We Who Are About to Die

I once worked at a hospital where every infraction of the rules was punished by death.  I was somewhat insulated from this because it is a little harder to replace a physician than that guy spooning pseudo-meat into my Chalupa but the nurses lived in a constant sweat of fear and even I had a nagging feeling that I was being watched carefully for the Straw That Would Break the Camel’s Back.

Smoke a cigarette on the hospital property?  Immediate termination.  Park in the doctor’s parking lot rather than make the long, dark walk from an isolated parking lot a couple of chalk outlines from the ghetto?  Immediate termination?  Take a verbal order from a doctor? Immediate termination?  Cell phone at the nurse’s station?  Immediate termination.

In fact, I was once texting while standing at the nursing station and some supervisor of something-or-another told me that cell-phones were not allowed and then looked on in helpless fury as I laughed and took his pictures to text to my friend.  This is a good way to make enemies and I’m sure I’m going to be the first one up against the wall when “Papa Doc” Press Gainey is installed as out Great Leader and Ruler for Life but I did not come through the irritating hell of medical school and residency to be scolded by a bureaucrat like some wayward candy striper.

It was a miserable place to work I suppose if you had kids in school, a mortgage, and no easy way to stick it to The Man.  The staff were on edge, always looking over their shoulders, and the turnover was high despite the usual Chrysobulls from the corporation promising love, community spirit, and all good things to their dearly loved but benighted employees.

The worst part of this was how the hospital handled complaints.  You could be the scariest crack addict in town, threaten the staff, and use language that would make a sailor run home to his momma but if you called or wrote the administration opining that you weren’t satisfied with your care the presumption was that somehow, somewhere, the nurse was at fault and if she had just rounded a little more often on the patient or brought them a pillow to rest their scabies-infested head the patient would have left as happy as a lamb.

That the endless miles of paperwork required of the nurses to document their rounding and pillow-dispensing not to mention start and stop times of simple IV medications were seriously impeding their ability to engage in direct patient care or that they were perpetually a few nurses short in a busy modern Emergency Department was never considered.

Naturally the administration’s solution was to create even more intricate paperwork traps to document compliance with hospital edicts.  Every room, for example, had a green rounding sheet outside of it upon which the nurse would sign her name every thirty minutes attesting that she had visited the patient.  And just as naturally towards the end of the shift the harried nurses, many of whom had been on their feet for the entire twelve-hour shift, surreptitiously filled out all of their sheets with fictitious times, risking immediate termination for doing it no doubt.

I mention this as a metaphor for American Medicine and American life itself.   That’s how it is nowadays whether you’re being yelled at by blue-shirted TSA commissars or trying to practice reasonable medicine and nursing in a hospital run by the Borg-like bureaucrats and lawyers who seem to have assimilated us all.

Like I said, most paperwork is a trap of some sort.  An intricate web of checkboxes, signatures, and dates designed to isolate and punish doctors and nurses for errors that are inevitable given the complexity of modern medicine, the titanic sums at stake, and the Jurassic predatory legal environment.  Like every other aspect of our insane over-litigated and over-regulated country, it is impossible to comply with every dictat of the bureaucracy so invariably most paperwork is done on automatic pilot and we even have complicated software packages to generate reams of irrelevant boilerplate.

The majority of paperwork is fraudulent.  We are all criminals now.

They Can Die

Everybody knows a few patients like this.  You know, the kind that despite every medical problem possible continue to live for years and years while otherwise healthy people rapidly succumb to the first major medical event of their lives.  A certain mythology has developed about these patients, namely that they are incredibly hardy and will even survive a nuclear war.

I had one of my Iron Men (as they are called) die the other day.  He was a sixty-year-old man with fifteen stents in his coronary arteries, one functioning carotid artery, countless strokes that had left him blind and paralyzed on his left side, a dialysis port in his chest because all of the available sites on his arms had played out like exhausted gold mines, congestive hear failure, a feeding tube, a tracheostomy, an ileostomy, one leg, and what his doctors charitably called morbid obesity but had to be lifted by six paramedics to be truly appreciated.

Emergency Departments are not busier on a full moon and Iron Men are not made of iron after all although these are pleasant conceits, like campfire tales, to keep us entertained.  My patient had only managed to cheat death because he was being followed by small squad of doctors and in his long and non-productive life had used millions of dollars of increasingly expensive and intricate medical care.  I know for a fact he spent three months of his last year alone in the ICU.

It’s the ICU.  Intensive care.  They can keep a flattened dead raccoon alive in the ICU indefinitely if you got it there quickly enough after running it over.  It is no virtue of the patient but the incredible effort and money we spend to squeeze every bit of life out of everybody that makes the difference.