“The guiding principle of all caregivers should be to know the patient, hear the patient and respond to what matters to the patient. It should make no difference where you practice; any provider can do this. Emergency departments can’t hide behind the excuses of “we’re too busy” or “it’s too chaotic” to avoid meeting this standard.” Dr. Yeh
It was just after 6 p.m. on Dec. 7, 2011, when I went to meet a colleague for dinner in Washington. It was dark and rainy, and I was about a third of the way across the intersection when I heard a thump and felt a sharp pain squarely in my backside. It took me a few moments to realize I’d been hit by a car. Before I could make sense of the situation, I had flown through the air and landed on the street.
“Are you OK?” a man asked me. I was so stunned that I said nothing – highly unusual for me.
When the emergency medical technicians arrived, they placed a C-collar around my neck and positioned me on a backboard for the short ride to the hospital.
The admitting team rushed me into an exam room, where they asked if I was having any pain. It seemed an odd question, seeing as a car had just plowed into me. Yes, I was in considerable pain, I told them. An IV was inserted, and the morphine began to flow.
A doctor came in and began an exam to detect risk of life- or limb-threatening emergencies. Then came a brief evaluation to ensure that I could come out of the C-collar and off the backboard, a visual inspection for external bleeding or misaligned bones, and an assurance that my heart and lungs were functioning normally.
I told the doctor that I had severe pain in my knee and backside. She ordered a CT scan of my abdomen and pelvis as well as a chest X-Ray. Wasn’t she going to examine my knee and backside?
When the tests were completed, I was wheeled out of the exam room, still flat on my back. By this time, roughly three hours after the accident, the emergency department was chaotically busy, and all of the rooms were filled, so I was parked in the hallway. A new round of clinicians stopped by my stretcher. “Well, everything looks fine on your tests,” the head clinician informed me. “There’s a little bleeding in the muscle around your hip area. We just don’t know if that’s going to continue, so we want to watch it. We’re going to admit you.” I gasped. I was still in denial that I had any serious injuries.
An inpatient bed wasn’t available, so I would be “boarded” in the hallway until one opened up.
I lay there on my gurney for nearly 15 hours with my BlackBerry, my cellphone and a morphine drip, watching the bustle of hospital traffic around me. Several times, my blood pressure was taken. When the pain returned every two or three hours, I caught the eye of hassled staff members and had them tell the nurse, who would come by to give me an infusion of morphine.
I felt alone and was struck by the demeanor of some hospital staff who rushed by. It seemed as if they were deliberately avoiding eye contact with any of us poor souls waiting in the hallway, lest they be interrupted and asked for help.
‘Nothing is broken’
In the morning, the day crew appeared. Residents went from stretcher to stretcher, sorting out patient dispositions. The staff learned that I was an emergency physician and moved me into a private room. The room was darkened so I could sleep, and the door was shut. I felt abandoned, clutching my nurse call button, a lifeline to the world.
A new trauma team stopped by later in the day. Because I had been stable all night and no major injuries had turned up on the CT scans, they decided I was ready for discharge. “Nothing is broken; you can go home now,” said one of the team members.
I was stunned. I was still in excruciating pain, and my knee and backside still hadn’t been checked. The good patient in me wanted to please the doctor and saunter out of the room, but the real person in me was scared. I told the team that I wasn’t sure I could walk. I was traveling on business and staying alone in a hotel room, so I might not be able to care for myself, I said. Again, they told me: “Nothing is broken, so you can walk.”
By now, no one had examined my swollen right knee or left hip area. I knew that serious ligament or cartilage injuries could be sustained without broken bones. No one had talked with me about whether I would be able to function safely at home or about follow-up care.
With trepidation, I said I was happy to go home. “Do you think I’ll be OK at the hotel?” I said. “My knee is swollen, and I’m not sure I can walk on it.” They sent for physical therapy to help.
The PT team attempted to stand me up, and I nearly crumpled to the floor. I couldn’t support my weight, let alone walk. They helped me back onto the stretcher and then left the room to brief the admitting team.
The resident returned. “There’s no medical reason to admit you,” he said, “but if you can’t walk, we’ll just have to.” The good patient in me felt embarrassed that somehow I had failed the “test” and was now an unnecessary admission.”
Finally, an exam
The trauma team returned to tell me that a bed had opened up – in the maternity ward. There, nurses came in and out as I asked, over and over, it seemed, “Is anyone going to look at my knee?”
At the end of the day, an orthopedic consultant appeared. He determined that I had a ligament tear and recommended putting me in a splint and getting me an MRI scan when I returned home to Boston. Finally, I had a partial diagnosis.
That night, I began to experience numbness and tingling in my leg and my hip. Three times, doctors or nurses came through, and each time I explained my concerns but was not evaluated. It wasn’t until 24 hours later, during the night of my second day of hospitalization, that I had a neurological exam, which revealed contusion of both the sciatic and the gluteal nerves.
On my third day in the hospital, someone asked if the admitting trauma team had done a history and physical. It had not. A resident finally did them. By my fourth day in the hospital, I was both medically and functionally stable, able to move cautiously with assistance and a walker. I insisted on getting transferred to a rehabilitation facility near my home in Boston.
What about the patient?
Nearly two years later, after extensive rehabilitation, I am still limping and use a cane. I still need wheelchair assistance at airports and struggle with my balance on uneven ground. It is a challenge to put away bath towels on an upper shelf without tipping over.
As a medical professional who became a trauma patient, I was struck by the uneven nature of my care, which was marked by an over-reliance on testing at the expense of my well-being. Instead of feeling like a connected patient at the center of care, I felt processed. This is disconcerting, especially at a time when patient-centered care – that is, care delivered with me, not to me or for me – is supposed to be becoming the new normal.
Despite some national consensus on quality standards, we have continued struggling to measure “the good of the patient.” Tests may provide us with data, but giving them doesn’t mean we’re necessarily serving the patient. Instead of using a test to discover information about the patient, it is being used to define whether a patient even is a patient.
No more excuses
Weeks after my accident, I began rehabilitation to work on activities of daily living such as taking a shower and using stairs. The art of care flickered back to life. Here, personalized patient care was the rule, not the exception. I saw staff members treating patients with dignity and listening to what mattered to them.
Each member of the rehabilitation team asked me what “my goal” was. I told them it was to be able to go up and down the stairs in my house.
The guiding principle of all caregivers should be to know the patient, hear the patient and respond to what matters to the patient. It should make no difference where you practice; any provider can do this. Emergency departments can’t hide behind the excuses of “we’re too busy” or “it’s too chaotic” to avoid meeting this standard.
This story is excerpted from the Narrative Matters section of the journal Health Affairs; it can be read in full at www.healthaffairs.org. Yeh is chief medical officer for AARP Services.
I’ve seen it in my own visits to hospitals. The reason they were avoiding looking at her knee was because there was more money to be made in doing the other “tests” and such.