The most expensive bed in the hospital
November 19, 2022 2:51 PM Subscribe
Things I've noticed while visiting the ICU (Substack) "This is one of the nicest and best-resourced ICUs in the country. So, my assumption has been that the faults of this ICU unit are likely shared by all ICUs, while the virtues probably are not."
Summary:
1. The ICU is filled with old people.
2. There are many consults, but the ICU attending is king (or queen).
3. Sometimes nurses are the footsoldiers of the ICU regent, and sometimes they’re governors.
4. Everyone agrees that sleep is important, but nobody has any idea beyond that.
5. Almost every patient has delusions and nightmares, but nobody knows why or how to fix it.
6. The ICU staff is literally constantly changing.
7. The ICU is great at managing acute issues, and struggles a lot more with longterm issues.
8. The ICU is a good place to not die, but a bad place to recover.
Summary:
1. The ICU is filled with old people.
2. There are many consults, but the ICU attending is king (or queen).
3. Sometimes nurses are the footsoldiers of the ICU regent, and sometimes they’re governors.
4. Everyone agrees that sleep is important, but nobody has any idea beyond that.
5. Almost every patient has delusions and nightmares, but nobody knows why or how to fix it.
6. The ICU staff is literally constantly changing.
7. The ICU is great at managing acute issues, and struggles a lot more with longterm issues.
8. The ICU is a good place to not die, but a bad place to recover.
I'm actually curious about how common it is to spend a month in the ICU. That seems utterly hellish. I wonder if part of why this sounds so weird is that the ICU system was set up for much shorter-term stays than his father's.
posted by ArbitraryAndCapricious at 3:46 PM on November 19, 2022 [3 favorites]
posted by ArbitraryAndCapricious at 3:46 PM on November 19, 2022 [3 favorites]
This has to be one of the dumbest things I've read in a while:
"Or, to put it in even starker terms, 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. I’m not sure if this is a good thing, but I don’t think anyone has a better solution."
Wow, what a revelation: older people need medical specialists more than young people. I guess the "better solution" is some kind of Logan's Run scenario where nobody lives past 30. Then, the youngsters will have no problem getting medical specialists. Of course, that means that all the specialists will be 18, but that's fine.
posted by jonathanhughes at 3:47 PM on November 19, 2022 [56 favorites]
"Or, to put it in even starker terms, 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. I’m not sure if this is a good thing, but I don’t think anyone has a better solution."
Wow, what a revelation: older people need medical specialists more than young people. I guess the "better solution" is some kind of Logan's Run scenario where nobody lives past 30. Then, the youngsters will have no problem getting medical specialists. Of course, that means that all the specialists will be 18, but that's fine.
posted by jonathanhughes at 3:47 PM on November 19, 2022 [56 favorites]
Anyone encouraging the FTX Future Fund to do anything but fuck off into the sun (which it did of its own accord, because it was a tower of shit) is not going to be the most self-aware influencer at the TED talk
posted by scruss at 3:58 PM on November 19, 2022 [19 favorites]
posted by scruss at 3:58 PM on November 19, 2022 [19 favorites]
Everyone has #5 delusions in part because of the #4 sleep thing, but not entirely! Some of it is still a bit mysterious! I know some of the research-adjacent docs who were working on this a few years ago and I'm pretty sure they flung their hands up and we're down to 'try to keep a vaguely normal sleep-wake cycle, consider opening the blinds during the day' orders that are ignored, and have been, since Florence Nightingale recommended them. It's probably in part because you're basically dying and the ICU yoinks you back constantly.
Anyway, all these tech bros (like this post from a while back) want to solve for human condition and, haha, we can't. Being an anthropologist who moved into healthcare and is married to a programmer puts me in an interesting position to look at these modern cultural models. Everyone should have to do a customer service job as part of their life, some of which could be patient care.
I'm not a fan of the attitude towards his non-ICU nurses but there is a big influx of new grads who don't have experience and that nurse probably had sicker patients that were consuming more time, as opposed to having a 1:1 ratio or closer to it, like he did in the ICU. Meanwhile, his noticing that 'ICU ignored the neurologist' component is probably two parts - one, hospital politics, wherein departments are like boarding school houses and compete in secret, obscure, and archaic ways, and two, that there isn't much actionable that can always be done from a neuro and especially neuropsychiatric standpoint for someone whose body is actively trying to die.
As for length of stay, my snap guess is that the average is only 1-2 days but the ones who stay more than three or so days may end up staying for a very long time. In trying to look this up, I found a paper on 'how to figure out length of stay across papers' which demonstrates we aren't even good at measuring this across units.
posted by cobaltnine at 3:59 PM on November 19, 2022 [5 favorites]
Anyway, all these tech bros (like this post from a while back) want to solve for human condition and, haha, we can't. Being an anthropologist who moved into healthcare and is married to a programmer puts me in an interesting position to look at these modern cultural models. Everyone should have to do a customer service job as part of their life, some of which could be patient care.
I'm not a fan of the attitude towards his non-ICU nurses but there is a big influx of new grads who don't have experience and that nurse probably had sicker patients that were consuming more time, as opposed to having a 1:1 ratio or closer to it, like he did in the ICU. Meanwhile, his noticing that 'ICU ignored the neurologist' component is probably two parts - one, hospital politics, wherein departments are like boarding school houses and compete in secret, obscure, and archaic ways, and two, that there isn't much actionable that can always be done from a neuro and especially neuropsychiatric standpoint for someone whose body is actively trying to die.
As for length of stay, my snap guess is that the average is only 1-2 days but the ones who stay more than three or so days may end up staying for a very long time. In trying to look this up, I found a paper on 'how to figure out length of stay across papers' which demonstrates we aren't even good at measuring this across units.
posted by cobaltnine at 3:59 PM on November 19, 2022 [5 favorites]
wee-hours blood draws are sleep deprivation vampire bat hell,, can confirm.
icu nurses are superhuman, can confirm.
not dead. grateful.
posted by Dashy at 4:01 PM on November 19, 2022 [19 favorites]
icu nurses are superhuman, can confirm.
not dead. grateful.
posted by Dashy at 4:01 PM on November 19, 2022 [19 favorites]
Every day, someone walks into the ICU for the first time. But it's not every day that someone writes that experience down in a thoughtfully observed way. Some insiders here have shed some additional light on those experiences, but the outrage expressed by some angers and frustrates me, and makes me reconsider whether my time reading these discussions is well spent.
I wish I could say I was disappointed, but it too common to be surprised by: anything that ends up on MeFi that is even remotely critical, or even analytical, generally receives a chorus of uncharitable kneejerk responses that angers me and makes me want to engage in a way that isn't helpful to the topic, to the forum, or to my own state of mind.
I'm no medical insider, but a few institutional failures this article points out look like they merit discussion:
1. Failure to coordinate care. This person's father was repeatedly dosed with a medication they had a negative reaction; he felt completely helpless to prevent nurses from repeating this course of action again and again, because there was no coordination of care. Nurses seem not to coordinate at all except where it is hierarchically mandated.
2. Failure to agree on standards of practice, specifically on sleep. Similar to the above, but caretakers sound like they have no community of understanding when it comes to care. They are completely on their own, and thus free to have their own theories, which may be sensible or completely wackadoo.
3. Enormous amounts of money spent on institutionalized care of elders. Discussion here treats this decision as not worth discussion, but (1) almost 20% of our GDP is spent on medical care, and (2) this means that each one of us who lives in the US is extremely likely to spend a good chunk of our lives in this institutionalized setting. A setting where, note:
4. You are likely to experience horrifying delusions and nightmares!
Anyway. Thanks for the post; I'll be thinking about this if/when I have to deal with one of my parents ending up in the ICU....
posted by billjings at 4:29 PM on November 19, 2022 [27 favorites]
I wish I could say I was disappointed, but it too common to be surprised by: anything that ends up on MeFi that is even remotely critical, or even analytical, generally receives a chorus of uncharitable kneejerk responses that angers me and makes me want to engage in a way that isn't helpful to the topic, to the forum, or to my own state of mind.
I'm no medical insider, but a few institutional failures this article points out look like they merit discussion:
1. Failure to coordinate care. This person's father was repeatedly dosed with a medication they had a negative reaction; he felt completely helpless to prevent nurses from repeating this course of action again and again, because there was no coordination of care. Nurses seem not to coordinate at all except where it is hierarchically mandated.
2. Failure to agree on standards of practice, specifically on sleep. Similar to the above, but caretakers sound like they have no community of understanding when it comes to care. They are completely on their own, and thus free to have their own theories, which may be sensible or completely wackadoo.
3. Enormous amounts of money spent on institutionalized care of elders. Discussion here treats this decision as not worth discussion, but (1) almost 20% of our GDP is spent on medical care, and (2) this means that each one of us who lives in the US is extremely likely to spend a good chunk of our lives in this institutionalized setting. A setting where, note:
4. You are likely to experience horrifying delusions and nightmares!
Anyway. Thanks for the post; I'll be thinking about this if/when I have to deal with one of my parents ending up in the ICU....
posted by billjings at 4:29 PM on November 19, 2022 [27 favorites]
This guy works in medicine, right? Biology? Pharmaceuticals? REALLY?
Pretty much every explanation you give of why things work the way they do he also acknowledges so is the objection mostly that he’s stating the obvious?
posted by atoxyl at 4:29 PM on November 19, 2022 [1 favorite]
Pretty much every explanation you give of why things work the way they do he also acknowledges so is the objection mostly that he’s stating the obvious?
posted by atoxyl at 4:29 PM on November 19, 2022 [1 favorite]
Enormous amounts of money spent on institutionalized care of elders. Discussion here treats this decision as not worth discussion, but (1) almost 20% of our GDP is spent on medical care, and (2) this means that each one of us who lives in the US is extremely likely to spend a good chunk of our lives in this institutionalized setting.The ICU is not "institutionalized care." It's acute care, where you go to get very intensive, lifesaving interventions until you are stable enough to move to a less-intensive setting. It is kind of the opposite of institutionalized care. And the reason that old people are more likely to be in the ICU is that old people are more likely to be extremely sick. I'm not sure why one would point that out, except to suggest that very sick people shouldn't get care if they happen to be old.
posted by ArbitraryAndCapricious at 4:36 PM on November 19, 2022 [21 favorites]
The ICU is not "institutionalized care." It's acute care, where you go to get very intensive, lifesaving interventions until you are stable enough to move to a less-intensive setting. It is kind of the opposite of institutionalized care.
By institutionalized I mean that it takes place in an institutional setting: patients are immersed in the institution of the hospital, which has its own social rules and hierarchy that is separate from the social settings of home and work. Whether you are a doctor or a gas station attendant or a child or a priest is less relevant in the hospital than the fact that you are a sick patient.
posted by billjings at 4:51 PM on November 19, 2022 [7 favorites]
By institutionalized I mean that it takes place in an institutional setting: patients are immersed in the institution of the hospital, which has its own social rules and hierarchy that is separate from the social settings of home and work. Whether you are a doctor or a gas station attendant or a child or a priest is less relevant in the hospital than the fact that you are a sick patient.
posted by billjings at 4:51 PM on November 19, 2022 [7 favorites]
The elderly stuff rubbed me the wrong way, but otherwise I felt more or less about this piece as billjings does.
I and much of my family literally have lifetimes of intimate experience with healthcare and hospitals and, I suppose, it's my fate to be the devil's advocate in both directions in many such discussions about healthcare. To wit, laypeople greatly overestimate what medicine understands and what it can do and this misunderstanding cuts in both directions: patient expectations are unrealistic but the inadequacies of modern medicine also mean there's a lot of room for improvement.
We don't know why so many ICU patients suffer from delusion or what to do about it? Yeah, that's just one among many, many examples of the systemic interdependencies influenced by critical illness and the ICU environment and don't expect that problem to be solved any time soon.
ICU staff can't coordinate an awareness of a patient's poor reaction to Haldol? Yeah, that's not excusable.
A modern ICU is really an impressive feat of knowledge, skill, and organization and, indeed, they're typically very good at intensive care. But the ICU, like health care in general, is very far from what we want — and frequently imagine — it to be, and in some cases its failures are preventable or even egregious.
My one enduring observation from a lifetime of chronic health care is that a very necessary change for the better would be for our culture to stop alternately idealizing and villifying medicine and physicians and instead to have more realistic understanding and consequent set of expectations. Both the idealization and the villification have been obstacles to improving health care and outcomes.
posted by Ivan Fyodorovich at 5:19 PM on November 19, 2022 [24 favorites]
I and much of my family literally have lifetimes of intimate experience with healthcare and hospitals and, I suppose, it's my fate to be the devil's advocate in both directions in many such discussions about healthcare. To wit, laypeople greatly overestimate what medicine understands and what it can do and this misunderstanding cuts in both directions: patient expectations are unrealistic but the inadequacies of modern medicine also mean there's a lot of room for improvement.
We don't know why so many ICU patients suffer from delusion or what to do about it? Yeah, that's just one among many, many examples of the systemic interdependencies influenced by critical illness and the ICU environment and don't expect that problem to be solved any time soon.
ICU staff can't coordinate an awareness of a patient's poor reaction to Haldol? Yeah, that's not excusable.
A modern ICU is really an impressive feat of knowledge, skill, and organization and, indeed, they're typically very good at intensive care. But the ICU, like health care in general, is very far from what we want — and frequently imagine — it to be, and in some cases its failures are preventable or even egregious.
My one enduring observation from a lifetime of chronic health care is that a very necessary change for the better would be for our culture to stop alternately idealizing and villifying medicine and physicians and instead to have more realistic understanding and consequent set of expectations. Both the idealization and the villification have been obstacles to improving health care and outcomes.
posted by Ivan Fyodorovich at 5:19 PM on November 19, 2022 [24 favorites]
The "OMG old people are using health care!!!" point seems kind of stupid at face value, but the US seems to have spent the past two years talking about the importance and scarcity of health care without any kind of long term plan to fix the many problems that appeared, thanks to it being controlled mainly by capitalism. I suppose the author describes themselves as having a cold, "realist" utilitarian view of the world.
The sleep thing struck a chord with me - I've only been hospitalized once, for a single night, a long time ago, but a family member distinctly remembers me not appreciating being woken up in the middle of the night. When you're already at the hospital for your primary issue, in an unfamiliar bed, with constant noises all night long, with needles poked into your body and covered in sensors, in a not-quite dark room; someone waking you up every few hours seems like it would cause its own set of problems over the long term.
posted by meowzilla at 5:37 PM on November 19, 2022 [6 favorites]
The sleep thing struck a chord with me - I've only been hospitalized once, for a single night, a long time ago, but a family member distinctly remembers me not appreciating being woken up in the middle of the night. When you're already at the hospital for your primary issue, in an unfamiliar bed, with constant noises all night long, with needles poked into your body and covered in sensors, in a not-quite dark room; someone waking you up every few hours seems like it would cause its own set of problems over the long term.
posted by meowzilla at 5:37 PM on November 19, 2022 [6 favorites]
Almost every patient has delusions and nightmares, but nobody knows why or how to fix it.
I've been to hospital four times in the past two years, a total of 18 days. Before that I hadn't stayed in a hospital for 19 years.
Valium and oxycodone for breakfast, lunch and dinner. They kept asking if I want valium and I kept saying yes. I was stoned the entire time I was there. Totally wasted, high as a kite. Playing braindead mobile games, meals in bed, waking up with drool on my face. Forgetting what day it is.
On top of being stoned, you're put in an environment you've only seen on TV. Usually very suddenly and without warning. Hospitals are extremely weird places. The nurse jargon, the inscrutable equipment. The necessary offenses to modesty by strangers like sponge baths or removing a catheter. Other strangers dropping by to draw blood.
And then of course there is the pain.
So no, I don't think it's a great big mystery why people have delusions and nightmares. I hope I never get to a place where all the above is so commonplace in my life it no longer unsettles me.
posted by adept256 at 5:42 PM on November 19, 2022 [9 favorites]
I've been to hospital four times in the past two years, a total of 18 days. Before that I hadn't stayed in a hospital for 19 years.
Valium and oxycodone for breakfast, lunch and dinner. They kept asking if I want valium and I kept saying yes. I was stoned the entire time I was there. Totally wasted, high as a kite. Playing braindead mobile games, meals in bed, waking up with drool on my face. Forgetting what day it is.
On top of being stoned, you're put in an environment you've only seen on TV. Usually very suddenly and without warning. Hospitals are extremely weird places. The nurse jargon, the inscrutable equipment. The necessary offenses to modesty by strangers like sponge baths or removing a catheter. Other strangers dropping by to draw blood.
And then of course there is the pain.
So no, I don't think it's a great big mystery why people have delusions and nightmares. I hope I never get to a place where all the above is so commonplace in my life it no longer unsettles me.
posted by adept256 at 5:42 PM on November 19, 2022 [9 favorites]
The author also doesn't seem to realize there's a NICU and PICU.
posted by meowzilla at 5:47 PM on November 19, 2022 [9 favorites]
posted by meowzilla at 5:47 PM on November 19, 2022 [9 favorites]
I've spent a lot of time as a hospital patient, with only one ICU stay of an unknown number of days. While it's never easy to sleep in the hospital, my impression of the ICU is that it was noticeably louder than other wards. It seemed to be a combination of more patients closer together being hooked up to more monitoring equipment, a more open floor plan, and more staff coming and going. Once I regained consciousness, I don't believe I slept again until I got back to the medical ward.
(It didn't help that there was some kind of leaking issue with my IV that resulted in me being wet and cold the entire time.)
posted by The Underpants Monster at 5:48 PM on November 19, 2022 [3 favorites]
(It didn't help that there was some kind of leaking issue with my IV that resulted in me being wet and cold the entire time.)
posted by The Underpants Monster at 5:48 PM on November 19, 2022 [3 favorites]
It's interesting to see this perspective. Some things I could say are not 'factually correct' but his sense of what is correct is revealing about the family experience. I'm not an ICU nurse but I'm a nurse who works in a hospital and so can say some stuff here is wrong like, If a person has a bad reaction to haldol, that SHOULD be noted in the chart and the doc should not prescribe it, but you can see where the system failed by what was done to this person's dad.
I can share some tips: (Don't be afraid to tape a sign to the TV that says "Leave off!" or "Golf ONLY" or whatever. Don't be afraid to call early every shift and check in with the new nurse and introduce yourself and share a couple tidbits (Can you please open dad's curtains during the day? Also, he hates MSNBC) or whatever. It helps if you're nice and bring gifts. They will still treat you like just another patient at the patient factory - they can't help it - this is just another Wednesday for them. But that stuff can sometimes make a little difference. If you make a big fuss everyone will talk shit about you but you also may get better care.
The observation that "the ICU is full of old people" does sound dumb but actually I think it's not. Most old people don't walk out of the ICU anything like how they walked in. There is a place to have a discussion about quality of life, realistic expectations for what recovery and post-hospital life will look like for folks who are already frail and receiving a ton of ICU interventions. Not a right or wrong answer but a more realistic understanding of what it means to be in an ICU depending on your baseline health and life-stage.
posted by latkes at 6:27 PM on November 19, 2022 [24 favorites]
I can share some tips: (Don't be afraid to tape a sign to the TV that says "Leave off!" or "Golf ONLY" or whatever. Don't be afraid to call early every shift and check in with the new nurse and introduce yourself and share a couple tidbits (Can you please open dad's curtains during the day? Also, he hates MSNBC) or whatever. It helps if you're nice and bring gifts. They will still treat you like just another patient at the patient factory - they can't help it - this is just another Wednesday for them. But that stuff can sometimes make a little difference. If you make a big fuss everyone will talk shit about you but you also may get better care.
The observation that "the ICU is full of old people" does sound dumb but actually I think it's not. Most old people don't walk out of the ICU anything like how they walked in. There is a place to have a discussion about quality of life, realistic expectations for what recovery and post-hospital life will look like for folks who are already frail and receiving a ton of ICU interventions. Not a right or wrong answer but a more realistic understanding of what it means to be in an ICU depending on your baseline health and life-stage.
posted by latkes at 6:27 PM on November 19, 2022 [24 favorites]
Perhaps the writer thought there would certainly be old people in the ICU, but perhaps percentage wise, not as many. I can say from my few times visiting ICU so far, agree, it was mostly unconscious elderly people. But my sample size is very small. Surely there must be times when there are batches of younger people. Like there's a terrible bus crash or something?
posted by bitterkitten at 6:52 PM on November 19, 2022
posted by bitterkitten at 6:52 PM on November 19, 2022
going to ICU was one of the most surreal experiences of my life, not helped by my being there because of a medication putting my phosphorus way way high and i think they were just following some kind of routine cover your ass procedure - so i did not feel deathly ill, nor completely understood just why i was supposed to be that sick when i didn't feel that sick - and the nurses seemed very surprised and uncomfortable that i was actually ambulatory and with the program - i got the feeling they weren't used to that
but it was weird - they had these ventilators that people were on and they would go beep beep unless something was going wrong and then they'd go beep beep beep beep in a major chord and this went on all night
i didn't have any hallucinations or stuff but it was tiring and deeply weird - i was very glad when they got me out
by the way patients don't get to walk in and out of icu's
(and this was all years ago, i'm fine)
posted by pyramid termite at 6:56 PM on November 19, 2022 [6 favorites]
but it was weird - they had these ventilators that people were on and they would go beep beep unless something was going wrong and then they'd go beep beep beep beep in a major chord and this went on all night
i didn't have any hallucinations or stuff but it was tiring and deeply weird - i was very glad when they got me out
by the way patients don't get to walk in and out of icu's
(and this was all years ago, i'm fine)
posted by pyramid termite at 6:56 PM on November 19, 2022 [6 favorites]
Like there's a terrible bus crash or something?
School children? They would be in the pediatric ICU. Maybe a surgical ICU for trauma. (I don't work in the medical field, just guessing)
Upon re-read, the author was in the cardiovascular ICU which is heart stuff - which disproportionately affects the elderly so he's just completely mistaken about his first point.
posted by meowzilla at 7:10 PM on November 19, 2022 [1 favorite]
School children? They would be in the pediatric ICU. Maybe a surgical ICU for trauma. (I don't work in the medical field, just guessing)
Upon re-read, the author was in the cardiovascular ICU which is heart stuff - which disproportionately affects the elderly so he's just completely mistaken about his first point.
posted by meowzilla at 7:10 PM on November 19, 2022 [1 favorite]
The pandemic has changed the ICU experience. Some surgeries require ICU observation, any transplant, open heart, massive trauma, open brain surgery, heart attacks, acute respiratory failure, some acute illnesses, near fatal legionaires, pneumonia, covid, infections of unknown etiology until identified, and then a course of emergency treatment, identified; burn patients, patients with critical wounds from weapons, or vehicular trauma.
Trauma effects people of all ages, not just elderly people. However, elderly people can be more fragile and don't respond well to massive trauma.
We can't monetize people when it comes to acute care, the elderly are not worthless. Sometimes old age is literally the only time some people have ever had time, for themselves, to even consider their health. It could be, the ICU is the first time the author has seen a lot of older people.
posted by Oyéah at 7:24 PM on November 19, 2022 [6 favorites]
Trauma effects people of all ages, not just elderly people. However, elderly people can be more fragile and don't respond well to massive trauma.
We can't monetize people when it comes to acute care, the elderly are not worthless. Sometimes old age is literally the only time some people have ever had time, for themselves, to even consider their health. It could be, the ICU is the first time the author has seen a lot of older people.
posted by Oyéah at 7:24 PM on November 19, 2022 [6 favorites]
I spent 12 days in the ICU with viral pneumonia. There are a bunch of things that really suck, but the thing I hated the most was the sleep deprivation. I was woken up every 3 hours for 12 days. It was brutal.
I love nurses. Life savers.
posted by Chuffy at 9:56 PM on November 19, 2022 [2 favorites]
I love nurses. Life savers.
posted by Chuffy at 9:56 PM on November 19, 2022 [2 favorites]
He's making some awfully sweeping generalizations about ICU care from his one experience in a specialized CVICU. I'll admit that, as an ICU nurse, I bristle easily at someone who thinks they know what the ICU does from their narrow scope, especially after the last three years.
Still, he makes some good observations, alongside the flawed. Sleep is virtually impossible in the ICU, and delirium is a constant concern. Nurses have a lot of latitude in some things, especially agitation and anxiety, but all those medications still stem from discussions with our docs. It is also really hard to pass on the "softer" information across multiple shifts, but haldol poor reactions should have been entered as an allergy. But keeping track of all that is hard, no doubt, and we are flawed.
But the biggest piece, that he flirts with a bit, is that ICU care is expensive, complicated and often futile. Thrashing bodies just to keep them alive is not a problem we can solve within the walls of the ICU - it's a societal problem, requiring hard conversations about death and aging and whether a bit more quantity of life is worth the brutal quality that often follows a long ICU stay.
posted by Pantengliopoli at 9:57 PM on November 19, 2022 [20 favorites]
Still, he makes some good observations, alongside the flawed. Sleep is virtually impossible in the ICU, and delirium is a constant concern. Nurses have a lot of latitude in some things, especially agitation and anxiety, but all those medications still stem from discussions with our docs. It is also really hard to pass on the "softer" information across multiple shifts, but haldol poor reactions should have been entered as an allergy. But keeping track of all that is hard, no doubt, and we are flawed.
But the biggest piece, that he flirts with a bit, is that ICU care is expensive, complicated and often futile. Thrashing bodies just to keep them alive is not a problem we can solve within the walls of the ICU - it's a societal problem, requiring hard conversations about death and aging and whether a bit more quantity of life is worth the brutal quality that often follows a long ICU stay.
posted by Pantengliopoli at 9:57 PM on November 19, 2022 [20 favorites]
The pandemic has changed the ICU experience.
The pandemic has changed the entire hospital experience, if not permanently then in ways that are profound and not easily fixable.
posted by Halloween Jack at 10:22 PM on November 19, 2022 [3 favorites]
The pandemic has changed the entire hospital experience, if not permanently then in ways that are profound and not easily fixable.
posted by Halloween Jack at 10:22 PM on November 19, 2022 [3 favorites]
Like there's a terrible bus crash or something?
School children?
Public transport may be woefully inadequate in most of the U.S., but some cities do have public buses that adults ride.
posted by The Underpants Monster at 11:35 PM on November 19, 2022 [6 favorites]
School children?
Public transport may be woefully inadequate in most of the U.S., but some cities do have public buses that adults ride.
posted by The Underpants Monster at 11:35 PM on November 19, 2022 [6 favorites]
I had been aware of how much of our healthcare is utilized by the elderly, but this really put it in stark focus. We are spending an enormous amount of our healthcare budget on patients in the last 5 or 10 years of their life. This includes every part of healthcare: nurses, speciality doctors, primary doctors, surgeons, etc. Pretty much all these patients are on Medicare, which means your taxpayers dollars are making this happen.
The author seems to think that only he and his young or youngish peers are contributing to the cost of healthcare of patients on Medicare, and that it is these "young" taxpayer dollars making up the cost.
But when I was in CCU a few years ago, and utilizing Medicare (for which I pay almost $5,000 in premiums and copays annually) it might be noted that I contributed, through payroll taxes, into the system since my first job at age 16 until retirement - - and continue to pay taxes now!
So most people on Medicare are not getting a free ride on the back of the "taxpayer dollars of (younger) others." We have already contributed, and paid our way for healthcare and lifesaving measures, thank you.
posted by alwayson_slightlyoff at 11:42 PM on November 19, 2022 [36 favorites]
The author seems to think that only he and his young or youngish peers are contributing to the cost of healthcare of patients on Medicare, and that it is these "young" taxpayer dollars making up the cost.
But when I was in CCU a few years ago, and utilizing Medicare (for which I pay almost $5,000 in premiums and copays annually) it might be noted that I contributed, through payroll taxes, into the system since my first job at age 16 until retirement - - and continue to pay taxes now!
So most people on Medicare are not getting a free ride on the back of the "taxpayer dollars of (younger) others." We have already contributed, and paid our way for healthcare and lifesaving measures, thank you.
posted by alwayson_slightlyoff at 11:42 PM on November 19, 2022 [36 favorites]
I was in hospital for three weeks once with pneumonia, three days of those in the ICU. I was 26, and in enough pain that they had me on morphine to knock me out for those first three days, and afterwards I am very thankful that my body seems to respond to illness by trying to sleep through it.
I did nearly die of kidney failure at one point because one of the drips got put in wrong and I bloated up like a balloon - luckily my late stepfather held a medical fellowship and that was enough to both identify the problem and make the doctors fix it, otherwise they thought he was just some idiot upstart trying to tell them their jobs.
The nurses were delightful. I had the most luxurious bedlinen in the ward and they helped me wash my - at the time - extremely long hair. I love nurses.
posted by HypotheticalWoman at 12:37 AM on November 20, 2022 [2 favorites]
I did nearly die of kidney failure at one point because one of the drips got put in wrong and I bloated up like a balloon - luckily my late stepfather held a medical fellowship and that was enough to both identify the problem and make the doctors fix it, otherwise they thought he was just some idiot upstart trying to tell them their jobs.
The nurses were delightful. I had the most luxurious bedlinen in the ward and they helped me wash my - at the time - extremely long hair. I love nurses.
posted by HypotheticalWoman at 12:37 AM on November 20, 2022 [2 favorites]
I hope this doesn't lower the tone too much but I'm currently obsessed with this (fan)fictional story written by an ICU resident and set in an ICU ward... Don't want to link in case the author doesn't want the attention but memail if you're curious I guess. There's a lot of specialized jargon and talk about the hospital hierarchy (shift changes, reports, "levels", residents vs attendings) and it really does seem like a different world even from the rest of the hospital.
posted by subdee at 12:57 AM on November 20, 2022 [1 favorite]
posted by subdee at 12:57 AM on November 20, 2022 [1 favorite]
I'm actually curious about how common it is to spend a month in the ICU
My dad was in ICU for 3 weeks. I think our experience was consistent with this piece’s…they were writing my dad’s lack of cognitive ability off, for good reason really as he’d had a brain aneurysm, until they realized he also had a raging UTI. 24 hrs after that treatment started he was talking. It was the neurologist who diagnosed it.
I’ve had NICU experiences too and they felt very different, but that’s probably at least partly because you have less sense of what “should” be happening.
posted by warriorqueen at 4:45 AM on November 20, 2022 [4 favorites]
My dad was in ICU for 3 weeks. I think our experience was consistent with this piece’s…they were writing my dad’s lack of cognitive ability off, for good reason really as he’d had a brain aneurysm, until they realized he also had a raging UTI. 24 hrs after that treatment started he was talking. It was the neurologist who diagnosed it.
I’ve had NICU experiences too and they felt very different, but that’s probably at least partly because you have less sense of what “should” be happening.
posted by warriorqueen at 4:45 AM on November 20, 2022 [4 favorites]
I found the ageism distasteful, but beyond that, most of what he says is true. ICUs are very good at one specific thing: keeping bodies alive. The "insights" about fragmentation of care or the deliriogenic environment are almost cliche about hospital care in general, and ICUs just dial that up to 11. Things in the ICU change on the order of minutes, so it's impossible to think about the days, weeks, months. To use a warfare metaphor (with reservations), the ICU is about tactics, not strategy.
I hated my required ICU rotations as a medical student and resident. It felt like we were flogging people, especially older folks, who had minimal chance of recovery. It sometimes felt like a relief when the long-term residents, the ones with half their body weight in tubes and drains, managed to die, because it meant we could stop torturing them. There seemed to be very little rhyme or reason as to who lived and who died, at least if there was a reason it was totally opaque to me. The Greeks had it right with their idea of the Fates snipping a thread.
I recently revisited my diaries from those days, which are full of what I now recognize as moral distress, moral injury. The patients I remember best are the ones whose families let us get to know them as people, like the guy whose room was plastered with photos of him playing guitar or hiking with his kids (not going to lie, it was hard to enter that room some days and see the disconnect between that man in the photos and the husk swallowed up by the bed, but it was also motivating, like this is a MAN not a set of labs and chest X-rays and ins/outs from his various tubes and drains).
Mostly in the ICU you round with everyone staring at their own computer screen on a little cart. A white coat thrombus, one of colleagues called it, of residents, fellows, students, nurses, attending, propagating down the hall with their Workstations on Wheels. You never enter the patient's room, because there are too many of you, you can't fit, and the patient is probably on contact/droplet/airborne precautions anyway.
The only time I liked the ICU was on my palliative care elective, when we were called in to help with family meetings. I loved the way my attending started these. Not with the medical jargon, like literally every other patient-doctor interaction I'd seen in 4 years of med school to date, but with an invitation. "Tell me about your grandmother." From that simple sentence, you can hear a life, and the values of that life, and that -- not the daily CMP -- needs to be the guiding principle in the ICU.
I ran as far away as possible from the ICU as soon as they'd let me. I'm glad they exist, and I'm glad, especially after the last few years, that they still attract young residents and fellows and especially nurses to staff them. But by the grace of God I'll never find myself in one again.
posted by basalganglia at 4:50 AM on November 20, 2022 [32 favorites]
I hated my required ICU rotations as a medical student and resident. It felt like we were flogging people, especially older folks, who had minimal chance of recovery. It sometimes felt like a relief when the long-term residents, the ones with half their body weight in tubes and drains, managed to die, because it meant we could stop torturing them. There seemed to be very little rhyme or reason as to who lived and who died, at least if there was a reason it was totally opaque to me. The Greeks had it right with their idea of the Fates snipping a thread.
I recently revisited my diaries from those days, which are full of what I now recognize as moral distress, moral injury. The patients I remember best are the ones whose families let us get to know them as people, like the guy whose room was plastered with photos of him playing guitar or hiking with his kids (not going to lie, it was hard to enter that room some days and see the disconnect between that man in the photos and the husk swallowed up by the bed, but it was also motivating, like this is a MAN not a set of labs and chest X-rays and ins/outs from his various tubes and drains).
Mostly in the ICU you round with everyone staring at their own computer screen on a little cart. A white coat thrombus, one of colleagues called it, of residents, fellows, students, nurses, attending, propagating down the hall with their Workstations on Wheels. You never enter the patient's room, because there are too many of you, you can't fit, and the patient is probably on contact/droplet/airborne precautions anyway.
The only time I liked the ICU was on my palliative care elective, when we were called in to help with family meetings. I loved the way my attending started these. Not with the medical jargon, like literally every other patient-doctor interaction I'd seen in 4 years of med school to date, but with an invitation. "Tell me about your grandmother." From that simple sentence, you can hear a life, and the values of that life, and that -- not the daily CMP -- needs to be the guiding principle in the ICU.
I ran as far away as possible from the ICU as soon as they'd let me. I'm glad they exist, and I'm glad, especially after the last few years, that they still attract young residents and fellows and especially nurses to staff them. But by the grace of God I'll never find myself in one again.
posted by basalganglia at 4:50 AM on November 20, 2022 [32 favorites]
>anything that ends up on MeFi that is even remotely critical, or even analytical, generally receives a chorus of uncharitable kneejerk responses
This. People look for minor weak points or gaps in the author's logic and frame a hypercritical comment around them, exulting in the feelings of self-satisfaction and one-upmanship that ensue.
It's a bad habit that, frankly, should be left to commenters on less thoughtful sites than Metafilter.
MeFites, you're better than this.
posted by Gordion Knott at 5:31 AM on November 20, 2022 [4 favorites]
This. People look for minor weak points or gaps in the author's logic and frame a hypercritical comment around them, exulting in the feelings of self-satisfaction and one-upmanship that ensue.
It's a bad habit that, frankly, should be left to commenters on less thoughtful sites than Metafilter.
MeFites, you're better than this.
posted by Gordion Knott at 5:31 AM on November 20, 2022 [4 favorites]
A system that is bad at passing soft information is also bad at knowing how bad it is at passing all information. The fact that keeping on top of a loved one's health will get you shit-talked by a staff who themselves are just getting by - and if you imagine the shit talking results only in more attention and not also inferior care you are deluding yourself - suggests the entire war-triage system in place is at fault for suffering and death.
Nurses have hard, burnout-guaranteeing jobs. It's not their fault that information passing among shifts is hard.
Oh wait - yes it literally is. Justifying it with time constraints and burn out and the system discouraging it doesn't mean it's okay, and doesn't excuse life-threatening mistakes. We pretend it does because paying barely enough for shift coverage and socializing costs of fatal errors is cheaper.
The unions that represent such staff are just as culpable because they're playing defense of benefits when they have the most powerful strike action levers imaginable.
The level of medical shrugging as if there's no other way to approach care (thrombus of staff who never interact, oh yeah that should have been recorded as an allergy *shrug*) is enraging. It's the only industry where nearly every decision can be life or death and the people executing and leading it are literally trained to dehumanize for their own well being. Like soldiers. It's an outmoded delusional justification and a few decades from now I hope it's as repulsive as ice pick lobotomies and intentional radiation exposure experiments.
The medical establishment is predicated on dehumanizing because it is cheaper (in dollars and burnout), not because it is better or safer. That does not excuse any practitioner and pretending it does perpetuates a view rooted in a history of racism, misogyny, and white supremacy where care quality is expected to be provided on a sliding scale - it's just harder to ignore when it's no longer silenced minorities suffering from casual weaponized incompetence.
posted by abulafa at 5:53 AM on November 20, 2022 [1 favorite]
Nurses have hard, burnout-guaranteeing jobs. It's not their fault that information passing among shifts is hard.
Oh wait - yes it literally is. Justifying it with time constraints and burn out and the system discouraging it doesn't mean it's okay, and doesn't excuse life-threatening mistakes. We pretend it does because paying barely enough for shift coverage and socializing costs of fatal errors is cheaper.
The unions that represent such staff are just as culpable because they're playing defense of benefits when they have the most powerful strike action levers imaginable.
The level of medical shrugging as if there's no other way to approach care (thrombus of staff who never interact, oh yeah that should have been recorded as an allergy *shrug*) is enraging. It's the only industry where nearly every decision can be life or death and the people executing and leading it are literally trained to dehumanize for their own well being. Like soldiers. It's an outmoded delusional justification and a few decades from now I hope it's as repulsive as ice pick lobotomies and intentional radiation exposure experiments.
The medical establishment is predicated on dehumanizing because it is cheaper (in dollars and burnout), not because it is better or safer. That does not excuse any practitioner and pretending it does perpetuates a view rooted in a history of racism, misogyny, and white supremacy where care quality is expected to be provided on a sliding scale - it's just harder to ignore when it's no longer silenced minorities suffering from casual weaponized incompetence.
posted by abulafa at 5:53 AM on November 20, 2022 [1 favorite]
Abulafa, if you think I'm shrugging off the enormous number of problems the modern hospital and healthcare system has, you are incorrect. We are all intimately aware of how dysfunctional it is.
posted by Pantengliopoli at 6:30 AM on November 20, 2022 [2 favorites]
posted by Pantengliopoli at 6:30 AM on November 20, 2022 [2 favorites]
The unions that represent such staff are just as culpable because they're playing defense of benefits when they have the most powerful strike action levers imaginable.
Nurses are legally forbidden from going on strike (in Canada at least).
posted by heatherlogan at 6:34 AM on November 20, 2022 [1 favorite]
Nurses are legally forbidden from going on strike (in Canada at least).
posted by heatherlogan at 6:34 AM on November 20, 2022 [1 favorite]
Some of these ring true, some don't. It isn't worth litigating; it's just one guy's impression. One of the things that's easy for people in the system to forget is that most patients and families have never been here and have no idea what is going on. For example, the roles of the different trainees, specialists, types of nurses, numerous other staff might get clarified to somebody who might remember. A lot of physicians don't seem to know that OT isn't PT's last name.
I was woken up every 3 hours for 12 days. It was brutal.
At least you didn't have a head injury. Hourly neurologic checks until you tell us where the gold is.
I'm actually curious about how common it is to spend a month in the ICU. That seems utterly hellish. I wonder if part of why this sounds so weird is that the ICU system was set up for much shorter-term stays than his father's.
Yes, 30 days is a very long ICU stay in most contexts. Most care is fundamentally supportive. It is the exception that person has X problem with a well defined medicine that cures it; most of the time care is about limiting or bypassing damage while the person heals. When bodies don't do that, the system doesn't work well.
This also relates to the many observations about seemingly futile care. It's true that a huge amount of medical care is provided in the last 6 months of life. The interventions and support systems designed for a body capable of healing buy a modest delay in those who aren't. We aren't very good at recognizing when recovery is unlikely, or at limiting futile care even when it's obvious.
posted by a robot made out of meat at 9:03 AM on November 20, 2022 [8 favorites]
I was woken up every 3 hours for 12 days. It was brutal.
At least you didn't have a head injury. Hourly neurologic checks until you tell us where the gold is.
I'm actually curious about how common it is to spend a month in the ICU. That seems utterly hellish. I wonder if part of why this sounds so weird is that the ICU system was set up for much shorter-term stays than his father's.
Yes, 30 days is a very long ICU stay in most contexts. Most care is fundamentally supportive. It is the exception that person has X problem with a well defined medicine that cures it; most of the time care is about limiting or bypassing damage while the person heals. When bodies don't do that, the system doesn't work well.
This also relates to the many observations about seemingly futile care. It's true that a huge amount of medical care is provided in the last 6 months of life. The interventions and support systems designed for a body capable of healing buy a modest delay in those who aren't. We aren't very good at recognizing when recovery is unlikely, or at limiting futile care even when it's obvious.
posted by a robot made out of meat at 9:03 AM on November 20, 2022 [8 favorites]
A lot of physicians don't seem to know that OT isn't PT's last name.
Lol.
posted by latkes at 9:24 AM on November 20, 2022 [1 favorite]
Lol.
posted by latkes at 9:24 AM on November 20, 2022 [1 favorite]
Right as I was finishing up this essay/list/listicle, my dad was declared healthy enough to get moved from the ICU to a stepdown unit.
A stepdown unit has much less intensive monitoring than an ICU unit. One nurse covers several patients. As my family and I found out, it also has much less skilled nurses. Our nurse is a trainee, who seems entirely overwhelmed by covering my dad. She’s been continually absent from his room, and leaves a lot of care to his untrained “patient care assistant”. His assistant, in turn, is also overwhelmed, and so I and my family personally end up providing my dad with a lot of help.
[...]
But, it does seem ironic that, at some point in his care, the best thing for him seems to be an overwhelmed nurse who mostly leaves him alone with his family. 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?
People come to some important realizations about this (or not quite, in this case) in different ways, often because their hand is forced.
Seeing the world through a lens of able-bodied privilege for most of your life, and then having to see the unmediated reality of what all of the moving parts of moving from ICU to non-acute, non-intensive longer-term care and the lack of options for receiving and/or affording that care in an environment of your own choosing and in the community in which you live comes as a real shock to people who have -- through the blissful ignorance perpetuated by both institutional and culturally-transmitted ableism -- had the privilege of not having to think about it until they have no choice in the matter.
Alice Wong's My ICU Summer: A Photo Essay does a better job here:
Healthcare is supposed to be person-centered, right? My discharge process was not by any means. The discharge planner assigned to me did the best he could but my sisters could tell he had a lot of patients in his caseload. Emily called almost everyday with questions and to check if he got the orders from my doctors for my respiratory care DME (durable medical equipment) company and other new DME providers.
My doctors cleared me to leave on Thursday, June 30th and I thought everything was lined up with the DME provider for what I was supposed to have at home. The morning of that day a doctor told me the DME provider did not have my machines or an RT available and that because it was the holiday weekend, I would have to stay at the ICU until next week. I was crushed along with my sisters who were near exhaustion and could not sustain more 24-hour shifts in the hospital with me. The doctor was incredibly apologetic saying he and everyone involved tried to find a solution with the DME provider but it was their company policy. Perhaps it was a combination of supply chain and workforce issues but somewhere somehow there was a breakdown in communication and I was the last to know.
As a bonus fuck you, I learned that the DME required one of their RTs to come to the hospital and give a 3-hour training with my new BiPAP machine to my sisters and the EARLIEST the RT could come was July 6th. On top of that, the company required that I stay another day with their machine at the hospital to ensure the settings were correct. I ended up staying an entire extra week at the ICU, at a significant cost to the healthcare system and my own well-being.
On the 7th of July I was beyond ready to go. My IVs and PICC line were removed, I changed into real clothes, and I got out of my bed and into my wheelchair. And then the discharge planner called to say the DME provider had concerns and did not advise me to leave.
[...]
I spent a few hours that afternoon contemplating my choices. I never went home with a trach before and there were a lot of things that could potentially happen. A nurse I talked with about this bullshit situation surmised that this was a liability issue and that the DME provider didn’t want me to come home with their machines before their RT gave an ok. Another discharge planner added that if I left against the DME company’s policy that there was a small chance that they would charge me the full cost of the equipment because they might not be able to bill insurance without their clearance. I’m like, “What the fuck?” This was all about money and bureaucracy and it put me in an untenable situation. Four whole weeks. I still felt vulnerable but I knew my sisters had my back. I decided to go home. Fuck capitalism. Fuck the medical industrial complex. Fuck ableism.
[...]
Another example of ableism is how poorly community-based services are funded and valued in the United States. My sisters and I knew we needed more help at home and a friend referred us to a nursing concierge service. The person Emily spoke with said she could help us find, hire, and train people. I informed her of the services I needed and my date of discharge. Several days before she informed us the level of care I needed required licensed caregivers and that she could not hire them on our behalf and that agencies would probably charge $50 or more for professionals such as LVNs (licensed vocational nurses). I thought everything was all set, giving me a small sliver of comfort but nope.
We had to start over again and with the help of my friends, we received multiple referrals to individual attendants and registries. My parents, who are my primary paid caregivers through two programs, could not manage everything once my sisters resumed their regular lives. Two people are not enough to help me 24/7 with my intensive and frequent needs. To supplement my care, my parents ended up paying out-of-pocket for a team of caregivers. We tried to find people who were participants in the same home care program as my parents but the paltry $18/hour rate made it difficult to find people for the hours I need and the tasks I need help with. The system drives people toward institutions. It is designed to segregate expendable and ‘non-productive’ disabled and older people like me. Out of sight, out of mind.
posted by mandolin conspiracy at 10:37 AM on November 20, 2022 [15 favorites]
A stepdown unit has much less intensive monitoring than an ICU unit. One nurse covers several patients. As my family and I found out, it also has much less skilled nurses. Our nurse is a trainee, who seems entirely overwhelmed by covering my dad. She’s been continually absent from his room, and leaves a lot of care to his untrained “patient care assistant”. His assistant, in turn, is also overwhelmed, and so I and my family personally end up providing my dad with a lot of help.
[...]
But, it does seem ironic that, at some point in his care, the best thing for him seems to be an overwhelmed nurse who mostly leaves him alone with his family. 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?
People come to some important realizations about this (or not quite, in this case) in different ways, often because their hand is forced.
Seeing the world through a lens of able-bodied privilege for most of your life, and then having to see the unmediated reality of what all of the moving parts of moving from ICU to non-acute, non-intensive longer-term care and the lack of options for receiving and/or affording that care in an environment of your own choosing and in the community in which you live comes as a real shock to people who have -- through the blissful ignorance perpetuated by both institutional and culturally-transmitted ableism -- had the privilege of not having to think about it until they have no choice in the matter.
Alice Wong's My ICU Summer: A Photo Essay does a better job here:
Healthcare is supposed to be person-centered, right? My discharge process was not by any means. The discharge planner assigned to me did the best he could but my sisters could tell he had a lot of patients in his caseload. Emily called almost everyday with questions and to check if he got the orders from my doctors for my respiratory care DME (durable medical equipment) company and other new DME providers.
My doctors cleared me to leave on Thursday, June 30th and I thought everything was lined up with the DME provider for what I was supposed to have at home. The morning of that day a doctor told me the DME provider did not have my machines or an RT available and that because it was the holiday weekend, I would have to stay at the ICU until next week. I was crushed along with my sisters who were near exhaustion and could not sustain more 24-hour shifts in the hospital with me. The doctor was incredibly apologetic saying he and everyone involved tried to find a solution with the DME provider but it was their company policy. Perhaps it was a combination of supply chain and workforce issues but somewhere somehow there was a breakdown in communication and I was the last to know.
As a bonus fuck you, I learned that the DME required one of their RTs to come to the hospital and give a 3-hour training with my new BiPAP machine to my sisters and the EARLIEST the RT could come was July 6th. On top of that, the company required that I stay another day with their machine at the hospital to ensure the settings were correct. I ended up staying an entire extra week at the ICU, at a significant cost to the healthcare system and my own well-being.
On the 7th of July I was beyond ready to go. My IVs and PICC line were removed, I changed into real clothes, and I got out of my bed and into my wheelchair. And then the discharge planner called to say the DME provider had concerns and did not advise me to leave.
[...]
I spent a few hours that afternoon contemplating my choices. I never went home with a trach before and there were a lot of things that could potentially happen. A nurse I talked with about this bullshit situation surmised that this was a liability issue and that the DME provider didn’t want me to come home with their machines before their RT gave an ok. Another discharge planner added that if I left against the DME company’s policy that there was a small chance that they would charge me the full cost of the equipment because they might not be able to bill insurance without their clearance. I’m like, “What the fuck?” This was all about money and bureaucracy and it put me in an untenable situation. Four whole weeks. I still felt vulnerable but I knew my sisters had my back. I decided to go home. Fuck capitalism. Fuck the medical industrial complex. Fuck ableism.
[...]
Another example of ableism is how poorly community-based services are funded and valued in the United States. My sisters and I knew we needed more help at home and a friend referred us to a nursing concierge service. The person Emily spoke with said she could help us find, hire, and train people. I informed her of the services I needed and my date of discharge. Several days before she informed us the level of care I needed required licensed caregivers and that she could not hire them on our behalf and that agencies would probably charge $50 or more for professionals such as LVNs (licensed vocational nurses). I thought everything was all set, giving me a small sliver of comfort but nope.
We had to start over again and with the help of my friends, we received multiple referrals to individual attendants and registries. My parents, who are my primary paid caregivers through two programs, could not manage everything once my sisters resumed their regular lives. Two people are not enough to help me 24/7 with my intensive and frequent needs. To supplement my care, my parents ended up paying out-of-pocket for a team of caregivers. We tried to find people who were participants in the same home care program as my parents but the paltry $18/hour rate made it difficult to find people for the hours I need and the tasks I need help with. The system drives people toward institutions. It is designed to segregate expendable and ‘non-productive’ disabled and older people like me. Out of sight, out of mind.
posted by mandolin conspiracy at 10:37 AM on November 20, 2022 [15 favorites]
The unions that represent such staff are just as culpable because they're playing defense of benefits when they have the most powerful strike action levers imaginable.
Look, my spouse is a nurse and was part of the largest private health care strike in history a few months ago. It was a three-day strike which was legal only because travel nurses could be bussed in to look at patients, during which management explicitly barred striking nurses from directly communicating with the scabbing travel nurses. Report therefore had to be passed in writing, not in person, which is obviously worse for patients.
They still don't have a fucking contract. Haven't since May. Management is still fucking them around. There will probably be another, longer strike soon. The unions are doing their best but I can't emphasize enough what a terrifying pain in the ass strike coordination is, or how aggressively management is dedicated to refusing to relinquish profit and control.
The units are literally relying on overtime to psych over burnout. New hires are filling roles because the entire North American healthcare system is overstretched and burnt out, especially in hospitals, and still for-profit hospital administrations insist on trying to wring blood out of a stone rather than pay enough to handle any of the systemic problems that have left hospital nurses this burned out and angry.
There will be more strikes. But this shit will continue to happen until someone brings administrators to heel, and in the interim more nurses are going to leave and further strain the system. Existing legislation that often sharply restricts how and when nurses can strike, precisely because of that "leverage", is not helping things either.
posted by sciatrix at 1:29 PM on November 20, 2022 [19 favorites]
Look, my spouse is a nurse and was part of the largest private health care strike in history a few months ago. It was a three-day strike which was legal only because travel nurses could be bussed in to look at patients, during which management explicitly barred striking nurses from directly communicating with the scabbing travel nurses. Report therefore had to be passed in writing, not in person, which is obviously worse for patients.
They still don't have a fucking contract. Haven't since May. Management is still fucking them around. There will probably be another, longer strike soon. The unions are doing their best but I can't emphasize enough what a terrifying pain in the ass strike coordination is, or how aggressively management is dedicated to refusing to relinquish profit and control.
The units are literally relying on overtime to psych over burnout. New hires are filling roles because the entire North American healthcare system is overstretched and burnt out, especially in hospitals, and still for-profit hospital administrations insist on trying to wring blood out of a stone rather than pay enough to handle any of the systemic problems that have left hospital nurses this burned out and angry.
There will be more strikes. But this shit will continue to happen until someone brings administrators to heel, and in the interim more nurses are going to leave and further strain the system. Existing legislation that often sharply restricts how and when nurses can strike, precisely because of that "leverage", is not helping things either.
posted by sciatrix at 1:29 PM on November 20, 2022 [19 favorites]
I'm not going to argue from the left flank on unions. I am going to point out that But this shit will continue to happen until someone brings administrators to heel isn't going to be done by anybody other than labor, ever.
The unions are striking for a contract - does that contract specify patient care standards or is it about hours and ratios? Both are important, but the observation I made was about unions missing an opportunity to champion better care as an end of its own rather than assuring us it will naturally result from better contract terms. Because it won't and hasn't so far.
The answer is not blame the victim (the patient, the staff), but only one of those victims is also in control of how carefully and defensibly their job is executed, and has fallen back to a position that your lethal emergency is just another Wednesday.
posted by abulafa at 1:54 PM on November 20, 2022 [1 favorite]
The unions are striking for a contract - does that contract specify patient care standards or is it about hours and ratios? Both are important, but the observation I made was about unions missing an opportunity to champion better care as an end of its own rather than assuring us it will naturally result from better contract terms. Because it won't and hasn't so far.
The answer is not blame the victim (the patient, the staff), but only one of those victims is also in control of how carefully and defensibly their job is executed, and has fallen back to a position that your lethal emergency is just another Wednesday.
posted by abulafa at 1:54 PM on November 20, 2022 [1 favorite]
The unions are striking for a contract - does that contract specify patient care standards or is it about hours and ratios? Both are important, but the observation I made was about unions missing an opportunity to champion better care as an end of its own rather than assuring us it will naturally result from better contract terms. Because it won't and hasn't so far.
I don't understand this. Proper limits on hours and ratios (that is, number of patients per staff member) are fundamental to good care, and it's not like they're okay now. Expecting nurse unions to dictate care standards, as opposed to whether nurses are given adequate resources to meet those care standards, seems to be asking them to go well outside their remit.
posted by praemunire at 3:36 PM on November 20, 2022 [14 favorites]
I don't understand this. Proper limits on hours and ratios (that is, number of patients per staff member) are fundamental to good care, and it's not like they're okay now. Expecting nurse unions to dictate care standards, as opposed to whether nurses are given adequate resources to meet those care standards, seems to be asking them to go well outside their remit.
posted by praemunire at 3:36 PM on November 20, 2022 [14 favorites]
The answer is not blame the victim (the patient, the staff)
It has absolutely been proven that better care ratios and more staffing directly lead to improved quality of care. 100%.
If the answer is not to blame the victim (agreed!) then how are you blaming the staff for the declining quality of care? Do you think we want to be running so lean that the entire hospital doesn't have a code team, because the ICU can barely take care of its own patients, let alone the rest of the house? Do you thing the medsurg floors are proud of having to take care of 6-7 patients every day, when they normally have 4? Do you think the ED enjoys packed lobbies filled with suffering people with nowhere else to go?
Maybe I'm reading you wrong, and I should certainly not be commenting here because I can't separate my own emotional response to your comments, but it's really unclear to me what point you're trying to get across.
posted by Pantengliopoli at 4:48 PM on November 20, 2022 [8 favorites]
It has absolutely been proven that better care ratios and more staffing directly lead to improved quality of care. 100%.
If the answer is not to blame the victim (agreed!) then how are you blaming the staff for the declining quality of care? Do you think we want to be running so lean that the entire hospital doesn't have a code team, because the ICU can barely take care of its own patients, let alone the rest of the house? Do you thing the medsurg floors are proud of having to take care of 6-7 patients every day, when they normally have 4? Do you think the ED enjoys packed lobbies filled with suffering people with nowhere else to go?
Maybe I'm reading you wrong, and I should certainly not be commenting here because I can't separate my own emotional response to your comments, but it's really unclear to me what point you're trying to get across.
posted by Pantengliopoli at 4:48 PM on November 20, 2022 [8 favorites]
I spent even less clinical time than basanganglia in the ICU—just one day of one rotation—but that was enough to show me that I never wanted to come back. I have nothing but respect for any clinician who can thrive in the ICU, but the writer’s observation that ICU nurses were so much more skilled overall rubs me the wrong way for a couple reasons.
1) Nursing school both implicitly and explicitly promotes the message that the ICU is just where the best and brightest people belong. As a result, a lot of very smart, type-a people really gun for those jobs either at graduation or after finishing a requisite amount of time on a med-surg floor, and a lot of people who may be more reserved or have less stellar grades don’t even bother trying.
2) The truth is, though—nursing’s internal hierarchy of prestige, much like that in medicine, is utterly fucked. It results in a lot of people getting funneled into hospitals who’d really thrive more in the community, because hospitals are prestigious and have more structured training in place. Within the hospital, it means that people clamor for higher acuity units and the med-surg floors have ridiculous turnover and are treated as training grounds, rather as speciality areas in and of themselves. It means that there is much less money and respect for those in nursing homes, psychiatric units, and other places with high patient loads and fewer acute events.
3) Like I said, I have nothing but respect for the specific skills ICU nurses have. I read tons of medical records for patients who are hospitalized, and every time I have someone in the ICU on a ventilator I find myself frantically googling all the vent settings to try and understand. I don’t know shit about how to manage the various kinds of drips that ICU patients are on. However—if you want to know how to break down the concept of blood pressure in simple terms for someone who hasn’t seen a doctor in years? I’m your person. You want to know how to contact RN case managers and social workers at a broad swath of my city’s hospitals, and maybe get some insight as to which ones are likely to be the most helpful and pleasant to deal with? I can do that too. Not saying that an ICU nurse necessarily can’t do those things, just that these and others are particular skills I have honed working in different non-hospital environments. My one wish for nursing education, and nursing more broadly, is that the skills developed in every environment be equally respected.
posted by I am a Sock, I am an Island at 5:14 PM on November 20, 2022 [13 favorites]
1) Nursing school both implicitly and explicitly promotes the message that the ICU is just where the best and brightest people belong. As a result, a lot of very smart, type-a people really gun for those jobs either at graduation or after finishing a requisite amount of time on a med-surg floor, and a lot of people who may be more reserved or have less stellar grades don’t even bother trying.
2) The truth is, though—nursing’s internal hierarchy of prestige, much like that in medicine, is utterly fucked. It results in a lot of people getting funneled into hospitals who’d really thrive more in the community, because hospitals are prestigious and have more structured training in place. Within the hospital, it means that people clamor for higher acuity units and the med-surg floors have ridiculous turnover and are treated as training grounds, rather as speciality areas in and of themselves. It means that there is much less money and respect for those in nursing homes, psychiatric units, and other places with high patient loads and fewer acute events.
3) Like I said, I have nothing but respect for the specific skills ICU nurses have. I read tons of medical records for patients who are hospitalized, and every time I have someone in the ICU on a ventilator I find myself frantically googling all the vent settings to try and understand. I don’t know shit about how to manage the various kinds of drips that ICU patients are on. However—if you want to know how to break down the concept of blood pressure in simple terms for someone who hasn’t seen a doctor in years? I’m your person. You want to know how to contact RN case managers and social workers at a broad swath of my city’s hospitals, and maybe get some insight as to which ones are likely to be the most helpful and pleasant to deal with? I can do that too. Not saying that an ICU nurse necessarily can’t do those things, just that these and others are particular skills I have honed working in different non-hospital environments. My one wish for nursing education, and nursing more broadly, is that the skills developed in every environment be equally respected.
posted by I am a Sock, I am an Island at 5:14 PM on November 20, 2022 [13 favorites]
My one wish for nursing education, and nursing more broadly, is that the skills developed in every environment be equally respected.
Exceptionally well said.
posted by Pantengliopoli at 5:21 PM on November 20, 2022 [1 favorite]
Exceptionally well said.
posted by Pantengliopoli at 5:21 PM on November 20, 2022 [1 favorite]
I'm responding to this:
They will still treat you like just another patient at the patient factory - they can't help it - this is just another Wednesday for them. But that stuff can sometimes make a little difference. If you make a big fuss everyone will talk shit about you but you also may get better care.
This has been my experience both inside the system and adjacent to its practitioners, and I am blaming them and their ineffectual unions for being in a position to apply labor pressure and instead of doing so quibbling at the edges and focusing on classic institutional boondoggles (which I guess are considered within their remit) instead of patient care.
It won't be legislators or patients who can make any difference here when those who consider themselves one of the good ones still idly ignore another alarm, wake another patient into delirium, and then complain that the system is what's at fault when they fail to so much as pass on an allergic reaction notation. Sure, the attending is an arrogant asshole who never checks in, so the patient should pay with suffering and possibly death?
I'm saying that's not okay, and defending it as somehow the result of administration and forces beyond their control is a peace-of-mind preserving fiction.
posted by abulafa at 5:28 PM on November 20, 2022
They will still treat you like just another patient at the patient factory - they can't help it - this is just another Wednesday for them. But that stuff can sometimes make a little difference. If you make a big fuss everyone will talk shit about you but you also may get better care.
This has been my experience both inside the system and adjacent to its practitioners, and I am blaming them and their ineffectual unions for being in a position to apply labor pressure and instead of doing so quibbling at the edges and focusing on classic institutional boondoggles (which I guess are considered within their remit) instead of patient care.
It won't be legislators or patients who can make any difference here when those who consider themselves one of the good ones still idly ignore another alarm, wake another patient into delirium, and then complain that the system is what's at fault when they fail to so much as pass on an allergic reaction notation. Sure, the attending is an arrogant asshole who never checks in, so the patient should pay with suffering and possibly death?
I'm saying that's not okay, and defending it as somehow the result of administration and forces beyond their control is a peace-of-mind preserving fiction.
posted by abulafa at 5:28 PM on November 20, 2022
It's currently a radical (if, IMHO, the right) position that unions should go to war for larger public goods, although it's also fashionable at the moment to at least include some common good demands at the bargaining table, especially if you work in the public sector.
Keep in mind though, the US is only about 9% unionized and there are numerous laws that constrain our ability to bargain over anything besides a narrow set of benefit and working-conditions issues. (Unfortunately, the critically underfunded NLRB website is down right now but outlines some topics that are 'forbidden' to bargain over.)
Wildcat strikes without union support, or more rarely, sizable 'illegal' strikes with sanction of the established union are hard to pull off and sustain, and put the union at risk of massive financial and legal risk, which disinsentivises such bold action. If your union is bankrupt by taking 'illegal' strike action, you're back starting at zero.
To organize a strike action large enough to impact healthcare policy would have to include multiple unions representing tens of thousands of workers across multiple workplaces. Conceivably, in the US at least, you could focus on one state a time and try to impact specific policies in that state.. although in the healthcare sector, policy is largely impacted by federal funding mechanisms (Medicare). Anyway, what specific policies would these striking healthcare workers be fighting for?
Yeah, all of us in this healthcare system are culpable for the state of affairs we are in, but changing it requires some really thoughtful and strategic thinking, planning and organizing. Not an argument against this, just saying the demand that 'unions should strike for better ICU care' is an argument that I think would take more thinking through to be actionable.
If you're a healthcare worker interested in radical organizing with other healthcare workers though - reach out!
posted by latkes at 5:30 PM on November 20, 2022 [3 favorites]
Keep in mind though, the US is only about 9% unionized and there are numerous laws that constrain our ability to bargain over anything besides a narrow set of benefit and working-conditions issues. (Unfortunately, the critically underfunded NLRB website is down right now but outlines some topics that are 'forbidden' to bargain over.)
Wildcat strikes without union support, or more rarely, sizable 'illegal' strikes with sanction of the established union are hard to pull off and sustain, and put the union at risk of massive financial and legal risk, which disinsentivises such bold action. If your union is bankrupt by taking 'illegal' strike action, you're back starting at zero.
To organize a strike action large enough to impact healthcare policy would have to include multiple unions representing tens of thousands of workers across multiple workplaces. Conceivably, in the US at least, you could focus on one state a time and try to impact specific policies in that state.. although in the healthcare sector, policy is largely impacted by federal funding mechanisms (Medicare). Anyway, what specific policies would these striking healthcare workers be fighting for?
Yeah, all of us in this healthcare system are culpable for the state of affairs we are in, but changing it requires some really thoughtful and strategic thinking, planning and organizing. Not an argument against this, just saying the demand that 'unions should strike for better ICU care' is an argument that I think would take more thinking through to be actionable.
If you're a healthcare worker interested in radical organizing with other healthcare workers though - reach out!
posted by latkes at 5:30 PM on November 20, 2022 [3 favorites]
quibbling at the edges
If you think patient ratios and staff hours are "the edges" or "boondoggles" we have very different views of what makes good patient care even possible to begin with.
posted by praemunire at 6:38 PM on November 20, 2022 [8 favorites]
If you think patient ratios and staff hours are "the edges" or "boondoggles" we have very different views of what makes good patient care even possible to begin with.
posted by praemunire at 6:38 PM on November 20, 2022 [8 favorites]
At least you didn't have a head injury. Hourly neurologic checks until you tell us where the gold is.
I WISH! The first time I went to the hospital with a head injury they stuck me in an oubliette and treated me like a criminal every time I called for help.
posted by The Underpants Monster at 7:28 AM on November 21, 2022
I WISH! The first time I went to the hospital with a head injury they stuck me in an oubliette and treated me like a criminal every time I called for help.
posted by The Underpants Monster at 7:28 AM on November 21, 2022
Having accompanied 2 parents in cognitive decline through stints in the ICU, so much of this rang true. At every turn I kept thinking, there has to be a better way than this, with issues both small and large. Still I remember the ICU as a place of safety and solace in a way- a nurse always seemed to be nearby and willing to listen to our concerns or requests and really tried their best to meet us. The heroism of nurses is a theme in the comments. I remember well some small moments of sheer kindness-- a nurse putting lotion on my mom's feet so lovingly, or a one carefully suctioning my dad so gently--these things have stuck with me. Moments when I didn't feel like I was screaming inside "there's a person inside this body!"
The ICU was the only place on our 6 month bounce from hospital to nursing and back and forth with my dad that we experienced an honest to goodness effort to have an end of life conversation with our family (and we needed it) about my dad. Such a crucial medical intervention that so often feels like it goes ignored.
posted by rene_billingsworth at 9:00 AM on November 21, 2022 [3 favorites]
The ICU was the only place on our 6 month bounce from hospital to nursing and back and forth with my dad that we experienced an honest to goodness effort to have an end of life conversation with our family (and we needed it) about my dad. Such a crucial medical intervention that so often feels like it goes ignored.
posted by rene_billingsworth at 9:00 AM on November 21, 2022 [3 favorites]
But the biggest piece, that he flirts with a bit, is that ICU care is expensive, complicated and often futile. Thrashing bodies just to keep them alive is not a problem we can solve within the walls of the ICU - it's a societal problem, requiring hard conversations about death and aging and whether a bit more quantity of life is worth the brutal quality that often follows a long ICU stay.
For a variety of reasons, I am the designated medical emergency person and "hospital concierge" for a number of my friends. (Which, by the way, if you are single or otherwise don't have an obvious default person that is going to show up if you end up in the hospital, for the love of god ask someone to be that person. And then ask a backup person if they're unavailable for some reason. I've never once minded going to a hospital because a friend asked me to be there for them; I have been annoyed to discover a friend was in hospital but hadn't made any arrangements for anyone to be contacted, and then wondered... should I show up? Do they have a distant cousin somewhere who's going to? How involved do they really want their parents? And then you end up with that circular-Spiderman meme of friends standing in the waiting room, trying to decide who's the closer friend/relative/whatever and who gets to go home absolved of responsibility. Awkward!)
The US healthcare system is capable of being an exceedingly brutal machine, if you are any combination of (1) alone, (2) not obviously sick or injured in a life-threatening way for which there is a single, well-accepted treatment, (3) physically, intellectually, or culturally different from the average patient in a way likely to make caregivers unsympathetic.
It's not because of the failings of individual doctors or nurses, Paramedics or EMTs or techs or anyone else. In fact, I think the brutality of the system exists despite the best efforts of many people involved in it, steeped in it every day, to try and make it as humane and effective as they can. But the actual medical practitioners can only do so much, when the entire system is structured from high above, by the insurance companies and hospital operating groups (and increasingly investment bankers, and of course politicians), to move patients through as quickly as possible, extracting as much money from them en route, and not really giving a shit about whether they're made well or not, except insofar as it affects their liability insurance rates. To the hospital, that is the organizational entity operating the building, you are basically one small step removed from a head of cattle being prodded up the ramp into a meatpacking plant. You are the sum of your ICD codes and insurance coverage, in the same way the cow is to the meatpacker just the sum of the cryo-vac'd cuts of meat it becomes.
That is healthcare under capitalism. Maybe someday we will fix it, probably via single-payer like most other civilized jurisdictions in the world. But right now, if you end up getting hit by a bus or whatever, that's the system you're going to be fed into.
If you can, try and find someone with at least a reasonable understanding of that system to be your advocate, if you end up in a position where you can't advocate for yourself. (And as the patient, your ability to advocate for yourself is by definition limited.) Having someone with you, particularly in sub-acute care with high patient/provider ratios, can be the difference between getting to the bathroom with assistance, and sitting in your own shit and piss for a few hours. Or having cold ice water more than a few times per day. Or having the TV channel changed, or the window shades opened/closed... all the little stuff that can become maddening when you're just sitting there being acted on by others. And it is unfortunately sometimes the most polite and don't-want-to-make-trouble people who sit there, quietly, until suddenly they turn into a "trainwreck" patient (more often than you'd expect due to a UTI; seriously, the number of people who die from UTIs is staggering) who's visibly sick and starts getting reactive intervention after intervention, typically in the end (after a few repeats of this process) until someone finally decides to stop the medical-zombie game and they die.
That's not to say that care in the average US ICU is bad. Medical science can do amazing things in certain scenarios. If you're a tubby dude with atherosclerosis, there is literally no better time or place in human history to have a heart attack than inside a modern US hospital. Or a dude with a flail chest from a motorcycle crash. Or a dude with a GSW to the neck. But if you are, say, a teenage woman with mysterious abdominal pain, or a Black woman with preeclampsia... well, the numbers are a lot less good. Improving, at least before COVID, but not great in the absolute sense.
And if you have any friends in healthcare or healthcare-adjacent fields, in all seriousness ask them sometime (if you are good enough friends to ask this sort of thing) what their personal preferences are w/r/t healthcare for themselves. I think the average person would be surprised to know how many interventions healthcare practitioners would not want performed on themselves, either under any circumstances or unless there was a really good case made for it. And in my informal survey of friends and acquaintances, the more medical education a person has, generally the longer the list is of interventions they'd like to never have done to them is.
posted by Kadin2048 at 2:26 PM on November 21, 2022 [7 favorites]
For a variety of reasons, I am the designated medical emergency person and "hospital concierge" for a number of my friends. (Which, by the way, if you are single or otherwise don't have an obvious default person that is going to show up if you end up in the hospital, for the love of god ask someone to be that person. And then ask a backup person if they're unavailable for some reason. I've never once minded going to a hospital because a friend asked me to be there for them; I have been annoyed to discover a friend was in hospital but hadn't made any arrangements for anyone to be contacted, and then wondered... should I show up? Do they have a distant cousin somewhere who's going to? How involved do they really want their parents? And then you end up with that circular-Spiderman meme of friends standing in the waiting room, trying to decide who's the closer friend/relative/whatever and who gets to go home absolved of responsibility. Awkward!)
The US healthcare system is capable of being an exceedingly brutal machine, if you are any combination of (1) alone, (2) not obviously sick or injured in a life-threatening way for which there is a single, well-accepted treatment, (3) physically, intellectually, or culturally different from the average patient in a way likely to make caregivers unsympathetic.
It's not because of the failings of individual doctors or nurses, Paramedics or EMTs or techs or anyone else. In fact, I think the brutality of the system exists despite the best efforts of many people involved in it, steeped in it every day, to try and make it as humane and effective as they can. But the actual medical practitioners can only do so much, when the entire system is structured from high above, by the insurance companies and hospital operating groups (and increasingly investment bankers, and of course politicians), to move patients through as quickly as possible, extracting as much money from them en route, and not really giving a shit about whether they're made well or not, except insofar as it affects their liability insurance rates. To the hospital, that is the organizational entity operating the building, you are basically one small step removed from a head of cattle being prodded up the ramp into a meatpacking plant. You are the sum of your ICD codes and insurance coverage, in the same way the cow is to the meatpacker just the sum of the cryo-vac'd cuts of meat it becomes.
That is healthcare under capitalism. Maybe someday we will fix it, probably via single-payer like most other civilized jurisdictions in the world. But right now, if you end up getting hit by a bus or whatever, that's the system you're going to be fed into.
If you can, try and find someone with at least a reasonable understanding of that system to be your advocate, if you end up in a position where you can't advocate for yourself. (And as the patient, your ability to advocate for yourself is by definition limited.) Having someone with you, particularly in sub-acute care with high patient/provider ratios, can be the difference between getting to the bathroom with assistance, and sitting in your own shit and piss for a few hours. Or having cold ice water more than a few times per day. Or having the TV channel changed, or the window shades opened/closed... all the little stuff that can become maddening when you're just sitting there being acted on by others. And it is unfortunately sometimes the most polite and don't-want-to-make-trouble people who sit there, quietly, until suddenly they turn into a "trainwreck" patient (more often than you'd expect due to a UTI; seriously, the number of people who die from UTIs is staggering) who's visibly sick and starts getting reactive intervention after intervention, typically in the end (after a few repeats of this process) until someone finally decides to stop the medical-zombie game and they die.
That's not to say that care in the average US ICU is bad. Medical science can do amazing things in certain scenarios. If you're a tubby dude with atherosclerosis, there is literally no better time or place in human history to have a heart attack than inside a modern US hospital. Or a dude with a flail chest from a motorcycle crash. Or a dude with a GSW to the neck. But if you are, say, a teenage woman with mysterious abdominal pain, or a Black woman with preeclampsia... well, the numbers are a lot less good. Improving, at least before COVID, but not great in the absolute sense.
And if you have any friends in healthcare or healthcare-adjacent fields, in all seriousness ask them sometime (if you are good enough friends to ask this sort of thing) what their personal preferences are w/r/t healthcare for themselves. I think the average person would be surprised to know how many interventions healthcare practitioners would not want performed on themselves, either under any circumstances or unless there was a really good case made for it. And in my informal survey of friends and acquaintances, the more medical education a person has, generally the longer the list is of interventions they'd like to never have done to them is.
posted by Kadin2048 at 2:26 PM on November 21, 2022 [7 favorites]
At least you didn't have a head injury. Hourly neurologic checks until you tell us where the gold is.
I am grateful for the care I received, AND I was really glad to leave the hospital to get some sleep (and a real shower). I got some really brutal feedback from a family member when I commented about being glad the sleep deprivation was almost over, and it wrecked me.
This is something that I'm still processing for myself, but in a nutshell, when someone is giving honest and open feedback about their experience, telling them "It could've been worse, you didn't have to do THIS thing" and/or letting them know that they sound ungrateful for the life-saving work of the nurses and techs who are doing their best to save you lacks...empathy? Sympathy? I don't know, it rubs me the wrong way. Trying to explain a traumatic event in terms of the thing you struggled with the most isn't exactly an invitation to be told it could've been a lot worse and/or that such feedback is invalid because you should be happy to be alive (what my family member did to me, I am not conflating the two, just trying to give a little extra context). I don't think this is the intent of your comment, but it is kind of how I took it (merely because of my previous experience).
Explaining and complaining are different things. Being critical about the experience you went through is part of the process...can't improve something if you're invalidated for pointing out stuff you struggled with during a traumatic, scary, your-life-is-in-somebody-else's-hands experience.
Also also, yes, I'm glad it wasn't much worse, but my ICU experience was an ordeal I don't ever want to experience again...
posted by Chuffy at 2:33 PM on November 21, 2022 [2 favorites]
I am grateful for the care I received, AND I was really glad to leave the hospital to get some sleep (and a real shower). I got some really brutal feedback from a family member when I commented about being glad the sleep deprivation was almost over, and it wrecked me.
This is something that I'm still processing for myself, but in a nutshell, when someone is giving honest and open feedback about their experience, telling them "It could've been worse, you didn't have to do THIS thing" and/or letting them know that they sound ungrateful for the life-saving work of the nurses and techs who are doing their best to save you lacks...empathy? Sympathy? I don't know, it rubs me the wrong way. Trying to explain a traumatic event in terms of the thing you struggled with the most isn't exactly an invitation to be told it could've been a lot worse and/or that such feedback is invalid because you should be happy to be alive (what my family member did to me, I am not conflating the two, just trying to give a little extra context). I don't think this is the intent of your comment, but it is kind of how I took it (merely because of my previous experience).
Explaining and complaining are different things. Being critical about the experience you went through is part of the process...can't improve something if you're invalidated for pointing out stuff you struggled with during a traumatic, scary, your-life-is-in-somebody-else's-hands experience.
Also also, yes, I'm glad it wasn't much worse, but my ICU experience was an ordeal I don't ever want to experience again...
posted by Chuffy at 2:33 PM on November 21, 2022 [2 favorites]
if you have any friends in healthcare [...] ask them sometime [...] what their personal preferences are w/r/t healthcare for themselves
I have--at the ripe old age of 48--an advanced directive that states that if I'm brought to the hospital in such a state that I'm incapable of making medical decisions for myself, I refuse any and all life-sustaining measures. No CPR, no defibrillation, no intubation, no time trached and PEGed, NOTHING. Cover me with a nice blanket, make sure my hair looks OK, and get the Dilaudid and the Zofran started.
Dying in the ICU is my very worst fear.
posted by jesourie at 5:19 PM on November 21, 2022 [3 favorites]
I have--at the ripe old age of 48--an advanced directive that states that if I'm brought to the hospital in such a state that I'm incapable of making medical decisions for myself, I refuse any and all life-sustaining measures. No CPR, no defibrillation, no intubation, no time trached and PEGed, NOTHING. Cover me with a nice blanket, make sure my hair looks OK, and get the Dilaudid and the Zofran started.
Dying in the ICU is my very worst fear.
posted by jesourie at 5:19 PM on November 21, 2022 [3 favorites]
Wow.
So many have already hit a bunch of what's just absolutely horrible about this article. I'll try and be brief and add some additional context from working in a hospital/clinic environment.
1. The ICU is filled with old people.
meowzilla beat me to it, but there are also NICU, PICU (and MICU! CVICU, which is where this guys dad is! So many ICUs) units. So, that pulls all the young ones away, which is really something you want. Allows for more specialization. Reduces diseases jumping from older people to younger or vice versa.
Many other have already mentioned the inherent ageism in that sentence. The other thing to recognize is, medical visits are HIGHLY more common at the beginning of life as well as end of life.
Oh, wait. We're also complaining about taxpayers paying for the ICU? How did his dad get Lung Cancer? That was conveniently not mentioned. I would not be surprised if it was tobacco use. So, really, using his own logic, his dad should foot the bill because he chose a lifestyle that was not healthy.
The ICU staff is literally constantly changing. The ICU has a difficult staffing job. It’s a 24 hour center filled with skilled and highly skilled staff. So, ICU staff tend to work 3 days a week for 12 hours each day
At my hospital, this is common for the entire hospital.
First, from a patient perspective, the nurses and doctors are constantly changing. This is confusing for a deluded patient, and it’s difficult for their loved ones. For example, we kept having to tell nurses not to put the news on the TV, as my dad, a fervent Republican, gets worked up by MSNBC or CNN. However, each new nurse would put MSNBC or CNN on, usually confused by my dad’s request for CNBC, the business channel. Finally, we had to just write “TV: golf” on the whiteboard in his room.
oh. I see where this is going now....
Second, there’s no institutional memory beyond the medical chart. While the medical chart says what was prescribed, it never says anything beyond that. So, for example, my dad’s poor reaction to Haldol was not included on the chart. We had to inform each new nurse not to give him Haldol, and then still had a new nurse give him Haldol when he was agitated.
So, "one of the nicest and best-resourced ICUs in the country." can't chart correctly or share information in shift handoff. This is a communication problem. This is any job.
My day job is supporting the Electronic Health Record system for our hospital(s) and clinic(s). We use Epic, which is pretty much the most used in the US. You can set a tag so that whenever a patient's chart is opened it AUTOMATICALLY forces a pop-up, where that information can be shown. It's granular enough that you can have it open just for you, for your entire department, or if it's an ob/gyn encounter, pulls up two notes!
missed the para and footnote that scruss pointed out re: FTX. Just confirms my idea that this guy is an ass who thinks he knows what's going on in the medical world from observing it a whole month.
posted by a non mouse, a cow herd at 7:26 PM on November 21, 2022
So many have already hit a bunch of what's just absolutely horrible about this article. I'll try and be brief and add some additional context from working in a hospital/clinic environment.
1. The ICU is filled with old people.
meowzilla beat me to it, but there are also NICU, PICU (and MICU! CVICU, which is where this guys dad is! So many ICUs) units. So, that pulls all the young ones away, which is really something you want. Allows for more specialization. Reduces diseases jumping from older people to younger or vice versa.
Many other have already mentioned the inherent ageism in that sentence. The other thing to recognize is, medical visits are HIGHLY more common at the beginning of life as well as end of life.
Oh, wait. We're also complaining about taxpayers paying for the ICU? How did his dad get Lung Cancer? That was conveniently not mentioned. I would not be surprised if it was tobacco use. So, really, using his own logic, his dad should foot the bill because he chose a lifestyle that was not healthy.
The ICU staff is literally constantly changing. The ICU has a difficult staffing job. It’s a 24 hour center filled with skilled and highly skilled staff. So, ICU staff tend to work 3 days a week for 12 hours each day
At my hospital, this is common for the entire hospital.
First, from a patient perspective, the nurses and doctors are constantly changing. This is confusing for a deluded patient, and it’s difficult for their loved ones. For example, we kept having to tell nurses not to put the news on the TV, as my dad, a fervent Republican, gets worked up by MSNBC or CNN. However, each new nurse would put MSNBC or CNN on, usually confused by my dad’s request for CNBC, the business channel. Finally, we had to just write “TV: golf” on the whiteboard in his room.
oh. I see where this is going now....
Second, there’s no institutional memory beyond the medical chart. While the medical chart says what was prescribed, it never says anything beyond that. So, for example, my dad’s poor reaction to Haldol was not included on the chart. We had to inform each new nurse not to give him Haldol, and then still had a new nurse give him Haldol when he was agitated.
So, "one of the nicest and best-resourced ICUs in the country." can't chart correctly or share information in shift handoff. This is a communication problem. This is any job.
My day job is supporting the Electronic Health Record system for our hospital(s) and clinic(s). We use Epic, which is pretty much the most used in the US. You can set a tag so that whenever a patient's chart is opened it AUTOMATICALLY forces a pop-up, where that information can be shown. It's granular enough that you can have it open just for you, for your entire department, or if it's an ob/gyn encounter, pulls up two notes!
missed the para and footnote that scruss pointed out re: FTX. Just confirms my idea that this guy is an ass who thinks he knows what's going on in the medical world from observing it a whole month.
posted by a non mouse, a cow herd at 7:26 PM on November 21, 2022
I am grateful for the care I received, AND I was really glad to leave the hospital to get some sleep (and a real shower). I got some really brutal feedback from a family member when I commented about being glad the sleep deprivation was almost over, and it wrecked me.
I didn't at all mean for this to invalidate your experience, but to highlight that the issue is common and often quite severe. There are broad classes of patients who receive the same terrible sleep disruption by being woken up literally every hour to verify that their neurologic exam hasn't changed.
posted by a robot made out of meat at 9:15 AM on November 22, 2022 [1 favorite]
I didn't at all mean for this to invalidate your experience, but to highlight that the issue is common and often quite severe. There are broad classes of patients who receive the same terrible sleep disruption by being woken up literally every hour to verify that their neurologic exam hasn't changed.
posted by a robot made out of meat at 9:15 AM on November 22, 2022 [1 favorite]
I have been both an advocate for a patient, spending nights in the hospital over weeks at a time, as well as a patient, spending far too much time in the ICU. I've seen other patients and people in the hospital who are just rude and/or ignorant, but I also get a little defensive about the inside baseball...nurses and doctors have seen worse, I'm sure. I just kinda don't need to hear that in terms of my own ordeal...didn't mean to jump on you. Hope we're cool.
There is a lot of chaos...an example: I didn't find out that I went into renal failure until the day I was discharged. If anybody told me that, I wasn't coherent, because, legit, it was a total surprise to me.
I can't imagine what it's like to be woken up every hour. I mean, after a couple of days of that, who could tell if their neurologic exam wasn't jacked up because of the hourly wake ups? My fever dreams for 14 straight hours were kind of like that, waking up every hour for almost a full day...I had the albuterol mask on every 3 hours like clockwork...that sucked. It all sucked. Blood draws, the machine that goes BING! etc...hospitals are no place to rest.
posted by Chuffy at 10:57 PM on November 22, 2022
There is a lot of chaos...an example: I didn't find out that I went into renal failure until the day I was discharged. If anybody told me that, I wasn't coherent, because, legit, it was a total surprise to me.
I can't imagine what it's like to be woken up every hour. I mean, after a couple of days of that, who could tell if their neurologic exam wasn't jacked up because of the hourly wake ups? My fever dreams for 14 straight hours were kind of like that, waking up every hour for almost a full day...I had the albuterol mask on every 3 hours like clockwork...that sucked. It all sucked. Blood draws, the machine that goes BING! etc...hospitals are no place to rest.
posted by Chuffy at 10:57 PM on November 22, 2022
I had a septic infection on my leg, so I spent some time in ICU last month. I was sick enough that the interruptions and so on didn't really bother me, it was when they transferred me to a regular room that my sleep schedule got totally fucked up. It's taken me weeks to get mostly back to normal.
posted by tavella at 7:51 PM on November 23, 2022 [1 favorite]
posted by tavella at 7:51 PM on November 23, 2022 [1 favorite]
« Older Key takeaway: Reading multiple books at the same... | Just Say 'Yes' to PR Newer »
This thread has been archived and is closed to new comments
posted by The Underpants Monster at 2:53 PM on November 19, 2022