[HN Gopher] Things I've noticed while visiting the ICU ___________________________________________________________________ Things I've noticed while visiting the ICU Author : exolymph Score : 98 points Date : 2022-11-18 20:21 UTC (2 hours ago) (HTM) web link (trevorklee.substack.com) (TXT) w3m dump (trevorklee.substack.com) | HEmanZ wrote: | These threads always have lots of people jumping on doctors and | their decisions/callousness/lack-of-reason/etc.etc.etc. My wife | is a physician (OBGYN) at a major city hospital that primarily | serves a very poor population. I'd like to share her schedule, | and see if you think what kind of care you could perform under | these circumstances: | | Monday - Friday - Wake up at 4:30 AM - Get to hospital by 5AM to | start rounding on patients - Sometimes work inpatient all day | sometimes clinic thrown in, but usually not done working until 7 | PM, without even a 15 min break or a chance to eat a meal (15 | hour day) - Come home and do about an hour of notes - At least | once per week, wake up in the middle of the night to deliver a | patient who asked for that kind of continuity of care. | | Saturday: - Wake up around 5am to be in by 6am to start the day - | Work inpatient, usually without time for a 15min break for food, | until 10AM SUNDAY (28 hours shift) | | Repeat 49 weeks/year (days of 24/hr shift can vary and she | usually gets one weekend off/month). Her average time at the | hospital last year was 96 hours/week. | | How much confidence do you have that you'd be able to take care | of a complicated pregnancy at the end of a 28 hour shift, having | not eaten for more than 24 hours, having 10 other patients on | your mind, and having had only a couple of hours sleep the night | before? It's no wonder to me anymore to me birth outcomes are so | bad in understaffed hospitals in poor areas... | thfuran wrote: | That sounds illegal. | HEmanZ wrote: | Nope, not where we live. | | I have seen administration do some blatantly illegal shit | around physicians with COVID, but I don't want to write that | up here. | rscho wrote: | Doctors answer: yes. And? | chips_n_fries wrote: | And she is not a resident or in a training/certification | program? | DoingIsLearning wrote: | > So, when it comes to prescribing (...) Giving psychiatric | medicine "as needed"? Go wild. | | This implies a lack of duty of care which is painfully unfair. | | As a counter story to this I have a friend of mine who is a | _former_ ICU nurse with a gigantic scar on her forearm. | | I much later in our relation found out that the scar is from a | patient who basically ripped her forearm biting down on it while | she was trying to stop him from tearing out a central line in his | own neck. | | It's ironic that in trying to stop a patient from having a | massive central line bleeding she ended up bleeding herself. | | Outside hospitals we fail to realize how disoriented and | irrational patients can get when coming out of anesthesia or with | certain diseases. | | So yeah 'as needed' is absolutely right because everyone is | entitled to work in a safe environment. | maxerickson wrote: | The solution to difficulty booking doctors isn't to pontificate | on how to allocate their time, the solution to difficulty booking | doctors is to make more doctors. | | There's lots of levers that could be pulled in the US. Cut down | on undergraduate requirements, incentivize large health systems | to fund more training (people like to complain that the federal | government only funds a fixed number of residency slots, as if a | trillion dollar industry is just absolutely helpless to do | anything). | | Medical care suffers under the bizarre idea that central planning | and capacity management will control costs. Meanwhile, costs are | spiraling up and up and up. Train more doctors and all the stupid | games being played to optimize their utilization start to go | away, because it is less worth it when demand is less than | supply. | spfzero wrote: | I get what you're saying, but I don't think more doctors is the | answer. Hospitals will only hire the absolute minimum number of | doctors they can possibly get away with, other than the ones | who actually bring in new business. | | This is the reason: as soon as the medical industry has | established a consensus price for some procedure or other item | of care, the hospital administration starts to work on figuring | out how to do it for the least possible cost. The price has | been set in stone, no need for further justification. Medicare | or whoever WILL pay that much. The price is fixed so the only | knob left to turn is cost, and cost will be reduced all the way | down, until service is just above a level so poor that patients | would decide to stay home. | natosaichek wrote: | Totally agree. Also, let people open more medical care | facilities. Right now "Certificate of Need" legislation is | killing lots of viable options for care _outside_ hospitals. | e40 wrote: | On why there are too few doctors: | | https://www.theatlantic.com/ideas/archive/2022/02/why-does-t... | ntonozzi wrote: | . | maxerickson wrote: | It's not illegal for other entities to fund residencies! | | I anticipated your argument in my other comment... | NegativeLatency wrote: | Just getting accepted to a medical school is pretty hard unless | you're amazing/very good at the tests. | | Had a cousin and a friend (both I would characterize as smart | and hard working) take several years after undergrad and | eventually "settle" for physicians assistant schools. | j-bos wrote: | I personally want my doctors to be amazing and very good. For | now tests a a fair proxy for that, it's the 8 years that seem | ridiculous, esp when looking at non US countries. | ncrmro wrote: | I woke up in the ICU after getting hit on my motorcycle with a | brain bleed and ton of other damage and all I can say it I'm | super grateful for everything they did. | Ensorceled wrote: | I noticed a lot of the same things when my dad was in the ICU. | Some additional thoughts: | | 1. "Almost every patient has delusions and nightmares" I | personally felt "off" when visiting my father. The sounds, | smells, lights and constant buzz of activity all contributed to a | feeling of being in a surreal dreamworld. Lack of sleep | contributes. I can't imagine what my father experiencing. | | 2. Food was HORRIBLE. One meal was a low quality hamburger on a | plain, white bread bun with a slice of "american cheese", fries, | iceberg lettuce salad with a couple of slices of cucumber and a | single slice of tomato, a container of apple sauce and glass of | milk. Lots of salad dressing and ketchup. They wouldn't let us | bring better food into the ICU and my dad didn't want to "make | waves". | | 3. Family is critical. My father got better care because I, or my | brother, was there to act on his behalf. Having obnoxious family | members is worse than having none from what I saw. | tomcam wrote: | Very well thought out article, but I promise your life will | improve if all you do is read the caption on the first image. | parker_mountain wrote: | This is not a picture of a real hospital. This is a picture of | Mystic Falls hospital, from the CW show "The Vampire Diaries". | If I remember correctly, the guy on the left is an evil vampire | hunter (the vampires in the show are mostly heroes, except when | they're evil and trying to take over the world), and the doctor | on the right is maybe a vampire? Or she might just be friends | with a vampire but not realize it. Or she gets killed by a | vampire. I forget and refuse to look it up. It's a really | stupid show. | bombcar wrote: | I suspect it IS a real hospital, depending on if the show was | set in a hospital or not. If they only needed it for a few | scenes, you just rent out a hospital or something that looks | similar enough. | bbarnett wrote: | No, it's a real hospital, and a real scene, but they're all | reverse vampires. | bombcar wrote: | Isn't a reverse vampire just a blood infusion doctor? | a_shovel wrote: | I don't have much personal experience with hospitals, but there's | a trend I've noticed across several articles now where the | medical system is characterized by an unpredictable and frequent | alternation between extreme competence and extreme incompetence. | | The author's dad was being seen by a variety of highly trained | specialists all working to treat him, but "people need to sleep" | seems to be a recent discovery in the ICU world, and if his | family hadn't been there to help, every new nurse would have | tried to give him the same medication that gave him a bad | reaction, over and over, just because there wasn't an established | place to write that (obviously important) information down. | | I've read that food with better nutrition than regular hospital | food may reduce mortality rates by as much as _half_ [0]. That 's | such a huge effect that it's shocking that hospital food is just | expected to be bad. Everyone says nutrition is vital for health, | but hospitals don't seem to care. | | I think the root problem is cost-cutting. Management cuts costs | until the brink of disaster, and tries to hold it there for as | long as possible. This is not a system that strives for the best | outcome for patients within reasonable limits of the resources | available; this is a system that attempts to extract as much | value as possible from the patients, and patient death is only | prevented as a means to that ends. | | [0] | https://www.sciencedirect.com/science/article/pii/S073510972... | blue039 wrote: | tunap wrote: | >"people need to sleep" | | Sleep is almost impossible with regular check-ups... 30 min or | 60 min, don't remember. Excepting the comatose and most | medicated(maybe not?), a person's sleep cycle is unable to | reach REM when a stranger approaches and fiddles on regular | intervals. I would think monitoring from afar(sensors, cameras) | would be more beneficial, but I was informed the liability | factors preclude such remote monitoring. | | edit: to add context, I slept in the room on separate occasions | with 2 family members. While tests were not performed, the | regular checks were mandated. I was exhausted after my shifts | ended. | cactus2093 wrote: | From reading the abstract you are completely mischaracterizing | this study. | | For the average person healthy food usually means food with | fewer calories and more micro-nutrients, like eating more | broccoli and less white bread. | | This study is about malnourished patients who need more | calories than they can even digest from an average meal so they | need specialized high-calorie foods that are customized for | their own metabolism. It's essentially exactly the opposite of | what "healthy food" means in any other context. | | So it has nothing to do with any narrative about cost cutting | and the quality of ingredients used in hospital cafeterias. | cco wrote: | A closer reading of the intervention shows that it wasn't | _just_ "more calories". | | But I think that is missing the forest for the trees, what | this study showed is that when a patient is left on their | own, they consume an inadequate diet that _puts their health | at risk_ in a hospital. By a big margin! | | I would imagine, though the study didn't show this, that the | primary factor in recovery here was having a human | (dietician) actually paying attention to your recovery. On | intake they put together a plan, and followed up routinely to | ensure that the patient has consuming their diet. | | The GP's point is valid, hospitals are missing out on a 50% | increase in health outcomes because they're letting patients | fend for themselves with regard to nutrition. You're right | that it isn't as easy as spending $6 per meal vs $3 to buy | "better" food. But what it means is that hospitals are | failing their patients because they aren't thinking and | acting with a holistic eye towards patient outcomes. | Negitivefrags wrote: | I don't think the problem is cost cutting. I think the problem | is just the same problem that every human enterprise has. | | Most people just don't give a shit outside thier immediate | responsibility. | | Looking at the global view and actually making changes that | require persuading other people is a hard and often thankless | task. | | Many people who do give a shit get this crushed out of them | early in their career by the negativity you will face if you | try. | | Much easier to just accept the status quo. | | Occasionally you get a group of people who really care and come | together determined not to let things be crappy and they can | form an organisation that is significantly more effective for a | time. But once the rot of "We can't fix things" sets in, it's | really really hard to turn things around. | msrenee wrote: | Cost cutting is definitely to blame for how understaffed | hospitals are. Then Covid happened and it got even worse. | It's definitely not all due to Covid though. Even the "not- | for-profit" medical group in my area has been pushing doctors | and PAs to take more and more patients, well past what | they're comfortable with. Nursing staff has been cut down to | nothing compared to 10 years ago. Wages haven't gone up to | match the increase in workload. | | Again, this started before Covid, the pandemic just | highlighted how much these cuts screwed over both healthcare | professionals and patients. | rscho wrote: | I work in a hospital, and occasionally in ICUs. You're wrong. | Most workers are very much jaded, but they do care. Problem | is, the system crushes you to death if you don't set pretty | harsh limits to protect yourself. In a lot of cases, that | means de-humanizing your work, put your feelings aside and | work like a machine. Good little machines are just what | management wants, right? Now higher management... wow, those | people really don't give a hoot about anything that's not | themselves! | | A second major contributor to inertia, is that the | initiatives from lower echelons are usually set for failure | by the intricacies of bureaucracy. And said bureaucrats are | completely unimaginative about what they could do to fix | things, because they never leave their office to see what's | really happening in the trenches. So yes, in fine the problem | is the extreme stupidity stemming from human collective | behaviour. Complain, and suddenly _you_ are the problem! | gowings97 wrote: | What percent of patients have a medical need to be woken up | every few hours then? | rscho wrote: | You'd be surprised to see what happens to staff going | against waking up patients all night. You get the | "dangerous sloth" sticker on your forehead real quick on | the morning grand rounds. | halpmeh wrote: | Everything you said is spot-on, but, brining things full | circle, the lack of "shit giving" could be due to cost | cutting. People don't have an incentive to care. The end | result, vis-a-vis their personal situation, is unchanged | whether or not they go the extra mile. Part of this is | because they exist in a rigid corporate structure hyper- | focused on value extraction and not at all focused on the | development of human capital. | lazyasciiart wrote: | I don't know why the haldol reaction didn't go in his chart, | but the whiteboard in the room (which is present in every high | level hospital room I've been in) is _exactly_ where the TV | information and other patient preferences should be, and is the | second best place after the chart to put a drug reaction. Cost | cutting has nothing to do with "nobody wrote it on the place | for writing it". | colechristensen wrote: | >The author's dad was being seen by a variety of highly trained | specialists all working to treat him | | The training doesn't really matter. Context is very important | as is caring about doing a good job. You'll find a severe lack | of both in hospitals. You eventually have to stand up and | defend yourself against bad healthcare... or search endlessly | for good healthcare which is terribly difficult to find. | citilife wrote: | For point #4 (about sleep) and point #5 (about delusions) - these | are probably related. If you don't get enough sleep you get | rather paranoid. | | Having been in the ICU with various family members I notice they | check on you A LOT and that often will wake you up. This lack of | consistent sleep (either from injury, illness or checks) make | people rather paranoid. Further, sitting still and waiting often | makes people a bit stir crazy. | ivraatiems wrote: | My wife is a physician who works in a critical care setting. She | did not read or approve this post; these are my thoughts as | someone who hears a lot about the other side of this environment: | | For the most part this seems like a sensible and reasonable | article communicating what must have been an extremely difficult | situation for the author. In case the author reads this: I'm | really glad your dad got better and I know everybody working in | the hospital appreciated the amount of patience and restraint it | seems like you showed in helping him without being that patient | family member who goes off the handle about everything. (There | are so many of those.) | | Many of the issues the author points out are very real - | constantly-rotating doctors, attending disregarding consults once | the consult leaves the room, the ICU not being set up for | anything but bare survival - all of that is totally true from | what I understand. I think, if anything, the author fails to | understand how systematic and critical those issues are when he | says things like this: | | > So, digestive issues, hormonal issues, and mental issues all | get short shrift. Basically, if there's an obvious symptom, a | consult will come in to try to treat the symptom. Then they'll | take another test in a day or so, see what happens, and go from | there. There's no sense of a scientific method, reasoning from | first principles, or even reasoning from similar cases though. | | I don't think this is giving the medical practitioners a fair | shake here. Doctors do a huge amount of this kind of reasoning | and research, even in the ICU. The trouble is often not a lack of | reasoning, but a matter of, as with everything else you note, | resources. Like you realized, the goal of the ICU is "keep | patients alive at all costs, and worry about their comfort once | they're able to be alive without our help for a while." Judgments | are made with that in mind. It's not that they can't do reasoning | about complex problems, it's that spending time on a complex but | non-fatal problem means somebody with a potentially fatal problem | won't get that time, and that's not what the ICU is for. Anything | that can be solved later... will be solved later. | | So the real question is not "Why didn't they help this patient | with his digestive issues?", it's "Why didn't they move this | patient out of the ICU once he reached the point where non-life- | threatening digestive issues were relatively of any importance?" | possiblydrunk wrote: | From personal experience, one of the most frustrating things | about the ICU (if you're there for any anything beyond a day) is | dealing with the variability in the availability, skills, and | temperaments of the nurses on duty. The 'right' nurse can make a | huge difference in how fast the patient recovers and how | difficult the stay is. | mberning wrote: | I think people expect that things could go significantly better, | if the "system" were better. I disagree. In most cases, by the | time they hit the ICU, you have a patient that is circling the | drain from old age and chronic conditions and all you can do is | manage it. No amount or quality of care is changing the outcome. | jeffrallen wrote: | Hospitals make you sick. Intensive care unit make you intensively | sick. What a tragedy that something we need so much is so bad for | us. | [deleted] | osmano807 wrote: | Surgeon here. I'm about more surprised by the discussion here | than from the article itself. | | > 2. There are many consults, but the ICU attending is king (or | queen). There's a concept called _doctor 's autonomy_. The | attending physician has the primary "guard" of the patient care, | so unless dynamics of power, consultations are more like | suggestions than law. So, the final care is generally dependent | on the attending physician, for good or worse, be lack of | confidence in the other physician be his perceived better | understanding of the disease. | | > 3. Sometimes nurses are the footsoldiers of the ICU regent, and | sometimes they're governors. I saw examples of nursing saving and | harming patients while disobeying orders. They have a co- | participation in care and generally have studied to a degree that | enable them to make some decisions. | | > 4. Everyone agrees that sleep is important, but nobody has any | idea beyond that. We have decades worth of knowledge, but _de | facto_ we don 't have a systematized and validated way of sleep | care. We have studies on daytime nap and on sedatives effects on | quality of sleep, but no full truths. Some day we'll have a | better care. | | > 6. The ICU staff is literally constantly changing. The | institutional memory are the patient medical records. If the | Haloperidol adverse reaction was not noted in there, it was a | fault of the care providers. Sometimes nurses chooses to ignore, | and the repercussions should be analyzed case by case. The cited | whiteboard worked as an "expanded" medical record, as registering | that trigger could be seen as too tangential to a disease focused | medical record. | | > 7. The ICU is great at managing acute issues, and struggles a | lot more with longterm issues. Long term issues are not the | concern of ICU. If it's not critical, the care can and maybe | should be postponed until better. Of course, we have to be | prudent, for example bowel function could be potentially urgent | if not intervened early. Frequently I could and should not treat | patients depression on an ICU, but it's reasonable to treat | intrusive symptoms of early post-traumatic stress disorder, for | example. | | Free T4 is the method used to assess thyroid hormone | supplementation, not TSH. Delirium, delusions, illusions and | hallucinations have a non-pharmacological and pharmacological | treatment, and antipsychotics are not the only ones used. | | > 8. The ICU is a good place to not die, but a bad place to | recover. The ICU is meant to give patients a better opportunity | to not be critical anymore. When they're not critical, we start | to deescalate our measures, such as monitoring and IV lines, for | example. | | People are different, and so are doctors. As the good, so the bad | sprouts everywhere. | pmarreck wrote: | Excellent criticisms (having dealt with my mom's passing in 2020) | | I noticed that the incessant beeping all night has decreased | quite a bit, of late (at least in my local hospital, St. Francis | Heart Center) | rootusrootus wrote: | As a counterpoint, my experience with my dad being in the ICU was | great. They saved his life a couple times when he needed to have | his heart paddle-started. And they managed to stabilize him and | let him get sleep as much as possible so he could be transitioned | out of the ICU. I never once got the impression that anyone was | incompetent, or that they were having trouble remembering | strategies, reactions to medicine, etc. | | But this was Kaiser. Other hospitals may indeed be a shit show. | wahern wrote: | I wonder if there's a selection effect where on the one hand | particularly demanding people avoid Kaiser because of the | somewhat impersonal policies and practices, and on the other | hand as an HMO Kaiser enjoys a much lower percentage of | indigent and high-risk patients, which altogether permit Kaiser | to build a system around the 80% instead of the 20%. | chiefalchemist wrote: | When when one of my parents had a stroke years ago, we spent a | week in the ICU. It was a special ICU for stroke victims. The | care and staff were exceptional. We were lucky such an ICU was in | our area. | | On the other hand, subsequent hospital visits (non-ICU) were a | cluster fuck. Noise, lights on, nurses constantly waking my | parent up, could-care-less doctors, etc. And getting healthy | enough to be transferred to an extended care facility was a shit | show. It's was like the hospital but worse. Both experience | seemed to have little to do with health and recovery. | | My point is, the article author is in for a shock once his dad | gets out of the ICU and into the "general population". I can't | imagine that's going to be better than the ICU. I hope I'm | mistaken. | | My take away from this experience is: | | 1) Make choices that maximize your health the best you can. | | 2) If you can, be rich - like fuck you money rich. The kind of | rich where your "general population" hospital experience will be | like being in the ICU. | rscho wrote: | Rich people always get the worst possible care, in my | experience. Life-prolonging care, yes. But at what cost? Those | are the people that get the most "experimental" medicine out | there. Rich people select for the most greedy docs, not for the | most capable ones. | [deleted] | warner25 wrote: | > There's no sense of a scientific method, reasoning from first | principles, or even reasoning from similar cases though. It's all | shooting in the dark, and most of the time I felt like I could | have done just as good a job on these longterm issues... | | This articulates very well what I've usually felt when dealing | with doctors. It's like the story of a programmer finding that | his code outputs 5 when it should be 4, and then adding... | if(return_value == 5): return_value = 4 | | ...to fix it, and being satisfied. What I _want_ is something | like in the television show _House._ The main character is | unhinged and anti-social and takes extreme risks, but at least he | demonstrates curiosity to really figure out and understand the | root of what 's going on. To be fair, I don't actually think that | doctors lack curiosity or are incapable of doing this, the | medical _system_ as it 's set up just doesn't allow it. For | chronic issues, I've usually figured them out for myself, as a | layperson, by persistently keeping track of things, searching the | web, reading, and experimenting over months and years. | rscho wrote: | I'm sorry but curiosity and creativity are certainly the ndeg1 | enemy of the patient, especially in ICU settings. Curiosity and | creativity are grandpa's medicine, and a total antithesis to | evidence-based modern medicine, that attempts (and largely | fails) to be an application of science instead of the whims of | the decision-makers. | | What you should want is curious and creative _researchers_, but | precise and totally unimaginative clinical staff. Those are | often the same person. See the problem? You want protocols | applied down to the last detail. You want nothing left out of | standard operating procedure. That's what kills patients in | practice. | | You might mean creativity in the sense of "let's have guys who | think about the right things, and search for rare diagnoses and | analyze stuff to see what could work, like Dr House". But that | simply can't be done in practice. You can't be testing for | every rare thing, because the tail of low probability diagnoses | is much too long! And believe me, you _really_ don't want | creative doctors around... | titanomachy wrote: | If medical treatment was actually as formulaic and fully- | solved as you imply, we wouldn't take the best students of | every generation and make them spend ten years training to | become doctors. We'd just have nurses, checklists, and | diagnosis flowcharts. | rscho wrote: | I'm precisely not implying that medicine is currently | "fully solved". I'm implying that we should strive to | gather more information, synthesize it better and study how | to make it useful. | | As a clinician, I'd say yes to a bicycle for the mind. But | currently, my job is already plenty full with worrying | about applying what's known in a correct manner without | seeking to break new ground while treating patients, which | would be very dangerous and given the odds of success, very | stupid. What I'm implying is that the general public has a | completely skewed view about what really kills patients in | the ICU: mundane infections and "medical errors", which are | not really errors at all but in a large majority of cases | failures and complications of usual procedures. | jmhmd wrote: | The main thing that House MD has, that no other doctor in the | world has, is not so much his superior intellect. It's that he | and _five_ other doctors spend 100% of their time on a single | case, and can sit around all day discussing it, trying | different things. If real world doctors had even a fraction of | that luxury, you would see a lot more of what you describe. | lazyasciiart wrote: | Also, the cases are usually in desperate enough straits that | "here, swallow this seagull poop!" doesn't get hints thrown | out of the hospital. | coding123 wrote: | Jeez, no kidding. I imagine if they made a realistic doctor | show they'd be constantly showing the doctor at the bar (on | days off) trying to make money on side gigs like health | startups. | | Stumbling in a hangover to appointments on "work days" and | giving everyone the same diagnosis as the last (and likely | whatever sickness they themselves had recently). Also giving | everyone fluids and an ativan so the patient says - "i feel | much better doc". | | It's kind of an open secret that the ER just gives a | diagnosis of dehydration, provides fluids and ativan to get | the pipe rolling and charge $4k a pop. Sure they might catch | a case of undiagnosed covid, rsv or something else from time | to time. | | Also I'm not kidding but I would LOVE such a show. | [deleted] | kingsloi wrote: | Interesting take. | | I was in a paediatric cardiac ICU when my daughter battled with | heart disease for 7 of her 8 month life. Another dad who we got | close to in the ICU said the phrase "practising medicine says it | all...". | | My experience is same same but different. It was during COVID, so | we welcomed the nurse change, sad/happy to see one go and welcome | another. Paediatric ICUs and their staff, I'd say are top tier in | most respects. Parents are involved with most/all decisions, and | nurses/drs respect most wishes, don't like your child being | disturbed at night for non-100%-necessary stuff? Ask social | services (etc) to print out a sign with your wishes and stick it | on your room door. May not 100% work, but worth a shot. It did in | ours. | | Sleep is somewhat respected as this is when babies develop/heal | best, unfortunately it's an ICU, and these are sick kids who need | 24/7 complex care, so there's sometimes little wiggle room. I | attended a conference in Chicago on heart disease and it's | outcomes (npcqic.org), and sleep and proper nutrition (not just | feeding TPN) are definitely hot topics. I know the NICUs are | extra hard on any additional sleep/disturbance other than 100% | necessary. | | But shoutout to nurses, drs, any medical staff, ICUs are sterile, | haunting, traumatic places. I witnessed things I can never | forget. They do the same, and have to do it again, and again. | anjc wrote: | > the next time you have trouble booking a surgeon or even a | gastroenterologist, you can remember that America's supply of | surgeons and gastroenterologists is being disproportionately used | by the AARP crowd. | | What a horrible sentiment. | gopher_space wrote: | It's painfully easy to start thinking in numbers when you're | paying six thousand a month to warehouse your grandmother's | body. | | The number of tests people want to run on someone we all hope | dies tomorrow is insane. | notacoward wrote: | Funny, I pay even more than you mention to support my own | mother in relative comfort in a nursing home, and I don't | find it "painfully easy" to think that way at all. I | certainly don't hope she dies tomorrow. You might want to | reconsider saying such things in public. | | Note: my mother, not my grandmother, and I _have_ lived that | ordeal for several years. Some interaction is still possible, | but recognition has been beyond her for a while. As long as | she seems to take some pleasure in her surroundings, no | matter how dim or muted the signs, you won 't catch me | framing my thoughts about her in terms of dollars I could | save. | gopher_space wrote: | Sounds like your grandmother can still recognize and | interact with people. Mine was basically a warm body for | the last five years of her life. | | Prolonging that existence is not a kindness in any sense, | and I hope you don't have to go through such an ordeal. | chki wrote: | I think a more generous reading of the comment you are | replying to could be (and probably is reasonable): It is | hard to pay a lot of money for somebody that is living in | agony with no chance of getting better, where death might | be a good option for them personally. I would not | understand the comment to criticize supporting people | living in relative comfort. | notacoward wrote: | "Warehousing her body" suggests otherwise. When people | talk about someone as a "body" they usually mean | insensate IMX. People whose loved ones are in pain tend | to use different, even more colorful, language. I know I | did, when that was the case. | chki wrote: | > People whose loved ones are in pain tend to use | different, even more colorful, language. | | The human experience varies wildly and I would not make | such assumptions. Caring for somebody without the hope of | improvement for years can make you bitter or even resent | the person that no longer resembles the one you loved. | Mezzie wrote: | What's terrible about it? | | I'm a younger (34) person with substantial healthcare needs (I | have MS). Everything is always oriented towards the old, and I | also pay taxes that are used to support them while getting | nothing in return despite having similar needs. | jewayne wrote: | You also seem to have MCS: Main Character Syndrome. | notacoward wrote: | > I also pay taxes | | Do you really get _nothing_? And who is paying for whose | care? You mention taxes, but they 've probably been paying | taxes even longer. And why do you think health care is a | strict _quid pro quo_ anyway? Some of us believe care should | be allocated where it 's needed, not where it's paid for. Put | another way: why is it a problem that they _are_ getting | care? Isn 't it that you _aren 't_? This doesn't have to be a | zero-sum game. If you feel that you're in competition with | someone else for care, the problem is pretty clearly that | there aren't enough providing it. | | Saying others have less right to health care is pretty | terrible no matter _which_ way the finger points. | cliquecover wrote: | It's horrible but true. How do you budget for and prioritize | access to scarce resources? | polishdude20 wrote: | In a way I think this is ok though? Like, when I reach that age | I sure as hell hope I'll have more access to doctors than | younger people? | notacoward wrote: | I had a strong reaction to that too. _Of course_ we devote more | health-care effort to people in the last 5-10 years of their | life, which primarily (but not entirely) means older people. | There is practically no world in which that wouldn 't be the | case, because everyone's health trajectory eventually trends | downward. By the time someone reaches the ICU (other than as a | result of trauma) not only the immediate problem but likely | several others will have progressed to problematic levels. | That's also where the most labor- and dollar-intensive | treatments tend to be applicable. It's just basic statistics, | really. Cars also cost more in maintenance late in their life | cycles, and so do many other things. A flat age distribution in | the ICU would be _super weird_ and probably an even worse | allocation of resources. | | I don't think the author really meant that to come across as | callous as it sounded. Probably just poor choice of words. I'm | only addressing it because _someone else_ reading it here might | interpret it in more of an "older people stealing from younger | ones again" kind of way for demographic or ideological reasons. | | ETA: it already happened as I was writing this. | questime wrote: | Because of demographics this is a problem we will have to | confront regardless - do you think medicare/medicaid spending | will become 80% of government spending? | virgildotcodes wrote: | Maybe with higher taxes and a reallocation of defense | spending we'd be able to sustain a more humane society for | longer. | | Is it indefinitely sustainable? Not sure. I don't know if | it's as easy as just extrapolating from recent trends because | there may be countless unknowns from biomedical advances to | climate destabilized societies to being turned into | biological batteries for our machine overlords in the next | few centuries. | ch4s3 wrote: | Having medicare operate under a fee for service model will | never be sustainable in the long run. We already spend $ | 755 B on Medicare, which is roughly equivalent to the DoD's | $ 767 B, and Medicare is notoriously wasteful[1][2]. | | [1] https://www.healthaffairs.org/do/10.1377/hpb20220506.43 | 2025/ | | [2] https://vbidcenter.org/wp- | content/uploads/2021/10/jama_shran... | skyyler wrote: | https://www.usaspending.gov/agency/department-of- | defense#:~:.... | | >In FY 2022, the Department of Defense (DOD) had $1.64 | Trillion distributed among its 6 sub-components. | | Where are you getting this 767B number? | ch4s3 wrote: | The treasury department's website[1]. I wonder if your | link is rolling in the VA? I can't quite tell. | | [1] https://fiscaldata.treasury.gov/americas-finance- | guide/feder... | skyyler wrote: | >Department of Defense--Military Programs | | I wonder if that means they're subtracting portions of | the DoD budget that aren't technically military | operations. | ch4s3 wrote: | As with many of these categories it can be hard to pin | down accurate numbers. | MBCook wrote: | I didn't read it as an indictment (why are we wasting all this | money on people who are dead soon anyway?) but more of just a | straight observation that makes sense if you think about it but | probably isn't what most people would expect if asked | unprompted. | questime wrote: | It's politically toxic to discuss but a ton of money goes to | keeping people not dead (not really alive either). You could give | a lot more people medicare/medicaid if we let a 90 yr old with | dementia/diatebetes/etc. pass with dignity. | TheOtherHobbes wrote: | Any form of euthanasia runs into the legal and moral problem of | who decides? And why? | | You might think everyone wants to act in the best interests of | their relatives, but of course that's not true. Some people | will want to speed the natural process along because that | inheritance looks really appealing, and no one is really going | to miss the old guy/gal anyway. | | Besides, that's not really the problem. The problem is | profiteering by insurance companies and the hospitals they | (effectively) run for profit, with patient wellbeing as a | regrettable requirement they have to put some effort into. | itestyourcode wrote: | Is it the same dilemma if we can kill one to save more? | wellareyousure wrote: | Yes, certainly people in medicine are aware. | | > we let a 90 yr old with dementia/diatebetes/etc. pass with | dignity. | | Often it's a 4 week old baby. | | For every 1 sophisticated family member, there are 19 | unsophisticated ones, who toss a weighted coin and, if it's | heads, they decide they want their dying, non-responsive | relative - possibly their baby, possibly their mom, etc. - to | be kept alive at all costs. I don't know if this is politically | toxic as much as it is cultural, and possibly globally | cultural. | questime wrote: | > Often it's a 4 week old baby. | | You are stretching the word often, most people in the ICU are | close to the end of their life. A lot of people don't realize | but most of the time if you needed to spend weeks in an ICU | you are probably not "living" in a dignified way. Almost all | ICU doctors/nurses I've talked to would rather have a DNR in | their old age than live like that. | Eleison23 wrote: | Your human dignity is not predicated on how much pain | you're in, how awake you are, or how able you are. | z3rgl1ng wrote: | This is an oft-repeated piece of received wisdom that is | empirically untrue. | | https://www.statnews.com/2018/06/28/end-of-life-health-spend... | robocat wrote: | Wow: just sample bias! We need to also look at the old people | who had expensive care and survived (95% of costs in that | article). Money does gets spent on hospital care just before | death (5%), but predicting how to avoid "wasting" that money | is hard. | voz_ wrote: | I don't think its politically toxic, but rather, extremely | humane that we care for our elderly. The real unfortunate part | is that we, in the working class, have to make due with sharing | slices of the pie so more money can go to our exploiters and | owners - especially in the US, we are such a wealthy nation, | and yet here we are bickering around who deserves care based on | age. Sad. | MBCook wrote: | > I don't think its politically toxic | | Ever hear of the Obamacare death panels? The ones where | doctors would decide if your loved one was too old and | shouldn't get treatment? | | Yeah. That's this. | | What it really was that Medicare would pay for consultation | with doctors (?) to discuss end of life care and setup living | wills and DNRs and such if the person wanted. | | That way if something happened and they were taken to the | hospital they could be treated the way they wanted to be and | not stuck in a coma on a vent for the rest of their life if | that was against their wishes. | | But the Republicans branded then "death panels" (which for | political purposes was _brilliant_ ). So the choice of having | help making those decisions was removed. | questime wrote: | I disagree, spending on these things is growing at 2x GDP | growth so yes more of the pie is going to this. What I'm | suggesting is that at some point the pie isn't big enough for | this. No matter what happens eventually standard of care will | roll back/fewer people will be covered etc. Ideally we can | innovate out of this situation but after spending 8 years | working in healthcare I've gotten cynical about it. | neonate wrote: | We don't care for our elderly. We fear death. | | If our society really cared for the elderly, they would be | integrated and respected, not segregated and shunned. We do | the latter because we fear age, sickness, and death. Fear | isn't caring. | rscho wrote: | > We fear death | | In the US. It's perhaps the most striking difference that | hit me during my stay overseas. In the Old World we | occasionally get people completely panicking about their | own death. In the US, seemingly _everyone_ is like that. | neonate wrote: | I'd like to hear how elders are treated in these | societies that don't fear death as much. | rscho wrote: | I'd wager: not very differently. But not out of fear. The | social isolation of old age is the same everywhere. Young | people have their own lives to live. | croes wrote: | Where do you draw the line? At what age, what illness do you | refuse to treat a patient even though he may not want to die? | | You could give a lot of people medical treatment with a proper | healthcare and tax system. Why don't we try that first? | chiefalchemist wrote: | Many of the top causes of death, per the CDC, are from diseases | that can be prevented or naturally mitigated. We're all going | to get old. We're all going to die. But carrying two or more | "pre-existing conditions" into your later years is going to | decrease your quality of life, as well as your use of | healthcare. | | My point is, what's not sociopolitically allowed is discussing | how personal choice as well as normalized systematic issues | (e.g., urban food deserts) are killing us, slowly. It's | unfashionable to suggest someone's weight is (ultimately) | unhealthy. But the USA wants to have its cake and eat it too, | literally. That's not working out. It's not sustainable. | | Finally, not to get off topic but over the last couple of weeks | there's been a thread or two on HN based on acticles suggesting | the GDP and similar "classics" economic metrics are hiding | underlying social issues. That is, for example, healthcare care | contributes to the GDP (or whatever) but that healthcare is for | diabetes, opioids, faltering mental health, etc. We're falling | apart but not to worry the economy is doing just fine. | | It's complicated. But to your point, the fact that some | important topics are ofc limits isn't helping. Until that | changes the status quo will continue. | nativecoinc wrote: | There's a lot of talk about supposedly un-PC, taboo subjects | that are just not so. | | We have many common diseases that are outright labeled | "lifestyle disease". And tabloids scream at you with | headlines like "This one weird thing will dramatically | [increase/decrease] your chances of getting Alzheimers". | Impolite subject? Sure, telling _an individual_ that they | should just lose weight is an asshole move since it won't do | any good, so in _that_ sense it is uncouth. But as a general | background noise that we are all supposed to accept? Oh, it's | not taboo at all. | | It is of course completely irrational considering the toll | that the actual disease would have on me, but I am in part | afraid of getting something like T2 Diabetes just because of | the social stigma of getting a Lifestyle Disease (sort of | like a negative lifetime achievement award). | | And as far as critique is concerned: I've been thinking | lately that the term "lifestyle" can be misleading for about | 30% of our lives. Because being "sedentary" is a lifestyle | now, and many of us spend a whopping 50% of our waking, | everyday lives being very sedentary in an office. (As for the | non-waking time we seem to be stuck with sedentariness.) When | I think of "lifestyle" I think of choices, but having a job | is hardly a choice for most people. So if the powers that be | really want to hold us 100% accountable for our own bad | choices, then they should at least give us standing desks, | those small walking treadmills, the opportunity to _go | outside_ and walk for longer phone calls and meetings, etc. | ryandrake wrote: | > My point is, what's not sociopolitically allowed is | discussing how personal choice as well as normalized | systematic issues (e.g., urban food deserts) are killing us, | slowly. It's unfashionable to suggest someone's weight is | (ultimately) unhealthy. | | The recent push to try to re-frame obesity as healthy, | fashionable and sexy seems particularly bizarre and | unexplainable. It's the opposite of what happened with | cigarettes, which started out as fashionable and healthy, | then slowly became known as unhealthy and finally fell out of | cultural fashion. | lazyasciiart wrote: | I think the root of it is recognition that mental health is | as important as physical health, and that losing weight | isn't as easy as many people assume, and shouldn't be done | the way many people try - so actively shaming and | criticizing fat people for being fat is of negative health | utility overall. | chiefalchemist wrote: | > o actively shaming and criticizing fat people for being | fat is of negative health utility overall. | | Fair enough. But then what do you suggest we do as an | alternative to normalizing diabetes and obesity? | | To your point - kinda - about losing weight. Changing | behavior isn't any easier when there are too few | environmental signals to nudge behavior in a more healthy | direction. As humans, we are wired to assume the norm we | see around us. How do we reverse the tide when abnormal | (and unhealthy) has been normalized? When everywhere you | look, there are people just like you? | | I do agree. Mental health is important. But a component | of that is (dealing with) adversity. I'm certainly not | condoning repetitive malicious bullying, but the current | climate has outlawed any/all references to traits | connected with being unhealthy. At this point there are | no social deterrents, are we really better off? | | Have we robbed Peter to over-feed Paul? | ch4s3 wrote: | It's pretty well know and often discussed that up to 1/3 of | Medicare spending is wasted. Being fee for service doesn't help | but neither does spending 13-25% of all medicare dollars on end | of life care[1]. | | What's worse is how much of Medicare's wasted spending goes to | harmful treatments. | | [1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6610551/#:~:te | x.... | [deleted] | w10-1 wrote: | It's a tough situation, and I'm glad his father is finding help. | | I've spent a fair bit of time in ICU's on both sides. I think the | observations and conclusions show misunderstandings. Generally, | opinions are not ignored, nurses don't go wild, the patient | population makes sense for an ICU, the institutional memory is | actually fantastic, etc. | | And most importantly: "There's no sense of a scientific method, | reasoning from first principles, or even reasoning from similar | cases though" This is complete and utter hogwash, borne of a | difficult experience. | | They key idea is this: in complex cases, doctors have to identify | the condition that matters most, and prioritize that. | Collaboration is necessary to get the picture and give care, and | perhaps to consider alternatives, but it's not how you make | decisions. | | It's hard to see symptoms ignored or under-treated. But it's very | likely that delusions do not make a difference in the patient's | recovery, but something like lung surfactant matters most. So | everything from fluid intake to drug dosage and activity are | direct accordingly. Unless they're symptoms of the main issue, | discomforts can be prioritized later after the main issue | resolves. | | "Identifying the main condition" means understanding the actual | insult and the healing process for this patient; understanding | how symptoms, labs, and imaging reflect all the conditions i.e., | how it presents (and skews labs or self-perception); and | understanding how all the interventions may interact with the | disease/disability states, from drug interactions to liver and | immune-system complications, etc. | | It's not uncommon for other doctors and nurses and patient | advocates to have some slice of this complex picture, but it's | the attending who has it all, and the experience of other cases | and knowledge of the underlying conditions and interventions. | | And, for the most part, the attending is not responsible for | explaining their understanding or reasoning to anyone. They do | offer reasons and make records, but there's no place or time or | even audience for comprehensive account of why other alternatives | weren't considered or followed. | | Science, and medical trials, try to isolate single factors to get | reproducible outcomes. Medicine in the ICU has to accommodate | multiple factors, by focusing on the main disease/healing process | and optimizing for that. | | As for value to society: good ICU attendings are key to good | outcomes for patients and their families. It takes decades to get | good. They produce far, far more value than they're paid, largely | because they do it as a mission. If they see people, particularly | those who enjoyed the benefit of their dedication and service, | disrespecting and misunderstanding them, it's likely to dissuade | them from continuing or dissuade others from their difficulties. | | So complain all you want about digital advertising and go full- | disruptive to fossil fuels, but please be very, very careful when | attacking health care. Otherwise we'll end up with Russian | hospitals where you bring your own materials and pay your friends | of friends for side work. | Wonnk13 wrote: | For context see my comment here | https://news.ycombinator.com/item?id=33625584#33647770 | | One thing that this article touches on, but I think needs to be | emphasized even more is that the stark reality is that the only | advocate for the patient is the patient themselves, or perhaps a | caretaker. | | The burden is on me to ask questions about fertility and sperm | banking because my oncologist is well... an oncologist not a | fertility expert. I have to ensure that every department is | communicating with every other department. | | Hospitals and physicians are fantastic at solving discrete | issues, but the bigger picture is often lost in the chaos. I can | do it as a technically adept 34 year old, it's horrifying to | think about how someone closer to 80 goes about it. | dheera wrote: | I was in an ICU for a week after a cardiac arrest. I don't | remember much of it other than a lot of hallicunations. | | I had family there to advocate for me, but there's no way in | hell I would have been able to advocate for myself. I was | literally seeing things around me in the ICU room that didn't | exist. My family were probably the only ones that realized that | that wasn't the real me. | | The hallucinations stopped happening as soon as I was moved to | a normal patient room for the rest of my recovery, and I have | full working memory of that normal patient room. | chki wrote: | > The hallucinations stopped happening as soon as I was moved | to a normal patient room for the rest of my recovery | | To be fair (and this is also true for the article itself), it | might be difficult to distinguish cause and effect here. | Being moved into less intensive care means that you are more | stable which might lead to other issues becoming better in | the following days regardless of whether you are in the ICU | or not. | voz_ wrote: | Great, well written article, I wish your father a speedy | recovery. | | Anecdotally, when I was in the hospital (much more minor, at a | much younger age), they kept waking me up at 3am to draw blood | and clean and do god knows what, and the light outside my room | was constantly on. It felt... at best annoying, at worst, | downright jarring and disruptive. It certainly feels like the | sleep and rest parts of recovery and care need to be revisited. | bombcar wrote: | There was an interesting article that showed "state of the art | delivery rooms" from the 1950s - and they were ALL oriented | around the doctor and nurse's convenience. | | Now we've moved back toward "birthing centers" which focus on | the mother and the baby; perhaps it is time for something | similar to grow across all aspects of care. | nobody9999 wrote: | >Anecdotally, when I was in the hospital (much more minor, at a | much younger age), they kept waking me up at 3am to draw blood | and clean and do god knows what, and the light outside my room | was constantly on. It felt... at best annoying, at worst, | downright jarring and disruptive. It certainly feels like the | sleep and rest parts of recovery and care need to be revisited. | | After ACL reconstruction surgery many (~30) years ago, I was | required to stay overnight due to both the general anaesthesia | and the lateness (late afternoon) of the procedure. | | I had a similar experience with the nurse coming in every two | (2) hours to take my vitals. I was trying to sleep, but she | kept waking me up. I groused about wanting to rest, but was | informed (direct quote) "this isn't a hotel!" | | And it's not. Rather it's a money printing facility for the | owners of the health care system that runs the hospital. | [deleted] | dm319 wrote: | For older patients and those with significant co-morbidities, we | often advise against intubation and ICU admission in the UK. | Usually if the disease process can't be reversed on the ward with | current therapy, it is often unlikely in this group of patients | for it to reverse on ICU. However, it does depend on the context. | There was an interesting article that talks about doctor's | choices as an end-of-life patient [1] - they often choose not to | opt for aggressive life-prolonging treatments because they know | how it is like. I think that doctors need to improve the way we | talk about death with patients, and doctors can be just as guilty | as everyone else at ignoring the inevitability of death. | | [1] https://www.zocalopublicsquare.org/2011/11/30/how-doctors- | di... | the__alchemist wrote: | Elephant in the room, related to the article's first point: We | have to tackle ageing. Many of the other diseases (cancer, heart | conditions etc) and causes of mortality are highly correlated | with it. | lazyasciiart wrote: | Heart conditions, for one, aren't caused by aging - they are | caused by being around for a long time so that the slow process | of atherosclerosis has time to become dangerous. We need to | prevent that process from happening by following standard | health advice, really. | georgeg23 wrote: | The hallucinations sound like a side effect from lorazepam | (Ativan) -- something hospitals give almost everyone but is a | hardcore drug. | | Consider asking nurses to stop administering it after you do your | own research. | | https://www.webmd.com/drugs/2/drug-6685/ativan-oral/details#...). | Fatnino wrote: | I went to the hospital for debilitating shoulder pain. | | Came out 3 hours later with an xray that showed nothing wrong | and a bottle of Ativan. Still no idea why they gave that to me. | I didn't take any of the pills. | | And the bill came out to over 7 thousand dollars. | copperx wrote: | It's hard to pin it down to a single drug. Having had both my | grandmother (80) and mother (60) in the ICU, and both got | hallucinations without Ativan. It could be so many things: | | * The aftermentioned lack of sound sleep | | * Anesthesia | | * Painkillers | | In the case of my grandmother, hallucinations and incoherence | lasted about three months after she was home. My mother's | lasted about 2-3 weeks. It was scary. They both eventually | recovered. But it is true that nobody in the hospital bats an | eye when acute dementia-like symptoms are mentioned. "It's | normal," they say. | ChrisMarshallNY wrote: | About 26 years ago, I spent some quality time (7 days) in ICU. I | wasn't just at Death's Door. I was pounding on it, and loudly | demanding admittance. | | _> Everyone agrees that sleep is important, but nobody has any | idea beyond that. _ | | I didn't sleep for pretty much the entire week. I was on lots of | opiates and opioids, though, so I spent most of that week in a | weird quasi-sleep "dream state." | | I don't recommend the experience. | | Most expensive hotel I've ever been in. | theNJR wrote: | My wife just gave birth and it was my first multi-night hospital | stay. The midnight pokes and checks were infuriating. It also | doesn't help that dads aren't the patient after a birth, so they | aren't fed or given a bed. Constant nurse changes were difficult | too. | | On the plus side, I was surprised at the decent quality of food | given to my wife. Steamed vegetables and mid grade proteins with | every meal. | | After two nights we made the case to be discharged. Everyone, | including nurses and family, thought we were crazy to leave so | early. Best decision we made and my wife recovered great. With | the built in iOS medication reminder app and a blood pressure | monitor I was able to manage her just fine. | languageserver wrote: | > After two nights we made the case to be discharged. Everyone, | including nurses and family, thought we were crazy to leave so | early. | | In my country you don't even stay a single night if everything | goes fine. There is no medical need for parents and child to | stay at any hospital if there were no complications | misterprime wrote: | Congratulations! We just went through the same thing and | decided to leave after one night in post-partum. It's much | better to be at home if there's nothing concerning that needs | medical attention. | | Side note: it was surprising how well the "dad chair" served as | a place to sleep after being awake for 24 hours. | ed25519FUUU wrote: | I'm fresh off of spending 24 hours in the ICU and I can say the | OP is right. It's impossible to actually "recover" there at all. | My singular goal while there was simply to get home to my bed, | even if it meant I could potentially die. I didn't care. I wanted | out. ___________________________________________________________________ (page generated 2022-11-18 23:00 UTC)