Walking in other people’s shoes: a thought experiment

People I work with have a different view on healthcare. I think there are four pillars in care: PATIENTS, PROVIDERS (docs and nurses), SUPPORTS (pharmacists, lab staff, social workers, etc.) and MANAGERS. Each brings something different to care.I have found it difficult to build a rapport with hospital administration. It is challenging for me to understand their plan, their goals, their measures—probably because of very limited interaction and communication. My opinion isn’t sought, my experience seems irrelevant, and my role as a contributor to the wellbeing of my community does not seem valued. Yet managers and administrators are good people, who have had to suffer the ravages of fiscal restraint, COVID and system malfunction. System collapse, actually.Let’s start with a patient, Sandy Roberts. She is 78 years old. She is admitted to hospital on Dec. 22 with chest pain. How do the four agencies of care see her, from their own unique perspectives?The family physician, Dr. Norman White, takes the call from Millicent, her daughter. He tells her “She needs ER care, dial 911.”He is correct, of course, this unsettling call will ruin his day, especially coming at 4:45pm. He is unsure if he will be contacted by the ER doc, but he makes sure his staff stay late to fax off a summary sheet, and phones the triage personally. He hasn’t seen Sandy since George died, and feels the three-year gap was probably too long. He hopes Sandy will do well. She’s a nice person who did a lot for the food bank last year.The ER doc, Dr. Barry Tones, introduces himself to Sandy as she arrives in Trauma Bay (a holding tank for the Cardiac ward). She gets an intravenous, nasal prongs oxygen, and an aspirin. The EKG tech isn’t happy: she has two ward cardiograms lined up, and now she’s left her dinner for what might be nothing. The stat EKG, however, shows an acute inferior MI.Barry completes a screening history and physical, and calls the internist on for cardiac care. Thrombolysis is suggested: no bleeding issues here. Barry knows she will be out of his hands shortly, and he can get on with the four other patients who arrived at the same time as Sandy. His personal interest is Sports Medicine and Obstetrics: he never did like the stress of arrhythmia and pain and potential demise. He leaves soon as Dr. Henderson appears.Dr. Henderson supervises thrombolysis and knows she will need a high acuity bed post treatment. That will mean moving one person out to the general ward, and it’s already 7:00 pm. Nursing staff change-over is at 7:30 p.m., so she will have to wait. Surely there will be a bed for this lady: corridor care is not an option. What with Christmas coming up, who knows when the cardiac catheterization will be done at the tertiary care centre across town?Sandy, by this time, has surrendered herself to medical intervention. She doesn’t know what an inferior STEMI is, what ectopics are, or if thrombolysis might be repeated. She worries she might die. She worries that Millie might have an asthma attack, with all this excitement and all. She worries that her dog, Woof, won’t get his dinner tonight. She worries she might die. Fortunately, her pain improves with meds and morphine, and the oxygen is reassuring. She puts her faith in the hospital “doing their best,” although she doesn’t know it is running overcapacity, and she’ll be sharing a room with three men (two COVID positive, one confused). She has trouble telling Dr Henderson about her urinary incontinence, and gluten intolerance. She wanted to bring her three medications in with her but in the rush forgot (paroxetine, topiramate, ranitidine). She answered “no” to all the screening questions, but now remembers her hemorrhoids bled last month—was that important? What is an 'angiogram,' and would it hurt? Why does she need to transfer to another hospital for it, and will it be safe? Was her GP coming in to see her tonight, if not why not? What was her nurse’s name (Sandy doesn’t have good hearing), was it Miriam or Marion?Sandy stays in ER overnight, given the bed situation on the ward. Madelene, her nurse, had a fight with her boyfriend, Brad, and now is in a panic about the stability of that relationship. Her car was towed the night before last (transmission oil leak) and she is now dependent on a lift home from Benny, the LPN on floor 4. Madelene has been having palpitations recently, mostly from stress, which she medicates liberally with red wine. Tonight, she has been assigned the care of Sandy, a senior who is hard of hearing, doesn’t know her meds, and who is having a heart attack. She has three other patients: an abdominal pain, a urinary retention and a drug-seeking youth with mental health issues. Sandy asks a lot of questions, so Madelene avoids prolonged contact—except when giving her drugs and recording her vitals. She charts a lot on Sandy, not so much on the others. Sandy is snowed with Gravol and morphine, and it looks like she has had only simple reperfusion arrhythmias. Maddy’s other patients will keep her busy into the small hours.To Madelene, Sandy is the nice 78-year-old lady with cognitive issues who should be on the cardiac ward, but is stuck with her. When she’s transferred, she parks most of her memories and makes up with Brad.Amie Smith is the clinical nurse co-ordinator, the administrator that night, in charge of beds and staffing. She has been told of three nurses who have called in sick, one of them with 15 minutes notice (“COVID-like cough”), and an over-census situation she can’t fix anytime soon. “Why can’t we move patients off floor 5?” she says at morning report. She is met by blank looks from the huddle of managers and community health workers. “Well, if we had a place to put Mr. Blackwood, and Doris Dougherty . . .” A chuckle goes around when Doris’s name comes up: a pleasant 75-year-old lady with morbid obesity, diabetic leg sores, and moderate dementia, who has been there for 7 weeks. “No place like home, and no home to place her in . . .”Amie has taken phone calls all night, from staff, from remote hospitals, and the dialysis unit, a pharmacy and a GP. Now Dr Henderson is breathing down her neck. She wasn’t trained to take all this flack. Her intuition is to apply for a desk job in the next town, daytime hours, “Quality Measures Advanced Planning and Development Co-ordinator for Region 6.” Better money, less hassle—in short, a life. Morley Throgmorton has been a level 2 administrator for ten years. He will be looking at retiring in the next couple of years, with a good benefits package. He is in charge of matching the expenditure to the budget, and God help him if he is over by a dollar. He limits staff overtime work, and sometimes reins in clinic hours. He keeps good company with Ben Giesbrecht (MLA) on the golf course every Wednesday. Morley has done well to almost match service with demand (well, not-at-all to be honest). He does his job well enough to pass his annual review with flying colours. No body count to worry about. Patient complaints are directed elsewhere. He can always deflect blame towards a nurse med error, or a doctor shortage, or a lack of system resources. Morley doesn’t know about Sandy, except she’s going to be an inpatient LOS anomaly (it’s Christmastime).We knew all this would happen 20 years ago, but most political terms are four years long. Did we plan well enough? No. Were tAVRs (minimally invasive aortic valve replacements), ICDs (implantable cardio-defibrillators) and rotary atherectomy (catheter clearance of coronary artery plaque) commonplace 20 years ago? No. Was Sandy (then 58) preparing for life as a widow, and was Millie aware her mum would be flying solo? No.Doctors and nurses would like to share their perspective of prevention, diagnosis, treatment and optimal longitudinal care. Their opportunity to input ideas is very limited. Nurses are human too and can take pressure up to a point, when altruism, humanism, and care values break. The introduction of EMRs hasn’t made the hospital a more caring environment—it likely has shifted it to a more documented and structured system, one that patients don’t really understand.Patients just want to be given the best care possible and be free of suffering and the fear of death. Administrators want to get by in a business lacking sufficient oversight and resources and hold on to some vestige of the status quo. Canada’s healthcare system isn’t what it used to be. It is not the envy of the world. We have huge problems with access, and follow-up, and seniors care. Tommy Douglas died in 1986—holding on to his values today seems optimistic. One day we will have to decide between poor care and none. Time to invest in radical system reform—NOW.

Walking in other people’s shoes: a thought experiment

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