What I Learned in the Emergency Room

Last week my father was admitted to the hospital for the fourth time in as many weeks; he had complications following surgery to implant a pacemaker. I was his self-appointed patient advocate as they triaged him in the emergency room, transferred him to an acute care room, and finally admitted him to the cardiac section of the hospital. For eight hours, I learned some serious lessons about organizational systems and using the Mutual Learning approach to deal with them. Here are a few of the things I learned.

Not testing inferences can be painful.

Actually, my lessons started the previous week when my father had his pacemaker implanted. The surgeon came out of the operating room and approached my mother. When my mother asked whether everything went okay, he said “yes”. My mother didn’t believe him; the surgeon was looking down as he answered and my mother described his face as distressed. She thought something had gone wrong but, she didn’t test her inference. When I later asked her why she didn’t, she said that she was exhausted and that she was concerned about putting the surgeon in a difficult spot. My father was released from the hospital in less than two days.

Within a week, he was back in the hospital (for the third time) with intense pain in his chest and neck. For two days the doctors could not identify the cause of the pain. When my father asked if it could somehow be related to a condition in his neck, the cardiologist said, “It’s interesting you mention that.” Only then did he learn from the cardiologist (who is in the same medical practice as the surgeon) that my father’s heart had stopped as the surgeon was implanting the pacemaker. The surgical team had to “manhandle” my father to quickly flip him over and revive him, contributing to the intense pain my father was feeling.

Had my mother tested her inference with the surgeon, she likely would have learned about my father being flipped during surgery. That information would have helped my father immediately help the cardiologists identify the cause of his intense neck pain.

I’m guessing that most of you reading this are thinking that the surgeon should have told my mother about this when she asked if everything went okay. You’re right. (Read on for more about this.) But this story isn’t about “others” using the Mutual Learning approach or even being reasonable, it’s about you and me (or our family members) using it as consumers. Lesson: Sometimes not testing inferences can be more of a pain in the neck than testing them.

What am I assuming?

After my father had been admitted to the emergency room (ER), he told the nurse that he had diabetes and needed to eat at a certain time and needed to take certain medications before he could eat. He asked the nurse to order his medications, carefully explaining his reasoning that the medication could only control his diabetes if he took it before eating. After more than an hour, my father’s food arrived; but, through some error, only part of his diabetes medication arrived from the centralized hospital pharmacy. My father’s blood sugar was dropping so low that the nurse was concerned he might go into shock. The nurse encouraged him to eat. My father explained that eating without first taking the medication would not control his blood sugar, but he was so hungry that he ended up eating anyway.

By now, we had already been waiting several hours for my father to be transferred to a cardiac room. All his tests had been completed, but the ER doctor had not told us the results. When I asked the nurse what we were waiting for, he said, “I’m waiting for transport” (the unit that physically transports patients from one place to another). After more time passed, I contacted the patient representative to get my father moved to his room. She approached the nurse and the conversation went something like this:

Patient Representative: “What’s delaying the transfer?”
Nurse: “I’m waiting for transport.”
Patient Rep: “Did you call transport?”
Nurse: “Not yet. I’m waiting for the rest of his meds.”
Patient Rep: “Forget about the rest of the meds. Get him to his room.”

Hearing this conversation, I was angry that he hadn’t called transport and that he hadn’t told me when I asked him. I also realized that I had assumed the nurse had called transport when he said he was “waiting for transport.” Lesson: No assumption is too obvious to test.

Rational people do irrational things.

After talking with the nurse, I learned why he was waiting for the medication to arrive before calling transport. The system would not let him transfer medications from the ER to other hospital rooms. If transport arrived before the medications, my father would need to reorder the same medications after he got to his cardiac room! It was the same story with the test results. After my father was transferred out of the ER, the ER doctor could not give him the results. He would have to get them from a hospital cardiac physician who would call the ER doctor! As my father pointed out, all of this was relevant information the nurse should have shared with him so that the two of them could have jointly worked out a solution.

It would be easy to describe the nurse as uncaring or incompetent, but the reality is more complex. He was working in a system that required him to do things that any patient would consider irrational. Lesson: In dysfunctional systems, rational people do seemingly irrational things.

Discussing an undiscussable issue with people who hold your life in their hands.

During my father’s fifth hospitalization he talked with the surgeon and cardiologist together. He told them what my mother had experienced after the surgery and then asked, what led you not to tell me? The surgeon initially said that my father’s heart stopping was not unusual and that the surgery was a success. I told the surgeon that his not sharing the information had two consequences: my mother didn’t believe him and it delayed my father’s diagnosis and pain.

My father clearly explained why he raised this issue with the doctors – he wanted the surgeon to understand the problems it created for him. And he explained that he was not raising this because he was interested in taking legal action; he was grateful that the surgeon had saved his life on the operating table. And he still was concerned about how the surgeon dealt with him. The surgeon apologized profusely to my father and essentially said that he should have shared the information. With that, my father was able to let go of the issue and continue letting the surgeon care for him. Lesson: When you want to maintain a relationship, it’s critical to have a heart-to-heart (surgeon) conversation.

Since I started writing this piece, my father was admitted to the hospital for the fifth time and released. His cardiologist told him that they needed to get him out of the hospital as soon as possible – the system there would cause him more problems than the benefit he’d receive.

Originally published January, 2006