Notes

stePs you CaN taKe to ProteCt yourself Finally, after laying all of this groundwork to dispel some of the hys- teria surrounding the IOM report, as well as making you aware of the dangers no one has previously informed you of, we can now discuss some specific measures you can take to protect yourself in the unfortu- nate event that you, or a loved one, are hospitalized.
have a PersoNal PhysICIaN This is first and foremost. If you are hospitalized, you want someone who is familiar with your health, personality, and wishes at the helm. Ideally, this will be a doctor who still admits his or her own patients to the hospital. When your own doctor is writing admission orders and doing daily rounds, you will have a greater chance of influencing care. Hopefully, this will be predicated on having selected your physician by the criteria we discussed in Chapter 10. When this is the case, your prior discussions and meetings will be in your doctor’s consciousness, and will make their way into your treatment plan. It is quite uncom- mon for primary care doctors to admit their own patients for reasons we have covered previously. Even if your doctor does not do his own admissions, the fact that you have a doctor will positively influence those providing your inpatient care. Your doctor’s practice style and philosophy will be known and this will influence your care in a positive way. Your doctor provides referrals to the specialists who may be called in on your case, and these specialists will be more responsive and will operate in a way that keeps your doctor happy. The ideal circumstance is that you have a primary care doctor who participates in a cash-only plan or concierge practice, has opted out of Medicare and Medicaid, and does not file directly with insurance. This means you will have to pay your doctor out of pocket and get reimbursed by your insurance. In some cases, these doctors avoid all the hassle by having an agreement with their patients that they will not bill for inpatient services. In this case, you will have someone at the helm of your care that can be more resistant to government-mandated treatment protocols and length-of-stay requirements.
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do Not be hosPItalIZed uNless absolutely NeCessary The best way to avoid the dangers of hospitalization is to avoid being admitted in the first place. For instance, if the reason for admission is the need for IV antibiotics, then try to accomplish this on an outpa- tient basis at an infusion center. If you have a blood clot in your calf or thigh and need anticoagulation, see if you can be self-taught how to administer your Lovenox (blood thinner) injection at home. If you have a respiratory illness that requires breathing treatments and oxy- gen by nasal cannula, see if this can be set up through a home health agency. Many times hospitalization occurs only because of technical issues with treatment. If there is no difference between treatment in the hospital versus similar treatment administered at home or at an outpa- tient facility, then you should not be hospitalized. Before agreeing to hospitalization, make sure there is something that is going to be done to you in the hospital that cannot be done elsewhere.
dIreCt admIssIoN or er admIssIoN? Which is the better route? The answer is: it depends. If your admission is elective or for the performance of an inpatient procedure, and you are stable, then direct admission is the way to go. You can be seen at your admitting doctor’s office and your doctor can make arrangements for you to go directly to an inpatient room with his admission orders in hand (or transmitted electronically). If, however, you are acutely ill, unexpectedly ill or injured, or unstable in any way, then it is best to be admitted through the ER. In some cases, you may have to go directly to the ER and your doctor will become aware of your illness after the fact. In other cases, your doctor may send you to the ER for stabilizing treatment and workup. In such situations, the ER can carry out treatments quickly that cannot be accomplished on the floors. Lab tests, x-rays, and other tests can be acquired in a much more expe- dited fashion, and their interpretation by the emergency physician can guide your treatment and determine the setting to which you should be admitted. Advance notice from your doctor before your arrival at
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the ER can help represent the acuity of your situation, so that you are triaged appropriately and your evaluation is expedited. ERs around the country are bursting at the seams, but if you are unstable or acutely ill, it is where you need to be.
have aN advoCate This is where developing the strong social connections implicit in a primal lifestyle will come in handy. You need to have established the sort of close personal relationships that ensure a support system will rally around you when you are hospitalized. You really want to have a close friend or family member with you throughout your hospitaliza- tion. Not merely for the moral support, but also to help look out for your best interests. If the person(s) staying with you have a medical background, all the better. Your advocate needs to be very defensive of you, and unafraid to ask questions on your behalf. Your advocate can be a watchdog who makes certain that the people who care for you have washed their hands and properly identified you before admin- istering treatment. Your advocate can be on point when you are too tired or ill to concentrate fully. Your advocate can help communicate your wishes when you feel too vulnerable to assert yourself. Just the mere presence of someone who looks intelligent and interested will be enough to make the people involved in your care bring their “A” game. Ideally, your advocate(s) will be with you at all times, even if this means friends and family are working in shifts. If this cannot be achieved, then try to have your advocate present for the medical team’s morning and afternoon rounds, where scarce time should be applied. If you are hospitalized away from home, or are otherwise unable to have such a support system, ask the nurse in charge of your care if the hospital is able to assign a patient advocate to you.
brING your stuff Make sure you bring (or have been brought by someone else) your cell phone, tablet, and/or laptop, along with their respective chargers.
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These are your connections to the outside world. If you have selected the right doctor, he will also be your connection to the person in charge of your care. He will likewise be a source of entertainment during the long boring stretches. You can look up issues related to your treatment on the Internet, investigate any potential drug-drug interactions, or check out websites like thennt.com. Also, do not forget other “stuff” like your toiletries, a change of clothes for when you are discharged, and your favorite pillow and comforter.
brING a faCt sheet I highly suggest preparing ahead of time a “fact sheet” to bring with you to your hospital admission. This is a sheet that you can hand to anyone filling in information on your chart. All of this information is required for documentation in the medical record. Some of it is incred- ibly important, while some is utterly ridiculous. All of it is mind-numb- ingly tedious for whoever is stuck entering this data. The fact that it is such an agonizing part of your admission makes it error prone, and like an early mistake on a trigonometry test, its impact will be passed forward throughout this—and possibly any future—hospitalizations. Your admitting nurse or doctor will be incredibly pleased if you hand over a document with the following information:
• Full name • Birthdate/current age • Social Security number • Race (it can actually be relevant) • Gender • Religion (if any) • Your primary language • Marital status • Occupation • Allergies (medication, food, or anything else); include the nature of the reaction (extremely relevant) • Prior exposure to general anesthesia and if there were any problems
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• Your current weight in kilograms (your weight in pounds divided by 2.2) • Your current height in inches and centimeters (multiply inches by 2.54) • If you use tobacco or alcohol. Specify type and amount (can be relevant). Include exposure to second hand smoke • If you have been subject to domestic violence in the past two years (only if you wish to disclose) • If you have firearms in the household (only if you wish to disclose) • Your last tetanus booster • If you have had this season’s flu or pneumonia vaccine • Your preferred emergency contact and medical power of attorney if you become incapacitated • If you have a living will or advanced directive • Your preferences for resuscitation status (full code, CPR, ventila- tor, do not resuscitate) • Organ donation status/preferences • Your insurance and policy number • Your family doctor and his office phone number
If you can hand a sheet like this to the person doing your intake documentation, he or she may fall down and kiss your feet.
brING your medICatIoN lIst Be sure to bring the worksheet you composed if and when you were trying to come off medications. This should include all of your med- ications with both trade and generic names. Include the dose, how taken (oral, transdermal, etc.), and the dosing interval. Also include all supplements that you take, even those you fear might make you look odd. For example, fish oil may postpone an invasive procedure because of its blood thinning properties. Vitamin K may be relevant if you are going to receive prophylactic therapy for deep vein thrombosis, and olive leaf extract has calcium channel blocking properties. The possible interactions are extensive, so list all of your supplements. Any medi-
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cations that will be continued in the hospital, along with the medica- tions that are ordered during your admission, will be combined on a “medication reconciliation form.” Make certain that a hard copy of this is kept in your paper chart. Also request a hard copy you can keep on your person. If the hospital’s computer portal or EMR crashes, a hard copy of this form can be a real life saver. At the time of discharge, you should receive another medication reconciliation form that includes your prior medications and any new medicines you will be sent home with, along with how long you will be on these new medications. Make sure you have such a form to take home at discharge. Use it to update your medication worksheet.
Name, raNK, aNd serIal Number Whenever someone enters your room to do anything for you or to you, demand that they confi rm your full name and birthdate. Do not let this slide, even if your nurse has seen you 20 times that day. Remember he or she is overburdened and likely does not remember your name. Every so often, give them a fake birthdate or wrong middle name and make sure they catch it. If they do, just give them an “I was just testing you” tease and then provide the proper information. If they let it slip by, let them know they screwed up and that you don’t want it to happen again. If you are blown off , request the charge nurse or hospital administrator.
"My full name is Denzel Washington."
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BE “THAT GUY” (OR LADY)
Some readers may not be the “pushy” type, and may think the suggestion to quiz every nurse and doctor on your name and birth- date is just too awkward. But consider this: the mere fact that you ask this type of thing will keep everyone on his or her toes when dealing with you. That is exactly what you want. If the nurses all chuckle and roll their eyes behind your back, it means they are thinking about your case even after they’ve left the room. The fol- lowing statement is critical to understand: if something bad (and preventable) happens to you in the hospital, it’s not going to be due to a malicious intent to hurt you. Rather, it will be caused by an honest mistake due to fatigue or overwork. The best way to prevent that from happening to you is to make yourself stand out from the moment you show up. This is one of the rare situations where yes indeed, you want to be “that guy” (or lady). hj
WalK, CouGh, aNd deeP breaths If your condition permits it, make certain to get out of bed and walk around the ward or hospital at least two times per day. Every two hours that you are awake, practice coughing and deep breathing. The walking helps to prevent venous blood from pooling in your legs where it could form a blood clot or deep venous thrombosis. The walking, along with the coughing and deep breathing, prevents a condition called atalecta- sis. When you lie in bed for a prolonged time and do not breath deeply enough, the lower segments of your lungs do not ventilate fully. As a result, the tiny air sacs do not expand and will fill with fluid. When this happens, you can develop a fever that can create confusion about your condition. Even worse, the fluid can colonize with bacteria from the hospital environment and actually develop into pneumonia. Hos-
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pital-acquired pneumonias tend to be more virulent and difficult to treat than community-acquired pneumonias and represent one of the greatest dangers of hospitalization.
brING your haNd Gel On the wall of your room, right by the door, should be a dispenser of an alcohol-based instant hand sanitizer. Anyone who enters your room should hit that dispenser before touching you or anything in your room. If they fail to do so, immediately offer them a hit of your hand gel before they touch you, the bed rail, or the computer keyboard. The last thing you want is some MRSA or multi-drug resistant bacteria from your neighbor down the hall deposited on you or on any surface in your room.
be PrePared for rouNds You may only be able to communicate with your doctor or team of doctors once or twice per day. This is the time where discussion about tests, procedures, and treatments will occur. It is your sole opportu- nity to be prepared for what is going to happen, and to bring your preferences into the equation. As such, make sure you discuss with your doctor when to expect rounds to occur. Let your nurse know this information as well, and make sure that it is confirmed by his or her experience. Let your nurse know that you want to have a heads-up about rounds, and under no circumstances should you be allowed to sleep through rounds or be off the floor when they occur. When the team comes to your room, you need to have all of your questions and concerns prepared. Rounds are performed in a rapid-fire fashion and can be over before you know it. Make sure you get the opportunity to have all of your questions answered and for the next stage of your hospitalization to be clearly laid out. Ask if you can use your smart phone to record the discussion so you will have it for future reference. Also, make sure your advocate(s) are present for rounds. The presence of articulate and well-dressed friends and family will put everyone on notice that all involved need to be on their toes.
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food Hospital food is almost universally horrible. It is generally straight out of the ADA guidelines, minus any hope for palatability. Ask your doc- tor if you can have your own food brought in for you. Your advocate(s) can keep you on an optimal primal diet that will help speed your heal- ing and recovery. If you must eat hospital food, specify a gluten-free diet and then pick around with primal principles in mind.
dIsCharGe PlaNNING As important as the admission process is, the discharge process can be even more important. Unfortunately, many patients’ experience of discharge planning is having a nurse walk into the room to announce “congratulations, you are being discharged.” The next thing you know, you are in a wheelchair on the way to the front entrance of the hospital while you frantically dial your cell phone for a ride home. One of the reasons for this is the extreme push to get patients out of the hospital as quickly as possible: the inpatient payment formulas only allow payment for a certain number of days for a given diag- nosis. Therefore, make certain that you are truly ready for discharge. You may simply still feel ill, or you may not have been able to make the appropriate social arrangements at home. When you check in for admission, you will sign a form acknowledging your right to block any discharge that you feel inappropriate—which is based on Medicare law, but is often given to all patients. If you state that you do not feel ready, and yet you are still pushed to leave, then tell your nurse, doctor, and discharge planner that you wish to exert your right to appeal the discharge. This will usually buy you more time. If this fails, bring the issue to the hospital administrator. In general, though, you should be happy to be discharged at the soonest possible time. Even so, you need to leave with a clean and well- planned transition. Your discharge medications and home instructions for self care, as well as exact dates, places, and times for follow-up, should all be provided in an easy to read (legible) format. A specific discharge time, arrangements to gather all of your belongings, and a
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way home should all be in place the day before (or the morning of) your discharge. Again, make sure all of your questions and concerns are addressed before leaving. Once everything is in order, grab your bag of belongings along with your get-well balloons and climb into the wheelchair for your ride to the front awning. Congratulations! You survived.