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R&R in a hospital? Surely you jest

After major surgery, the author discovered firsthand why some of his inpatients go downhill.

By William T. Sheahan, MD
Family Physician/Winter Park, FL

Many of my patients over the years have left the hospital in worse condition than when they were admitted. Now I understand much better why they succumbed to the "cascade of deterioration."

Recently I had a total hip replacement due to dysplasia. I was told to arrive at the hospital at 12:01 am on the day of my surgery, to avoid being billed for an additional hospital day. My wife’s parents came to our house to watch our two children, both of whom had the flu. My wife and I got to the hospital at 11:45 pm and were told to sit in the emergency room waiting area until called by the admitting clerk. The ER was packed with people with different ailments, and periodically a rescue squad would pull up outside. At about 1:15, the clerk called us, and I got to my room at approximately 1:45.

A nurse met us on the orthopedic floor. He seemed annoyed that it had taken me almost two hours to get admitted. He completed his paperwork and nursing physical in about 15 minutes and asked me to stay awake because the lab tech would be up soon to draw my blood. After that, he said, I could sleep until 5 am, when it would be time for my shave and body scrub in preparation for surgery at 7:30.

When the lab tech hadn’t arrived by 3:30, I walked to the front nursing desk and was told the tech would be in as soon as possible. At 5:45, I reminded the staff that I hadn’t been given a gown, razor, or scrub brush. I was handed these items and told to take a shower.

At 6:30, the lab tech arrived. She was upset because it was so late and she was going to have to take my blood down to be tested stat. She didn’t wear gloves when she drew my blood, but I decided it wasn’t a good time to remind her about universal precautions.

Minutes later, the OR aide arrived to take me down to pre-op holding. He told me to give my glasses to my wife, even though I protested that I couldn’t see a thing without them. He had forgotten to bring a blanket for the transport stretcher. I was wheeled through the hospital and down the elevator sleep-deprived, cold, and unable to see.

When I squint, I can focus slightly without my glasses. The woman in the pre-op holding slot next to me was yelling, cursing, and being restrained while having an ABG drawn. The man on the other side of me wasn’t responsive and appeared to have an intracranial pressure monitor in place. I could see how frightening this could be to other patients.

The surgery went well. Eyeglasses were allowed in the recovery room, and one of the aides was nice enough to get them for me. I remember how much better I felt when I could see again. I got up to my room about noon. After a while, I told my wife I was fine and suggested that she go home to our kids. The man in the next bed had been operated on the day before. He spent most of the day snoring. I spent most of my time pumping my feet and squeezing my buttock muscles. Despite TEDS and Lovenox injections, I was sure I would develop a DVT without this effort. The same technician as before drew my post-op labs. She didn’t wear gloves this time, either.

My IV alarm periodically sounded throughout the day. Sometimes it would take only 15 minutes for the nurse to reset it so the piercing sound would stop. A nurse came in about 10:30 pm and woke my roommate to see whether he needed anything to help him sleep. He said he hadn’t slept all day, so she gave him a sleeping pill. The snoring restarted. Now he had long apneic episodes. Every time I feared he might be dead, he would let out a loud snort and begin snoring again.

About two hours later, the night shift nurse came by to take vital signs. She turned on all the lights in the room, waking my roommate. She asked whether he needed anything to help him sleep. He said Yes. She gave him another sleeping pill. Shortly after she left, he resumed snoring, with even longer apneic spells.

I was able to catch some short naps, interrupted by the IV alarm. In response to the call button, the nurse would usually yell, "WHAT DO YOU WANT?" She would turn on all the room lights in order to press the alarm reset button. My nearly comatose roommate didn’t notice. An overhead announcement was made at 2 am to let all hospital staff know that the cafeteria would be closing in 15 minutes.

At about 2:30, I was rolled on my side with a foam wedge strapped to my legs. The nurse said she wanted me on my side for about an hour. I didn’t notice that the call button was out of reach. The nurse closed the door as she left. For the next three or four hours, the IV monitor alarm sounded. I couldn’t reach the reset or call button. The staff couldn’t hear the alarm with the door closed. My roommate was unresponsive with his double-dose hypnotics. The room started to seem hot. It was a long night.

At about 6:30 am, the room door opened. The night nurse was getting ready to leave. She was shocked to find that the room temperature was over 100 degrees because the thermostat had malfunctioned. She was also annoyed that my IV had infiltrated. Why hadn’t I called? She didn’t seem concerned that I had spent four hours, instead of one, rolled on my side.

That morning, three air-conditioning troubleshooters weren’t able to fix the thermostat. A single room became available, and I moved in. I saw my previous roommate’s physician making rounds and let him know his patient probably had sleep apnea. I suggested it might be a good idea to discontinue the sleeping pills.

The nurse admitting me to the new room realized that I hadn’t voided since surgery. She said she would be back shortly to in-and-out catheterize me. Motivated by my memories of patients who had had traumatic in-and-out urinary catheterizations, I declined and assured her that I would go on my own. My wife arrived at the same time. After about an hour of concentrating while she made the bathroom faucet drip, I was able to fill the bedside urinal.

My wife stepped out briefly to get some food. Soon afterward, a nursing aide arrived, with a big basin of soapy water and a washcloth. . "Good morning! Time for a bed bath," she chirped, and whipped off my blanket and gown. I told her I could bathe myself, with a little help from my wife, and she left abruptly. When my wife got back to the room, I was still lying in bed naked and uncovered.

The physical therapist came in later. It felt great to get up on the walker. The orthopedic surgeon was making rounds and was happy things were going well. I let him know I was planning to leave the next day. "None of my patients have ever left that soon," he commented. I didn’t tell him I thought I’d feel much safer at home.

That afternoon I started having myalgias, arthralgias, and fever. I was sure I had the same flu my kids did. I was terrified that my surgeon would call in an infectious disease colleague, who would then surely send me for a bunch of X-rays, labs, and cultures. I decided not to let the nursing staff know. My wife gave me a bottle of acetaminophen that I kept handy and out of sight, and I chewed on ice chips before the nurse came to take vitals.

That night was one of my longest ever. The nurse covering my room had never worked on an orthopedic unit. He apologized whenever he turned me in a way that caused pain. He said he’d never had training or instruction on how to do block turns with patients with hip replacements. Through the early morning hours, the smell of everything in my room gave me the sensation that I wanted to throw up. The sheets, towels, soap, and water all had a distinctive objectionable odor.

At 5 am, I called my wife and told her to pick me up when our kids woke. I asked the nurse to call the orthopedic surgeon and tell him that "Dr. Sheahan’s hip is doing great but he has the flu and is going home." When my wife arrived at 8:30, I felt like the cavalry had arrived. Within an hour, I was home in my own bed. One of my partners called in a prescription for antiemetics and analgesics. My rehabilitation went great. At six weeks post-op, my orthopedic surgeon was happy with the results, and so was I.

Hospitals are short-staffed. Nurses seem to spend more time charting than doing patient care. Brief clinical assessments often trigger a series of treatment decisions that may not be in the patient’s best interests. Night shift workers seem to have little regard for the importance of maintaining patients’ circadian rhythms.

My experience has made me an advocate for outpatient treatment whenever appropriate. When hospitalization is necessary, I encourage a family member or friend to stay with the patient as much as possible.

My three-day hospital bill–without the surgeon’s fee–totaled more than $25,000. You would have thought I was staying at the Ritz.

William Sheahan. R&R in a hospital? Surely you jest.

Medical Economics

2001;3.