In my last post, I described my battle against the hospitalist team and the GI Fellow who had decided early on and without hesitation that I needed another colonoscopy — my second one in a week. Once I found and presented the attending GI physician with sufficient evidence to demonstrate that my symptoms were more consistent with an upper GI bleed than a lower one, he responded quickly and unambiguously.
“This is your second hospital stay in a week,” he said. “We have to get this moving and get you out of here.” It was Sunday afternoon.
“I’m ordering another endoscopy, just to make sure the first one didn’t miss anything,” he continued. “We’ll also do a capsule endoscopy. They’ll insert a camera-pill at the same time we perform the endoscopy. I’ll schedule both procedures for early Monday morning and have them place the capsule so that at 5:30 pm someone can pick up the image pack. We should begin to get some results on Tuesday.”
“Will you be performing those procedures?” I asked hopefully.
“No,” he said. “Another attending is on call here after today.”
“So I lose you at…?” I asked.
“Midnight,” he said. “But I’ll still be in the hospital tomorrow. After all, I do have patients here to see.”
What was that supposed to mean? I assume he was referring to people whom he’d seen as outpatients and then admitted to the hospital for specific procedures. But wasn’t I his patient, too?
His remark suggested something about his personal investment — or lack thereof — in those who, at least in my case, enter the hospital by way of the emergency room. Never mind that most of us are in worse shape than those a physician may regard as his “real patients.”
“You’ll be in very capable hands,” he assured me. “You’ll have the doctor who trained me.”
That was good enough for me.
The second endoscopy would become the most important step in reaching a diagnosis. I’ll come back to that in my next post. But the story of what happened to the imaging pack for the related camera endoscopy is an example of how a physician’s directives can go unheeded by those whose only job should be to follow them.
As required, I wore the imaging pack for the entire day. At 6:00 pm, I rang for the nurse.
“Can I help you?” came the response over the speaker.
“Yes,” I said. “The attending GI wanted the pack for my capsule endoscopy picked up at 5:30 pm. Can you make sure it gets picked up before everyone in the GI lab goes home?”
“I’ll check on it,” she replied.
At 6:30, I rang for the nurse again.
“Can I help you?” she asked.
“Yes, can someone tell me why the camera endoscopy pack still hasn’t been picked up?”
“I’ll let your nurse know,” said the anonymous voice.
At 7:00 pm, a hospital transport worker arrived to take me via gurney for a CT scan. The attending GI physician who’d performed my second endoscopy that morning had ordered it after seeing an anomaly. His willingness to entertain the possibility that my case was atypical saved my life.
As I lay on the transport gurney, I asked the nurse what was happening with the camera pack.
“I paged the resident, who said he’d paged the GI resident on call, who said it was no big deal. They would probably pick up the pack tomorrow,” she said.
I was furious.
“Well, despite the views of the various on-call hospitalist and GI residents, the attending GI who ordered the camera endoscopy thought it was a very big deal. Here’s what I want you to do while I’m gone for my CT. Call the attending GI physician who ordered a prompt retrieval of the camera pack so processing of the images could begin. Tell him the pack is still sitting on my shelf and ask him how we get it where it’s supposed to be. Because I’ll tell you where it’s not supposed to be: in my room.”
“I’m not allowed to do that,” the nurse responded. “I have to call the resident on call and then he has to call the GI resident on call.”
As my wife and I headed for my CT scan, I was fuming.
“The CT will be on the same floor as the GI lab,” I suggested. “Maybe we can find someone down there who will pick up the damn pack. I’ll take it to them myself on a gurney, if I have to.”
Once on the CT floor, my wife made a beeline for the GI lab.
“Follow her,” I told the transport guy pushing my gurney down the hall as fast as he could. This is what black humor feels like when you actually experience it, I thought.
We sped behind her as she entered the GI lab and searched for someone who could help.
As I rolled into the empty GI lab on my gurney, a short, stocky, middle-aged woman stood with a mop next to her steel cleaning bucket.
“She can run around here all she wants,” the woman said as she shook her head in disbelief while my wife raced through the entire GI lab. “But ain’t nobody here. They all gone home.”
Indeed, they had.
After the scan, I returned to my room where the dreaded camera pack remained on my shelf. Meanwhile, the nurse to whom I’d barked out orders relating to the problem had benefited from a shift change — she was gone and her replacement was clueless about just about everything, so I gave up for the evening.
When I awoke at 7:00 am Tuesday morning, the pack was still there. In walked the only person who had provided anything remotely resembling continuity of care during my first two admissions: a third-year medical student.
“How was your evening?” he smiled.
“You see that camera pack?” I answered coldly. “The attending GI who ordered the camera endoscopy wanted it picked up at 5:30 pm yesterday. Your job is to find out why it’s still there.”
An hour later, he came back. “It looks like you might be going home today,” he said happily.
I pointed to the pack on the shelf.
“I’m sure they’ll pick up the pack soon,” he said.
“What does ‘soon’ mean?” I was fed up.
“I don’t know,” he said meekly. “The GI lab is very busy.”
“And I’m very much bleeding,” I replied.
An hour after that, I wandered into the hall and found the medical student.
“What’s the story on the pack?” I asked.
“I’m waiting to hear back from the GI Fellow,” he said. At that point, the phone rang. “That’s her calling now.”
He was right. I heard only his end of the call, which went like this:
“I’m very sorry to bother you…I know you’re very busy…We have an imaging pack from a camera endoscopy that hasn’t been picked up…Oh, yes…Sorry…Yes…Sorry to bother you….Thanks.”
I was watching the impact of the medical pecking order in action: Attending physicians were at the top, then came their Fellows, followed by residents and finally, interns. Medical students occupied a status somewhere below nurses. He hung up the phone. It was 10:00 am.
“She said they’d pick it up as soon as they could,” he explained. “But they have to be the ones who pick it up. No one else can deliver it to them. And then they’ll send it to wherever it gets processed.”
I glared at him.
“You know, they do these imaging studies on an outpatient basis,” I said slowly and calmly. “So how about if I just have my wife take it down there and tell them that this pack is from an inpatient.”
He seemed puzzled: “I don’t think you can do that. When you’re inpatient, they have to pick it up.”
“Just to warn you,” I said sternly, “I’m going to come out here every 30 minutes and harass you until someone picks up that pack and takes it where it’s supposed to go. I have family members here who will deliver it personally, but you’re telling me that’s not an option. Whatever else is happening here, you and the GI lab have violated the the directive that the attending GI issued when he ordered the camera endoscopy on Sunday. We’ve already lost an entire night because of someone’s ineptitude and bureaucratic absurdity. So every 30 minutes you’ll hear from me — until it’s no longer in my room.”
At 10:30 am, someone from the imaging processing department — not the GI lab — walked into my room and picked up the pack.
“Where are you taking the pack for processing?” I wondered. “The GI Lab?”
“Oh, no,” he said. “We do the processing in a special department across the street.”
Perfect. The GI Lab that apparently insisted on being in the middle of a retrieval process — and messing it up — had nothing to do with processing the pack to get the results.
The 17 hours from 5:30 pm Monday night to 10:30 am Tuesday morning may not sound like a long time, but when you have uncontrolled internal bleeding from unknown origins, every minute of delay translates into something real, namely, blood leaving my body. I wonder how some of the players in this vignette would have felt and acted if it was leaving theirs.
In the end, it boils down to three simple issues. One is the set of bureaucratic obstacles that interfere with the effective delivery of health care. Someone — anyone — could have delivered my pack in a timely manner. But for no good reason relating to patient needs, the bureaucratic structure did not allow it.
Second, a patient benefits greatly when a conscientious health care worker is willing to challenge such bureaucratic obstacles. My nurse who went off duty at 7:00 pm on Monday wasn’t one of those people — and it’s not fair to expect any of them to play the role of aggressor-advocate on behalf of a patient. But I had other nurses throughout my subsequent stay who had no reservations about rocking the boat. They didn’t care whose ire they incurred and their efforts made a positive difference in my experience.
The third point may be most important. There should be sufficient continuity of care so that a single attending physician becomes vested in a patient and remains an active participant in the diagnostic and treatment process. In theory, hospitalists are supposed to perform the “PCP-in-the-hospital” function. In my case, the reality is that they failed miserably in my first two admissions.
The attending GI who ordered the camera endoscopy understood the gravity of my condition, as well as the need for speedy action to deal with it. But he went off duty at midnight and I never saw him again.