Our EDs are bad mouthed by the pubic, but their service is actually spectacular. There is a trick to it though.
Medical Republic’s publisher recently spent a week in a public hospital unexpectedly after his appendix decided to pack it in. Here’s a couple of observations on the turnaround from his previous, and only other, stint in hospital, which was 29 years ago.
1: Emergency isn’t so bad … if you have an emergency
Everyone likes to whinge about the time it takes to get properly attended to in Australian emergency departments and how bad the service is, especially in some of the big city emergency departments (EDs) like St Vincent’s in Sydney. Here’s an important tip. If you are screaming with pain and you make it as far as the triage station you’re probably going to find the service nothing short of spectacular. Couple of other quick hints: It’s good to have a few vital signs going rapidly downhill….blood pressure 90/50, rapidly rising temperature; you know the drill. And if you’re in awful pain try hard not swear or carry on, especially in a big city hospital because they might mistake you for an “ice” addict and call the burly security guards; you might be dying, but you need to remember to be nice. Bottom line, if you want a great customer experience, then be dangerously ill, and make sure you are seen and heard and polite. They really don’t like losing you before you make it inside.
2: Medical centre’s on the other hand, are bad places to be in trouble
Medical Centres are surprisingly different when you have an emergency and are in danger. Many, even the big corporate ones (or at least one of them which I won’t name here except to say the decor was fantastic and they had TV with lots of medical ads on it), don’t have any type of triage. It’s a bit surprising, especially in a place like Darlinghurst in Sydney, where there are lots of emergencies (perhaps the locals know to just hit the ED straight up). The receptionist will be immaculately attired, polite, and will give you reasonably accurate waiting information (in my case, “there are 10 people before you, I’d recommend you go somewhere else”) but after that promptly ignore your screaming while 10 people before you with sore throats or a persistent cough are seen. It wasn’t all bad though. I learnt that I could get a bulk bill cardiologist if I went to their centre in Chatswood on Wednesdays, for instance. And when I did make it to the doctor, a very well-attired Iranian man, he was really very efficient. Within a couple of minutes he gave me a letter, asked if I was still able to walk and pointed me to the emergency ward a few hundred metres down the road. I figure it wouldn’t take much to fix up the service in this place. The doctor was great. Everything up to that point needs an expensive consultant to do a little time-and-motion work though.
3: How to get morphine quicker than almost everyone else
I think the thing I most remember about my visit to St Vincent’s is repeatedly getting asked: “Rate your pain on a scale of 1 to 10.” I’m a typical idiot bloke who loves to say “zero” while wincing with stabbing pains in my stomach. What I found very quickly though was that this approach paid off in spades with most of the staff when it comes to short-circuiting all the normal “hoo haa” you have to go through to get some good narcotics into you. They obviously don’t trust the ones who say 9 or 10. In some sort of perverse reverse psychology, I noted that these patients were made to suffer through many and repeated interrogations before they made it to the “A” list of those of us in the room floating away with a morphine drip. The tough guy (or “wannabe tough” in my case) gets the cigar (morphine in this case).
4. Pain won’t kill you but narcotics can of course
If the only possible way to take away all your pain is to get so much morphine you stop breathing reliably then you probably need to have a good look at your self control as a patient. Im told that most opiate addictions start with real, painful injuries or surgical episodes ( the latter in my case) . Pain is a miserable state so if you take something that makes you feel better, you start to crave it just for the relief of relief. Narcotics of course, are very addictive in the sense that your brain develops a hunger for it. It doesn’t take that long and you (me) , the average, slightly over weight, just above middle age business guy, with nice kids, beautiful wife, 4 dogs, a cat and a gold fish, find yourself on the path to potentially one day being like Nigel. Nigel arrived next to me at 3am on the first night in ED and he had clearly been on an ice bender. Until that point of time, all had been very peaceful in St Vincent’s ED and I was beginning to think all the talk about the place was just hype. Until Nigel arrived, no way could you make a reality show in this place. Nigel had been beaten to a pulp, couldn’t remember a thing, didn’t know why he was in ED (even though he had blood streaming down his face) and was clearly very upset about the whole night he’d had so far , including being in hospital . He wasn’t up for co-operating at all with three oversized Maori security personnel. So if you don’t want to end up like a scene in Trainspotting, try a little bit of self discipline as you go through your ‘episode’ and don’t blame it on the poor old doctors and nurses when finally they take your morphine or endone away and politely explain to you why. It has to end some time.
5: What happened to nurse Ratchett and doctor Evil?
The last time I was in hospital, some 29 years ago, things were very different. No one was nice to me or seemed to care. Back then, I was probably in more trouble and pain than this time around – I’d compound fractured my tib and fib. But no matter. I was just a “tag” and “bag” screaming wreck of a patient to be processed. The experience was so bad that I promised myself never to go hospital again. Until this slight emergency, I’d managed to keep that promise to myself. So imagine my surprise when everyone was attentive, polite, even on the odd occasion, good looking, young and snappily dressed. I was quite suspicious for the first couple of hours. What, I thought, were they actually planning for me? Well, nothing but mostly very good care and service as it largely turned out. But I didn’t know that on the first night in the ED, thankfully loaded up a little on morphine. The first night was a real eye-opener. Firstly, until Nigel (and then Molly) arrived, everything was very peaceful. And it wasn’t the morphine talking. There was no one there. What sort of city centre ED was this place? Where were all the emergencies? I was checked on regularly, I saw lots of doctors who were communicative and explained stuff and comforted me. I felt welcomed and genuinely cared for.
And then when things did go off the rails, the arrival of Nigel the ice addict, and his friend Molly and a couple of others, all at about 3am, I was fascinated to listen to how well most of the young nurses (not all of them, but most), handled these very difficult arrivals. One female nurse in particular, who must have only been in her early 20s, talked down Nigel (and then his friend Molly) with her country girl banter and almost certainly avoided the dreaded strap down and a bit of rough stuff from the ever-smiling security guys. This young women was a figure of empathy and genius interpersonal skills. She definitely saved Nigel and Molly from a lot of grief that was about to beset them in the form of a less- skilled male nurse and the security guys with itchy feet. I reckon she could easily get a gig at the UN. This wasn’t how nurses treated people 29 years ago. Today they listened, engaged, found common ground and talked people down so they could be looked after and felt good about themselves. I’m sure it doesn’t always go that way but I was mightily impressed. I wondered if I’d just struck a couple of unusual characters or if there was training and procedure behind all this good work? I had to wait a few days to find out. So far this was more like a well-run hotel than a hospital.
6: Beware the 5am changeover
If there is one bit of advice I could give that may save someone’s life one day, it’s “beware the 5am changeover”. For all the good work everyone had done with me until 5am that next morning, it nearly came all undone on the changeover. The changeover, is when your nurse and others in their team, hand over to the next team. You’ll get a few a day. The most dangerous in my limited experience is the early morning changeover. Everyone is tired I guess and don’t listen much. In my case, some numbnut nurse didn’t even remember I was there, let alone that I needed a morphine top up every few hours. Being so tough (stupid) I let it ride for a bit. “They’ll realise I’m here in increasingly excruciating pain eventually” I reassured myself. They, whoever they were, didn’t. I very suddenly fell off a pain cliff. I started shivering and went into some sort of fit. I couldn’t even scream properly. I actually thought I might die. I hadn’t been like that ever. Eventually someone noticed and within about a minute there were at least 15 people around my bed – a mix of nurses, doctors, students and maybe a few passers-by who just wanted to see some guy dying in a fit on a bed. I didn’t care. I was relieved as I bounced up and down because I thought that someone would just whack me up with my missed morphine dose and things could get back to normal. No such luck. Turns out that among the now over 20 medical professionals gathered around me, most of them asking me to “just relax and breathe” and many looking panicked, there wasn’t anyone who had a clue what I supposed to be on, what was wrong with me and worst of all, what to do. No decision-makers in the room. Bugger.
I kept writhing and bouncing around like I was electro-convulsing. One nurse grabbed my head and I turned on her like Linda Blair in The Exorcist. Things weren’t going well. I couldn’t speak. I was starting to get scared they were going to mistake me for Nigel and tie me up. They were trying to take my temperature. The thermometer popped 3m across the room and nearly poked the eye out of the guy in the bed next to me who had come in overnight with no memory after being knocked off his bicycle. I was trying to say Moooooorppphhhiiiiii=n=e…but it just wasn’t coming out right. I read something recently about doctors and patients making important decisions together. I figured I’d try and help them all. But I was going downhill quick. I was starting to fade with no oxygen.
Then when all seemed lost an authoritative, loud and mature voice from the back – recently arrived I guess – shouted out “just give him his bloody morphine and prep him as quick as you can. We need to open him up and see what we’re dealing with here !” All 22 juniors somehow organised themselves and obeyed. Funny how effective a voice of authority can be. The day was saved. I got my forgotten morphine and things settled down pretty quickly. I thought to myself: “Watch the bloody changeovers Jeremy”.
7: Is it really necessary to tell me I might come out of surgery with a colostomy bag and no bowel?
I don’t mean to be critical here because other than the changeover everyone was communicative, professional and nice. Other than nearly dying, I was sort of enjoying the change in pace from my normal mostly monotone day in the media business. But is there any possibility that too much communication might be a bad thing? From the night before and some conversations I’d had with doctors, I thought I might have either a dud appendix or maybe gall bladder. I was scheduled to do a whole wad of tests before things went south on the changeover and the good doctor with the big voice decided to just open me up and look. Before surgery, though, I needed some de-briefing apparently…by about 10 people as it turns out. Normally I might have thought this was an OK idea. But since no one had any idea what was actually wrong with me, they decided to paint me a very broad canvass in order to make sure they actually covered all bases. Not to get into the gory detail here but let’s just say that as well as the obligatory burst appendix, gall bladder, kidney stones, et al, they kept listing things until we eventually got to “some chance of bowel or stomach cancer”, then, some very exotic condition that sounded awful but which I can’t pronounce ( I lost it in the blur of the drugs), and, finally, the coup de grace, and thanks guys, “you might have a perforated bowel”, the worst-case scenario of which might be that they “had to cut a whole lot of my bowel out. So if I felt a plastic bag by my side when I woke up, I shouldn’t freak out”. Huh? They wanted to tell me more but I demanded they stop immediately. I thought I might die of anxiety or fright before I made the operating table. I had to argue with them because apparently it was some insurance thing or communication protocol they’d been ordered to perform. This was much more like 29 years ago. They had to tick a lot of boxes on forms back then I recall. I wondered what complete idiot came up with a protocol to scare the living crap out of someone before emergency surgery. Shouldn’t they be trying to be calm me down? Not the fault of the workers I guessed. Someone had told them to do it. Just in case the idiot I’m referring to above reads this, it didn’t help one bit knowing all that stuff. In fact I think my gut is OK now but I might have a mild case of post-traumatic stress disorder from the pre-surgery briefing.
8: I might just swap all the drugs for the good experience
I’ve always believed that experiences, especially good ones, are much better than drugs. (Some of my friends would argue of course that drugs led to their greatest experiences but I’m pretty sure we are talking about completely different things, so I’ll not go down that path). Someone somewhere has definitely been working on how hospital staff interact with patients in the last 29 years. This wasn’t all luck. I was there for 7 days. I was chatting about this to Dr Sam Prince recently, a 32-year-old entrepreneur doctor who, among other things, runs a start up genetics company (Life Letters), heads the “One Disease” program, and owns more than 100 restaurants, many at the very high end of the culinary scale. What Sam discovered very early in running restaurants is that it isn’t the food and the act of eating that brings people back. He measured how long it took them to eat on average and in a 1.5 hour stint it was only 8 minutes. He quickly assessed it was the “experience” of his restaurants. The people, the music, the service and so on. The whole lot together. I told him about my visit to St Vincents and I said to him that I’d had a great experience – biased to some degree by my initial fear in going to hospital. He was “surprised” but not surprised. “Surprised” because he hadn’t thought things had come as far as the rosy picture I was painting. “Not surprised” because he ultimately felt that “experience” was so important to everything where customers were concerned. And as a doctor, he told me, patients are definitely customers of the healthcare system. He is about to open a whole new group of retail wellness centres and by the look of them, the experience is going to be nothing short of entering a brand new Apple store for the first time. Thinking about my experience and all that morphine (and my love of that drug), I decided that my recovery was probably better served by the experience of being well looked after and feeling I was cared for, than the all drugs and technology used on me. Someone is thinking in hospital land. At least they are at St Vincents. Experience really counts in making people better quickly.
9: What makes a good hospital experience?
I think this is pretty simple. People who are knowledgeable and who are good at communicating (maybe add, who have some natural empathy). People who are “people” people and know their medical stuff as well, and probably ones who quite like their job (I might be going too far there I know). I’m not saying my visit was perfect. I still think that changeover nurse nearly killed me, and the 22 medical personnel stuck for something to do when I was fitting, wasn’t great communication or organisation. But they came through for me in the end. I reckon I left hospital much earlier than the doctors thought I would or maybe even wanted me too, hence saving us all money. After my surgery my lungs collapsed and I got pneumonia, so the week overall wasn’t easy medically. But from a human point of view it was pretty good. And I think that contributed quite a lot to my wellbeing and speed of recovery.
Thanks to all of those many staff who saw me and looked after me that week. I still left reasonably exhausted physically. But I was mentally much stronger than when I came in, which is pretty amazing. I felt like paying on the way out (I had opted for public on the first night). Stunning effort everyone. Keep up the great work.
