ETA: You are about to read a very imperative shit fit that I'm required to have right now. Much as it may seem like I hate all health care workers, that is not true. We have truly had wonderful health care workers. Mostly nurses and therapists, but an occasional doctor, even an occasional egotistical arrogant asshole doctor that undoubtedly smokes crack in-between patients, but whose skills are teh awesome. Insurance companies, though? Yeah, we pretty much hate all of them across the board.
Over the weekend, D started getting sick again and had a fever. His nurse came over and found a VERY DISGUSTINGLY STINKY leftover piece of wound vac foam that had not been removed as it should have in some previous dressing change. It looks like psuedomonas.
So he is back in the hospital. This time, at the burn center again because they do the best job as far as controlling infection. The bad part of that is that the kids and I can't visit him there. kids under 12 aren't allowed. At it is clear across town and hard to get to anyway. I would have to find a babysitter to cover three hours of simply travel time. I'm glad he is there, though. They are militant about infection prevention. I get sick of the fact that he can't go into the hospital for long without risking that the hospital itself will make him sicker. Irony, no?
I have not been able to write coherently about the subject that Bliss requested: How medical people should approach people with disabilities. Because there is just so, so much wrong with it all right now. And it goes beyond people with disabilities and to just patients in general, especially those with chronic conditions. And then it goes to a systemic level in my head. Mainly I want to shake doctors and say, "Why don't you fight for us?" "Why don't you care for and value our lives?" Because they generally don't. The whole thing just blows up in my head.
D and I were discussing the fact that since his initial foot amputation, every problem after that has been contributed by or due to medical error or other external factors in the medical system that are beyond our control. To give you a rundown:
- In July of 05, D had terrible pressure wounds on both feet. Although he does take responsibility for the fact that he delayed in getting treatment for too long, a big part of the problem there was that a tilt-in-space seating system for his wheelchair was prescribed in 2002 to help his foot circulation. This would help in preventing pressure wounds in his feet and aid in healing. It took over FOUR YEARS for the red tape of Medicare to approve of that chair. He had his left foot amputated and a skin graft done on his right foot. He was hospitalized (sometimes in the BICU) for 3 months.
- In December of 05, he got the chair he needed, but it didn't work properly. Basically, it was a lemon. It took six months to get Medicare to approve repairs. In which time he used his old, stationary wheelchair. In January, his right foot had still not healed and taken to the graft. Although this is probably no one's fault directly, not having the proper wheelchair did not help. Also, the specialized air mattress that D needed after his foot amputations could only be rented by Medicare, and they only allowed for it to be rented for 10 weeks. Then they took it away. D went back in the hospital in Jan. of 06, and had additional surgery on his foot. He recovered in a nursing home, because we were not given enough funds for the amount of home health he needed at home. At home, this would have cost roughly $160 a day. His nursing home charges were between $700 and $1200 a day. Also, many nursing homes would not take him as a patient because he wouldn't turn a profit. So he did not have a choice as to where to go.
- He was hospitalized/nursing homed this time from early January to late April. During his time in the nursing home, he was not able to eat the high calorie/high protein diet that was prescribed for him. They offered things like plain, white bread with a piece of cheese and Bologna, tea, and a fruit or even just jello for a meal. His family and I had to supplement the food he ate in there almost daily. Furthermore, while in the nursing home, he acquired another pressure sore on his foot, and a very problematic pressure sore on his coccyx (butt bone). He left in April not having recovered, but because it was getting dangerous for him to stay in the nursing home.
- All summer of 06 was spent trying to heal the coccyx sore. He spent part of June and most of July bed-bound in his apartment in a makeshift bed that he made out of an old gel mattress, memory foam, and an inflatable overlay he bought online.
- In August, he had another skin graft surgery on the coccyx wound. He was hospitalized from August to November. All of these wounds were infected with MRSA or other bacteria, so each hospitalization required a PICC line and IV antibiotics.
- 2007 was a good year. No major hospitalizations or medical problems to speak of.
- In November of 2007, he was to go in for a routine surgery to change out his infusion pump as the batteries were running low. We were excited to get the new ($20,000!) pump because it would need less maintenance. According to the infectious disease dudes, the pain management surgeon should have started prophylactic antibiotics before surgery and also had D hospitalized a few days before surgery and prepped with a few days worth of antibacterial showers and betadine in isolation before surgery. None of this was done. No special precautions were taken due to his history of MRSA. In fact, every time he is in the hospital, they put a big fat sign on the door that says you need to gown, glove and mask before entering the room. I would say about one of ten medical personnel ever bothers to do this. The main culprits I see are the food handlers. Who go from room to room picking up trays, throwing the trays together that people have eaten off of and then going to the next room without even washing their hands. Once, D had a visitor who was a social worker from the hospital. She actually had to ASK what the big stop sign on the door was for. She thought that he just didn't want visitors. (When I worked at a medical school, I worked in a different building devoid of any kind of patient contact in an office setting. And we STILL had to take seminars and tests about universal precautions and infectious diseases. WTF?)
- After the surgery, D started getting sick and the wound didn't heal and was oozing goo. The pain management people treated it with antibiotics without culturing it. They did not consult with Infectious disease. It was D who eventually had to do that.
- In January of 08, the pump literally started coming out of D's body. Pain management decided it must come out. We found out later that the new 'best practices' was to try to leave the pump in and put the appropriate antibiotics direction into the pump. Thus preventing baclofen withdrawal syndrome.
- Ah, yes. Baclofen withdrawal syndrome. No one warned us or told us anything about this. It was never mentioned. It can cause dangerous fluctuations in blood pressure, hallucinations and incoherence, autonomic dysreflexia, and it can disguise infection. Basically, you can easily die from it. D was sent home from the hospital and within a day was incoherent and having hallucinations, incoherence, and fluctuating blood pressure. One night in particular, his BP was going from the 60/40 range to 240systolic over something I forget now. It just happened to be one of those nights when D had back to back to back visitors. First me, then Jason, and then his dad were all there and were very concerned. It was hard to have a conversation with him. He was short of breath. D's dad (with Jason, who is a nurse, on the phone) made the decision to call 911. I think that if people had not been there and taking his BP, he may have died that night. He was not coherent enough to make good decisions for himself.
- I had these absolutely crazy conversations with him on the phone for two or three days when he would talk a mile a minute and repeat everything multiple times and not really understand what you were saying to him. He got through withdrawal there with the help of Demerol, and came back home in a few days.
- He was much more coherent, but then the pharmacy (yea! for Rite Aid) called and said that the hospital had prescribed two drugs that were dangerously incompatible. The usual uproar ensued and new IV antibiotics were prescribed.
- Weeks went by and the antibiotics were finished but the open incision didn't heal. Goo upon goo was still leaking out of it. Pain management did nothing. Infectious Disease said the case was pain management's job. The wound people at crazy hospital A said it was infectious disease's case. Finally, D went to Hospital B's wound people. They put him on the wound vac.
- And here we are, pseudomonas in the wound and a strip of wound vac dressing discovered. Infectious disease saw him today after he called yesterday and said he was sick. They may have found more wound vac dressing stuck up in the wound. they admitted him to the Burn Center.
Still with me? Probably not, but this is more for me anyway. The thing is, even in this long list of events, I have left out a million little mistakes that were made with medication, communication, wound dressing stuff, treatment plans that contradict other treatment plans. People who don't have much contact with health care are so funny, it's cute. They act like health science is so exact and that mistakes are rare. And if there is a mistake, MALPRACTICE! I'm here to tell you that mistakes happen ALL. THE. TIME. Every single day. And I'm not counting bad outcomes from best guess judgment calls. I'm talking stupid mistakes. Most are unintentional, many are not serious, many are caught in time. But many, many mistakes don't necessarily cause death, but cause very prolonged and debilitating illnesses. I could tell you stories, not just from D, but from my experiences as a patient and worker in the hospital and my dealings with some of my other friends who have chronic conditions that would probably blow. your. mind.
Health care is a mess. An absolute mess. It is systemic. It is often not directly tied to the incompetence of the health care workers themselves, but to the adverse conditions they must work in and the system they must deal with. The thing is, if you don't have to deal with health care very much, you are probably going to be ok. But it severely affects those who have to live in the system. It severely affects the disabled.
With disabled patients, I basically see a few major disaster areas that affect them the most (but also all patients to some extent.)
- There is this attitude that disabled people don't have lives. That they are devalued and have no quality of life. Doctors are sometimes very laissez faire about D and other disabled people. They don't want to deal with us, they triage us out of their circle of concern. They don't actually think that we are worth fighting as hard for. Sometimes, when I get this attitude from doctors, I have had to tell them, "Look, D is valuable to us. We want him alive and healthy. He has children. He has a father who is devastated anytime he sees D suffer. He has talents and friends and a life worth living. I need him. Very much so. He is not some DNR case we are waiting to be unburdened from. So, I certainly understand that you will be doing everything you can to ensure his well-being." This conversation has really helped in many cases. And every time I have it with some egotistical neurosurgeon who wants to get rid of D so he can go do Big, Elite, Studly Neurosurgeon things, I find myself incredulous that I actually have to say these things. That I actually have to prove that D is valuable enough for health care.
- Along with that, there is this attitude that disabled people can't or don't take care of their own health. Many times, a doctor or therapist will prescribe A,B, and C therapies and treatments. And then they tend to give up on you if you haven't complied exactly or they give you attitude about it. They seem to have NO idea that while they said for you to do A,B and C; another doctor said for you to do D,E and F; the PT told you to do G,H, and I: And the RT told you to do J,K, and L, and the nurses told you to do M-Z. Furthermore, C is contraindicated to F and B is a complete contradiction of K. Furthermore, you actually have to eat, sleep, work, and actually have a little free time. There just isn't enough hours in the day to do A-G, much less A-Z. So, since no one helps to prioritize or coordinate these things, we have to pick and choose on our own. Sometimes we may pick and choose the wrong things to prioritize, or we picked the one that contradicted you and that is pissing you off. It isn't that disabled people are necessarily being non-compliant (a word I fucking despise, BTW) it is that you medical people can't get together a coherent plan of care.
- And along with that, health care workers sometimes don't seem to understand or care about the medical jujitsu (hat tip to Kathryne) that needs to be done to get anything done. This medical insurance business is absolutely fucking crazy. People seem to think D is at home, leisurely lying around all day, recuperating and living off disability. He actually works ALL DAY LONG just to stay alive and get the health care that he can fight for. That apartment is never peaceful and quite. The phone rings off the hook all day long. Insurance companies wanting this or that. Durable medical equipment companies wanting this or that approval from insurance companies. Doctors offices wanting insurance information. Home health nurses and therapists wanting to schedule this or that. People coming in and out all day long. Mail, insurance forms and medical bills stack up daily. (I told D the other day that we could probably wallpaper the entire Sears Tower with the CMS/Medicare statements that come in.) Phone calls and paperwork he has to do to insure that he keeps his Medicaid, his Tricare, his Medicare and social security, his attendant care. You don't get put on disability and just stay there, you have to prove it again and again at the drop of a hat. At anytime, any one of the dozen agencies that provide services to D will just decide that he needs to get a billion documents together to prove he is still disabled, still poor, and still under insured. Tax returns, doctors reports, income statements, rent and utility receipts, and whatever else we decide need to be in our office! And they need it in TEN DAYS or you lose all of your services and you will have to reapply, which will take you anywhere from 3 months to five years to get re-approved, and in that time you will not be able to see any doctors, receive nursing or attendant care, or get food stamps...which basically means you will probably die. There are two conversations that I just refuse to have with anyone right now. One is regarding how easy it is to be on disability and how there are a bunch of fakers out there (because it is such a luxurious life!) And the other is anyone who argues against universal, single payer health care. Unless you fight for your life DAILY with insurance bureaucrats whose system have caused you great physical and emotional pain and have regularly taken life saving health care away from you and made you fight for it for months and years on end...then seriously, you better shut the fuck up. You have absolutely no idea what you are talking about. And doctors who opt out of Medicare and Medicaid? Doctors who fight for their own profits and not systems change? Evil greedy bastards. I'm not saying you don't have issues in our system, you do. Like, I think that if the government isn't going to compensate you well for Medicare/aid patients then they should help you out with your student debt and your malpractice insurance. I think we need the system to recruit doctors (and help them succeed) who care about patients and care about justice in health care instead of getting these (many of them privileged) doctors that are in it for status or money. But, fight for us, why don't you. In fighting for us, I think you will also be fighting for yourselves. I certainly have sympathy for the shit practices have to go through in regards to insurance reimbursement and liability issues.
- The number one thing that has compromised D's health, and many other disabled people's is a complete lack of comprehensive care. For people who have complex health conditions that require many specialties, the care is dangerously fragmented. The left hand doesn't know (or seem to care) what the right hand is doing. There are stupid, arbitrary rules about which nursing agency can do what and take orders from which doctor at what hospital. D will sometimes have three different nurses come in on one day. The wound care nurse, the infusion nurse, and the general nurse. This would be okay if they had special skills in these areas, but they sometimes don't. We had an infusion nurse with years of experience on the wound vac (believe me, it is a skill), and then a wound nurse who was just starting to be trained on the wound vac. Sometimes, these nurses can't confer with each other because they work for different agencies. There is also a lot of passing the buck to someone else. There is also a terrible amount of just taking care of the acute problem that is right in front of you and completely disregarding the big or long-term picture. Doctors don't want to communicate with each other. They don't want to admit they don't know something and get a consult. They don't want to work as a team because it is more time-consuming. It is very 'treat 'em and street 'em' out there, and that is why there is a huge amount of bounce backs. This is D's fifth time in the hospital for this pump issue. And they are really no where close to a long-term comprehensive solution. Nor are they really interested in finding one. They will get D's vitals stable for the time being, and then they don't care anymore. D and I have hypothetically talked several times about moving to Denver so that we could be close to Craig Hospital, which uses a team approach to patient care. Everyone, doctors, nurses, therapists, patient, caregivers, family members and friends, sit down at least once a week and decide on a plan of care. I know that is a bit harder to do logistically when you are in different buildings in different hospitals, but guess what? There is the phone, fax, conference calling, emailing with cc to everyone. There could be a system where one doctor is in charge and everything goes through her so she can see the big picture and make the final decisions that make the most overall sense. (The Jon-Luc Picard strategy.) TALK TO EACH OTHER, DAMN IT! How hard can it be?
- Also, actually know about rehab and other services for the disabled. And if you don't, get a good social worker who does and use her. Many times, doctors are the "gatekeepers" into the disability world. Obviously they have to look through the lens of the medical model, but they should at least be aware of the social model. And that there is life after disability. Many times, it is the doctor who says, "This is it. There is nothing more I can do. You now have this permanent disability. Have a nice life" as he slams the door. I'm sure it is hard to call it quits after trying to cure or prevent disease and disability, but after you close the medical door, open the disability community door. It is the only way people with disabilities get their lives back. You as medical people can be very powerful in this regard. You could offer hope instead of just failure. It is a total shame, but I know a ton of blind people who went blind due to diabetes or a head injury or what not. They went through a few surgeries and nothing worked. Then, there was that one appointment with the doctor. They all remember it. It was the one where the doctor said, "This is it. You are disabled." And then they left with nothing. NOTHING. And these blind people would go home and quit their job, sell their house, move back in with their parents or something, and sit. Just sit and do nothing. Sometimes for YEARS. My friend Susan sat for two years before she knew that there was free rehabilitation available. My friend MRY sat for three years before he knew. I knew someone else who sat for 6, before anyone ever offered help. These people can't read the phone book, use the computer, read, nothing. They have no access to information. Their parents are sometimes elderly and unknowing, computer illiterate. How hard would it be to give someone the proper referrals to rehabilitation and advocacy groups? A fucking brochure is what we are talking about. I think this has gotten better with the internet and people's friends looking up things and trying to help. But you know how most people get services? Social security comes calling, demanding that they prove they can't work and in order to prove that sometimes you are required to go through rehabilitation first. That's all well and good for social security to refer you, but social security can take YEARS to do this. Friends and family should not get a newly disabled person plopped on their doorstep with nothing and have to go searching on their own. Doctors have a responsibility to have knowledge of all the services and options available and a patient should not be dismissed from care until a rehab plan has been locked in. And also, doctors can help by advocating and medicalizing (with insurance companies) rehabilitative care. There are now years long waiting lists in most states for developmental disability services and blind services. There is literally next to nothing available for newly deaf adults. For people with SCI and the like, they are usually rehabbed in hospitals. But there are a variety of options here and patients should be given all the information to make good decisions. There is a world of difference between the rehab results from an SCI patient who goes to Craig Hospital vs. one who goes to, say, Little Town Hospital Rehab Where We Mostly Give Old People A Walker With Tennis Balls on its Feet. Also, SCI rehab hospital stays have gotten ridiculously short. Stays used to average 6 to 9 months. Now SCI patients are getting kicked out in two or three. You can't get rehabbed and recovered in two or three months. And in the long run, it is going to cost the health care system. Poorly rehabbed people have more health problems, require more attendant care, and are hospitalized at greater rates than those that got good, long rehab stays.
- Finally, it is OK for doctors to not be familiar with something about us as disabled people...on the first visit. I do not expect all of my doctors to know about Stickler's/Alport's syndrome. D does not expect all doctors to instantly know about baclofen withdrawal or autonomic dysreflexia. But after taking a Hx on the first visit....GO LEARN ABOUT IT. Get into your little medical textbooks, go online and read medical journals, talk to your colleagues, whatever it takes. Instead of grandstanding and acting like you know all about it, or being embarrassed that you don't, just go research it already. And at least know something about it in the next visit or two. Also, if you don't know a patient well and are unfamiliar with his case, actually listen to what he is telling you! So if D comes into the ER and says, you can't put me on a regular gurney, I need some kind of air flow mattress, or only Demerol will be effective in regards to my autonomic disreflexia right now, or please use this vein, not that vein because you will have to poke me 80 times and you will end up using this vein anyway...actually listen. Because people with chronic illnesses actually know some stuff. And they are not all trying to get a Demerol hit or make your lives difficult. They are actually trying to make your lives easier. Don't disregard what they say as if it isn't important or you know better...because you probably don't. When a new patient with complex issues comes in, guess who is the expert and knows more about their care? THEY DO! So listen, please. And lose the condescending attitude.
This probably isn't what you had in mind, Bliss, and I'm sorry for being so angry. None of this is directed at you, personally, of course. But I am ANGRY. My kids, again today, had to say goodbye to their father and I can't tell them when they will see him again. And I get scares sometimes that the answer will be never. And I know that D is a complicated case, but some of these things are just so utterly dumb that I can't hardly stand being in my skin when I think about them. A person like D has enough unpredictability from his body itself. It would be nice if he also didn't have to deal with the antagonizing unpredictability of ignorant and incompetent staff, corrupt and exploitive insurance companies, and a system that basically would rather see him dead.