Notes From the Other Side

I was at work about 4:30 p.m. when I first noticed epigastric abdominal pain.  It intensified and became diffuse as I sat through an evening meeting. By the time I arrived home at 9:30 p.m. my abdomen was distended and tender everywhere.   I paced, sat down, lay down, and tried to rest.   At 12:30 a.m. I was lying fully clothed on the bed and my wife said: “That’s it.  We’re going to the emergency room.

She drove the Mini.  Every speed bump awoke the pain.  Registration and triage occurred promptly but everything seemed to be moving in slow motion.   Words spoken loudly sounded like screams.  I received medicine for pain and nausea and sat in the waiting room, drinking CT contrast from a large Styrofoam cup.  An hour passed.  A nurse approached and led me to an ER bed.    I put on a gown and waited for the CT scan of my abdomen.  Everyone was kind and attentive.  I lay waiting, trying to keep my left arm straight so that I wouldn’t occlude the IV line planted in my left antecubital fossa. 

The CT scan was imminent.  I waited.  Escort would be coming soon.  I waited.   I sent my wife home to get some rest.  I called my nurse to ask about the study, and she said she would check.  I waited.   Finally the escort came and wheeled me toward the scanner. I learned that somehow my name had been accidentally removed from the task list of the CT technicians.  They apologized.

The CT technicians treated me like they knew I was in pain.  One of them called me “buddy” in a friendly way.  The radiologist and ER physician puzzled over my scan for awhile and decided I had appendicitis.

As I waited to be admitted, my boss appeared in the cubicle to provide moral support and practical advocacy.   My wife returned with my daughter a little later and assumed those functions.   At about 10:30 AM I was wheeled to the pre-surgical area and met the surgical nurses, the surgeon and the anesthesiologist.  Everyone washed their hands as they entered and left the room, and everyone asked for two identifiers (“Tell me your name and your birthday”) before giving me anything.  The surgeon drew x’s on my abdomen near the appendix.  Then I was wheeled into the operating room and the anesthesiologist told me that he was going to give me something to help me relax. 

I think the recovery room nurse called me “Bob” because I had told another nurse before surgery that they should use that name to call me out of anesthesia.  My mouth was very dry.  Nothing hurt.

Family visited in my room that evening, and I drifted off to sleep occasionally as they sat with me. When they left I awoke fully and began a long night of effort to reboot my physiology.  My mouth had never been so dry.  I pushed my IV pole around the room, trying to coax saliva onto my tongue and awaken my viscera.  My nurse and technician visited frequently.  They could see I was uncomfortable and offered me medicine for pain, but the fact was that I really had no pain.  As she left in the morning my nurse said quietly, “I wish I could have done more.

By 11 a.m. all discomfort had subsided, and I felt well enough to leave the hospital.  The escort made an obvious effort to avoid jostling me as we rolled through the hospital lobby and out onto the sidewalk where my wife awaited with the Mini.  She slowed for speed bumps as we drove home.  There was no pain this time.  

That was two weeks ago today.   When I walk fast or begin to lift something I notice a pulling sensation in my lower abdomen, and then I remember that I had surgery.  I walk slower. 

When I remember the experience I notice feelings of relief and of gratitude.   My pain was managed promptly.  A diagnostic procedure was initiated within minutes of my arrival.  I was taken back to my ER cubicle as soon as one became available.  I was attended by staff who gave every appearance of caring about my comfort and safety.   A surgeon fit me into his busy OR schedule. I had little pain postoperatively and, if I’d had much pain, I would have gotten all the analgesia I needed.  I had no serious complications and was able to go home the next day.  I was driving in 48 hours and back to work full-time on the fifth post-op day. 

In this era of high scrutiny and overreaching oversight, score one for the health care system; this was a very good outcome.  Our system and our healthcare workers did right by this patient.   I wish Michael Moore had been with me in Baltimore County that night, filming away.

Of course he would have noted a few miscues and imperfections. Unnecessary noise, unnecessary waiting, a need for vigilance on the part of the patient and advocacy on the part of family to make certain that things stayed on track.    But I – and we all – know that we don’t have failsafe systems. Things frequently don’t go as well as they could.  We can always improve.  

And as a physician and sometimes patient in Baltimore County, I don’t take this as a demoralizing surprise.  I take it as an indisputable verity and a call to action.  In the days of its ascendency, before its recent slips and falls, Toyota was known for the quality of its products.  A major factor in its success was the attitude that quality and efficiency can always improve, and that it is everyone’s responsibility to identify opportunities for improvement and develop solutions. 

Hospitals and healthcare systems in Baltimore County – including St Joseph’s Hospital, Greater Baltimore Medical Center, and Sheppard Pratt Health System – are using so-called lean methods, derived from Toyota Production System (TPS) principles and practices, to drive change for the better in hospital-based care.  Physicians are growing increasingly knowledgeable about these ideas and in many settings are helping to lead lean-inspired improvement efforts.   I have watched and worked with quality leaders in the aforementioned institutions and have seen for myself that these methods can make healthcare systems work better for patients and those who minister to them.

So we’re working to make things better.   And it’s my belief that these efforts - led increasingly by physicians - will yield a system of care that moves closer every year to the aspirational standard set by the Institute of Medicine, i.e., care that is consistently safe, effective, timely, patient-centered, equitable and efficient.  But to tell you the truth, we already really shine around here much of the time.  In fact, on one cold night in January, for at least one grateful patient, Baltimore County was a damn good place to get sick.