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Things I've noticed while visiting the ICU
- the__alchemist 4y agoElephant 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 4y agoHeart 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.
- tomcam 4y agoVery 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 4y agoThis 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.
- anjc 4y ago> 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.
- questime 4y agoBecause 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 4y agoMaybe 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 4y agoHaving 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/hpb20220506.432025/ https://www.healthaffairs.org/do/10.1377/hpb20220506.432025/ [2] https://vbidcenter.org/wp-content/uploads/2021/10/jama_shrank_2019_sc_190005.pdf https://vbidcenter.org/wp-content/uploads/2021/10/jama_shran...
- skyyler 4y agohttps://www.usaspending.gov/agency/department-of-defense#:~:text=Each%20year%20federal%20agencies%20receive,making%20financial%20promises%20called%20obligations%20 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?
- questime 4y agoIt'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.
- voz_ 4y agoI 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 4y ago> 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 4y agoI 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 4y agoWe 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.
- voz_ 4y agoGreat, 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 4y agoThere 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.
- barry-cotter 4y ago> 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. And women are still giving birth lying down, fighting gravity, for the doctor’s convenience.
- nobody9999 4y ago>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.
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- georgeg23 4y agoThe 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#:~:text=Also%2C%20lorazepam%20may%20have%20the,such%20as%20agitation%2C%20hallucinations https://www.webmd.com/drugs/2/drug-6685/ativan-oral/details#...).
- Fatnino 4y agoI 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.
- jmcgough 4y agoProbably assumed it was somatoform
- copperx 4y agoIt'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.
- maxerickson 4y agoThe 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.
- NegativeLatency 4y agoJust 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 4y agoI personally want my doctors to be amazing and very good. For now tests are a fair proxy, it's the 8 years that seem ridiculous, esp when looking at non US countries.
- a_shovel 4y agoI 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/S0735109721009384 https://www.sciencedirect.com/science/article/pii/S073510972...
- colechristensen 4y ago>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.
- cactus2093 4y agoFrom 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.
- possiblydrunk 4y agoFrom 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.
- chiefalchemist 4y agoWhen 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 4y agoRich 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.
- warner25 4y ago> 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.
- jmhmd 4y agoThe 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 4y agoAlso, the cases are usually in desperate enough straits that “here, swallow this seagull poop!” doesn’t get hints thrown out of the hospital.
- coding123 4y agoJeez, 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.
- Wonnk13 4y agoFor context see my comment here https://news.ycombinator.com/item?id=33625584#33647770 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 4y agoI 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 4y ago> 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.
- Sevii 4y agoHallucinations are one of the most common symptoms of sleep deprivation.
- dm319 4y agoFor 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-die/ideas/nexus/ https://www.zocalopublicsquare.org/2011/11/30/how-doctors-di...
- citilife 4y agoFor 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.
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- theNJR 4y agoMy 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 4y ago> 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 4y agoCongratulations! 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.
- froggertoaster 4y agoFather of four here, had one two months ago. > It also doesn’t help that dads aren’t the patient after a birth, so they aren’t fed or given a bed. Yes, and? You're free to go to the cafeteria and buy food or leave and go buy food. And there's usually at least a chair. What do you expect, a Marriott?
- ars 4y agoThe father is the wife (and baby's) advocate in the hospital, and should leave as little as possible. You need to be there for every test and consultation. So yah, they should be bringing the father food, and there should be a bed for him because the father is critical in having good care for the wife.
- HEmanZ 4y agoThese 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 4y agoThat sounds illegal.
- chips_n_fries 4y agoAnd she is not a resident or in a training/certification program?
- jeffrallen 4y agoHospitals make you sick. Intensive care unit make you intensively sick. What a tragedy that something we need so much is so bad for us.
- ivraatiems 4y agoMy 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?"
- ghufran_syed 4y agoIt’s also impossible to infer the logical process from a superficial observation of the tests being done - that would be like inferring the code architecture from what’s displayed on an output device, in rare cases it might be possible, but usually not
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- pmarreck 4y agoExcellent 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 4y agoAs 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 4y agoI 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%.
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- w10-1 4y agoIt'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.
- DoingIsLearning 4y ago> 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.
- kerryoco 4y agohis "go wild" sounds like it's blaming the nurses, which it is partly, but I think moreso he's trying to point that this situation is just pretty awful. Or at least he should be trying to focus on the bigger picture. I certainly don't blame the nurses for showing up to work and trying. But I think we can all see how the 'path of least resistance' and financial incentives also leads us to this 'medical factory' type of treatment of people. And that's not the nurses' problem, that's just all our problem.
- ncrmro 4y agoI 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.
- mberning 4y agoI 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.
- kingsloi 4y agoInteresting 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.
- tomcam 4y agoCried a little reading that. What agony, losing a child in slow motion. My best to you and yours.
- froggertoaster 4y ago> What agony, losing a child in slow motion. These words are both poetic and heart-wrenching.
- hackeraccount 4y agoI'm a cynic to some degree. I think suffering doesn't ennoble people for the most part - it just makes them bitter and angry. I realize this wasn't your point - and who knows maybe I'm misreading you - but this comment makes me reconsider my view on that. I have a child and having to go through something like what you describe makes me feel sick. Doing that and then having any degree of empathy - sympathy even - for the people involved is a credit to you.
- ChrisMarshallNY 4y agoAbout 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.
- ed25519FUUU 4y agoI’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.
- Ensorceled 4y agoI 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.
- etrautmann 4y agoYes - my wife is a physician and she routinely describes how well meaning family members make care harder for their loved ones by trying too hard in the wrong ways. Requesting more care doesn’t get you better care - “squeaky wheel gets the grease” doesn’t really apply in many situations.
- Ensorceled 4y agoI certainly saw that. The issue we had was my sister grilling everyone who came into the room, or even walked by, often the same questions that she already asked that person earlier. I could see everyone starting to dread seeing her. The “squeaky wheel gets the grease” doesn't apply if people are avoiding the patients room. My father's cardiologist was explaining the procedure he was about to perform and my sister and mother were so upset they just flooded him with irrelevant questions and questions that he had already answered. I kept trying to get them to stop talking over top the surgeon and actually listen to the answers he was giving. He finally asked me if I could "socialize this with your family" so he could return to the operating room.
- throwaway2037 4y agoI have heard an equal number of stories that are exactly opposite. Only through aggressive, pushy "squeaky wheel" behaviour was someone able to get the correct care.
- osmano807 4y agoSurgeon 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.
- Fomite 4y ago
- Spooky23 4y agoMy mom was the nurse empress of a large ICU (at least tactically). The biggest issue is there’s no “product manager” for your care. Each specialist doctor has an incentive to do as little as possible as often as possible to avoid having a death on their record, but to be able to bill. So the nurses usually are the most incentivized people to actually take care of you. From her point of view, the management ensured that the best care for patients happened when family was present, especially on irregular intervals, and for prisoners, who had a CO always watching and sometimes logging what happened. Her other big thing was hatred of EMRs. The loss of the clipboard made situational awareness tough.
- trynewideas 4y ago> The biggest issue is there’s no “product manager” for your care. Each specialist doctor has an incentive to do as little as possible as often as possible to avoid having a death on their record, but to be able to bill. So the nurses usually are the most incentivized people to actually take care of you. Man. Maybe this is a tangent, but remember primary care physicians? I can barely remember that as a concept. I waited so long to find a PCP taking patients at my last job that I quit before it happened. Was that a role they ever filled? It kind of feels like it should be considering the title, but being a US citizen I've never experienced it.
- roxgib 4y agoHere in Australia to see a specialist your GP has to refer you. To us the idea of going straight to a specialist is odd, if you have a non-emergency medical issue of any kind you just see your GP. Not saying we don't have issues, but I honestly don't know have people manage their medical issues without a GP to coordinate.
- Spooky23 4y agoThey make like $250k. Specialists make like $500k and up. So the business model is for health networks to vacuum them up and then hire a bunch of nurse practitioners for $100k. Some of these guys get laid off and end up working in dermatology offices getting commissions on expensive creams.
- duffpkg 4y agoAuthor of Hacking Health for O'Reilly, managed operating companies for hundreds of hospital facilities, etc... One widely under realized aspect to healthcare costs in the US (there are many) is the very high number of ICU beds per capita, ~35 per 100,000 people. While it gets a little complicated to compare apples to apples, a reasonable person could say we have 30% more than germany which is the only european contry that is close and double to triple most other nations we are typically compared against like the UK and Canada. ICU beds are extremely expensive to both build and operate. Also for the lay person the term "bed" has a specific regulatory meaning and does not refer to just the physical existence of the room and bed but means that it is operational with highly regulated amounts of staffing, services and equipment. Each "bed" has costs in the millions to build and equip and operating costs are typically in the neighbood of $10k to $40k per "bed" per day, occupied or not, a large portion being labor.
- Blammar 4y agoCan you explain why one ICU room costs millions, and why they cost 10k a day even if no one is in them? Neither makes sense to me. I can imagine say 100k in monitoring equipment in a room. Maybe it's the hospital inflation applied to equipment?
- Dma54rhs 4y agoFor one American medical workers earn absolute insane wages compared to their European counterparts.
- db48x 4y agoMost of the cost is people. It’s not much use calling it an ICU room unless there are doctors and nurses and anesthesiologists and other specialists on call to actually care for people intensively. Plus a janitor or two.
- duffpkg 4y agoAn ICU unit isn't exactly a single room. There are different configurations but they typically involve some sort of centralized monitoring station and 5-20 ICU "beds". Total cost of that / number of beds. Everything in hospital construction is expensive, ICUs are at the extreme end of that. Huge power requirements, medical gas lines, fixturing and surfaces needs to be able to be disinfected, special air, special water, on and on. It has requirements very similar to an operating theatre. The reason they cost so much even if no one is in them is because of what a "bed" means. It isn't the literal bed, it is a unit a treatable/treating capacity. Requiements vary somewhat by jurisdiction but it's going to mean 24/7/365 nursing and attending doctor staff. You can't just call them in when a patient shows up, they need to be scheduled and available. Then ICUs will also need a large cadre of oncall specialists, neurologists, cardiac, laboratory testing staff, and on an on to cover a huge range of possible patient needs. Stocked blood units, stocked medicine units. All those things have costs whether a patient in in the bed or not. Hospitals to a large extent spend an incredible amount of money on capacity. No wants wants to end up in a hospital to have them say, "oops, we didn't expect your spleen to rupture today, Dr. Bob won't be in till next tuesday so you are out of luck, sorry"
- ericmcer 4y agoHis observation that the ICU is full of the elderly reminded me of the Obamacare debates when I was younger. I always felt like I was taking crazy pills when I would leave my conservative elder parents who hated the idea of universal healthcare, and go to my younger liberal friends who were all for it. It was such a clear case of peoples ideology running directly against their self-interest. Young people being against paying for old peoples healthcare (while the elderly control a much larger share of the wealth) made sense to me, old people wanting more reassurance that they would always have healthcare made sense, but the two groups essentially wanting to self-sabotage was always confusing.
- crooked-v 4y agoFox News & co have spent decades training their target demographic to hate and fear anything that Democrats even pretend to like. There's nothing particularly age-inherent about it other than said demographic being both wealthier and less educated and thus a better group to target with the associated nonsense grifting.
- prenevikdale 4y agoI would hope that liberal young people (and we millennials) wouldn't be against paying for old people's health insurance at all. The hardest part of believing in a principle is doing so when you aren't benefitting from it. While I have little patience for Fox News lemmings of any age, I have noticed that the relative lack of older folks in our daily "internet trenches" has caused the digital zeitgeist to take on a distinct anti-elderly tone. From lighter- hearted mockery, to blaming a nebulous organized "boomer" class for birthing every modern sin of civilization, and everything in between. In any event, as more internet literate adults experience the full lifespan, it may create a corrective trend. By the way, nearly every reply in this thread has been more informative and thought-provoking than the original article on Substack. A really interesting thread to follow, thanks to the contributors.
- JamesianP 4y agoIf you abandon your ideals when it conflicts with your own self-interest, it is not ideology at all, just self-interest. You are criticizing integrity here. such as it is..
- fernly 4y ago> 1. The ICU is filled with old people... Pretty much all these patients are on Medicare, which means your taxpayers dollars are making this happen. This ignores the (I think) very strong possibility that the old people are preferentially selected by the system because, thanks to Medicare, they can _afford_ the ICU. Many people aged less than 65 cannot. Consider the idea that if we had something like "Medicare for all", the population of the ICU would better reflect normal demographics. That said, as a beneficiary of Medicare I can only be grateful. I had several days in a top-quality hospital and a procedure by a top-quality surgeon, and after all the EOBs had come in, I ended paying out of pocket... nothing at all.
- ericmcer 4y agoOld people having more health issues is not really a crazy observation to make. I would be blown away if medical care needed was equal across all ages.
- fernly 4y agoIt wouldn't be. Clearly age brings medical problems. However, I'm saying that the cheap access to hospital care afforded by Medicare, could be skewing the distribution of ICU patients. If we had universal medical insurance comparable to Medicare, the ICU population might be closer to the demographic norm.
- ghufran_syed 4y agoability to afford the ICU is not relevant at all when the docs decide to put someone there or not, based on my 14 years practicing in the US. Do you have any experience to the contrary? I’m pretty sure that would be illegal in the US
- fernly 4y agoA very quick DDG search turns up stories from reputable outlets: "Americans dying because they can't afford medical care"[1], "66% of Americans fear they won’t be able to afford health care this year"[2], "Nearly 46m Americans would be unable to afford quality healthcare in an emergency"[3], "Nearly 1 in 4 Americans are skipping medical care because of the cost"[4], and more are easily found. If this doesn't reflect people avoiding hospitals, or leaving early AMA, and thus reducing the number of pre-Medicare patients by some amount, I'd be very surprised. [1] https://www.theguardian.com/us-news/2020/jan/07/americans-healthcare-medical-costs https://www.theguardian.com/us-news/2020/jan/07/americans-he... [2] https://www.cnbc.com/2021/01/05/americans-fear-they-wont-be-able-to-pay-for-health-care-this-year.html https://www.cnbc.com/2021/01/05/americans-fear-they-wont-be-... [3] https://www.theguardian.com/us-news/2021/mar/31/us-affordable-healthcare-uninsured-underinsured https://www.theguardian.com/us-news/2021/mar/31/us-affordabl... [4] https://www.cnbc.com/2020/03/11/nearly-1-in-4-americans-are-skipping-medical-care-because-of-the-cost.html https://www.cnbc.com/2020/03/11/nearly-1-in-4-americans-are-...
- mhalle 4y agoAs a person who has spent plenty of time in ICUs or other hospital floors in my life as a patient, I can add some more background to the mental health / delirium aspect. First, it definitely isn't just ICUs, just most common there. High stress environment, powerful medicines, poor sleep, and just sickness. Next, a fair number of patients in hospitals may already be predisposed to psychiatric conditions, or at least be mentally fragile. Some abuse substances. That adds to the whole environment, and hardens staff. I experienced hepatic encephalopathy because of liver failure, which really impacted my mental state, and at least some of the staff bundled me in with the crazies. Empathy would have gone a long way to reduce the stress for me. On the other hand, I am empathetic to them. The job is tough. But most importantly though, given these mental stresses and challenges for vulnerable people, there is almost no psychiatric support for patients, staff, or families. That's shocking to me considering how many people experience "ICU delirium". There is almost no backup for staff to help with otherwise normal patients who, say, might think you are a monster trying to kill them. If there was one thing I would fix, that's it. Psychiatric support on floors, helping staff ease the mental challenges of extremely vulnerable patients.
- jlarocco 4y ago> The ICU is filled with old people. What else would you expect? Health deteriorates as people age, so old people, having deteriorated for a longer amount of time, will generally need more health care. Good insights overall, though.
- prenevikdale 4y agoI actually thought the article was narcissistic and shallow, and I didn't find the author to have anywhere near the experiences or qualifications to make the judgments in his article. The contributions in this thread have been orders of magnitude more interesting than the OP.
- Fomite 4y agoA lot of medical dramas and things that shape people's perceptions portray ICUs are filled with exciting and puzzling cases that need to be solved.
- ler_ 4y agoI'm a nurse and I find the 7th point on the post especially relevant. I will add a disclaimer that I never worked in the ICU so I can't speak for what happens in that type of unit. There is a serious issue with the flow of information in healthcare, (or at least in the U.S, I never worked elsewhere to know if it's any different). But If you find something during your shift which will be important to know later on, it will certainly be lost as soon as you are off for a few days, or even as soon as a new nurse comes on. To think of a somewhat crude example, if you find out that it is much easier to obtain a blood sample from the veins on the left arm of a patients vs the right, many nurses will still stick the right arm countless times hoping to get something. And you can leave a chart note about things like that or speak about it during report, but for the most part few people will think "hm, I wonder what everybody else had to deal with." They are probably too busy handling a thousand different things happening all at once. And, even if that is not the case, from what I observed it's simply not part of how things are done. And very often patients will get (justifiably) angry, saying "I've been complaining of x thing for days!" or some version of that. I think it would be much better for both patients and healthcare staff alike if there was a greater emphasis placed on focusing on the series of successes and failures that happen over the course of someone's care, not just seeing it as a single shift or a single problem happening in some isolated point in time.
- gundmc 4y agoThis comes up every once in a while when discussing the crazy 24+ hour shifts that doctors in residency are often assigned. One argument in favor of keeping the hours is that continuity of care is by far the factor most strongly correlated with good patient outcomes. So the argument goes that a change in caregiver is more detrimental to the patient than continued care from one doctor even if that doctor is sleep deprived. I am not knowledgeable or qualified enough to weigh in on this, but it's something I've heard cited by multiple friends in the field.
- haldujai 4y agoAs a physician, shift length is honestly a red herring. As much as I hated doing 24-28 hour shifts on inpatient services, continuity of care does matter and errors do occur in handover. You have to keep in mind that medicine between 12am and 6am is what we call “keep people alive.” 6am to 12pm after an overnight is for handover. You’re not trying to diagnose a new illness overnight or make changes in management, your job is to deal with acute overnight concerns only. Furthermore, you’re supported by services such as RACE (an in hospital emergency response team) so you’re not dealing with critically ill patients alone. If you’re on a surgical service and need to go to the OR, staff/fellow + senior residents come in to help. Acute care services where you’re seeing new/undifferentiated patients and need to be on your game, such as ER and radiology, tend to limit shifts to 8-12 hours.
- ghufran_syed 4y agoIt’s worth noting that the patient’s condition is not an independent variable with respect to the level of care - the author’s father got moved to step down because they got better…and I’m glad to see that they continued to get better in step down. A UK judge once talked about balancing the “benefits and burdens of treatment” when making medical decisions, I think that’s a good way to think about it. The benefit of ICU care is less chance of deterioration and death - the burden is the pain, medication effects, discomfort, noise, confusion and many other things described in the article. It would also be less confusing for the family if the doctors could explain their thought process well, but a) not everybody is good at this, b) not every family member can necessarily even understand or remember this when they are distraught and sleep-deprived, and c) the health system (and patients) don’t want to pay for the time - if they paid double, the doc could spend twice as long with them, as happens with boutique / concierge doctors. Regarding the ICU doc disregarding the consult recommendations- the ICU described sounds like a “closed “ ICU where the intensivist makes the final decision, vs an “open” icu where a hospitalist will often be the one making the final decision regarding care. Either way, it seems obvious that someone has to coordinate the care and decide what’s important right now and what’s not - there are many tests that a consultant may recommend that won’t improve the chances of the patient improving right now, and can be done later on the med-surg floor of the patient survives that long. Many of the consultant recommendations may also be contradictory, someone has to take responsibility for picking and choosing a course of action [edit: fixed typo]
- pgrote 4y agoI spent 2 weeks in an ICU due to an appendectomy gone wrong followed by growing open wound and infection. Horrible time from a mental health perspective with visual and auditory hallucinations, feeling of paranoia concerning the medical team and nightmares. Hallucinations and paranoia stopped before I was discharged, but it took a couple of years for the nightmares to subside. Post-intensive care syndrome is something that happens that hardly anyone who hasn't been in an ICU knows about. Even when I was in the ICU the medical team never discussed it with me. My running joke to deal with what happened is that I aged 10 years the 2 weeks I spent there.
- Uptrenda 4y agoWhat he wrote about delusions and nightmares in the ICU really hits close to home. When I was younger I ended up in the ICU for an accidental poisoning. Initially I went in and out of consciousness, having horrific nightmares fed by the morbid happenings around me. We had many interesting patients come through the ICU. One person was there for a suicide attempt on prescription drugs. Another person had been in a car accident. At one point we even had a prisoner who had been stock-piling drugs to kill himself on. They had him hooked up to a dialysis machine which apparently works well when the drugs aren't fat soluble? It was like a real life episode of House. Meanwhile I wasn't mentally doing that great. When I was finally conscious I started hallucinating and hearing voices. I was hearing insults from the staff that weren't there and felt like everything was done with malicious intent. It was quite traumatic. I actually remembered these delusions for years afterwards and had trouble accepting that it wasn't real. It's only been a recent thing that I've even been able to speak about such experiences without shutting down emotionally. The work that doctors and staff do at ICUs is extremely valuable. But it's definitely not a great place for a vulnerable mind. I feel like there is more that could be done in such a situation. e.g. where someone is profoundly hallucinating. I was over-stimulated and noise was making everything worse. If I just had of had a dark room to recover in I probably wouldn't have been traumatized. Maybe even ear plugs or a mask. But I didn't even have that. I'm also kind of surprised by the OPs story because the ICU I was in was like this closed surgical ward filled with medical staff. ICUs don't really seem like a place to have visitors. I get the feeling many people there aren't even going to be conscious. OPs dad is lucky to have had such good family support.
- EMM_386 4y agoI have been in the ICU and can relate to the hallucinations. During one intense round, I was convinced the hospital wasn't real, and that I needed to leave immediately. My IV was preventing me from leaving, and I couldn't have that. So of course I ripped it out and tried my best to leave. The staff wasn't having it.
- xwdv 4y agoYou thought it wasn’t real as in you though everyone was an actor in a fake hospital building or you thought you were in a whole nother plane of existence?
- EMM_386 4y agoInteresting question ... plane of existence. I was hearing voices that convinced me I was not where I thought I was, it was an illusion of sorts and it was best to leave. Immediately. For reasons unclear to me.
- fhsm 4y agoHealthcare is mighty complex. The "why don't you just _____" or "the problem is _____" impulse among all who touch it is strong and typically well intended. Eventually it will even be right. For the many who have shown the impulse here, a bit of context: Apple global revenue in 2020 was 274B[0] and US healthcare spend was $4T[1]. If you can capture just 6% of just the US you've got an Apple sized (in one sense) operation. Six percent isn't so big, Google is at 90%[2]. Little old United Airlines picks up twice that 6% target for 13% share[3]. If you pulled in 13% of US healthcare you'd have a Walmart sized operation[4]. Apple, Google, Amazon, Microsoft have made a multiple runs at it. Maybe Apple Watch and PillPack count as successes, maybe. The world is waiting for, dying for, someone who actually knows _____. [0] https://www.statista.com/statistics/265125/total-net-sales-of-apple-since-2004/ https://www.statista.com/statistics/265125/total-net-sales-o... [1] https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical https://www.cms.gov/Research-Statistics-Data-and-Systems/Sta... [2] https://gs.statcounter.com/search-engine-market-share/all/united-states-of-america https://gs.statcounter.com/search-engine-market-share/all/un... [3] https://www.statista.com/statistics/250577/domestic-market-share-of-leading-us-airlines/ https://www.statista.com/statistics/250577/domestic-market-s... [4] https://www.macrotrends.net/stocks/charts/WMT/walmart/revenue https://www.macrotrends.net/stocks/charts/WMT/walmart/revenu... (obviously the math is approximate, the sourcing iffy, and the comparisons flaky ... particularly Walmart which is a big player in healthcare so is getting double counted).
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- jdkee 4y agoFrom the article, "We are spending an enormous amount of our healthcare budget on patients in the last 5 or 10 years of their life." It is even worse than that in the U.S., estimated at 10% of total healthcare expenditures in the last year of life. See https://www.wrvo.org/health/2019-09-30/ten-percent-of-all-healthcare-spending-in-the-u-s-goes-toward-end-of-life-care https://www.wrvo.org/health/2019-09-30/ten-percent-of-all-he...
- User23 4y agoThe single most important thing for anyone in the medical system is having a capable advocate. This story really drives that point home.
- derbOac 4y agoI've worked in ICUs; this is mostly accurate except for a few things. Older individuals do probably occupy most ICU beds but this really depends on the ICU. Some are dominated by acute traumatic injuries which can actually skew younger. The observation about attendings is accurate, but as one of those psychiatry and neurology consults, the gripes can go both ways. ICU physicians have a reputation for ignoring long term consequences of decisions. So you end up with a lot of "can they go off a ventilator? then they're fine" stuff. This is reasonable in some ways but sometimes there are patients who will probably predictably be ok and attending more to consequences 10 years later makes a huge difference in the rest of the life of the patient. Also, some ICUs are actually very neuro heavy depending on patient populations.
- jasongi 4y agoRE: the amount of people over 70. This isn’t just ICU, this is all of healthcare. Both culturally and legally humanity seems incapable of accepting death. The threshold for the amount of intervention we’ll do for a human dying is way too much. Sure, you can say DNR, but voluntary euthanasia laws are restrictive and the default from the medical and broader community is almost always try to survive at all costs.
- SanjayMehta 4y agoICU induced hallucinations are indeed a nasty side-effect. My father suffered terribly during his last few days. Some things are worse than death. Imagine being jetlagged all the time for 10-15 days while random people are poking and prodding you.
- samanator 4y agoSomething I've learned about the ICU and hospitals in general when my brother was passing away is that they are not designed for large families. I have 10 siblings (9 now?) and the hospital would only allow for 3 guests at a time. The head nurse in the ICU would only allow for 2 guests at a time, parents included. We had to fight, trick, and sneak in order for all of us to be together with him in his last days (e.g. we would loiter outside the hospital picking up discarded guest stickers and pass ourselves off as other people). What I learned from this is that I do _not_ want to die in a hospital.
- stordoff 4y agoI spent about ten days in a UK ICU with Covid-19, so figured I'd share a few comments based on my experience. I was in a room for one person, so I've no idea who else was in there. I didn't suffer any delusions/hallucinations, other than my memories of the first night being a little hazy (which can probably be put down to being moved at 3am unexpectedly and possible hypoxia). However, after I discharged, I felt like I could still hear the <90% SpO2 alarm going off in my head constantly for _weeks_ (I spent most of the ten days struggling to maintain 90% SpO2, so it was a noise I became very familiar with). > There are many consults, but the ICU attending is king (or queen) / Sometimes nurses are the footsoldiers of the ICU regent, and sometimes they’re governors It's hard to say specifically was making the calls, particularly as the PPE made it a little difficult to recognise people, but it definitely felt like there was continuity of care - treatment plans were discussed well in advance, and usually didn't change unexpectedly. The recommendations from the physiotherapist and nutritionist (my appetite was virtually non-existent), as well as my own requests, were followed by all of the staff involved as far as I could tell. > Everyone agrees that sleep is important, but nobody has any idea beyond that I couldn't sleep for the first two nights, but beyond that, I didn't find this to be an issue. I'd go to bed around 10:30, and wasn't disturbed until about 8 o'clock the next morning. As I understand it, HR/BP/O2 monitors could be checked from an adjacent room, and most of the non-critical alarms were muted (I believe they were still audible to staff outside of my room). There were a few times staff came in to check/adjust something, but never more than once a night (that I noticed at least). > The ICU is a good place to not die, but a bad place to recover I'm not sure I can agree with this. I was moved back to a ward for a few days before I was discharged, and felt that I would have recovered better had I stayed in the ICU (though I understand why that's not practical). The room of eight had two dementia patients who would yell out for most of the night. Obs were taken about every three hours, which woke me every time (BP was taken with a pressure cuff rather than the arterial line which was used in the ICU, and I wasn't routinely wearing a finger sensor). As a result, I got very little sleep until I was discharged. It was also much more difficult to get the attention of staff at times.
- _xnmw 4y agoThere should be a name for this, "medical theatre", analogous to security theatre. A brilliant performance art, with all its buzzing machines, expensive insurance, bright lights, pretty graphic logos, well-dressed specialists and doctors that aren't able to apply their knowledge correctly because they can't get simple things right, like letting patients sleep properly or recording and passing on information specific to a patient. All of this because the emphasis is on the "system" rather than the patient, and the solution is "more system". There is no amount of procedure that can replace genuine care and concern for a human being -- this man's father was lucky to have someone who was spending time with him observing these things, and presumably helping the staff avoid mistakes, and probably helping with the feelings of paranoia and hallucinations as well.
- rapjr9 4y agoI suspect part of what causes the hallucinations is withdrawal from alcohol combined with opiates. When you need emergency care nobody asks or seems to care if you are dependent on alcohol, they simply put you in the ICU and wait for you to wake up, going cold turkey. Maybe there is nothing they can do about it, but it seems like they should at least be aware of it and perhaps working on a solution. That they have not seems to be due to moral judgements (you shouldn't have been drinking so much in the first place.) Perhaps small intraveneous doses of alcohol would help (although the opiates would make that complicated since they interact with alcohol.) Maybe some type of blood cleaning would help. Ignoring it seems like the worst choice, particularly since it can cause physical effects besides hallucinations. This is one of a number of areas that medicine ignores. Another is environmental causes of diseases; when was the last time your doctor asked for air, water, soil, and food samples from your home as part of your regular checkup?
- oifjsidjf 4y agoA bit offtopic but an interesting book: Confessions Of A Medical Heretic - Robert S. Mendelsohn M.D. https://archive.org/details/confessions-of-a-medical-heretic/page/n1/mode/2up?view=theater https://archive.org/details/confessions-of-a-medical-heretic...
- m463 4y agoWith respect to sleep, I think that being disturbed (and/or medicated) might affect REM sleep. And if you don't get your REM sleep eventually your body will try and do it while you're awake. This means lucid dreaming aka delusions. I think an interesting possibility for an ICU would be to add EEG monitor along with EKG and others. You could not only measure heart rate, but the type and amount of sleep each patient gets. And then use the information to make the ICU better.
- hef19898 4y agoWow, that first paragraph is as cynical as it gets: " The ICU is filled with old people." It ends with people now knowing why it tales so long to get doctors appointments, and saying the author is not sure whether ir nit this is a good thing, that we (the articlee is about the US but is pretty much the same everywhere) spend so much of our health care resources on the old. While his dad, also not in his twenties, was cared for in the same ICU. Maybe he should visit an ICU for infants and babies next time... Staffing. Well, what can I say. Patients are there 24/7, staff is obviously not. That staff works in shifts, great realization. I am almost surprised that the author wasn't surprised ICU staff has vacation and sick days. And finally "The ICU is a good place to not die, but a bad place to recover.". No shit, Sherlock, tgat is basically what an ICU does, stabilizing patients enough to transfer them to a "normal" station for recovery, or, worst case, to a paliative unit if death is the only possible outcome. Oh, not to forget: "It really makes me think about how the hospital might be organized differently. If the hospital focused less on pure survival, might their patients recover faster?" What makes a emotionally involved amateur think that the people running ICUs, after sometimes years if nit decades of training in that exact field, don't think about this question constantly? And tgat the current state of ICU care represents the current optimal solution? I am so fed up with articles from people judging things by looking at them from the outside. Mind you, the articke in question here is one of the better ones.
- fedeb95 4y agoExactly my thoughts. I don't know anything about medicine, so my ultimate opinion is "I don't know". If I were to guess, the article just describes a well functioning medical structure and the author has some problem with people paying taxes.
- hef19898 4y agoI really wished "I don't know" would be the default position of otherwise smart, educated and exeperienced people once they step out of their fileds of expertiece. There is only so much that easily transfers from one domain to another, or from one industry to another.
- surgeryres 4y agoI am a vascular surgeon, and have many patients in the ICU constantaly. #6 confuses me - the original operating surgeon should be a constant through the patient’s stay. And while the ICU doctor might be the captain while the patient is in the ICU, the original surgeon is the general. He has complete control and should dominate the patient’s care. While the surgeon can not be bedside 24/7, they or someone from their team should “round” at least once daily on these ICU patients, talking to family, checking catheters and tubes, reviewing medicines, checking wounds. At least that’s how it’s done in Texas.
- hansthehorse 4y agoI recently had emergency surgery for an obstructed small intestine and the surgeon was pretty much in charge of my care. I can't tell you how many times I heard "we have to talk to the surgeon before we do xxx" Members of his team saw me every morning and he came around every afternoon. This was at the West Palm Beach Medical Center in SE Florida.
- jshaqaw 4y agoIn my few (luckily) interactions with American hospitals for serious matters I’m struck by how much the hospital looks like a unified organization from the outside but inside seems little more than common real estate and a joint marketplace for 1000 sub vendors. The system can produce amazing outcomes but suffers from a lack of coordination. It is telling that after a hospital stay you get 20 bills from different places which have no connection to each other.
- ca98am79 4y agohttps://web.archive.org/web/20221118233758/https://trevorklee.substack.com/p/things-ive-noticed-while-visiting https://web.archive.org/web/20221118233758/https://trevorkle...