Thursday, June 3, 2021

Coping with COVID - Could Hospital Administration Do Better?


Being A Medical Insider – Sometimes It Works, Sometimes It Doesn't

My Dad, a fine and noted neurosurgeon, was very much a doctor. He was chief of neurosurgery at Episcopal Hospital in a working class area of north Philadelphia. He was in private practice, and part of the deal was that he would go to many outlying hospitals in need of neurosurgical consultation. Stop doing that and your practice dries up, in contrast to the university medical center where all you had to do was to show up. It was a pain, I guess, but he got to see a lot of medicine as it was practiced in real life, in real places, with real people, by typical practicing docs.

His conclusion was contained in this advice: Every family needs a doctor in every generation, to protect the rest of the family from the crap that goes on out there.

That's good advice. Another way of saying it is what my med school classmates passed onto me: You know what they call the person who graduates last in the class? Doctor.

But, besides self-protection against the last-in-the-class dangers, if you are a doc, when you are dealing with medical issues, you are viewed as an insider. If you start getting pushed around by medical staff in any situation, you get to push back with force. And very importantly, as an insider, other docs will treat you with great care and respect because you are a member of the tribe. Of course everyone should be treated that way, and truth to tell, they often are. I can't tell you how proud I am to be a member of a profession that works so hard to treat everyone with respect. For the most part. Not always and not everywhere, but in my personal experience, for what it's worth, more often than not. I sure tried to inculcate that in my practice, I can tell you. Sometimes, giving respect and caring is the most important part of the job. Maybe mostly. But not to get carried away, truthfully, when I'm under the knife, give me the competence, not the emotion, I'll get that later.

Last Thursday was my time to take advantage of being an insider, but in a surprising fashion. At 3 AM my wife, who has a disability, fell in the bathroom, hit her head on the tile floor, was knocked unconscious, stopped breathing, had her face turn gray and her lips turn blue, and then she had a seizure. Then she started breathing but didn't wake up. It was very frightening. I called 911 and the very professional EMT's came to the rescue. They took her to their ambulance and transported her to Highland General Hospital, our county hospital and our nearest trauma center.

I called my step-daughter Sara, who is the doctor in our family of the next generation, like me a pediatrician, and a professor of Pediatrics at UC San Francisco Medical Center, where she is among various titles, chief of the eating disorders program. Sara lives just a mile away, so she got dressed, I picked her up, and we drove down to Highland. I worried about our getting into the ER to be with my wife, but our county is about to be a COVID-19 yellow-risk county, and I've had another incident during the pandemic when I was able to be with Ann as her caregiver. I hoped that both Sara and I, both being docs and both being vaccinated, would be able to be with her in the ER, as would be necessary for her and as would be appropriate for medical-decision making. Happily, we were able to be there with her. Happily, she received excellent care, the staff and docs were excellent, and of course Sara and I were treated as insiders, as colleagues. Happily, the CT scan was normal. Unhappily, having been there for several hours and waking up, she then had a second seizure, which was very unnerving for us.

Now it was the morning and we knew she would have to be there for a few more hours at least, and possibly be admitted, we were urged to go home as she slept, eat some breakfast and take a shower and then come back and figure out what to do next. We accepted their advice, but Sara said to them, we'll be able to both come back in to be with her, right? No problem, we were assured.

When we came back, however, the morning charge nurse had assumed her duties, and we were told at the entrance to the ER that we would not be allowed back in because of COVID restrictions. The tall red-bearded man who staffed the entrance indicated that he was not happy with this decision, and the shorter uniformed guard to the side said that there had already been pushback from Administration over our having been allowed to visit in the first place.

We reacted as anyone who knew us could predict. I was very angry and told them we were now taking her out, even Against Medical Advice (AMA), and driving her home or to another hospital. Sara cried. She observed how they were violating norms that require informed medical decision making for every patient. The red-bearded man gave me a card with the relevant phone numbers to protest. I yelled some more. I was about to get our car out of the parking lot so we could take Ann right now. Sara dissuaded me. I called the ER nursing cellphone number – they had given it to me on Sara's urging before we left – and told the nurse that we were exercising our right to take the patient out. She said that the doctors were about to deal with her case on their rounds so we should wait. We heard nothing more and they no longer answered the ER nurse cell phone. So I texted to them to please not make me take steps to free my wife that would be unpleasant. So, where we had a few hours before blessed our luck in receiving excellent care, we were now full into a shit show, triggered by administration.

Which is where a surprising feature of being an insider came into play. In her UCSF roles, Sara has trained and worked with many members of the profession. It happened that one of her former students worked at Highland. Sara called the number, and as luck would have it, this former student was on duty just one floor above the ER. She would visit the ER and try to set things straight. About 20 minutes later this former student came out of the ER entrance and greeted Sara and met me, and they would now allow one of us to go into the ER to be with Ann. Sara insisted that I be the one to go in.

Shortly after I was in the room, the morning ER doc came around. He had been alerted to our situation by Sara's former student, because, mirabile dictu, he was a UCSF colleague whom Sara had worked with previously. That is, he was a medical friend. That is, we were all insiders. So I got Sara on the speaker phone and we all talked the situation over. We decided that taking Ann home was medically permissible, even preferable, and that's what we did, by ambulance, with three strapping young men who were friendly and professional, the way I'm sure they generally were, but especially now, with a fellow medical professional.  We got home and in time the event receded in memory

But what a shit-show was heavy-handed hospital administration! There is no time for nuance in a pandemic, common-denominator thinking turns out to be extremely low on quality of thought, trusting no one to think. You just have to sneak thought in sideways, away from the eyes of the officious enforcers. Eventually, you just say – Give me a fucking break, asshole! And those who can think, the red-bearded man at the entrance, your fellow professionals, help you find your way into the cracks. When it is possible. Which it often isn't.  We were lucky, even as insiders.

To look at the issue from 30,000 feet, there is often a rift between those who do and those who administrate. Sometimes, it's tragic. See my recent post –

And see just today, how the heavy hand and light thought of administration of hospitals continues to be an affliction.

O tempora! O mores!


Budd Shenkin

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