method, reasoning from
| first principles, or even reasoning from similar cases though.
|
| I don't think this is giving the medical practitioners a fair
| shake here. Doctors do a huge amount of this kind of reasoning
| and research, even in the ICU. The trouble is often not a lack of
| reasoning, but a matter of, as with everything else you note,
| resources. Like you realized, the goal of the ICU is "keep
| patients alive at all costs, and worry about their comfort once
| they're able to be alive without our help for a while." Judgments
| are made with that in mind. It's not that they can't do reasoning
| about complex problems, it's that spending time on a complex but
| non-fatal problem means somebody with a potentially fatal problem
| won't get that time, and that's not what the ICU is for. Anything
| that can be solved later... will be solved later.
|
| So the real question is not "Why didn't they help this patient
| with his digestive issues?", it's "Why didn't they move this
| patient out of the ICU once he reached the point where non-life-
| threatening digestive issues were relatively of any importance?"
| ghufran_syed wrote:
| It's also impossible to infer the logical process from a
| superficial observation of the tests being done - that would be
| like inferring the code architecture from what's displayed on
| an output device, in rare cases it might be possible, but
| usually not
| isleyaardvark wrote:
| The author even mentions that a long term stay like their
| father's is rare. A lot of the criticisms are about what is,
| and I apologize for the expression, an edge case.
| possiblydrunk wrote:
| From personal experience, one of the most frustrating things
| about the ICU (if you're there for any anything beyond a day) is
| dealing with the variability in the availability, skills, and
| temperaments of the nurses on duty. The 'right' nurse can make a
| huge difference in how fast the patient recovers and how
| difficult the stay is.
| SanjayMehta wrote:
| ICU induced hallucinations are indeed a nasty side-effect. My
| father suffered terribly during his last few days. Some things
| are worse than death.
|
| Imagine being jetlagged all the time for 10-15 days while random
| people are poking and prodding you.
| mberning wrote:
| I think people expect that things could go significantly better,
| if the "system" were better. I disagree. In most cases, by the
| time they hit the ICU, you have a patient that is circling the
| drain from old age and chronic conditions and all you can do is
| manage it. No amount or quality of care is changing the outcome.
| jeffrallen wrote:
| Hospitals make you sick. Intensive care unit make you intensively
| sick. What a tragedy that something we need so much is so bad for
| us.
| [deleted]
| jshaqaw wrote:
| In my few (luckily) interactions with American hospitals for
| serious matters I'm struck by how much the hospital looks like a
| unified organization from the outside but inside seems little
| more than common real estate and a joint marketplace for 1000 sub
| vendors. The system can produce amazing outcomes but suffers from
| a lack of coordination. It is telling that after a hospital stay
| you get 20 bills from different places which have no connection
| to each other.
| jdkee wrote:
| From the article, "We are spending an enormous amount of our
| healthcare budget on patients in the last 5 or 10 years of their
| life."
|
| It is even worse than that in the U.S., estimated at 10% of total
| healthcare expenditures in the last year of life.
|
| See https://www.wrvo.org/health/2019-09-30/ten-percent-of-all-
| he...
| fhsm wrote:
| Healthcare is mighty complex. The "why don't you just _____" or
| "the problem is _____" impulse among all who touch it is strong
| and typically well intended. Eventually it will even be right.
|
| For the many who have shown the impulse here, a bit of context:
| Apple _global_ revenue in 2020 was 274B[0] and _US_ healthcare
| spend was $4T[1]. If you can capture just 6% of just the US you
| 've got an Apple sized (in one sense) operation. Six percent
| isn't so big, Google is at 90%[2]. Little old United Airlines
| picks up twice that 6% target for 13% share[3]. If you pulled in
| 13% of US healthcare you'd have a Walmart sized operation[4].
|
| Apple, Google, Amazon, Microsoft have made a multiple runs at it.
| Maybe Apple Watch and PillPack count as successes, maybe.
|
| The world is waiting for, dying for, someone who actually knows
| _____.
|
| [0] https://www.statista.com/statistics/265125/total-net-
| sales-o...
|
| [1] https://www.cms.gov/Research-Statistics-Data-and-
| Systems/Sta...
|
| [2] https://gs.statcounter.com/search-engine-market-
| share/all/un...
|
| [3] https://www.statista.com/statistics/250577/domestic-
| market-s...
|
| [4]
| https://www.macrotrends.net/stocks/charts/WMT/walmart/revenu...
|
| (obviously the math is approximate, the sourcing iffy, and the
| comparisons flaky ... particularly Walmart which is a big player
| in healthcare so is getting double counted).
| osmano807 wrote:
| Surgeon here. I'm about more surprised by the discussion here
| than from the article itself.
|
| > 2. There are many consults, but the ICU attending is king (or
| queen). There's a concept called _doctor 's autonomy_. The
| attending physician has the primary "guard" of the patient care,
| so unless dynamics of power, consultations are more like
| suggestions than law. So, the final care is generally dependent
| on the attending physician, for good or worse, be lack of
| confidence in the other physician be his perceived better
| understanding of the disease.
|
| > 3. Sometimes nurses are the footsoldiers of the ICU regent, and
| sometimes they're governors. I saw examples of nursing saving and
| harming patients while disobeying orders. They have a co-
| participation in care and generally have studied to a degree that
| enable them to make some decisions.
|
| > 4. Everyone agrees that sleep is important, but nobody has any
| idea beyond that. We have decades worth of knowledge, but _de
| facto_ we don 't have a systematized and validated way of sleep
| care. We have studies on daytime nap and on sedatives effects on
| quality of sleep, but no full truths. Some day we'll have a
| better care.
|
| > 6. The ICU staff is literally constantly changing. The
| institutional memory are the patient medical records. If the
| Haloperidol adverse reaction was not noted in there, it was a
| fault of the care providers. Sometimes nurses chooses to ignore,
| and the repercussions should be analyzed case by case. The cited
| whiteboard worked as an "expanded" medical record, as registering
| that trigger could be seen as too tangential to a disease focused
| medical record.
|
| > 7. The ICU is great at managing acute issues, and struggles a
| lot more with longterm issues. Long term issues are not the
| concern of ICU. If it's not critical, the care can and maybe
| should be postponed until better. Of course, we have to be
| prudent, for example bowel function could be potentially urgent
| if not intervened early. Frequently I could and should not treat
| patients depression on an ICU, but it's reasonable to treat
| intrusive symptoms of early post-traumatic stress disorder, for
| example.
|
| Free T4 is the method used to assess thyroid hormone
| supplementation, not TSH. Delirium, delusions, illusions and
| hallucinations have a non-pharmacological and pharmacological
| treatment, and antipsychotics are not the only ones used.
|
| > 8. The ICU is a good place to not die, but a bad place to
| recover. The ICU is meant to give patients a better opportunity
| to not be critical anymore. When they're not critical, we start
| to deescalate our measures, such as monitoring and IV lines, for
| example.
|
| People are different, and so are doctors. As the good, so the bad
| sprouts everywhere.
| Fomite wrote:
| From an epidemiological perspective, one of the hardest things
| about evidence for critical care is that _ICUs are really,
| really hard places to conduct studies_.
| pmarreck wrote:
| Excellent criticisms (having dealt with my mom's passing in 2020)
|
| I noticed that the incessant beeping all night has decreased
| quite a bit, of late (at least in my local hospital, St. Francis
| Heart Center)
| pgrote wrote:
| I spent 2 weeks in an ICU due to an appendectomy gone wrong
| followed by growing open wound and infection. Horrible time from
| a mental health perspective with visual and auditory
| hallucinations, feeling of paranoia concerning the medical team
| and nightmares. Hallucinations and paranoia stopped before I was
| discharged, but it took a couple of years for the nightmares to
| subside.
|
| Post-intensive care syndrome is something that happens that
| hardly anyone who hasn't been in an ICU knows about. Even when I
| was in the ICU the medical team never discussed it with me. My
| running joke to deal with what happened is that I aged 10 years
| the 2 weeks I spent there.
| fernly wrote:
| > 1. The ICU is filled with old people... Pretty much all these
| patients are on Medicare, which means your taxpayers dollars are
| making this happen.
|
| This ignores the (I think) very strong possibility that the old
| people are preferentially selected by the system because, thanks
| to Medicare, they can _afford_ the ICU. Many people aged less
| than 65 cannot. Consider the idea that if we had something like
| "Medicare for all", the population of the ICU would better
| reflect normal demographics.
|
| That said, as a beneficiary of Medicare I can only be grateful. I
| had several days in a top-quality hospital and a procedure by a
| top-quality surgeon, and after all the EOBs had come in, I ended
| paying out of pocket... nothing at all.
| ghufran_syed wrote:
| ability to afford the ICU is not relevant _at all_ when the
| docs decide to put someone there or not, based on my 14 years
| practicing in the US. Do you have any experience to the
| contrary? I'm pretty sure that would be illegal in the US
| fernly wrote:
| A very quick DDG search turns up stories from reputable
| outlets:
|
| "Americans dying because they can't afford medical care"[1],
|
| "66% of Americans fear they won't be able to afford health
| care this year"[2],
|
| "Nearly 46m Americans would be unable to afford quality
| healthcare in an emergency"[3],
|
| "Nearly 1 in 4 Americans are skipping medical care because of
| the cost"[4],
|
| and more are easily found. If this doesn't reflect people
| avoiding hospitals, or leaving early AMA, and thus reducing
| the number of pre-Medicare patients by some amount, I'd be
| very surprised.
|
| [1] https://www.theguardian.com/us-
| news/2020/jan/07/americans-he...
|
| [2] https://www.cnbc.com/2021/01/05/americans-fear-they-wont-
| be-...
|
| [3] https://www.theguardian.com/us-news/2021/mar/31/us-
| affordabl...
|
| [4] https://www.cnbc.com/2020/03/11/nearly-1-in-4-americans-
| are-...
| halper wrote:
| Having experience from emergency departments in two different
| countries with "Medicare for all", it seems pretty much the
| same everywhere. There are two cohorts that make up the
| frequent flyers: the old and the drunk/addicts. The former get
| sick often and when they get sick they don't recover well; the
| latter end up in problematic situations like falling asleep
| outside in winter, getting in fights, overdosing or similar.
| ericmcer wrote:
| Old people having more health issues is not really a crazy
| observation to make. I would be blown away if medical care
| needed was equal across all ages.
| fernly wrote:
| It wouldn't be. Clearly age brings medical problems. However,
| I'm saying that the cheap access to hospital care afforded by
| Medicare, could be skewing the distribution of ICU patients.
| If we had universal medical insurance comparable to Medicare,
| the ICU population might be closer to the demographic norm.
| User23 wrote:
| The single most important thing for anyone in the medical system
| is having a capable advocate. This story really drives that point
| home.
| rootusrootus wrote:
| As a counterpoint, my experience with my dad being in the ICU was
| great. They saved his life a couple times when he needed to have
| his heart paddle-started. And they managed to stabilize him and
| let him get sleep as much as possible so he could be transitioned
| out of the ICU. I never once got the impression that anyone was
| incompetent, or that they were having trouble remembering
| strategies, reactions to medicine, etc.
|
| But this was Kaiser. Other hospitals may indeed be a shit show.
| wahern wrote:
| I wonder if there's a selection effect where on the one hand
| particularly demanding people avoid Kaiser because of the
| somewhat impersonal policies and practices, and on the other
| hand as an HMO Kaiser enjoys a much lower percentage of
| indigent and high-risk patients, which altogether permit Kaiser
| to build a system around the 80% instead of the 20%.
| chiefalchemist wrote:
| When when one of my parents had a stroke years ago, we spent a
| week in the ICU. It was a special ICU for stroke victims. The
| care and staff were exceptional. We were lucky such an ICU was in
| our area.
|
| On the other hand, subsequent hospital visits (non-ICU) were a
| cluster fuck. Noise, lights on, nurses constantly waking my
| parent up, could-care-less doctors, etc. And getting healthy
| enough to be transferred to an extended care facility was a shit
| show. It's was like the hospital but worse. Both experience
| seemed to have little to do with health and recovery.
|
| My point is, the article author is in for a shock once his dad
| gets out of the ICU and into the "general population". I can't
| imagine that's going to be better than the ICU. I hope I'm
| mistaken.
|
| My take away from this experience is:
|
| 1) Make choices that maximize your health the best you can.
|
| 2) If you can, be rich - like fuck you money rich. The kind of
| rich where your "general population" hospital experience will be
| like being in the ICU.
| rscho wrote:
| Rich people always get the worst possible care, in my
| experience. Life-prolonging care, yes. But at what cost? Those
| are the people that get the most "experimental" medicine out
| there. Rich people select for the most greedy docs, not for the
| most capable ones.
| [deleted]
| igammarays wrote:
| There should be a name for this, "medical theatre", analogous to
| security theatre. A brilliant performance art, with all its
| buzzing machines, expensive insurance, bright lights, pretty
| graphic logos, well-dressed specialists and doctors that aren't
| able to apply their knowledge correctly because they can't get
| simple things right, like letting patients sleep properly or
| recording and passing on information specific to a patient. All
| of this because the emphasis is on the "system" rather than the
| patient, and the solution is "more system". There is no amount of
| procedure that can replace genuine care and concern for a human
| being -- this man's father was lucky to have someone who was
| spending time with him observing these things, and presumably
| helping the staff avoid mistakes, and probably helping with the
| feelings of paranoia and hallucinations as well.
| jlarocco wrote:
| > The ICU is filled with old people.
|
| What else would you expect? Health deteriorates as people age, so
| old people, having deteriorated for a longer amount of time, will
| generally need more health care.
|
| Good insights overall, though.
| prenevikdale wrote:
| I actually thought the article was narcissistic and shallow,
| and I didn't find the author to have anywhere near the
| experiences or qualifications to make the judgments in his
| article. The contributions in this thread have been orders of
| magnitude more interesting than the OP.
| Fomite wrote:
| A lot of medical dramas and things that shape people's
| perceptions portray ICUs are filled with exciting and puzzling
| cases that need to be solved.
| warner25 wrote:
| > There's no sense of a scientific method, reasoning from first
| principles, or even reasoning from similar cases though. It's all
| shooting in the dark, and most of the time I felt like I could
| have done just as good a job on these longterm issues...
|
| This articulates very well what I've usually felt when dealing
| with doctors. It's like the story of a programmer finding that
| his code outputs 5 when it should be 4, and then adding...
| if(return_value == 5): return_value = 4
|
| ...to fix it, and being satisfied. What I _want_ is something
| like in the television show _House._ The main character is
| unhinged and anti-social and takes extreme risks, but at least he
| demonstrates curiosity to really figure out and understand the
| root of what 's going on. To be fair, I don't actually think that
| doctors lack curiosity or are incapable of doing this, the
| medical _system_ as it 's set up just doesn't allow it. For
| chronic issues, I've usually figured them out for myself, as a
| layperson, by persistently keeping track of things, searching the
| web, reading, and experimenting over months and years.
| rscho wrote:
| I'm sorry but curiosity and creativity are certainly the ndeg1
| enemy of the patient, especially in ICU settings. Curiosity and
| creativity are grandpa's medicine, and a total antithesis to
| evidence-based modern medicine, that attempts (and largely
| fails) to be an application of science instead of the whims of
| the decision-makers.
|
| What you should want is curious and creative _researchers_, but
| precise and totally unimaginative clinical staff. Those are
| often the same person. See the problem? You want protocols
| applied down to the last detail. You want nothing left out of
| standard operating procedure. That's what kills patients in
| practice.
|
| You might mean creativity in the sense of "let's have guys who
| think about the right things, and search for rare diagnoses and
| analyze stuff to see what could work, like Dr House". But that
| simply can't be done in practice. You can't be testing for
| every rare thing, because the tail of low probability diagnoses
| is much too long! And believe me, you _really_ don't want
| creative doctors around...
| dimal wrote:
| Maybe you don't want creativity in the ICU, but as a patient
| with chronic health issues, I do want creative clinicians.
| Over and over my entire life, I've gone to doctors with
| health issuesand watched as they mentally plug my symptoms
| into a flowchart that they learned in medical school, then
| they find that the symptoms don't match anything that a
| standard protocol can treat, then they shrug their shoulders
| and say they can't do anything. The latest case of this has
| been severe blood glucose drops in the middle of the night
| that wake me up with a pounding heartbeat. I waited four
| months for an appointment with an endocrinologist, then was
| told I don't have "true hypoglycemia" because it's not
| corrected by eating. End of story. No curiosity. No help.
| Goodbye. Again.
|
| Sorry, this is not acceptable. The only time I've gotten
| decent medical care for my chronic issues was when I was
| making enough money to pay for a doctor who only worked fee
| for service. He would troubleshoot things like an engineer,
| because he was a former engineer. He improved the quality of
| my life immeasurably.
|
| I think there's a difference between "evidence-based" and
| using only 100% manualized protocols. If medical science was
| better and actually had answers for everything, sure, let's
| stick to the manuals. But medical knowledge isn't even close
| to being that thorough. Clinicians need to be able to think
| on their feet when they look in the manual and there's
| nothing there. Otherwise, you're failing patients.
| jrgoff wrote:
| Yes, it's so tiresome and frustrating. I once had a period
| of a few months where my sleep was down to around 5
| hours/night (normally I would get 8-9), I was exhausted and
| my body just wouldn't sleep more than that. Went to a
| doctor who offered a couple of thoughts "some people only
| need that much sleep" and "there's only one thing it could
| be, but that's not what it is". He wasn't even going to
| test the "one thing" until I asked if he would. Turns out
| he was correct that that wasn't what it was, but obviously
| there was at least one other thing. My sleep ended up
| returning to normal though I still have similar periods
| where I can't get enough sleep.
|
| The only medical practitioners I've found willing to be
| more curious and to take a more holistic approach are
| naturopaths. I have had some notable improvements in my
| chronic health issues working with them, though I am a
| little uncomfortable with them given their general openness
| to things that seem pretty questionable to me (like
| homeopathy).
| Aeolun wrote:
| The fact that they're more open to believing that
| _anything_ might work cuts both ways :)
| dimal wrote:
| I think when dealing with chronic issues, it might be
| better to optimize for luck. [0] A little ridiculousness
| like homeopathy might be worth it to find the thing that
| actually works.
|
| [0]
| https://www.lesswrong.com/posts/fFY2HeC9i2Tx8FEnK/luck-
| based...
| opportune wrote:
| Completely agree. Any educated layperson can figure out and
| follow a clinical decision tree. I mean it can work in your
| favor if you know you need something and know how to get
| the decision tree to give you what you want, but otherwise
| clinicians should definitely be actual experts and not just
| meat following something a computer could do
| incone123 wrote:
| You still have the problem of writing a sufficiently
| detailed tree. I had a blood test last year and when I
| discussed the result with the doc, he asked me the clinic
| location where the blood was taken, because then he could
| estimate time between blood draw and lab test and
| interpret the result accordingly.
| Aeolun wrote:
| It's your blood usually tested immediately? At least my
| hospital gives me results right away (well, say within 30
| minutes).
| lostlogin wrote:
| It might be different where you live, but where I am, the
| vast majority of blood tests are not done at the
| hospital. Family doctors and lab test centres do it.
| rscho wrote:
| > Any educated layperson can figure out and follow a
| clinical decision tree.
|
| 12-15h a day, 6 days a week with not even a lunch break?
| You're sorely mistaken. It takes an expert to follow
| clinical workflows.
| dimal wrote:
| Are all doctors working these hours? I thought these were
| the hours for residency, not the average general
| practitioner or specialist working outside of a hospital.
| If they're working 15 hours a day, why are they only open
| 8?
| titanomachy wrote:
| If medical treatment was actually as formulaic and fully-
| solved as you imply, we wouldn't take the best students of
| every generation and make them spend ten years training to
| become doctors. We'd just have nurses, checklists, and
| diagnosis flowcharts.
| rscho wrote:
| I'm precisely not implying that medicine is currently
| "fully solved". I'm implying that we should strive to
| gather more information, synthesize it better and study how
| to make it useful.
|
| As a clinician, I'd say yes to a bicycle for the mind. But
| currently, my job is already plenty full with worrying
| about applying what's known in a correct manner without
| seeking to break new ground while treating patients, which
| would be very dangerous and given the odds of success, very
| stupid. What I'm implying is that the general public has a
| completely skewed view about what really kills patients in
| the ICU: mundane infections and "medical errors", which are
| not really errors at all but in a large majority of cases
| failures and complications of usual procedures.
| barry-cotter wrote:
| General Practice medicine seems to come close enough. No
| differences in patient outcomes between physicians and
| nurse practitioners.
|
| > Randomised controlled trial comparing cost effectiveness
| of general practitioners and nurse practitioners in primary
| care
|
| > Results: Nurse practitioner consultations were
| significantly longer than those of the general
| practitioners (11.57 v 7.28 min; adjusted difference 4.20,
| 95% confidence interval 2.98 to 5.41), and nurses carried
| out more tests (8.7% v 5.6% of patients; odds ratio 1.66,
| 95% confidence interval 1.04 to 2.66) and asked patients to
| return more often (37.2% v 24.8%; 1.93, 1.36 to 2.73).
| There was no significant difference in patterns of
| prescribing or health status outcome for the two groups.
| Patients were more satisfied with nurse practitioner
| consultations (mean score 4.40 v 4.24 for general
| practitioners; adjusted difference 0.18, 0.092 to 0.257).
| This difference remained after consultation length was
| controlled for. There was no significant difference in
| health service costs (nurse practitioner PS18.11 v general
| practitioner PS20.70; adjusted difference PS2.33, -PS1.62
| to PS6.28).
|
| https://scholar.google.co.uk/scholar?hl=en&as_sdt=0%2C5&q=d
| o...
|
| https://www.ncbi.nlm.nih.gov/pmc/articles/PMC27348/
| lostlogin wrote:
| More tests isn't a good things. The doctor was
| significantly quicker and could see 3 patients for every
| two the nurse saw.
|
| I'm not sure where this leaves us, as the cheaper
| training cost for the nurse is a factor too.
| thaumasiotes wrote:
| Medical treatment is obviously not fully-solved, or
| anywhere close.
|
| But it is just as formulaic as described above. The doctors
| aren't trying to solve your issue. They're following a
| flowchart, and if that doesn't work for you, that's your
| problem, not theirs. Next time, be a better patient.
|
| I've had doctors tell me "Good news! You don't have a
| problem!" when they were testing me to see if they could
| explain the problem I have. It's good news for them,
| because their next step is to tell me to fuck off. It's not
| good news for _me_ , but apparently they can't tell the
| difference.
| Gatsky wrote:
| Curiosity is essential. Eg guy with chest pain and trop rise
| gets sold by ED as a NSTEMI. But why is the pulse pressure so
| high? Hang on what is that scar on his back? Oh he had an
| aortic root repair 20 years ago after a car accident... Ok
| I'm calling in the radiologist at 2am to do a CT angiogram.
| Sure enough, his aortic root repair is failing, and he has
| new onset AR. Curiosity saved that guy's ass, following the
| protocol would have probably killed him.
|
| Creativity also has a role for non-critical conditions when
| standard treatments aren't working.
| Aeolun wrote:
| I guess this is why the hospital asks me to list historical
| surgeries.
| rscho wrote:
| So curiosity as a remedy for systemic failure to perform a
| full exam and actually do the job correctly in the first
| place? Not a very convincing argument.
| Gatsky wrote:
| Not really, the clinical signs were subtle, I couldn't
| hear the AR. If you had a 'protocol' to pick up these
| edge cases, you would be doing a CT and echo on every
| chest pain that walks in the door. The workup was
| perfectly evidenced based and standardised.
|
| I don't think it is ideal to operate this way though, to
| be clear. Obviously this could have easily been missed by
| me or anyone else. But you aren't arguing that point. You
| are approaching it from the perspective of minimising the
| variance in clinical quality. I don't agree with you that
| this requires standardising how clinicians _are_ , not
| just what they _do_.
| chrismorgan wrote:
| > _ndeg_
|
| Since you've used a slightly fancy Unicode character: I found
| U+00B0 DEGREE SIGN unpleasant here, and it took a brief bit
| of thought to understand. (A capital N would probably have
| helped a little, but the degree sign is still disconcerting.)
| The character you want is , U+2116 NUMERO SIGN. If you happen
| to be using a Compose key, `Compose N o`.
|
| For less fancy options, "#" and "number " would both be
| better choices and easier to read than "ndeg".
| rscho wrote:
| not all of us live in the US
| joenot443 wrote:
| I don't either but fully agree GP's assessment, you chose
| a strange character to use there.
| rscho wrote:
| It's the default on my keyboard, and the commonly
| accepted symbol in my language. Next time, I'll choose
| something else.
| chrismorgan wrote:
| I was not familiar with keyboard layouts including DEGREE
| SIGN handily, so I though there was at least a decent
| chance you had deliberately gone fancy. (I double-checked
| that it was deg and not o U+00BA MASCULINE ORDINAL
| INDICATOR, which I _would_ expect to see on some
| keyboards, and "No" is incidentally distinctly better
| than "Ndeg", since it's the shape of an o rather than a
| circle.)
|
| To the best of my knowledge, I have never come across
| "ndeg" before. "" plenty, "#" plenty, "No. " plenty, "no.
| " a few times, but not "ndeg" with a _lowercase_ n.
|
| Looking through
| <https://en.wikipedia.org/wiki/Numero_sign#Usages>...
| hmm, French AZERTY? I see now that it _does_ have deg
| readily accessible.
|
| I think another aspect that made it harder for me to
| recognise immediately was the lack of a full stop; I'd
| probably have recognised "ndeg 1" a bit faster. (I'd
| write " 1" rather than "1", though _personally_ I'd go
| fancy with NARROW NO-BREAK SPACE, but that's 'cos I enjoy
| doing crazy things like that.)
|
| P.S. I live in Australia. Similar Anglocentrism to the
| USA in language, though less pronounced in matters of
| culture.
| warner25 wrote:
| I appreciate your perspective as a professional in this area.
|
| Yeah, I'm not really looking for doctors to demonstrate
| _creativity_ (although House does), so I don 't think I'm
| asking for anything at odds with evidence-based medicine.
| What I'm saying is that I think you need to get to the bottom
| of what's actually happening (i.e. _why_ is the program
| outputting 5 when it should be 4) before you can know what
| evidence-based medicine to apply in a "precise and totally
| unimaginative clinical" way to actually fix the problem. As a
| patient, it just feels like the system, and therefore the
| doctors in the system, lack the curiosity to figure out
| what's actually happening. We often get the treatment for the
| most common issue even though it doesn't quite fit the real
| issue, or the common issue seems to just be a downstream
| effect of the real issue.
| jodrellblank wrote:
| _House_ is not real, it falls under "arguing from fictional
| evidence"; House's patients are written by a writing team to
| have obscure and surprising - yet easy to fix - ailments. They
| are generally young with acute short term symptoms leading to a
| race against time and a boolean toggle outcome healed/dead.
| They are rarely the 70+ year old ICU inhabitant with age
| related complications who is mentioned in the blog post with
| long periods of 'boring' illness to keep track of and treatment
| rotating between many doctors.
|
| House gets to choose his patients, he pre-rejects any that he
| doesn't want to deal with or has no ideas about, or no interest
| in. Real world doctors can't do that. House gets to do
| basically any test for any cost without having to justify it or
| argue with insurance, scheduling, resource constraints,
| practicality or side effects. If he needs an MRI, it's
| available, if he needs his team to spend all night tonight on
| blood tests in the lab, they can do that and the lab is there
| and they have no consequences tomorrow of having no sleep.
|
| House has plot immunity, the worst that happens to any hospital
| employees as a consequence of his behaviour is the loss of a
| lot of potential money, or some paperwork or audit. The show
| never focuses on the life of the patient who has to be on
| dialysis forever because of House's risky intervention before
| he knew what was really wrong. House blackmails and barters
| with and sleeps with the hospital administration to get away
| with things no real doctor could do.
|
| House and Wilson are named as a play on Holmes and Watson, and
| the original Sherlock Holmes books were notable because Holmes
| walked the reader through deducing interesting conclusions by
| looking at evidence anyone present could see but with a fresh
| viewpoint, things like the height of scratches on a wall.
| Recent Sherlock TV shows and films, he's written to magically
| know things that nobody could know, by means the viewer isn't
| shown and can't participate in, and presents them as amazing
| accomplishments to wow the viewer. House is the latter, in an
| episode I saw recently (Series five, episode 1) he is absent
| all episode with the usual array of organ failures and
| suspected pregnancy and suspected cancer, then in the last five
| minutes he walks in, stabs the patient in the leg, declares she
| has leprosy because she looked youthful, and walks out. And of
| course she has leprosy. It's not even good storytelling, it's a
| background thread for House and Wilson's interpersonal problems
| and his assistant's own terminal disease diagnosis.
|
| Or to put it another way, you read a blog post about heoric
| troubleshooting of some tech problem and it's good reading.
| That's self-selected from someone who had an interesting
| problem and the time and skills to diagnose it and the luck of
| it coming to an interesting conclusion. Most troubleshooting is
| not that, it's mostly the basics over and over, or it's above
| your skill level or outside your skills, or it might not be but
| you can't spend time on it, or it comes to a boring conclusion
| like "we never got to the bottom of it before the system was
| decommissioned".
|
| In Series 3, Dr Foreman goes to be head diagnostician at
| another hospital, pulls a House move of risk taking treatment,
| saves the patient, and gets fired. The dean of medicine tells
| him the procedures work for 95% of cases, and everyone needs to
| follow them in all cases because everyone thinks their hunch is
| in the 5%. It works for House because that's the show.
| jmhmd wrote:
| The main thing that House MD has, that no other doctor in the
| world has, is not so much his superior intellect. It's that he
| and _five_ other doctors spend 100% of their time on a single
| case, and can sit around all day discussing it, trying
| different things. If real world doctors had even a fraction of
| that luxury, you would see a lot more of what you describe.
| lazyasciiart wrote:
| Also, the cases are usually in desperate enough straits that
| "here, swallow this seagull poop!" doesn't get hints thrown
| out of the hospital.
| coding123 wrote:
| Jeez, no kidding. I imagine if they made a realistic doctor
| show they'd be constantly showing the doctor at the bar (on
| days off) trying to make money on side gigs like health
| startups.
|
| Stumbling in a hangover to appointments on "work days" and
| giving everyone the same diagnosis as the last (and likely
| whatever sickness they themselves had recently). Also giving
| everyone fluids and an ativan so the patient says - "i feel
| much better doc".
|
| It's kind of an open secret that the ER just gives a
| diagnosis of dehydration, provides fluids and ativan to get
| the pipe rolling and charge $4k a pop. Sure they might catch
| a case of undiagnosed covid, rsv or something else from time
| to time.
|
| Also I'm not kidding but I would LOVE such a show.
| Aeolun wrote:
| I'm half convinced the ER diagnoses everyone with no
| apparent issues with dehydration so they don't feel stupid
| about coming in for no reason.
| smileysteve wrote:
| You should check out The Resident. The first several
| seasons are about the doctor invested in a device that is a
| fraud, a private equity group buying the hospital, it
| eventually failing.
|
| Chicago MD has some of the aspects you mention, especially
| overloaded, drug abuse, blame, police interactions.
|
| New Amsterdam attacks it by the main character trying to
| solve the problems and running into bureaucracy.
| tomcam wrote:
| Are all of these well-written shows? They all look
| terrible in the descriptions but I'm hoping I'm wrong.
| smileysteve wrote:
| I rank New Amsterdam and the Resident better for the
| hospital politics; Chicago MD is more short episode drama
| (though does touch on mental health and social services
| more.
| hef19898 wrote:
| Back when ER was a hit show, there was survey among medical
| professionals and hospital staff asking for their favorite
| medical drama series and the reasons for it. Grey's
| Anatomy, and similar series, constantly beat ER. The reason
| was that medical staff considered ER _way too realistic_.
| Makes sense, why would I entertain myself during my off
| hours with what is basically a documentary about my on-duty
| hours.
| light_hue_1 wrote:
| You would not. 5 doctors talking about your case wouldn't
| help much.
|
| People really don't understand the dire and primitive state
| of current medicine.
|
| We are in the dark ages. We don't know why most drugs work;
| we have some notional idea but it's often an after-the-fact
| fiction that we tell. We don't know what causes the majority
| of diseases. In many cases we don't have treatments for the
| underlying problems, we only have treatments for symptoms.
|
| If you want to see House MD, then tell your congresspeople
| and senators to invest in funding medical research so we can
| one day maybe leave the dark ages.
| warner25 wrote:
| Yeah, that's what I mean by the medical system just not being
| set up to allow this. I generally see a different doctor
| every time I make an appointment, because I'm assigned to a
| team in a clinic with constant turnover, the appointments are
| 20 minutes long, and the doctor easily spends more time on
| boiler plate stuff in the computer system than examining and
| listening to me. I don't even think they have time to look
| over the basic medical history, let alone have a whiteboard
| session to consider all the pieces of the puzzle and
| brainstorm possible explanations.
| [deleted]
| fedeb95 wrote:
| Yes talking about scientific method and citing a TV show. Logic
| kingsloi wrote:
| Interesting take.
|
| I was in a paediatric cardiac ICU when my daughter battled with
| heart disease for 7 of her 8 month life. Another dad who we got
| close to in the ICU said the phrase "practising medicine says it
| all...".
|
| My experience is same same but different. It was during COVID, so
| we welcomed the nurse change, sad/happy to see one go and welcome
| another. Paediatric ICUs and their staff, I'd say are top tier in
| most respects. Parents are involved with most/all decisions, and
| nurses/drs respect most wishes, don't like your child being
| disturbed at night for non-100%-necessary stuff? Ask social
| services (etc) to print out a sign with your wishes and stick it
| on your room door. May not 100% work, but worth a shot. It did in
| ours.
|
| Sleep is somewhat respected as this is when babies develop/heal
| best, unfortunately it's an ICU, and these are sick kids who need
| 24/7 complex care, so there's sometimes little wiggle room. I
| attended a conference in Chicago on heart disease and it's
| outcomes (npcqic.org), and sleep and proper nutrition (not just
| feeding TPN) are definitely hot topics. I know the NICUs are
| extra hard on any additional sleep/disturbance other than 100%
| necessary.
|
| But shoutout to nurses, drs, any medical staff, ICUs are sterile,
| haunting, traumatic places. I witnessed things I can never
| forget. They do the same, and have to do it again, and again.
| hackeraccount wrote:
| I'm a cynic to some degree. I think suffering doesn't ennoble
| people for the most part - it just makes them bitter and angry.
|
| I realize this wasn't your point - and who knows maybe I'm
| misreading you - but this comment makes me reconsider my view
| on that. I have a child and having to go through something like
| what you describe makes me feel sick. Doing that and then
| having any degree of empathy - sympathy even - for the people
| involved is a credit to you.
| tomcam wrote:
| Cried a little reading that. What agony, losing a child in slow
| motion. My best to you and yours.
| froggertoaster wrote:
| > What agony, losing a child in slow motion.
|
| These words are both poetic and heart-wrenching.
| anjc wrote:
| > the next time you have trouble booking a surgeon or even a
| gastroenterologist, you can remember that America's supply of
| surgeons and gastroenterologists is being disproportionately used
| by the AARP crowd.
|
| What a horrible sentiment.
| gopher_space wrote:
| It's painfully easy to start thinking in numbers when you're
| paying six thousand a month to warehouse your grandmother's
| body.
|
| The number of tests people want to run on someone we all hope
| dies tomorrow is insane.
| notacoward wrote:
| Funny, I pay even more than you mention to support my own
| mother in relative comfort in a nursing home, and I don't
| find it "painfully easy" to think that way at all. I
| certainly don't hope she dies tomorrow. You might want to
| reconsider saying such things in public.
|
| Note: my mother, not my grandmother, and I _have_ lived that
| ordeal for several years. Some interaction is still possible,
| but recognition has been beyond her for a while. As long as
| she seems to take some pleasure in her surroundings, no
| matter how dim or muted the signs, you won 't catch me
| framing my thoughts about her in terms of dollars I could
| save.
| gopher_space wrote:
| Sounds like your grandmother can still recognize and
| interact with people. Mine was basically a warm body for
| the last five years of her life.
|
| Prolonging that existence is not a kindness in any sense,
| and I hope you don't have to go through such an ordeal.
| nativecoinc wrote:
| Before you jump the gun like that again: The context is
| most likely about the suffering of the patient in question
| from simply existing in that state, and there being no way
| to alleviate the suffering (only prolonging the life). Not
| about saving money.
|
| So it's a lose-lose: the patient suffers and society has to
| pay for their privilege to suffer (without recourse, most
| likely).
|
| And maybe you disagree fundamentally with things like
| assisted suicide. But someone who posts something like what
| you replied to most likely do not.
| notacoward wrote:
| Before _you_ jump the gun again...
|
| > Not about saving money
|
| Then why even bring it up, let alone cite it as something
| that change[ds] one's views?
|
| > maybe you disagree fundamentally with things like
| assisted suicide
|
| In fact I do not. There was a time when my mother wanted
| to end it, and I wasn't the one who stopped her. I
| respected her right to make her own choice. Her condition
| subsequently improved to the point where she no longer
| wished that, leading to the current status quo, but
| that's already far more than any of the pissants in this
| thread deserved to hear about it. Expressing one's own
| wish for a supposedly-loved one to die is indefensible,
| even if they also wish it for themselves.
| chki wrote:
| I think a more generous reading of the comment you are
| replying to could be (and probably is reasonable): It is
| hard to pay a lot of money for somebody that is living in
| agony with no chance of getting better, where death might
| be a good option for them personally. I would not
| understand the comment to criticize supporting people
| living in relative comfort.
| notacoward wrote:
| "Warehousing her body" suggests otherwise. When people
| talk about someone as a "body" they usually mean
| insensate IMX. People whose loved ones are in pain tend
| to use different, even more colorful, language. I know I
| did, when that was the case.
| chki wrote:
| > People whose loved ones are in pain tend to use
| different, even more colorful, language.
|
| The human experience varies wildly and I would not make
| such assumptions. Caring for somebody without the hope of
| improvement for years can make you bitter or even resent
| the person that no longer resembles the one you loved.
| notacoward wrote:
| > make you bitter or even resent the person
|
| And that's OK? I happen to think it's not, that
| bitterness and resentment hurt everyone involved, and I
| _know_ that it 's possible to resist those feelings. How,
| exactly, does the person who succumbs get to play Good
| Guy?
| nativecoinc wrote:
| No one's said that it makes them Good Guy. Only Human.
| Mezzie wrote:
| What's terrible about it?
|
| I'm a younger (34) person with substantial healthcare needs (I
| have MS). Everything is always oriented towards the old, and I
| also pay taxes that are used to support them while getting
| nothing in return despite having similar needs.
| jewayne wrote:
| notacoward wrote:
| > I also pay taxes
|
| Do you really get _nothing_? And who is paying for whose
| care? You mention taxes, but they 've probably been paying
| taxes even longer. And why do you think health care is a
| strict _quid pro quo_ anyway? Some of us believe care should
| be allocated where it 's needed, not where it's paid for. Put
| another way: why is it a problem that they _are_ getting
| care? Isn 't it that you _aren 't_? This doesn't have to be a
| zero-sum game. If you feel that you're in competition with
| someone else for care, the problem is pretty clearly that
| there aren't enough providing it.
|
| Saying others have less right to health care is pretty
| terrible no matter _which_ way the finger points.
| throwaway821909 wrote:
| More bluntly - if you're a greater-than-average user of
| healthcare resources, this seems like a dangerous line of
| questioning to bring up.
| Mezzie wrote:
| I wish we (Americans) had universal healthcare, but at this
| point I'm pretty jaded about that ever coming to pass. So I
| agree with you there, and your point about them having paid
| taxes is also a good one.
|
| That said, we do care for the elderly because of their
| vulnerability but we then shit on younger disabled people.
| Old people can have assets, most younger disabled people
| can't, and younger disabled people can lose their benefits
| by getting married. SSA also applies different criteria for
| disability and makes it functionally impossible to get if
| you're young enough versus in your 50s or 60s.
|
| I'm frustrated at being expected to extend infinite grace
| to the elderly when receiving very little/none, despite us
| being similarly vulnerable. I also dislike that in general
| our culture takes care of the elderly/gives them their dues
| without asking them to take up the corresponding
| responsibility. As a group, they care very little about the
| future.
|
| After years fighting/voting for better healthcare, very
| little has been accomplished. So am I just supposed to
| suffer and accept I matter less than an old person? That's
| kind of against basic animal survival instinct. My country
| seems determined to view it as a _quid pro quo_ , including
| the elderly.
| notacoward wrote:
| > am I just supposed to suffer and accept I matter less
| than an old person?
|
| Absolutely not. The situation is deplorable, and I hope
| we can get to a better one some day. Fight for all you're
| worth. All I'm saying is that _others who receive care_
| are not your enemies. (Or at least not _because_ they
| receive care. There 's bound to be some overlap.) The
| enemy is the people within the system who restrict the
| labor supply, drive up prices for everything else, make
| arbitrary rules like those you've mentioned, and so on.
| The politicians and profiteers, not the patients, define
| that system.
| Mezzie wrote:
| I agree with this. The problem for me comes in that
| elderly patients (again as a class/group, there are
| obviously exceptions) have no problem with this system.
| They don't care because they benefit. I've also gotten
| several snide comments from elderly people and heard
| numerous tales from other younger disabled people that
| it's happened to them too. That we're too young to be
| there/to be sick, snide comments about when/if we can't
| work, etc. In fact, given that the elderly are living off
| of social security + investments, they have common cause
| with the politicians and profiteers as they won't allow
| any action that either risks their property values or
| their investment income. If line go down, old people
| can't retire, so we can't do it.
|
| I will never have access to my enemy until there's a
| critical mass of upset people, and the elderly seem
| willing to let younger people die of treatable problems
| as long as they're not effected, so the only way to get
| them to care and join us seems to be to make them feel as
| insecure as the rest of us, which sucks.
|
| I believe the elderly have agency and for the ones who
| are still alive (since of course the people who live to
| 85+ to begin with are those who didn't have to ruin their
| health due to poverty and blue collar labor), they've
| used their agency to say 'we don't care about you'. Which
| is fine, but then they turn around and get all mad when
| they're not cared about in return. Either they want to be
| a part of a community, including accepting the
| responsibilities, or they don't. They need to stop
| wanting to have their cake and eat it too.
| throwaway821909 wrote:
| People who are net-contributors feel like they're likely
| to eventually be elderly, and unlikely to become
| disabled, I guess (so the inverse of your feelings)-
| combined with deception by governments that social
| security programs are like a savings account for the
| future, not a tax to pay for today's expenses.
|
| From each according to his ability, to each according to
| his needs is the only solution for healthcare.
| Mezzie wrote:
| I support universal healthcare, I just don't think it's
| going to happen in America.
|
| Right now the answer seems to be 'take as much from the
| young as you can and guarantee them nothing' and that's
| not sustainable. It's just that most of the young can
| avoid looking at this reality until they have a health
| problem.
| cliquecover wrote:
| It's horrible but true. How do you budget for and prioritize
| access to scarce resources?
| polishdude20 wrote:
| In a way I think this is ok though? Like, when I reach that age
| I sure as hell hope I'll have more access to doctors than
| younger people?
| notacoward wrote:
| I had a strong reaction to that too. _Of course_ we devote more
| health-care effort to people in the last 5-10 years of their
| life, which primarily (but not entirely) means older people.
| There is practically no world in which that wouldn 't be the
| case, because everyone's health trajectory eventually trends
| downward. By the time someone reaches the ICU (other than as a
| result of trauma) not only the immediate problem but likely
| several others will have progressed to problematic levels.
| That's also where the most labor- and dollar-intensive
| treatments tend to be applicable. It's just basic statistics,
| really. Cars also cost more in maintenance late in their life
| cycles, and so do many other things. A flat age distribution in
| the ICU would be _super weird_ and probably an even worse
| allocation of resources.
|
| I don't think the author really meant that to come across as
| callous as it sounded. Probably just poor choice of words. I'm
| only addressing it because _someone else_ reading it here might
| interpret it in more of an "older people stealing from younger
| ones again" kind of way for demographic or ideological reasons.
|
| ETA: it already happened as I was writing this.
| questime wrote:
| Because of demographics this is a problem we will have to
| confront regardless - do you think medicare/medicaid spending
| will become 80% of government spending?
| virgildotcodes wrote:
| Maybe with higher taxes and a reallocation of defense
| spending we'd be able to sustain a more humane society for
| longer.
|
| Is it indefinitely sustainable? Not sure. I don't know if
| it's as easy as just extrapolating from recent trends because
| there may be countless unknowns from biomedical advances to
| climate destabilized societies to being turned into
| biological batteries for our machine overlords in the next
| few centuries.
| ch4s3 wrote:
| Having medicare operate under a fee for service model will
| never be sustainable in the long run. We already spend $
| 755 B on Medicare, which is roughly equivalent to the DoD's
| $ 767 B, and Medicare is notoriously wasteful[1][2].
|
| [1] https://www.healthaffairs.org/do/10.1377/hpb20220506.43
| 2025/
|
| [2] https://vbidcenter.org/wp-
| content/uploads/2021/10/jama_shran...
| skyyler wrote:
| https://www.usaspending.gov/agency/department-of-
| defense#:~:....
|
| >In FY 2022, the Department of Defense (DOD) had $1.64
| Trillion distributed among its 6 sub-components.
|
| Where are you getting this 767B number?
| ch4s3 wrote:
| The treasury department's website[1]. I wonder if your
| link is rolling in the VA? I can't quite tell.
|
| [1] https://fiscaldata.treasury.gov/americas-finance-
| guide/feder...
| skyyler wrote:
| >Department of Defense--Military Programs
|
| I wonder if that means they're subtracting portions of
| the DoD budget that aren't technically military
| operations.
| ch4s3 wrote:
| As with many of these categories it can be hard to pin
| down accurate numbers.
| MBCook wrote:
| I didn't read it as an indictment (why are we wasting all this
| money on people who are dead soon anyway?) but more of just a
| straight observation that makes sense if you think about it but
| probably isn't what most people would expect if asked
| unprompted.
| questime wrote:
| It's politically toxic to discuss but a ton of money goes to
| keeping people not dead (not really alive either). You could give
| a lot more people medicare/medicaid if we let a 90 yr old with
| dementia/diatebetes/etc. pass with dignity.
| TheOtherHobbes wrote:
| Any form of euthanasia runs into the legal and moral problem of
| who decides? And why?
|
| You might think everyone wants to act in the best interests of
| their relatives, but of course that's not true. Some people
| will want to speed the natural process along because that
| inheritance looks really appealing, and no one is really going
| to miss the old guy/gal anyway.
|
| Besides, that's not really the problem. The problem is
| profiteering by insurance companies and the hospitals they
| (effectively) run for profit, with patient wellbeing as a
| regrettable requirement they have to put some effort into.
| itestyourcode wrote:
| Is it the same dilemma if we can kill one to save more?
| wellareyousure wrote:
| Yes, certainly people in medicine are aware.
|
| > we let a 90 yr old with dementia/diatebetes/etc. pass with
| dignity.
|
| Often it's a 4 week old baby.
|
| For every 1 sophisticated family member, there are 19
| unsophisticated ones, who toss a weighted coin and, if it's
| heads, they decide they want their dying, non-responsive
| relative - possibly their baby, possibly their mom, etc. - to
| be kept alive at all costs. I don't know if this is politically
| toxic as much as it is cultural, and possibly globally
| cultural.
| dang wrote:
| Could you please stop creating accounts for every few
| comments you post? We ban accounts that do that. This is in
| the site guidelines:
| https://news.ycombinator.com/newsguidelines.html.
|
| You needn't use your real name, of course, but for HN to be a
| community, users need some identity for other users to relate
| to. Otherwise we may as well have no usernames and no
| community, and that would be a different kind of forum. https
| ://hn.algolia.com/?sort=byDate&dateRange=all&type=comme...
| questime wrote:
| > Often it's a 4 week old baby.
|
| You are stretching the word often, most people in the ICU are
| close to the end of their life. A lot of people don't realize
| but most of the time if you needed to spend weeks in an ICU
| you are probably not "living" in a dignified way. Almost all
| ICU doctors/nurses I've talked to would rather have a DNR in
| their old age than live like that.
| Eleison23 wrote:
| Your human dignity is not predicated on how much pain
| you're in, how awake you are, or how able you are.
| Der_Einzige wrote:
| Uhh, yes it is to all three of those things.
|
| If I'm in pain, am delirious, and am unable to operate in
| the world. I've lost my dignity.
| IX-103 wrote:
| You mean yours.
|
| _My_ human dignity _does_ depend on whether I have to
| endure the rest of my life pooping my pants, not
| remembering my own name, and hooked up to some noisy
| machine telling my lungs to breathe and my heart to beat.
| z3rgl1ng wrote:
| This is an oft-repeated piece of received wisdom that is
| empirically untrue.
|
| https://www.statnews.com/2018/06/28/end-of-life-health-spend...
| [deleted]
| robocat wrote:
| Wow: just sample bias! We need to also look at the old people
| who had expensive care and survived (95% of costs in that
| article). Money does gets spent on hospital care just before
| death (5%), but predicting how to avoid "wasting" that money
| is hard.
| Sevii wrote:
| Canada is actually moving in that direction with their medical
| assistance in dying laws.
| voz_ wrote:
| I don't think its politically toxic, but rather, extremely
| humane that we care for our elderly. The real unfortunate part
| is that we, in the working class, have to make due with sharing
| slices of the pie so more money can go to our exploiters and
| owners - especially in the US, we are such a wealthy nation,
| and yet here we are bickering around who deserves care based on
| age. Sad.
| MBCook wrote:
| > I don't think its politically toxic
|
| Ever hear of the Obamacare death panels? The ones where
| doctors would decide if your loved one was too old and
| shouldn't get treatment?
|
| Yeah. That's this.
|
| What it really was that Medicare would pay for consultation
| with doctors (?) to discuss end of life care and setup living
| wills and DNRs and such if the person wanted.
|
| That way if something happened and they were taken to the
| hospital they could be treated the way they wanted to be and
| not stuck in a coma on a vent for the rest of their life if
| that was against their wishes.
|
| But the Republicans branded then "death panels" (which for
| political purposes was _brilliant_ ). So the choice of having
| help making those decisions was removed.
| questime wrote:
| I disagree, spending on these things is growing at 2x GDP
| growth so yes more of the pie is going to this. What I'm
| suggesting is that at some point the pie isn't big enough for
| this. No matter what happens eventually standard of care will
| roll back/fewer people will be covered etc. Ideally we can
| innovate out of this situation but after spending 8 years
| working in healthcare I've gotten cynical about it.
| neonate wrote:
| We don't care for our elderly. We fear death.
|
| If our society really cared for the elderly, they would be
| integrated and respected, not segregated and shunned. We do
| the latter because we fear age, sickness, and death. Fear
| isn't caring.
| rscho wrote:
| > We fear death
|
| In the US. It's perhaps the most striking difference that
| hit me during my stay overseas. In the Old World we
| occasionally get people completely panicking about their
| own death. In the US, seemingly _everyone_ is like that.
| neonate wrote:
| I'd like to hear how elders are treated in these
| societies that don't fear death as much.
| rscho wrote:
| I'd wager: not very differently. But not out of fear. The
| social isolation of old age is the same everywhere. Young
| people have their own lives to live.
| neonate wrote:
| > The social isolation of old age is the same everywhere
|
| That is certainly not true. Traditional societies and
| non-western societies have far different ways of relating
| to elders than we do, and even among western societies
| there are variations.
| rscho wrote:
| Well, yes I see what you mean. What I meant was: it's the
| same in the US and western Europe. But certainly if you
| go to more "old fashioned" places, the elderly usually
| live with the family and are taken care of. To be fair,
| this still happens even in "advanced" western societies.
| I seem to recall this also goes together with a lot of
| elderly abuse.
| prenevikdale wrote:
| I wonder if elder abuse is correlated with younger people
| "having their lives to live".
| croes wrote:
| Where do you draw the line? At what age, what illness do you
| refuse to treat a patient even though he may not want to die?
|
| You could give a lot of people medical treatment with a proper
| healthcare and tax system. Why don't we try that first?
| toast0 wrote:
| > Where do you draw the line? At what age
|
| 30? or 21, if you prefer the book ;p
| roxgib wrote:
| I assume we start by getting more information from patients
| about their wishes, and then following them accordingly. A
| large number of elderly people don't want hopeless and
| unpleasant medical interventions, but end up having them
| anyway because no one asked them.
| coryrc wrote:
| At some QALY/$.
| Fomite wrote:
| QALYs are hardly non-controversial.
| hnfong wrote:
| The original comment by questime literally said we should
| discuss the general topic even though it's controversial.
| chiefalchemist wrote:
| Many of the top causes of death, per the CDC, are from diseases
| that can be prevented or naturally mitigated. We're all going
| to get old. We're all going to die. But carrying two or more
| "pre-existing conditions" into your later years is going to
| decrease your quality of life, as well as your use of
| healthcare.
|
| My point is, what's not sociopolitically allowed is discussing
| how personal choice as well as normalized systematic issues
| (e.g., urban food deserts) are killing us, slowly. It's
| unfashionable to suggest someone's weight is (ultimately)
| unhealthy. But the USA wants to have its cake and eat it too,
| literally. That's not working out. It's not sustainable.
|
| Finally, not to get off topic but over the last couple of weeks
| there's been a thread or two on HN based on acticles suggesting
| the GDP and similar "classics" economic metrics are hiding
| underlying social issues. That is, for example, healthcare care
| contributes to the GDP (or whatever) but that healthcare is for
| diabetes, opioids, faltering mental health, etc. We're falling
| apart but not to worry the economy is doing just fine.
|
| It's complicated. But to your point, the fact that some
| important topics are ofc limits isn't helping. Until that
| changes the status quo will continue.
| [deleted]
| steve76 wrote:
| ryandrake wrote:
| > My point is, what's not sociopolitically allowed is
| discussing how personal choice as well as normalized
| systematic issues (e.g., urban food deserts) are killing us,
| slowly. It's unfashionable to suggest someone's weight is
| (ultimately) unhealthy.
|
| The recent push to try to re-frame obesity as healthy,
| fashionable and sexy seems particularly bizarre and
| unexplainable. It's the opposite of what happened with
| cigarettes, which started out as fashionable and healthy,
| then slowly became known as unhealthy and finally fell out of
| cultural fashion.
| lazyasciiart wrote:
| I think the root of it is recognition that mental health is
| as important as physical health, and that losing weight
| isn't as easy as many people assume, and shouldn't be done
| the way many people try - so actively shaming and
| criticizing fat people for being fat is of negative health
| utility overall.
| chiefalchemist wrote:
| > o actively shaming and criticizing fat people for being
| fat is of negative health utility overall.
|
| Fair enough. But then what do you suggest we do as an
| alternative to normalizing diabetes and obesity?
|
| To your point - kinda - about losing weight. Changing
| behavior isn't any easier when there are too few
| environmental signals to nudge behavior in a more healthy
| direction. As humans, we are wired to assume the norm we
| see around us. How do we reverse the tide when abnormal
| (and unhealthy) has been normalized? When everywhere you
| look, there are people just like you?
|
| I do agree. Mental health is important. But a component
| of that is (dealing with) adversity. I'm certainly not
| condoning repetitive malicious bullying, but the current
| climate has outlawed any/all references to traits
| connected with being unhealthy. At this point there are
| no social deterrents, are we really better off?
|
| Have we robbed Peter to over-feed Paul?
| ch4s3 wrote:
| It's pretty well know and often discussed that up to 1/3 of
| Medicare spending is wasted. Being fee for service doesn't help
| but neither does spending 13-25% of all medicare dollars on end
| of life care[1].
|
| What's worse is how much of Medicare's wasted spending goes to
| harmful treatments.
|
| [1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6610551/#:~:te
| x....
| [deleted]
| w10-1 wrote:
| It's a tough situation, and I'm glad his father is finding help.
|
| I've spent a fair bit of time in ICU's on both sides. I think the
| observations and conclusions show misunderstandings. Generally,
| opinions are not ignored, nurses don't go wild, the patient
| population makes sense for an ICU, the institutional memory is
| actually fantastic, etc.
|
| And most importantly: "There's no sense of a scientific method,
| reasoning from first principles, or even reasoning from similar
| cases though" This is complete and utter hogwash, borne of a
| difficult experience.
|
| They key idea is this: in complex cases, doctors have to identify
| the condition that matters most, and prioritize that.
| Collaboration is necessary to get the picture and give care, and
| perhaps to consider alternatives, but it's not how you make
| decisions.
|
| It's hard to see symptoms ignored or under-treated. But it's very
| likely that delusions do not make a difference in the patient's
| recovery, but something like lung surfactant matters most. So
| everything from fluid intake to drug dosage and activity are
| direct accordingly. Unless they're symptoms of the main issue,
| discomforts can be prioritized later after the main issue
| resolves.
|
| "Identifying the main condition" means understanding the actual
| insult and the healing process for this patient; understanding
| how symptoms, labs, and imaging reflect all the conditions i.e.,
| how it presents (and skews labs or self-perception); and
| understanding how all the interventions may interact with the
| disease/disability states, from drug interactions to liver and
| immune-system complications, etc.
|
| It's not uncommon for other doctors and nurses and patient
| advocates to have some slice of this complex picture, but it's
| the attending who has it all, and the experience of other cases
| and knowledge of the underlying conditions and interventions.
|
| And, for the most part, the attending is not responsible for
| explaining their understanding or reasoning to anyone. They do
| offer reasons and make records, but there's no place or time or
| even audience for comprehensive account of why other alternatives
| weren't considered or followed.
|
| Science, and medical trials, try to isolate single factors to get
| reproducible outcomes. Medicine in the ICU has to accommodate
| multiple factors, by focusing on the main disease/healing process
| and optimizing for that.
|
| As for value to society: good ICU attendings are key to good
| outcomes for patients and their families. It takes decades to get
| good. They produce far, far more value than they're paid, largely
| because they do it as a mission. If they see people, particularly
| those who enjoyed the benefit of their dedication and service,
| disrespecting and misunderstanding them, it's likely to dissuade
| them from continuing or dissuade others from their difficulties.
|
| So complain all you want about digital advertising and go full-
| disruptive to fossil fuels, but please be very, very careful when
| attacking health care. Otherwise we'll end up with Russian
| hospitals where you bring your own materials and pay your friends
| of friends for side work.
| Wonnk13 wrote:
| For context see my comment here
| https://news.ycombinator.com/item?id=33625584#33647770
|
| One thing that this article touches on, but I think needs to be
| emphasized even more is that the stark reality is that the only
| advocate for the patient is the patient themselves, or perhaps a
| caretaker.
|
| The burden is on me to ask questions about fertility and sperm
| banking because my oncologist is well... an oncologist not a
| fertility expert. I have to ensure that every department is
| communicating with every other department.
|
| Hospitals and physicians are fantastic at solving discrete
| issues, but the bigger picture is often lost in the chaos. I can
| do it as a technically adept 34 year old, it's horrifying to
| think about how someone closer to 80 goes about it.
| dheera wrote:
| I was in an ICU for a week after a cardiac arrest. I don't
| remember much of it other than a lot of hallicunations.
|
| I had family there to advocate for me, but there's no way in
| hell I would have been able to advocate for myself. I was
| literally seeing things around me in the ICU room that didn't
| exist. My family were probably the only ones that realized that
| that wasn't the real me.
|
| The hallucinations stopped happening as soon as I was moved to
| a normal patient room for the rest of my recovery, and I have
| full working memory of that normal patient room.
| Sevii wrote:
| Hallucinations are one of the most common symptoms of sleep
| deprivation.
| chki wrote:
| > The hallucinations stopped happening as soon as I was moved
| to a normal patient room for the rest of my recovery
|
| To be fair (and this is also true for the article itself), it
| might be difficult to distinguish cause and effect here.
| Being moved into less intensive care means that you are more
| stable which might lead to other issues becoming better in
| the following days regardless of whether you are in the ICU
| or not.
| ler_ wrote:
| I'm a nurse and I find the 7th point on the post especially
| relevant. I will add a disclaimer that I never worked in the ICU
| so I can't speak for what happens in that type of unit.
|
| There is a serious issue with the flow of information in
| healthcare, (or at least in the U.S, I never worked elsewhere to
| know if it's any different). But If you find something during
| your shift which will be important to know later on, it will
| certainly be lost as soon as you are off for a few days, or even
| as soon as a new nurse comes on. To think of a somewhat crude
| example, if you find out that it is much easier to obtain a blood
| sample from the veins on the left arm of a patients vs the right,
| many nurses will still stick the right arm countless times hoping
| to get something.
|
| And you can leave a chart note about things like that or speak
| about it during report, but for the most part few people will
| think "hm, I wonder what everybody else had to deal with." They
| are probably too busy handling a thousand different things
| happening all at once. And, even if that is not the case, from
| what I observed it's simply not part of how things are done. And
| very often patients will get (justifiably) angry, saying "I've
| been complaining of x thing for days!" or some version of that. I
| think it would be much better for both patients and healthcare
| staff alike if there was a greater emphasis placed on focusing on
| the series of successes and failures that happen over the course
| of someone's care, not just seeing it as a single shift or a
| single problem happening in some isolated point in time.
| jillesvangurp wrote:
| I have great respect for what people like you do. I've lived
| all over Europe and a have some first hand experience with care
| in different countries. Universally, nurses are heroes and it's
| just a very hard and often thankless job. Not to mention under
| paid in many places. But there's a big difference in what I
| would label as institutional stupidity between different
| countries. Some countries feature a lot of mismanaged health
| care facilities where things are bureaucratic, slow, etc. For
| example, Germany is hopeless on this front. Being in the health
| care system here means an endless sequence of forms that need
| to be filled in with the exact same data points over and over
| again and over worked nurses dealing with all that crap on top
| of their normal job. It's beyond stupid. Nobody shares any
| data. And it's inefficient and dangerous for patients because
| no doctor or nurse can possibly have the full picture.
|
| My home country the Netherlands is very different. My father
| had a stroke quite recently and spent some time in a very
| modern hospital where they are applying some of the latest
| insights for patient care. So, he was obviously hooked up to
| lots of equipment and intensely monitored. However, this
| hospital has separate rooms for all patients. Reason: it's best
| for the patients and helps them recover more quickly.
| Basically, more privacy for the patients and less restless
| nights. There are no TVs in these rooms. Instead patients are
| issued ipads with entertainment options and access to various
| things like indicating dietary preferences. Nurses carry ipads
| as well. Everything is digital. There are no paper charts in
| sight anywhere.
|
| The rooms were modern, clean, and clearly optimized for making
| patient handling easy and straightforward. What struck me was
| the attention to detail and level of pragmatism in this. For
| example, my father's room had wall mounted hangers for folding
| chairs. These are for visitors. And when they are folded they
| are not in the way. The room had a whiteboard and a locked
| cabinet for medication and supplies. The doors are sliding. So,
| it's easy to move things in and out. Like beds, wheel chairs,
| equipment, trolleys. Etc. And so on. Just a really well
| designed and thought through design and architecture. Well
| managed and efficient.
|
| BTW. This is not a private hospital: my country has a mandatory
| private insurance system: they can't reject people, people must
| be insured, and they can switch insurer. So, insurers mainly
| compete on quality care. Miserable patients and inefficient
| hospitals are bad for business and they are working to fix any
| issues there with hospitals. Which is why everyone, rich or
| poor, gets the same quality treatment in this hospital. It's
| way better than the private insurance I pay for in Germany. Way
| cheaper too. My German insurance is about 5x the price. I've
| been in a hospital here a few times and they can learn a thing
| or two about efficiency there.
| Aeolun wrote:
| The only bad thing about Dutch healthcare is that, if you are
| not acutely in need, it can take months to get a spot.
| throwaway2037 wrote:
| I have heard similar complaints about UK and Canada. From a
| cost perspective, it makes sense to me. I also wonder: If
| you make people wait months, how many people skip/cancel
| the appointment? Probably many.
|
| I have lived in two countries with very unfair healthcare
| systems. High income people get "health insurance"
| (whatever that term really means!) from their employer.
| They use it a LOT. Way too much. And their "health
| insurance" covers most of the cost. The number of times
| that I have seen high income people see a medical doctor
| for a runny nose (light head cold) stuns me. What an
| incredible waste of medical resources! As someone fortunate
| enough to have this "health insurance" at various times in
| my life, I am constantly saying "no" when doctors try to
| over-prescribe all manner of medicines. Obviously, they
| know my insurance will pay 100%!
|
| The #1 duty of a public healthcare system absolutely must
| be "acute need". Everything else is second priority, else
| they go bankrupt. It's rough. I don't know a better
| solution.
|
| Crazy idea: What if there was a kind of public auction
| system where people in the queue could set a price to sell
| their position? As long as it was fair and transparent, I
| might be OK with it.
| jillesvangurp wrote:
| I'd say that's universal across many countries. The flip
| side is that Dutch insurers do allow their patients to shop
| around for care. E.g. getting treated in Belgium or Germany
| for routine procedures is fairly common. Mostly these just
| are shortages of staff, equipment, etc. and being efficient
| sometimes also means that available care is fully utilized.
| Which just means people have to wait for non critical
| things sometimes.
| civilized wrote:
| I wonder if part of the issue is having to remember a bunch of
| random things about a bunch of different people so that you can
| apply the information at the relevant time. E.g. the left arm
| is easier to find a vein, but this information is only useful
| for 30 seconds a day during a blood draw, so it's hard for
| people to remember or even retrieve (how much notes do you have
| to read through to find this info?)
|
| If the info were somehow magically there when needed, it would
| be used, right?
| Aeolun wrote:
| Like, google glasses but for ICU workers?
| civilized wrote:
| I was gonna say augmented reality, but there are probably
| low-tech options that could do the trick.
|
| I would start with "sticky note on the relevant machine"
| type interventions first.
| ler_ wrote:
| Your comment made me think about this for a bit. It is
| almost fun imagining something like seeing a short little
| warning floating up in the air above a patient's arm,
| saying "blood draws from here". It would be pretty darn
| cool. If this were possible, it would be worth seeing how
| much it helps with continuity of care.
|
| To let my imagination run a little wilder, I tried to
| think of what a system like that would be in practice,
| and how it relates to the problems that we currently face
| with the systems we already have. As much as it would be
| interesting to have all that information available
| through some sort of AR, there are really three important
| things that I would like to see about a patient: code
| status, vital signs and how they get up from bed.
|
| It's really crazy to me how even the simplest of stuff is
| buried in a chart or EMR. Most do show the patients code
| status easily, but quite often it is in a small little
| font beside not-quite-as-relevant stuff like their
| marital status and what type of insurance they have. Why
| isn't this in big bold red letters in every room and in
| every chart as soon as you open up a document? Even for
| vital signs you have to click through two or three
| different things to get the information you need (but
| thank goodness I get to see some stuff right away, like
| that ICD-10 code for unspecified follow up for dietary
| counseling!)
|
| One thing I think a lot of people may also not realize is
| how little information a nurse often has to go off of
| when walking into a room. If I am answering a call light
| for a patient who is not one my assigned ones, and they
| are screaming that they need to go to the bathroom
| yesterday, and you see them with both feet planted on the
| floor ready to get up, you have a quick second to think
| about a few different things. 1) How alert is this
| patient? 2) How mobile are they, do we need two people in
| the room? 3) Is this someone with a massive diabetic
| ulcer who wasn't supposed to be putting any pressure on
| that heel at all and they are about to do just that? Of
| course, you can look at the whiteboard, but you better
| pray that it's updated haha.
|
| So, going back to the AR stuff. If I could have a
| snapshot of all this information as soon as I walked into
| a room, it would be a life saver, especially for
| situations like the above.
| gundmc wrote:
| This comes up every once in a while when discussing the crazy
| 24+ hour shifts that doctors in residency are often assigned.
| One argument in favor of keeping the hours is that continuity
| of care is by far the factor most strongly correlated with good
| patient outcomes. So the argument goes that a change in
| caregiver is more detrimental to the patient than continued
| care from one doctor even if that doctor is sleep deprived.
|
| I am not knowledgeable or qualified enough to weigh in on this,
| but it's something I've heard cited by multiple friends in the
| field.
| haldujai wrote:
| As a physician, shift length is honestly a red herring.
|
| As much as I hated doing 24-28 hour shifts on inpatient
| services, continuity of care does matter and errors do occur
| in handover.
|
| You have to keep in mind that medicine between 12am and 6am
| is what we call "keep people alive." 6am to 12pm after an
| overnight is for handover.
|
| You're not trying to diagnose a new illness overnight or make
| changes in management, your job is to deal with acute
| overnight concerns only. Furthermore, you're supported by
| services such as RACE (an in hospital emergency response
| team) so you're not dealing with critically ill patients
| alone. If you're on a surgical service and need to go to the
| OR, staff/fellow + senior residents come in to help.
|
| Acute care services where you're seeing new/undifferentiated
| patients and need to be on your game, such as ER and
| radiology, tend to limit shifts to 8-12 hours.
| gus_massa wrote:
| > _As a physician, shift length is honestly a red herring._
|
| This is how the Stockholm syndrome feels. I manage a few
| T.A. in the university, and they barely can think after a 6
| hours of teaching (two consecutive classrooms, with like
| half an hour of rest in each one for the students, and
| perhaps another informal half an hour in the middle).
| Sometimes they have to speak in the blackboard, sometime
| grade informal take home exercises, sometimes reply
| questions on the spot, and they get very tired. So we have
| a strict 6 hours per day rule. And if they make a mistake,
| nobody dies!
| haldujai wrote:
| It's essentially unheard of to have someone die because a
| resident made a mistake on call.
|
| On-call medicine is so rote as to not require much, if
| any, thinking. Ward medicine is far less intellectually
| challenging than teaching.
|
| Patients who are active/critical are not managed by a
| single tired resident overnight.
| tbihl wrote:
| That makes sense. When I worked shiftwork (8 hr days), you'd
| get good info from the people before you, but not about the
| people before them (after you), so you'd often have the same
| problem in that rhythm. But we would stay on shift for months
| on end, and obviously that helped with all the knowledge
| walking away all the time.
| watersb wrote:
| > _I think it would be much better for both patients and
| healthcare staff alike if there was a greater emphasis placed
| on focusing on the series of successes and failures that happen
| over the course of someone 's care, not just seeing it as a
| single shift or a single problem happening in some isolated
| point in time._
|
| I once had a week as a patient at the Mayo Clinic in Scottsdale
| AZ. There were many remarkable aspects of care there versus the
| impossible mess out here in the other world.
|
| But the single most significant aspect of care at Mayo Clinic
| is that the doctors and nurses and techs get to read your chart
| before seeing you.
|
| That's it. You write something in the chart, it doesn't get
| tossed. It might not get parsed completely, but the essential
| info is there. And the staff does not get penalized for reading
| it.
|
| (The other big reveal for me at Mayo was the sheer scale and
| throughput of the system. Healthcare at Mayo did not cost more
| than healthcare in my small town. It. Cost. The. Same.
|
| It took six months to get in, I had a week, then it was someone
| else's turn. I presume that the high paying "celebrity"
| customers can get seen more regularly. So it's not perfect. But
| holy cow I wish it were easier for healthcare professionals to
| do their job.)
| nradov wrote:
| In general for US healthcare providers there is little
| relationship between price and quality. They have to meet
| certain quality standards in order to operate at all, but
| outsides few limited areas they don't get paid more for
| delivering higher quality care. So quality (or lack thereof)
| tends to come down to organizational culture and management.
| Aeolun wrote:
| For someone that hasn't heard of they Mayo Clinic other than
| through webite articles describing medical conditions, are
| they that desired/high-quality?
| snarfy wrote:
| My wife was diagnosed Devic's disease, a rare disease with
| a grim prognosis. Almost every paper we could find on it
| had the name of a doctor that worked at the Mayo Clinic in
| Scottsdale. We lived in Arizona at the time so we went
| there and found that doctor. He corrected her diagnosis as
| MS, not Devic's. They both suck but Devic's is much worse.
| We paid out of pocket and getting the correct diagnosis was
| worth every penny.
| throwaway2037 wrote:
| I'm not sure if you live in the United States, but Mayo
| Clinic is probably a top 5 hospital system in the US. It is
| legendary. Just read the opening paragraph from Wiki:
| https://en.wikipedia.org/wiki/Mayo_Clinic
| The Mayo Clinic (/'meIjoU/) is a nonprofit American
| academic medical center focused on integrated health care,
| education, and research.[6] It employs over 4,500
| physicians and scientists, along with another 58,400
| administrative and allied health staff, across three major
| campuses: Rochester, Minnesota; Jacksonville, Florida; and
| Phoenix/Scottsdale, Arizona.[7][8] The practice specializes
| in treating difficult cases through tertiary care and
| destination medicine. It is home to the top-15 ranked Mayo
| Clinic Alix School of Medicine in addition to many of the
| highest regarded residency education programs in the United
| States.[9][10][11] It spends over $660 million a year on
| research and has more than 3,000 full-time research
| personnel.[12][13]
|
| A little deeper: Mayo Clinic has ranked
| number one in the United States for seven consecutive years
| in U.S. News & World Report's Best Hospitals Honor
| Roll,[19] maintaining a position at or near the top for
| more than 35 years.
| heavyset_go wrote:
| I think this is a symptom of hospitals being understaffed,
| whether that's from a deliberate lack of hiring or an actual
| labor shortage. I feel like many of the problems in this aspect
| of healthcare could be solved if doctors, nurses, etc weren't
| run ragged with insanely long shifts and expected to care for a
| ton of patients.
| throwaway2037 wrote:
| I don't know how to respond to your post. I'll try: Money.
| Skilled people cost money, a lot of money. I disagree with
| both of these: <<deliberate lack of hiring or an actual labor
| shortage>> They are making do with the amount of money that
| is available. It would be wiser to focus on why healthcare is
| so expensive in the United States compared to other highly
| advanced countries -- France, Germany, Netherlands, Finland,
| Japan, etc.
| 20after4 wrote:
| Thanks for sharing!
|
| Even outside the medical field, it seems like most humans are
| pretty bad about both writing down and consulting notes. Even
| worse for the notes written by another human. We really aren't
| particularly good at transferring knowledge / experience and it
| takes a lot of effort to do a good job of it, so most people
| don't even make much of an effort.
|
| This really seems like a problem that still needs a lot more
| attention, especially in critical places like hospitals and
| really any long term crisis response situation where there is
| important knowledge gained over time with a (poorly handled)
| hand-off to successors.
|
| I had some exposure to formalized incident management[1] at a
| previous job. There, I learned a few formalities and practices
| that seemed valuable, especially assigning a single coordinator
| to be responsible for continuity of information and
| coordination between many independent actors over a long
| period. The coordinator role had explicit hand off to their
| successor where the stated purpose was to transfer important
| working knowledge and prevent the kind of problems you (and the
| article) describe.
|
| 1. https://en.wikipedia.org/wiki/Incident_management
| ler_ wrote:
| I liked the way you framed this as something universal. Is
| there any field where one can quickly reference knowledge
| from your peers to just as quickly solve a problem in
| practice? Maybe it's asking too much. Though I suppose it
| wouldn't be necessary to get everyone on board with such an
| idea if you have that single coordinator who everyone knows
| as the reference point. Although, if you think about it, even
| then that person would have to be available 24/7, which isn't
| feasible.
|
| With patient documentation specifically, what I would really
| love to have is a simple search mechanism for patient notes.
| This still wouldn't solve the problem of getting everyone to
| capture the right information. But assuming the information
| is there, and I'm having a real hard time sticking that right
| arm, I would love to be able to search for "arm", "blood
| draw," "stick" and see what pops up. I hope it's not
| something I missed entirely, but I have never used an EMR
| with such a feature.
| throwaway892238 wrote:
| This is similar to problems that would often happen in car
| manufacturing. The person assembling the car the standard way
| finds a problem, but the problem doesn't get addressed, or
| information isn't disseminated correctly, so the cars go out
| with problems. Toyota developed a methodology whereby such
| problems are addressed immediately and fixes were disseminated
| immediately, and would not send a car out otherwise. That kind
| of obsessive attention to detail and "crazy" focus on quality
| is what made them the top automaker. But most businesses are
| led by management that refuse to believe that being slow or
| focusing on quality first will result in more profits. And none
| of their lower-level workers are trained on how to spot and fix
| quality issues, nor are they told to care.
|
| Hospital systems are the same way. Moronic, scared management
| that is fine with these kinds of problems as long as the dough
| keeps coming in, ignorant of the fact that _more_ dough would
| roll in (in addition to better health outcomes, which of course
| is not their first priority) if they would just focus on
| quality.
| retconn wrote:
| This is my favourite ever episode of This American Life,
| about NUMMI, the shop floor level and individually fraternal
| miracle that was created by workers at Toyota and GM in a CA
| GM plant, until management shut them down:
|
| https://www.thisamericanlife.org/561/nummi-2015
| throwaway2037 wrote:
| This episode is incredible! I also listened to it a few
| years ago. It provided so much insight into (a) Japanese vs
| American manufactoring and (b) the impact of poor labour
| union relations. (Please do not read [b] as me being
| personally anti-labour union. Some of the revelations from
| union members in that podcast were shocking to me --
| drinking and drugging while on the manuf line!)
| Aeolun wrote:
| > Moronic, scared management that is fine with these kinds of
| problems as long as the dough keeps coming in
|
| That sounds like it's the same in any sector? Especially IT.
| ler_ wrote:
| Very cool point. In my ideal world a whole nursing unit or
| facility would be a self-correcting operation. There are
| problems that a nurse on the floor can fix but it takes up
| time. If those problems were prevented to begin with, it
| would be much easier. I would like a system where the nurse
| notices a problem and simply sends it up to a manager /
| supervisor who 1) finds a way to handle the immediate problem
| and 2) always writes up and enforces a new guideline to
| prevent it from happening again.
|
| Good managers probably already do this, but healthcare has a
| very short supply of such people. It would be great if this
| type of improvement were the standard across the board. Let's
| say, for example, that you have latex and non-latex foley
| catheters mixed in the same bin in a supply closet. Your
| patients with latex allergies have gotten a latex catheter
| put in more than once and it now becomes a problem. Well,
| someone notices the issue, sends it up to someone above and
| now there is a new guideline to place the different catheters
| at least 3 feet apart, or something to that effect. It almost
| sounds silly, but people would be surprised how many of these
| mistakes happen over and over again due to equally silly
| reasons / lack of basic prevention.
| giantg2 wrote:
| Not lost, but I've had a lot of trouble with information being
| captured incorrectly.
|
| Things like date are pretty commonly messed up. I've also had
| doctors and nurses put their own, incorrect, interpretation on
| information I've given them when they repeat it to others. When
| I say "my child wasn't eating and drinking normally and had
| half of what they normally do throughout the day", it's
| incorrect to say "the patient didn't eat or drink all day".
| That's the type of shit that can look really bad if it's
| recorded and looked at later. But it's like nobody cares if
| they record things correctly.
|
| I've also had trouble with people not doing anything with
| important information. Like maybe you should slow down on the
| morphine and oxy if the patient is answering _fewer_ basic
| questions correctly than when they came out of surgery. But it
| 's OK if they can't tell you their own birth date - just give
| them more and later order a CT ro check for a stroke. Sorry
| guys, but it should be pretty obvious you're putting them into
| a opium stupor...
| civilized wrote:
| I've noticed recently that there are people out there who
| simply can't accurately listen to others and repeat back what
| they say. It's not about being stressed for time, the skill
| is just not there. You say ABC, they write CBD, and they have
| no idea it's not the same thing.
| mannykannot wrote:
| Add to that the people who reply to an email or other
| message without providing any response to the questions it
| explicitly poses.
| nradov wrote:
| OpenNotes can help a little with this, but only if the
| patient or one of their caregivers has the time and ability
| to do a detailed review of every chart note.
|
| https://www.opennotes.org/
| voz_ wrote:
| Great, well written article, I wish your father a speedy
| recovery.
|
| Anecdotally, when I was in the hospital (much more minor, at a
| much younger age), they kept waking me up at 3am to draw blood
| and clean and do god knows what, and the light outside my room
| was constantly on. It felt... at best annoying, at worst,
| downright jarring and disruptive. It certainly feels like the
| sleep and rest parts of recovery and care need to be revisited.
| bombcar wrote:
| There was an interesting article that showed "state of the art
| delivery rooms" from the 1950s - and they were ALL oriented
| around the doctor and nurse's convenience.
|
| Now we've moved back toward "birthing centers" which focus on
| the mother and the baby; perhaps it is time for something
| similar to grow across all aspects of care.
| barry-cotter wrote:
| > There was an interesting article that showed "state of the
| art delivery rooms" from the 1950s - and they were ALL
| oriented around the doctor and nurse's convenience.
|
| And women are still giving birth lying down, fighting
| gravity, for the doctor's convenience.
| nobody9999 wrote:
| >Anecdotally, when I was in the hospital (much more minor, at a
| much younger age), they kept waking me up at 3am to draw blood
| and clean and do god knows what, and the light outside my room
| was constantly on. It felt... at best annoying, at worst,
| downright jarring and disruptive. It certainly feels like the
| sleep and rest parts of recovery and care need to be revisited.
|
| After ACL reconstruction surgery many (~30) years ago, I was
| required to stay overnight due to both the general anaesthesia
| and the lateness (late afternoon) of the procedure.
|
| I had a similar experience with the nurse coming in every two
| (2) hours to take my vitals. I was trying to sleep, but she
| kept waking me up. I groused about wanting to rest, but was
| informed (direct quote) "this isn't a hotel!"
|
| And it's not. Rather it's a money printing facility for the
| owners of the health care system that runs the hospital.
| [deleted]
| ghufran_syed wrote:
| It's worth noting that the patient's condition is not an
| independent variable with respect to the level of care - the
| author's father got moved to step down _because_ they got
| better...and I'm glad to see that they continued to get better in
| step down.
|
| A UK judge once talked about balancing the "benefits and burdens
| of treatment" when making medical decisions, I think that's a
| good way to think about it. The benefit of ICU care is less
| chance of deterioration and death - the burden is the pain,
| medication effects, discomfort, noise, confusion and many other
| things described in the article.
|
| It would also be less confusing for the family if the doctors
| could explain their thought process well, but a) not everybody is
| good at this, b) not every family member can necessarily even
| understand or remember this when _they_ are distraught and sleep-
| deprived, and c) the health system (and patients) don't want to
| pay for the time - if they paid double, the doc could spend twice
| as long with them, as happens with boutique / concierge doctors.
|
| Regarding the ICU doc disregarding the consult recommendations-
| the ICU described sounds like a "closed " ICU where the
| intensivist makes the final decision, vs an "open" icu where a
| hospitalist will often be the one making the final decision
| regarding care. Either way, it seems obvious that _someone_ has
| to coordinate the care and decide what's important _right now_
| and what's not - there are many tests that a consultant may
| recommend that won't improve the chances of the patient improving
| _right now_ , and can be done later on the med-surg floor of the
| patient survives that long. Many of the consultant
| recommendations may also be contradictory, _someone_ has to take
| responsibility for picking and choosing a course of action
|
| [edit: fixed typo]
| m463 wrote:
| With respect to sleep, I think that being disturbed (and/or
| medicated) might affect REM sleep. And if you don't get your REM
| sleep eventually your body will try and do it while you're awake.
| This means lucid dreaming aka delusions.
|
| I think an interesting possibility for an ICU would be to add EEG
| monitor along with EKG and others. You could not only measure
| heart rate, but the type and amount of sleep each patient gets.
| And then use the information to make the ICU better.
| dm319 wrote:
| For older patients and those with significant co-morbidities, we
| often advise against intubation and ICU admission in the UK.
| Usually if the disease process can't be reversed on the ward with
| current therapy, it is often unlikely in this group of patients
| for it to reverse on ICU. However, it does depend on the context.
| There was an interesting article that talks about doctor's
| choices as an end-of-life patient [1] - they often choose not to
| opt for aggressive life-prolonging treatments because they know
| how it is like. I think that doctors need to improve the way we
| talk about death with patients, and doctors can be just as guilty
| as everyone else at ignoring the inevitability of death.
|
| [1] https://www.zocalopublicsquare.org/2011/11/30/how-doctors-
| di...
| the__alchemist wrote:
| Elephant in the room, related to the article's first point: We
| have to tackle ageing. Many of the other diseases (cancer, heart
| conditions etc) and causes of mortality are highly correlated
| with it.
| lazyasciiart wrote:
| Heart conditions, for one, aren't caused by aging - they are
| caused by being around for a long time so that the slow process
| of atherosclerosis has time to become dangerous. We need to
| prevent that process from happening by following standard
| health advice, really.
| mhalle wrote:
| As a person who has spent plenty of time in ICUs or other
| hospital floors in my life as a patient, I can add some more
| background to the mental health / delirium aspect. First, it
| definitely isn't just ICUs, just most common there. High stress
| environment, powerful medicines, poor sleep, and just sickness.
| Next, a fair number of patients in hospitals may already be
| predisposed to psychiatric conditions, or at least be mentally
| fragile. Some abuse substances. That adds to the whole
| environment, and hardens staff. I experienced hepatic
| encephalopathy because of liver failure, which really impacted my
| mental state, and at least some of the staff bundled me in with
| the crazies. Empathy would have gone a long way to reduce the
| stress for me. On the other hand, I am empathetic to them. The
| job is tough.
|
| But most importantly though, given these mental stresses and
| challenges for vulnerable people, there is almost no psychiatric
| support for patients, staff, or families. That's shocking to me
| considering how many people experience "ICU delirium". There is
| almost no backup for staff to help with otherwise normal patients
| who, say, might think you are a monster trying to kill them.
|
| If there was one thing I would fix, that's it. Psychiatric
| support on floors, helping staff ease the mental challenges of
| extremely vulnerable patients.
| surgeryres wrote:
| I am a vascular surgeon, and have many patients in the ICU
| constantaly. #6 confuses me - the original operating surgeon
| should be a constant through the patient's stay. And while the
| ICU doctor might be the captain while the patient is in the ICU,
| the original surgeon is the general. He has complete control and
| should dominate the patient's care. While the surgeon can not be
| bedside 24/7, they or someone from their team should "round" at
| least once daily on these ICU patients, talking to family,
| checking catheters and tubes, reviewing medicines, checking
| wounds.
|
| At least that's how it's done in Texas.
| Uptrenda wrote:
| What he wrote about delusions and nightmares in the ICU really
| hits close to home. When I was younger I ended up in the ICU for
| an accidental poisoning. Initially I went in and out of
| consciousness, having horrific nightmares fed by the morbid
| happenings around me. We had many interesting patients come
| through the ICU. One person was there for a suicide attempt on
| prescription drugs. Another person had been in a car accident. At
| one point we even had a prisoner who had been stock-piling drugs
| to kill himself on. They had him hooked up to a dialysis machine
| which apparently works well when the drugs aren't fat soluble? It
| was like a real life episode of House.
|
| Meanwhile I wasn't mentally doing that great. When I was finally
| conscious I started hallucinating and hearing voices. I was
| hearing insults from the staff that weren't there and felt like
| everything was done with malicious intent. It was quite
| traumatic. I actually remembered these delusions for years
| afterwards and had trouble accepting that it wasn't real. It's
| only been a recent thing that I've even been able to speak about
| such experiences without shutting down emotionally. The work that
| doctors and staff do at ICUs is extremely valuable. But it's
| definitely not a great place for a vulnerable mind.
|
| I feel like there is more that could be done in such a situation.
| e.g. where someone is profoundly hallucinating. I was over-
| stimulated and noise was making everything worse. If I just had
| of had a dark room to recover in I probably wouldn't have been
| traumatized. Maybe even ear plugs or a mask. But I didn't even
| have that. I'm also kind of surprised by the OPs story because
| the ICU I was in was like this closed surgical ward filled with
| medical staff. ICUs don't really seem like a place to have
| visitors. I get the feeling many people there aren't even going
| to be conscious. OPs dad is lucky to have had such good family
| support.
| [deleted]
| georgeg23 wrote:
| The hallucinations sound like a side effect from lorazepam
| (Ativan) -- something hospitals give almost everyone but is a
| hardcore drug.
|
| Consider asking nurses to stop administering it after you do your
| own research.
|
| https://www.webmd.com/drugs/2/drug-6685/ativan-oral/details#...).
| Fatnino wrote:
| I went to the hospital for debilitating shoulder pain.
|
| Came out 3 hours later with an xray that showed nothing wrong
| and a bottle of Ativan. Still no idea why they gave that to me.
| I didn't take any of the pills.
|
| And the bill came out to over 7 thousand dollars.
| jmcgough wrote:
| Probably assumed it was somatoform
| copperx wrote:
| It's hard to pin it down to a single drug. Having had both my
| grandmother (80) and mother (60) in the ICU, and both got
| hallucinations without Ativan. It could be so many things:
|
| * The aftermentioned lack of sound sleep
|
| * Anesthesia
|
| * Painkillers
|
| In the case of my grandmother, hallucinations and incoherence
| lasted about three months after she was home. My mother's
| lasted about 2-3 weeks. It was scary. They both eventually
| recovered. But it is true that nobody in the hospital bats an
| eye when acute dementia-like symptoms are mentioned. "It's
| normal," they say.
| ChrisMarshallNY wrote:
| About 26 years ago, I spent some quality time (7 days) in ICU. I
| wasn't just at Death's Door. I was pounding on it, and loudly
| demanding admittance.
|
| _> Everyone agrees that sleep is important, but nobody has any
| idea beyond that. _
|
| I didn't sleep for pretty much the entire week. I was on lots of
| opiates and opioids, though, so I spent most of that week in a
| weird quasi-sleep "dream state."
|
| I don't recommend the experience.
|
| Most expensive hotel I've ever been in.
| theNJR wrote:
| My wife just gave birth and it was my first multi-night hospital
| stay. The midnight pokes and checks were infuriating. It also
| doesn't help that dads aren't the patient after a birth, so they
| aren't fed or given a bed. Constant nurse changes were difficult
| too.
|
| On the plus side, I was surprised at the decent quality of food
| given to my wife. Steamed vegetables and mid grade proteins with
| every meal.
|
| After two nights we made the case to be discharged. Everyone,
| including nurses and family, thought we were crazy to leave so
| early. Best decision we made and my wife recovered great. With
| the built in iOS medication reminder app and a blood pressure
| monitor I was able to manage her just fine.
| froggertoaster wrote:
| Father of four here, had one two months ago.
|
| > It also doesn't help that dads aren't the patient after a
| birth, so they aren't fed or given a bed.
|
| Yes, and? You're free to go to the cafeteria and buy food or
| leave and go buy food. And there's usually at least a chair.
| What do you expect, a Marriott?
| languageserver wrote:
| > After two nights we made the case to be discharged. Everyone,
| including nurses and family, thought we were crazy to leave so
| early.
|
| In my country you don't even stay a single night if everything
| goes fine. There is no medical need for parents and child to
| stay at any hospital if there were no complications
| misterprime wrote:
| Congratulations! We just went through the same thing and
| decided to leave after one night in post-partum. It's much
| better to be at home if there's nothing concerning that needs
| medical attention.
|
| Side note: it was surprising how well the "dad chair" served as
| a place to sleep after being awake for 24 hours.
| ed25519FUUU wrote:
| I'm fresh off of spending 24 hours in the ICU and I can say the
| OP is right. It's impossible to actually "recover" there at all.
| My singular goal while there was simply to get home to my bed,
| even if it meant I could potentially die. I didn't care. I wanted
| out.
| EMM_386 wrote:
| I have been in the ICU and can relate to the hallucinations.
|
| During one intense round, I was convinced the hospital wasn't
| real, and that I needed to leave immediately.
|
| My IV was preventing me from leaving, and I couldn't have that.
|
| So of course I ripped it out and tried my best to leave. The
| staff wasn't having it.
| xwdv wrote:
| You thought it wasn't real as in you though everyone was an
| actor in a fake hospital building or you thought you were in a
| whole nother plane of existence?
| EMM_386 wrote:
| Interesting question ... plane of existence.
|
| I was hearing voices that convinced me I was not where I
| thought I was, it was an illusion of sorts and it was best to
| leave. Immediately. For reasons unclear to me.
| xwdv wrote:
| I mean where did you even expect to go if you were inside
| an illusion? Another illusion?
| Spooky23 wrote:
| My mom was the nurse empress of a large ICU (at least
| tactically). The biggest issue is there's no "product manager"
| for your care. Each specialist doctor has an incentive to do as
| little as possible as often as possible to avoid having a death
| on their record, but to be able to bill. So the nurses usually
| are the most incentivized people to actually take care of you.
|
| From her point of view, the management ensured that the best care
| for patients happened when family was present, especially on
| irregular intervals, and for prisoners, who had a CO always
| watching and sometimes logging what happened.
|
| Her other big thing was hatred of EMRs. The loss of the clipboard
| made situational awareness tough.
| trynewideas wrote:
| > The biggest issue is there's no "product manager" for your
| care. Each specialist doctor has an incentive to do as little
| as possible as often as possible to avoid having a death on
| their record, but to be able to bill. So the nurses usually are
| the most incentivized people to actually take care of you.
|
| Man. Maybe this is a tangent, but remember primary care
| physicians? I can barely remember that as a concept. I waited
| so long to find a PCP taking patients at my last job that I
| quit before it happened.
|
| Was that a role they ever filled? It kind of feels like it
| should be considering the title, but being a US citizen I've
| never experienced it.
| roxgib wrote:
| Here in Australia to see a specialist your GP has to refer
| you. To us the idea of going straight to a specialist is odd,
| if you have a non-emergency medical issue of any kind you
| just see your GP. Not saying we don't have issues, but I
| honestly don't know have people manage their medical issues
| without a GP to coordinate.
| Spooky23 wrote:
| They make like $250k. Specialists make like $500k and up. So
| the business model is for health networks to vacuum them up
| and then hire a bunch of nurse practitioners for $100k.
|
| Some of these guys get laid off and end up working in
| dermatology offices getting commissions on expensive creams.
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