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Wednesday Apr 11, 2012

What Happens When a Doctor Becomes the Patient?

It is a nice, but cold, calm spring day. We haven't had one of those in a while, so I saddle my horse, Cimarron, and walk him around the arena. (That's Cimarron and me in the photo below.)

Boy, it is good to be back in the saddle again. From a walk to a trot, then a trot to a lope, Cimarron cruises like he has not had time off for the winter. He stops on a dime, and then we lope in the other direction. Well, I think, I better not work him too hard on his first day back in action. Just as I decide that, his right front hoof catches a rock. He tries to recover, but fails as he falls to his knees and crashes on his face.

I am thrown forward, and my chest hits the saddle horn before I'm tossed in front of Cimarron. The 1,300-pound horse rolls on top of me.

Darkness. Then pain. Have I broken my back?

My feeble yells do not bring help.

"I guess no one is coming," I think.

I move one leg and then the other. That's a relief. I move my head, and my c-spine seems OK. I am, however, starting to develop significant left upper quadrant pain.

"Well, it's now or never," I say to myself as I get on my feet. I don't feel half-bad standing. Cimarron, who is fine, looks at me to see if I'm OK. It's a cowboy thing to get back in the saddle if you fall off so the horse still understands who is boss. I try to put my foot in the stirrup, but that is not going to happen.

I lead Cimarron 300 yards back to the barn and take off his saddle. What amazes me is that this doesn't cause any pain. I put Cimarron in his stall and head to the house. The closer I get, the more pain I feel. Everything hurts, and I'm lightheaded.

"Are you OK?" my wife asks. "What happened?"

"You don't look so good," she adds as I pass out on the living room floor.

When I come around, my abdomen is hurting. We live a half hour from town. I think it will be quicker to have my wife drive me to the emergency department (ED) than to call paramedics. I don't want to scare her, so I tell her it will be OK. As we drive, my left upper quadrant is feeling more swollen, and I am getting more lightheaded.

The medical assistant at the ED bay grabs my shoulders and chest and pivots me into a wheelchair. Well, I guess this is good test to make sure I don't have a spine injury. I almost pass out from the pain.

The assistant asks what happened, and I am able to say, "Horse accident, blunt trauma LUQ, near syncopal."

She gives me a quizzical look and says, "Would that be trauma?"

"Yes, that would be trauma."

Things move fast, then. They start an IV in my left antecubital fossa. "Not there," I tell them, but I am ignored.

I tell them I am allergic to shellfish, iodine and most narcotics. They fill me with Solu-Medrol and Benadryl and take me off for a CT scan. The room is air conditioned, and I am naked. I shiver, exacerbating the pain. I am unable to move from the gurney to the CT table, so they roll me over. They pull my arms over my head for the CT scan. More pain, and I am shaking visibly.

Back to the ED room. The nurse finally gives me warmed blankets. Yes! I am informed I can't have anything for pain because of my allergies, but I eventually talk them into Toradol. That helps a lot.

I am told that the trauma surgeon was called for a motor vehicle accident, and it will be a while before I will be seen. Five hours later, the surgeon enters the room laughing. "I bet you are in pain, aren't you?"

Hilarious. Luckily, I don't have a fractured spine or spleen. My blood work is fairly normal. Interestingly, my blood pressure is slightly high. Gee, I wonder why.

What I do have is five fractured ribs, both anteriorly and posteriorly. Believe it or not, there is no pneumothorax. I am admitted to the ICU because of my allergies to narcotics, and they can monitor me better there.

I know most of the ICU nurses. That is a comfort until I realize that I am going to have to urinate eventually.

I don't have an allergic reaction to a test dose of fentanyl, so they give me a regular dose. I am feeling better -- and hungry. It has been 18 hours since I last ate.

"Sorry, the kitchen is closed. Maybe your wife can go get you something."

No wonder I have not had to urinate -- yet.

Like most ICUs, there are no doors, bathrooms or privacy. Little things start to bother me, like the fact that it is 2 a.m., and the nurses are talking at normal volume and laughing at jokes.

"Dr. Spogen, why don't you sleep some? You will feel better in the morning."

I can't sleep, and every time I flex my left arm, the IV alert rings until the nurse silences it. That is why I didn't want them to put the IV there.

I don't feel better. In fact, every inch of me hurts. Worse yet, I have to pee. I finally muster the confidence to ask the nurse. They pull a curtain around me while holding my shoulder so I don't fall.

That urgent problem solved, I now notice that I am hot. My skin is burning up, and I am really red. Everyone decides I must be having an allergic reaction. I get another shot of Solu-Medrol.

Guess what? I get redder. Then it dawns on me that one of the side effects of steroids is flushing. As the Solu-Medrol works its way out of my body, the redness fades.

Finally, I get out of the ICU and am transferred to the medical floor. Maybe now I can sleep? The nurses on that floor are all quite nice. "Just let us know if you are having pain, Dr. Spogen, and I will get you some fentanyl. It's already ordered."

A couple of hours later I start to cough. If you ever have coughed with broken ribs, you know it is not comfortable. The more I try not to cough, the more I want to cough and the more painful it becomes. I finally call to ask the nurse for pain meds. She answers on the intercom that she will be right with me. Two hours later, she arrives and wonders why I refuse the medicine. The thing about broken ribs is that if you don't cough, sneeze or move, the pain goes away. My coughing fit had passed already.

On the second night of my stay, I try to go to sleep at 10 p.m. At 11, the nurse brings me ibuprofen. At midnight, the nursing assistant comes to check my vital signs. Every time I flex my arm, the IV alarm goes off, so the assistant shows me how to silence it. At 3 a.m., I get another round of meds. At 4 a.m., the phlebotomist comes for a blood draw. At 5 a.m., another set of vitals.

The nursing assistant asks how I slept. Is she kidding?

I begin to feel strange, somewhat like I am getting a viral infection. I feel myalgias, neuralgias, slightly nauseated and lightheaded. The nursing assistant checks my vitals. My pulse is OK. My blood pressure is OK. I don't have a fever.

"That's strange," she says.

"What's strange?"

"Your oxygen saturation is 78 percent. Why don't you take a couple of deep breaths?"

I do. No change in the oximetry.

"I'll go get the nurse."

What's odd is I don't feel short of breath. But it makes sense that I might have a little atelectasis, so I get out the incentive spirometer. Gradually, I feel better. Finally, at 7 a.m., two and a half hours later, the nurse comes in, mainly because there is a shift change.

"What about my oximetry?" I ask.

"Just keep taking deep breaths."

"How about you check my oximetry, just for fun?"

It is 95 percent.

They decide to keep me in the hospital another night because of my low oxygen. My pain is fairly well controlled with a fentanyl patch and ibuprofen, so they hook me up to a continuous pulse ox. The day passes uneventfully. I get ready to sleep at 10 p.m. I'm soon fast asleep, but the pulse ox alarm, which is set to go off if my saturation falls below 87 percent, wakes me up. I call for the nurse. A half an hour later, the alarm continues to blare and still no nurse. I struggle to get out of bed and manage to silence the alarm. I go back to bed and immediately fall back to sleep, but what seems like seconds later, the alarm rings again. This happens 12 more times before the nurse finally shows up.

I am furious, exhausted and maybe a little drug impaired.

They finally put me on supplemental oxygen. The alarm does not go off, but now I can't sleep. I get up at 5 a.m. and take the oxygen off because when I am up my oximetry is fine.

When the nurses change at 7 a.m., I ask them when the doctor is making rounds. They have no idea. How did I know that would be the answer?

I don't want to spend another night in the hospital, but I do need home oxygen. Having discharged a lot of patients on oxygen in the past, I know that getting insurance verification takes hours, so I am proactive and ask the nurse to see if the doctor can order home oxygen. Hours pass. No comments from nurses or doctors.

At 11:30, I'm pretty upset because there is no communication, and the ward clerk doesn't know anything. Shortly after that, transportation comes in to take me down for a chest x-ray.

"Good morning, Mr. Spongen. I'm here to get you for a chest x-ray. Do you know why you are getting an x-ray today?"

Already frustrated, this pushes me too far.

"That is DR. SPOGEN, to you. And NO, I have no idea why I am getting an x-ray."

I hate to play the doctor card, but I'm angry. I realize that this is the wrong person to vent my frustrations on, but it gets things done. The tech goes to the desk, and the nurse immediately appears. I tell her what I think needs to be done if I am to go home on oxygen, and she calls the doctor's office.

I get the x-ray, and when I return to my room, the doctor's nurse practitioner is there. He warns me that he needs to do a complete exam so they can send me home. Apparently, he has no clue what a complete exam is because all he does is listen to my chest and check my grip strength. I am pulling more than 3,000 cc on the incentive spirometry, so he confesses there is no reason to keep me in the hospital. He agrees that I should have home oxygen for at night, and says he will put in the order. He gives me two weeks of narcotics and tells me I should be OK to work in four days, but "Don't work or drive on narcotics."

Hmm … that does not compute. Oh well, I am getting out of here.

My wife arrives a few hours later. The nurse says I'm OK to leave. No signing papers, no wheelchair ride, just goodbye.

On my way out, I get a call from the home oxygen supply company. The order was not placed until 3 p.m., and they can't get insurance verification. They tell me I might want to spend an extra night in the hospital if I need oxygen because they cannot deliver it without verification. I cannot believe it! Finally, they agree to leave the oxygen if I give them a check for $1,500 in case insurance does not cover it.

I am home now and recovering from my injuries. I am a respected doctor who works every day in this hospital, yet look how I was treated. I now understand why some of my patients are upset with their hospital care.

The biggest flaw was poor communication. I had considered having my family doctor admit me instead of the surgeon. My family doctor would have listened to my concerns and would have communicated to me why I was getting an x-ray (I still don't know if it was ever read) and would have known to order the oxygen early enough to make sure there was insurance verification.

It was a good lesson for me, however. I will handle my inpatients differently in the future, and I will make sure they have their orders on time. I have admitted patients in the past who are doctors or nurses. As their physician, I will make sure they get private rooms, and that their privacy is respected. My students and residents will hear about my experience, and they will know the issues patients face.

As a physician, I knew when my treatment was not ideal, but most patients do not have this same knowledge. Maybe if all doctors and nurses spent some time as patients, we could make the system better.

Daniel Spogen, M.D., of Reno, Nev., is a first-year member of the AAFP Board of Directors. He is a professor and chairman of the Department of Family and Community Medicine and director of medical education at the University of Nevada School of Medicine.


Thanks for the story, Dan. My dad just had a similar experience. I was there the last day to advocate for him. But NOT a patient-centered experience. Wonder how we get this to change, especially with fewer family doctors going to the hospital these days.

Posted by Anne Montgomery, MD,FAAFP on April 11, 2012 at 03:44 PM CDT #

Well said, doctor. I'm sorry you had to endure this injury and this care. After delivering twin boys last year, I had a very similar experience during my inpatient stay. One of the nurses was strikingly abusive and mean. As a patient, my expectation is not to use my training and education. It is to be cared for. She had me in tears. I was proud to know that as a former FP hospitalist, I did my best to provide compassionate care, but didn't realize the climate "out there." I hope you are healing well and that your message reaches us all as a care community. Lots of love to Cimarron too!

Posted by Gretchen Phillips, M.D on April 12, 2012 at 08:50 AM CDT #

Glad to hear Cimmaron is okay. No, seriously, you survived a terrible traumatic injury with risks for so much more complication that would have placed many of our less healthy patients at risk for their life over the next days. And your story angered me, as it should all of us. Your local hospital has major SYSTEM problems, from the check in at the ER to the care while in X-ray, through your discharge, all well documented in your thoughtful story. And all of them cry for corrective actions/efforts through hospital team approaches to the systems we use to "care" for our patients. You deserved better; all our patients deserve better. Good luck pushing your story through your local QA program, and in 2 years of concerted team efforts, it would be nice to hear of the changes for the better. Keep healing--that takes more time than we docs like. Best wishes.

Posted by John Carroll on April 12, 2012 at 09:28 AM CDT #

Glad to see that you and your horse are on the mend. I can relate as I am a horsemen and MD. Even the office on a good day can’t beat the time on the trail with Dusty. My group is still admits and sees our patients in the hospital as well as maintaining a busy office practice. I am an EMT, RN, and MD and have worked in each of these areas. I, too, regret when the system abuses those we are entrusted to help. Compassion and compassionate care should be the norm, but technology and time can become a rate limiting step. We all someday will have the physician mantle removed and replaced by the ravages of time leaving only the aging patient in the bed. I endeavor to provide the kind of care that I will and should receive when I am in that state. I try to keep this in mind every day during my busy practice.

Posted by Raymond Decker, M.D on April 12, 2012 at 10:56 AM CDT #

Glad you and Cimmaron are OK I would strongly recommend riding with a helmet, OK I know it is easier for those of us who ride English (I ride a Trakehner - Dressage / Hunter), but there are Troxel cowboy hat helmets available or you could get a good Charles Owen helmet etc.

Posted by Roy Bishop on April 12, 2012 at 07:10 PM CDT #

Had a similar experience with my husband (a ER doc) who was admitted for CVA work-up. Nobody seemed to know what the heck was going on, and we had to forcibly direct his care. Little sleep was had, meds not given in timely manner (including asthma inhalers). When studies were done, we had to all but check out AMA b/c the hospitalist couldn't believe we wanted to leave (altho no therapy was occuring) and hadn't reviewed the chart. We took our concerns to the CMO, CEO, and hospital president. Will see what comes about. We were horrified by the experience. Continue to tell your story; we are the most credible "witnesses".

Posted by D. Sutcliffe on April 15, 2012 at 01:25 PM CDT #

So glad to hear you are out of the hospital and recovering, but I am so sorry you had such a bad experience. I do feel compeled, however to temper the negative accounts with a positive one from the community hospital where I am on staff. Recently, my husband, Chuck, had a screening colonoscopy and (very large) polypectomy. That went fine, but he didn't feel well next day and had abdominal pain. The surgeon who did the procedure was still at his office after 5 pm for a staff meeting and had us come over where he and the on call surgeon both examined my husband, ordered AAS that was done right away, treated him for presumed early infection, and followed up next day. He felt better, had stable exam and went home only to pass BRB. When he called the surgeon to report this, he was told to return for admission to the hospital. I met him at the hospital, rapid registration occured and I wheeled him to the ICU, but only after a second bloody BM in the public restroom. I retired my white coat in the doctor's lounge and let all the nurses know that I was the wife here, not MD. Shortly thereafter, my husband said he felt bad, and I watched his heart rate and BP steadily dropping, so I got a nurse and tried to maintain a calm facade so not to scare him, even as I am wondering if he is having an MI from blood loss and is he about to code. At least three nurses came in to help stabilize him. He's diaphoretic as they try to get EKG, O2 on, vitals, and call the hospitalist (who had been consulted because his BP was high on admit.) He feels worse supine and needs to have a BM. I told him go in the bed, but they got a bedpan under him and he filled it with BRB, then felt better, pulse and BP improve as he is no longer vasovagal. The hospitalist came in about that time and immediately took control, providing me with an enormous sense of relief. He order STAT transfusion (blood was already on hold) without waiting for labs for justification given the amouont of blood, and politely but firmly informed me of his reasoning, but not really asking my approval. Again, he had rapidly assesed the situation and calmly, competently took control. I could have hugged him. The surgeon who had performed the colonoscopy was there also, had already tried to get the GI doc on call on the phone unsucessfully (only negative thing that happened), but the hospitalist knew the other GI doc was in house finishing a procedure. He called him and even though he wasn't on call, he sent the endoscopy team to set up for emergency procedure and calmly explained to me and my husband what he was going to do, did the procedure in his room (with Chuck watching the video monitor the whole time), successfully clipped his polypectomy site ulcer and no more bleeding. I went to get a cup of coffee and a yogurt while this was going on and I couldn't be in the room, but really needed an excuse to get out of there, have my little break down, wash my face and return. They let him have clear liquids and the nurses got him popsicles, ginger ale, juice. The ward secretary came in with a recliner and blanket for me to sleep on that night, even though I had not requested it. All the docs (GI, hospitalist and surgeon) had let both of us know exactly what they thought was going on, what the plan was, and were totally professional and reassuring. The lights in the whole unit were dimmed about 10 pm and the staff stayed as quiet as possible. I didn't sleep much, only because he didn't either, and after they checked his labs the next morning they let him go home. Along with the discharge papers, the nurse brought a large bowl of frozen homemade chicken soup prepared by our cafeteria cooks for ALL patients at the time of discharge. (I had only learned about that policy a couple weeks before when I happened to stop in as the nurses were giving my patient their discharge packet and soup.)Onslow County Memorial Hospital is not a big teaching hospital, and I am sure there was some preferential treatment because they all know me, but I will put our nursing staff up against those at any large system any day of the week when it comes to dedication and compassion. I have seen that same level of care provided by our nurses with my own patients the majority of the time. Our CEO and Board are really trying to promote a healing environment with patient AND family centered care, and they really nailed it with the care provided to my husband. I can only hope we can keep it up and that we as Family Physicians can continue to advocate for our patients both in and out of the hospital.

Posted by Ruth W. Guyer, M.D. on April 17, 2012 at 01:09 AM CDT #

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