Quality of care in community hospitals

[WiseOne]

Sadly, I'm experiencing this first hand as my father has had another lobar (brain) hemorrhage.  I suspect I won't be posting much for a while, but I wanted to throw in this comment:  I am absolutely appalled at what happens at medical institutions outside of academic centers!!  I've been protected in ivory towers for so long I sort of forgot that out there in the wilds, nurses mix up medications on a regular basis, elementary precautions like SCD's to prevent deep vein thrombosis and IV fluids for dehydration don't happen without prompting, and slightly higher levels of care like round the clock Tylenol to control fevers (very important in acute brain injury) and antibiotics for presumed pneumonia require multiple phone calls and an unpleasant shouting session with the hospitalist.

Worse yet, these places apparently instill bad habits.  The consulting neurologist is someone I don't know, but a friend remembered him from residency and had a generally high opinion of him.  Yet, this guy can't do a neuro exam to save his life - as in, he still doesn't know that my father is globally aphasic because he doesn't know that when you test for comprehension you have to avoid giving visual cues.  He also missed intraventricular extension of the hemorrhage on the CT scan, as did the radiologist - we only know about it because he was nice enough to offer to let me see the scan.

So I guess now I get the distrust of physicians that most of you seem to have.  The ones I know are probably not the ones you know. Ironically, the average illegal immigrant from the Dominican Republic who lives in the South Bronx probably gets far better care than most of the people on this board would.  So...if you find yourselves in a situation where good quality care is really important, don't hesitate to insist on a transfer to a major center.  It's less comfortable for family and less accessible for visitors, but you'll be amazed at the difference.

[Benko]

There are some community hospitals with quite good care (though if you have an unusual disease you're better off at a university hospital, though perhaps not in July).  And yes, there are plenty of community hospitals which are as you describe. 

"He also missed intraventricular extension of the hemorrhage on the CT scan, as did the radiologist "
Does that really change clinical management? (out of curiousity).  Yes, I know that could lead to hydro down the road.

Unfortunately there are plenty of bad doctors and finding a good one is not always easy.

[notsheigetz]

Very sorry to hear of your father's situation.

My first wife developed a chronic cough at the age of 53 which was diagnosed as allergies. After not getting any better with the prescribed treatment she switched doctors who proceeded to agree with the diagnosis and only changed the prescribed medicine. One day she got a whiff of chlorine gas in her face as she was swimming in the pool when the filtration pump started up. I took her to the local hospital emergency room where they gave her a breathing treatment for asthma and sent her home. That evening she woke up barely able to breathe so I took her across town to the University Hospital. Finally, after more than nine months of visiting doctors and hospital emergency rooms they took a chest x-ray and discovered that BOTH lungs were collapsed. Also, there was a spot on one of the lungs which had to be investigated further. That turned out to be lung cancer which turned out to be fatal about nine months later. Whether earlier detection would have extended her life or not, I guess one can never know, but the gross incompetence in the whole affair was mind-boggling. I eventually got a bill from the first hospital that the insurance company didn't pay for some reason I don't remember and I wrote them back and told them I had documented proof that they sent my wife home with two collapsed lungs and if they wanted to pursue the matter in court I would be happy to oblige. I never heard from them again.

I would second the idea that academic hospitals are better if it weren't for the fact that we had several stories of gross incompetence in the news about the very same University hospital where I took my wife. One involved the amputation of the wrong foot and I forget the other one but it was just as bad.

I also have some stories to tell about my own misdiagnoses since those of my wife but I'll save them for another day.

[MediumTex]

A few years ago my sister in law was admitted to a community hospital because of extreme pain from a pulled muscle in her back.  She was also very obese.  She had been receiving Interferon treatments for hepatitis C and was nearing the completion of that treatment.

After a day or so in the hospital she picked up a staph infection.  The Interferon compromised her body's ability to fight the infection and she was dead within a week of experiencing the pulled muscle.

During that frantic week it was painfully obvious to me that the fact that she was obese caused all of the doctors to show far less interest in her treatment.  It was an incredibly sad thing to watch.  I was only able to visit her a couple of times in the hospital, but each time I was shocked at how amateurish the whole place seemed and how little interest her doctors seemed to show in any kind of creative approach to treating her.

It seems like the very first physician who saw her should have seen that she was taking an immunosuppressant drug and just given her some strong pain medicine and sent her home.  Admitting an obese person on an immunosuppressant to a hospital that has known staph infection issues (I learned about this later) when there was no life threatening reason for her to be in the hospital just seemed like a shockingly stupid thing to do. 

I've always wished that I could have done more for her, but my Dad had just passed away and I had raised so much hell with his doctors in the process of making sure that he got the best possible care (and he did) that when my sister in law got sick certain family members basically told me to STFU and let the doctors do their thing when it came to my sister in law's care.  I hated being in that position, but considering the more distant relationship and the fact that I was already emotionally exhausted from my Dad's experience, I basically just sat back and let things happen without getting too involved.  I hoped that maybe the doctors were more on top of things than they seemed to be, but they weren't, and she died.

WiseOne, I hope your Dad's situation has the best possible resolution.  Unfortunately, I think that being in an environment of sloppy dimwits just has a way of dulling everyone's mind and someone who comes into one of those situations sharp will over time get just as sloppy as everyone else and that sounds like what happened with the doctor you are describing.

[WiseOne]

Thank you, all.

MT and notsheigetz - these stories are beyond appalling.  I'm so sorry.  When hospitals become billing mills and the staff forget why they went into this profession in the first place, this is what happens.  Though you're right...there are exceptions in both categories.  And MT...I hope you're not thinking how you should have done more.  This is what's so infuriating about this experience:  I don't want to have to be my father's doctor and nurse manager, and I shouldn't have to be.  I just want to sit next to him and feed him and hold his hand.

"He also missed intraventricular extension of the hemorrhage on the CT scan, as did the radiologist "
Does that really change clinical management? (out of curiousity).  Yes, I know that could lead to hydro down the road.

It markedly worsens the chance for a meaningful recovery.  My sister and I have kept that to ourselves.  It's also made it easier to stop chasing after infection sources to explain fevers & vomiting.

[AdamA]

It seems like the very first physician who saw her should have seen that she was taking an immunosuppressant drug and just given her some strong pain medicine and sent her home.  Admitting an obese person on an immunosuppressant to a hospital that has known staph infection issues (I learned about this later) when there was no life threatening reason for her to be in the hospital just seemed like a shockingly stupid thing to do. 

Just to give some perspective on this, I see A LOT of low back pain in my practice (emergency medicine).  In my experience, it is very very very difficult to admit a patient for something like intractable musculoskeletal back pain, because the admitting physician will usually not accept the admission.  "You want to admit her for what?"

The fact that the doc who saw her first went through the trouble of admitting her makes me think that one of two things happened.  1.  The pain was so bad that the physician was uncomfortable giving high enough doses of pain medications to treat it and send her home (because these are usually narcotics).  Or 2, the pain pattern did not fit run what would have been typical for a pulled back muscle. 

In case 1, I think that even though it's always best to try not to admit people to the hospital unless it's truly necessary, it was probably still reasonable to keep her, because it's cruel to send someone home when their pain has not been controlled adequately. 

If it was for reason 2, I think that this was sloppy medicine.  If a physician suspects a more serious etiology for low back pain (or any complaint), they should pull the trigger on the workup right off the bat.  In this case, that would probably mean an MRI. 

In many places, getting an MRI requires an argument with a radiologist, and, after all the arguing, the MRI is still very often normal and it turns out to be plain ol' musculoskeletal low back pain.  ED docs get frustrated with this, and will often try to simply admit the patient for a period of observation. 

Although observation is a great tool in many situations, it also gives ED docs a false sense of security.  "I admitted the patient, so they'll figure it out on the floor."  Although this is okay sometimes, in many cases the admitting doctor taking over care gets "anchored" to the diagnosis and will miss the more serious illness too. 

So it would have been one thing to say, "I think it's a pulled muscle, but if she doesn't feel better in the morning, she might need an MRI," and another to say, "I'm admitting her for pain control."  If the ED doc says the first thing, the admitting will often demand the MRI up front, so the ED doc says the second to avoid this, with the hopes that the admitting physician will sort everything out later. 

Did she get admitted without an MRI?

Was the staph infection an infection that originated in her spine (ie, was it the cause of the back pain), or did she somehow get a blood borne staph infection unrelated to her back pain while in the hospital?

I know I'm presuming a lot here based on only two sentences...just my 2 cents. 

[MediumTex]

It seems like the very first physician who saw her should have seen that she was taking an immunosuppressant drug and just given her some strong pain medicine and sent her home.  Admitting an obese person on an immunosuppressant to a hospital that has known staph infection issues (I learned about this later) when there was no life threatening reason for her to be in the hospital just seemed like a shockingly stupid thing to do. 

Just to give some perspective on this, I see A LOT of low back pain in my practice (emergency medicine).  In my experience, it is very very very difficult to admit a patient for something like intractable musculoskeletal back pain, because the admitting physician will usually not accept the admission.  "You want to admit her for what?"

The fact that the doc who saw her first went through the trouble of admitting her makes me think that one of two things happened.  1.  The pain was so bad that the physician was uncomfortable giving high enough doses of pain medications to treat it and send her home (because these are usually narcotics).  Or 2, the pain pattern did not fit run what would have been typical for a pulled back muscle. 

In case 1, I think that even though it's always best to try not to admit people to the hospital unless it's truly necessary, it was probably still reasonable to keep her, because it's cruel to send someone home when their pain has not been controlled adequately. 

If it was for reason 2, I think that this was sloppy medicine.  If a physician suspects a more serious etiology for low back pain (or any complaint), they should pull the trigger on the workup right off the bat.  In this case, that would probably mean an MRI. 

In many places, getting an MRI requires an argument with a radiologist, and, after all the arguing, the MRI is still very often normal and it turns out to be plain ol' musculoskeletal low back pain.  ED docs get frustrated with this, and will often try to simply admit the patient for a period of observation. 

Although observation is a great tool in many situations, it also gives ED docs a false sense of security.  "I admitted the patient, so they'll figure it out on the floor."  Although this is okay sometimes, in many cases the admitting doctor taking over care gets "anchored" to the diagnosis and will miss the more serious illness too. 

So it would have been one thing to say, "I think it's a pulled muscle, but if she doesn't feel better in the morning, she might need an MRI," and another to say, "I'm admitting her for pain control."  If the ED doc says the first thing, the admitting will often demand the MRI up front, so the ED doc says the second to avoid this, with the hopes that the admitting physician will sort everything out later. 

Did she get admitted without an MRI?

Was the staph infection an infection that originated in her spine (ie, was it the cause of the back pain), or did she somehow get a blood borne staph infection unrelated to her back pain while in the hospital?

I know I'm presuming a lot here based on only two sentences...just my 2 cents.

Would the Interferon and obesity have made you more reluctant to admit her?

The risks associated with immunosuppressants seem to not be well understood by many patients (and some doctors).

I don't believe that the staph infection was related to the back pain. 

***

Returning to the topic of immunosupressants being poorly understood, here is the experience that my Dad had:

He was diagnosed with bullous pemphigoid (which is what I think God gave Job in the Old Testament--it's a REALLY nasty skin disorder) and prescribed Imuran to help control the immune system problem manifesting in the skin disorder.  He had quit smoking 5-10 years before, but had a prior history as a heavy smoker.  He was 64 at this point.  The Imuran helped a little with the skin disorder. 

At some point in this process he coughed up a small amount of blood and had no further symptoms that would suggest a lung problem.  The doctor took a chest x-ray and saw nothing unusual.  In the following three months he became progressively weaker and finally couldn't even get up.  We took him to a blood specialist because that's where his GP wanted him to go.  That doctor saw what looked like a superior vena cava blockage.  He had a CAT scan done and that's when we learned of the large tumor (about the size of a hot dog bun) that was wrapped around his esophagus and pushing against his SVC.

Based on the clean chest x-ray (which seems to me should have been a CAT scan), I think that he probably had a slow growing tumor that the Imuran kicked into high gear.

It seems to me that the dermatologist should have done more research into his background as a smoker and considered his age before prescribing the Imuran.

It seems to me that the coughed up blood should have triggered a lot more diagnostics, considering his history as a smoker and the possible effects of the immunosuppressant he was taking.

Once he was diagnosed with the stage 3B lung cancer, all sorts of treatment kicked in (including chemotherapy, which was a painful waste of time), but I would have liked to have seen more of that aggressiveness earlier in the process. 

He lived another 15 months.  If I knew then what I know now I would have been with him in the dermatologist's office the day the Imuran was prescribed with a LOT of questions.  I didn't realize how much difference an informed and engaged family member made then, though, so I just sort of went with the flow, assuming that all of the doctors were doing the proper issue spotting and coordination of treatment.

I should also mention that it seemed to me that the second each of his doctors learned that I was an attorney and that I seemed to be researching everything they told him and coming back with lots of questions, they seemed to get a lot more attentive.  My aunt is an ER nurse in another city and when I mentioned this to her her response was something along the lines of "duh."

Don't ever get lung cancer.  The treatment hasn't improved much in the last 40 years and it is far deadlier than most people realize.  It's by far the number 1 cancer killer.

[WiseOne]

Would the Interferon and obesity have made you more reluctant to admit her?

Although it's hard to guess after the fact based on limited info, I agree with AdamA...these would have made an admission more likely.  The immunosuppression may have made the ER doc suspect an abscess, and the obesity would complicate the exam.  If she weighed more than 300 pounds, an MRI would be impossible to get - but a CT (or CT myelogram, if they were thinking spinal abscess) could still have been done right there in the ER.

I bet that miscommunication and laziness probably had a lot to do with the outcome - I've been seeing the same thing here.  In my case, two specialists signed off leaving my dad, with a serious neurological condition, in the hands of a completely clueless primary MD, because each thought the problem was in the other's domain.  My sister and I rounded the two of them up and told them to Talk to Each Other, NOW.  In your case, the ER doc probably thought the primary would figure it out, the primary thought the patient was ok because the ER doc finished the immediate workup, and both probably consulted a neurologist who didn't see anything of immediate concern and signed off.

Finally...your dad had bullous pemphigoid???  That's incredibly rare - I've never seen a case!!  Given its unpleasant nature (and risk of infection from the skin breaches), Imuran was quite reasonable and it's not really that risky as immunosuppressants go.  It's hard to know if it affected the cancer course, because small cell lung Ca is incredibly aggressive no matter what.  The hemoptysis + smoking history, though, should definitely have prompted a chest CT - but it's quite likely that nothing would really have changed the outcome.  My uncle, with a 100+ pack year smoking history, developed lung Ca that also was misdiagnosed as heart failure until very late stage, and he quite rightly refused chemo.

[MediumTex]

WiseOne,

Thanks for that feedback.

It was non-small cell lung cancer, but that only made the situation slightly less dire.

[annieB]

My experience has been that if you are in the hospital for a serious condition,you had better have someone there all the time to advocate for you.Everyone on my team was a specialist and yet no one was the coordinator.Nurses were either saints or sinners.I wished that my PCP had been in charge.

[WiseOne]

The admitting service is responsible for coordination of care.  They get recommendations from the consulting services and decide whether to act on them.  Consultants sonetimes do their own thing, but they should talk to the primary team about it afterwards.

It's always helpful to have one family member designated to talk to the physician teams.  It gets frustrating to have to repeat the same information 5 times and leads to miscommunication.

[AdamA]

Would the Interferon and obesity have made you more reluctant to admit her?

I try very hard not to admit people to the hospital without clear cut reasons.  Procedural complications, medication side effects, and nosocomial infections are all very real things.  Hospitals are dangerous places!

Having said that, if I couldn't control her pain I would have offered her admission, even with the Interferon. 

Based on the clean chest x-ray (which seems to me should have been a CAT scan), I think that he probably had a slow growing tumor that the Imuran kicked into high gear.

It seems to me that the dermatologist should have done more research into his background as a smoker and considered his age before prescribing the Imuran.

It seems to me that the coughed up blood should have triggered a lot more diagnostics, considering his history as a smoker and the possible effects of the immunosuppressant he was taking.

An early CT would have probably been helpful in your father's case, at least diagnostically, and I'm not disagreeing with what you've said above.

There's another side to it, though.

CT scans are very helpful when the findings are clear, such as a tumor compressing the SVC.  I would say that this occurs in a minority of cases, though.  Frequently, even in a smoker, a CT of the chest will show something less compelling, like lymph nodes that might be cancerous, or nodules that might be granulomas, or a liver mass that's probably a cyst, but might be a malignant tumor (you can see the top of the liver on a chest CT). 

The only way to get to the bottom of all of these vague findings is usually to do another test, but this time the test is something moderately invasive like a biopsy or a bronchoscopy, both of which have the potential for serious complications (they're not frequent, but they're frequent enough). 

You're father sounds like a tough case.  64-year-old smoker, with one bout of hemoptysis.  I am speaking outside of my speciality now, but it does, in that case, sound like someone should have at least been thinking about lung cancer.  However, given that it resolved, it's hard to say.
(There may be guidelines about this somewhere in the Internal Medicine literature, but I'm not sure). 

Again, I don't disagree with what you've said above, especially if it is true that Interferon can actually accelerate tumor growth (I don't know). 

I just wanted to make the point that sometimes a physician will wait to start testing because sometimes tests confuse and complicate even more. 

I'm kind of passionate about this because I see a lot of young healthy patients who want me to do tests on them "just to be sure."  You can imagine all of the "incidental-omas" I would find on these people if I granted these requests.  It's always a problem in medicine when a test result doesn't match your clinical impression.  Usually the test is wrong in these cases, so it's best to order tests to confirm suspicions rather than to "just be sure." 

[MediumTex]

Thanks for that feedback Adam.

The only point I might make is that my Dad had completely quit smoking 6-7 years before he was diagnosed, so the lung cancer thing wasn't on our radars as much as it might have been if he was still a smoker.

I can imagine what you are saying about people wanting to be tested for everything.  If I was the doctor, I might be tempted to tell people "Look, you're going to die.  I don't know if it will be tomorrow or 50 years from now, but this thing isn't designed to last forever.  Right now, though, everything seems to be working okay."

[notsheigetz]

I can imagine what you are saying about people wanting to be tested for everything.  If I was the doctor, I might be tempted to tell people "Look, you're going to die.  I don't know if it will be tomorrow or 50 years from now, but this thing isn't designed to last forever.  Right now, though, everything seems to be working okay."

The night before I got the diagnosis of my wife's lung cancer God told me that her mission on earth was complete and she was going to die. Laugh if you want. I never said a word about this experience while she was going through her radiation and chemotherapy because she was thriving on hope but when she finally realized for herself that this was a losing battle I told her what God had told me and it gave her a very great peace.

[MediumTex]

I can imagine what you are saying about people wanting to be tested for everything.  If I was the doctor, I might be tempted to tell people "Look, you're going to die.  I don't know if it will be tomorrow or 50 years from now, but this thing isn't designed to last forever.  Right now, though, everything seems to be working okay."

The night before I got the diagnosis of my wife's lung cancer God told me that her mission on earth was complete and she was going to die. Laugh if you want. I never said a word about this experience while she was going through her radiation and chemotherapy because she was thriving on hope but when she finally realized for herself that this was a losing battle I told her what God had told me and it gave her a very great peace.

The experience with my Dad was agonizing.  We savored every bit of hope that we could realistically maintain. 

An experience like that tests you in countless ways.  I loved and admired my Dad like I was a little kid and he was the first person close to me who had ever died. 

I learned a lot about life during that experience.  Overall, I was very impressed with the medical care he received after his diagnosis.  He was treated at Baylor hospital in Dallas and we got to know some really outstanding doctors there.

(I should say more nice things about doctors.  As a group, they are some of the smartest, most dedicated and hardworking people you will ever meet.  Thanks to the regular posters here who are doctors--you are great people.)

[notsheigetz]

(I should say more nice things about doctors.  As a group, they are some of the smartest, most dedicated and hardworking people you will ever meet.  Thanks to the regular posters here who are doctors--you are great people.)

Agreed. Sometimes I feel guilty about not becoming a doctor myself, especially after an aptitude test recommended it as a profession. When all is said and done it is hard to think of a higher calling in life than healing the sick.

[dualstow]

This is a difficult thread to read.
Best wishes for your dad's health, WiseOne.

[notsheigetz]

This is a difficult thread to read.
Best wishes for your dad's health, WiseOne.

Death is highly overrated.

If you think it's the end rather than the beginning then you need to get a life.

[dualstow]

This is a difficult thread to read.
Best wishes for your dad's health, WiseOne.

Death is highly overrated.

If you think it's the end rather than the beginning then you need to get a life.

Okayyy. My logic circuits are shorting out trying to puzzle through the above.
All I know is, losing loved ones is one of the worst experiences I can imagine. Fretting over ailing loved ones is something I have experience with, and one of the most stressful events in life.

[WiseOne]

This is a difficult thread to read.
Best wishes for your dad's health, WiseOne.

Death is highly overrated.

If you think it's the end rather than the beginning then you need to get a life.

Okayyy. My logic circuits are shorting out trying to puzzle through the above.
All I know is, losing loved ones is one of the worst experiences I can imagine. Fretting over ailing loved ones is something I have experience with, and one of the most stressful events in life.

It is indeed.  We all thought we were going to lose Dad, but then along came a get out of jail free card.  Something wasn't adding up in the clinical picture, and I was making an absolute terror of myself to the consulting neurologist.  I was positive the MRI would show a new nonsurvivable brainstem stroke, but instead it turned out to be pituitary apoplexy - an extremely rare event.  Thanks to hormone replacement, he went from being completely unresponsive to nearly back to where he was before the whole episode - save for deconditioning and very limited vision, but we're all completely thrilled.

The thing is, I wonder if that MRI would have been ordered if I hadn't been there arguing away (they were insisting it was "fluctuations" from the initial hemorrhage).  Anyway, I'm back at work, dad is going to the rehab facility tomorrow, and we get to enjoy his company a bit longer.

It's been an exhausting two weeks....

[dualstow]

Wow, WiseOne. Hang in there and keep us posted.

[Benko]

The thing is, I wonder if that MRI would have been ordered if I hadn't been there arguing away (they were insisting it was "fluctuations" from the initial hemorrhage). 

Probably not, and good for you!

[WiseOne]

The thing is, I wonder if that MRI would have been ordered if I hadn't been there arguing away (they were insisting it was "fluctuations" from the initial hemorrhage). 

Probably not, and good for you!

Yes, I'm afraid the way it works most of the time is that the most obvious problem gets diagnosed, the patient is admitted, and then whatever happens happens ("no user-serviceable parts inside").  Maybe that's where medicine is headed - certainly low cost, but rather medieval in outlook. 

If I can offer a bit of advice to any of you who might find yourselves in a similar situation:  it's very difficult to think clearly when it's your family member involved.  I had a trusted neurologist friend on speed dial through the whole episode.

[notsheigetz]

My 94-year-old dad went into hospice this week. That doesn't mean he transferred from his long term care facility to another place. He is still in the same place but he is now, as best I can understand it (and I went through hospice with my first wife at home), officially in the end-of-life stage whatever that may mean. At this point I'm not exactly sure what the hospice worker does except that she visits my dad at the facility and the hospice fees are 100 percent paid for by medicaire (my mom still has to pay the $7k month for the facility however).

[MachineGhost]

It is indeed.  We all thought we were going to lose Dad, but then along came a get out of jail free card.  Something wasn't adding up in the clinical picture, and I was making an absolute terror of myself to the consulting neurologist.  I was positive the MRI would show a new nonsurvivable brainstem stroke, but instead it turned out to be pituitary apoplexy - an extremely rare event.  Thanks to hormone replacement, he went from being completely unresponsive to nearly back to where he was before the whole episode - save for deconditioning and very limited vision, but we're all completely thrilled.

He's actually receiving HGH injections now?  How old is he?

My 92-year old Grandma is back in the hospital within a month for pneumonia again.  On the first stay, a small tumor on her thyroid gland was discovered via CT which is why she was hot in the head all the time and needed a small fan blowing, even in the middle of winter.  All the "experts" have done about it is lower her synthetic thyroid medicine which she's apparantly been on for at least a decade.