Ode to the Bedpan

   Having taken a few years off to begin and run a primary care practice, it's time to start blogging again. Erstwhile followers have clucked disapprovingly about the sparsity, nay absence, of posts since 2011, while flattering me that they used to enjoy them. Today, finally out of activities to distract me from my tax return or writing the website content for my new medical aesthetics practice (www.skinlifemedical.com), I feel compelled to write a blog post.
    On telephone coverage today for myself and several other physicians, I got an amusing call from a hospital nurse confronted with an order to remove a Foley catheter (a catheter used to collect urine from the bladder during and after surgery to collect the urine)  The nurse noted that the patient could not yet walk steadily after hip surgery, and asked "What should I do? Should I just leave the Foley catheter in another day or should I let her be incontinent?"  Puzzled, I asked whether because of the hip surgery the patient was unable to raise herself for a bedpan,  Or was she was unable to control her bladder perhaps until the bedpan came? Or were they understaffed on the floor and unable to come in time to bring a bedpan when people called? "Oh, a bedpan!" the nurse exclaimed, "that's a good idea! I'm so glad I talked to you!"
   Some of you may be laughing as much as I was, and some of you may be wondering what was amusing. Regrettably perhaps, my reluctance to dampen your fun has ceded to the desire to express the sadness which followed my initial amusement. Writing about it will improve my mood, because it is so much more pleasant, as anyone in the word of quality improvement can tell you, to point out others' failings than to do one's own work. Taxes, anyone?  I think not!  And, my inattention will ensure that myown  failings will remain to provide an endless source of pleasure to my teenage daughter. And, to you, Gentle Reader, should you wish to elevate your own mood after reading the sad things I write herein.  Yes, instead of doing my taxes, or writing my website content for my new medical spa (www.skinlifemedical.com) I will spend a most pleasant half hour writing this post and shaking my head once again about how far our hospital staff will go to avoid doing the simple task of answering a call bell and bringing a patient a bedpan when needed. My mussar teachers will (oh, so gently) point out how mistaken this course of action is, and I am delighted to allow them that great pleasure too.
   Is it right to keep in a foreign object with the potential to damage our urethra and bladder and muscles which control continence, and with a great potential to introduce infection, rather than to arrange for the patient to ring a call bell when she has to go and then bring her a bedpan? When someone is unconscious for surgery or can't move at all, there is no option. But once she is even slightly mobile after surgery, and can't walk, isn't it better to use a bedpan than to leave in a Foley catheter?  Yet the bedpan is so out of use that this nurse had completely forgotten the option existed!
   Bringing a bedpan rather than leaving in a Foley catheter creates many other opportunities that improve a hospitalized person's health care. Since the patient will need more frequent encounters with staff for bedpans than to change a Foley bag, it offers more opportunities to introduce ourselves with a smile. These personal encounters with staff make some people feel secure when they are hospitalized and vulnerable, whereas others feel their privacy has been invaded. Regardless of which type of person we are treating, and I believe the former are more prevalent in the great majority of hospitals, the encounters offer many other opportunities for improving health care. For example, after removing the bedpan and wiping, a nurse or aide can examine the backside for pressure ulcers (bedsores), reposition to avoid causing bedsores with prolonged immobility, evaluate if the mental status is OK (cognitive issues such as hallucinations or confusion may indicate overmedication or onset of infection postoperatively), ask if the person needs water, and check that the call bell and telephone are within reach.  In addition, removing the Foley catheter makes it easier for hospital staff to try to help someone begin to walk (have you tried walking with a large plastic tube sticking out your urethra and a bag of urine hanging from your leg?) How sad that the nurse didn't even think of this option before calling.
  Bedpans do have some downside. As mentioned above, we invade patient's privacy more frequently with bedpans than with Foleys where our postoperative care is limited to emptying the bag. And, nurses or nurses' aides can spread infection when bringing bedpans too if they don't wash their hands.  Because bedpans require more patient encounters with staff, they require more nurses' aides in hospitals.  As administrators try to reduce hospital costs, I am sure there are pluses and minuses to the equation of more Foley catheters and fewer people interactions. These are things which can be studied. My hunch is that the humble bedpan and the equally humble aides who bring and empty it probably are cost-effective given the complications they prevent. Or, maybe Americans should just spend more money on new versions of the iPhone.  Or let Comcast make another $1 billion dollars per year by charging each American household $10 more a month for what they said was included in the package to begin with when they sold it to us.  Or perhaps each doctor and hospital should pay for yet another electronic health record because the one we have isn't working and doesn't talk to anybody else's and we should spend a good portion of our societal and healthcare budget on health IT.  Our society seems to be fine with all that waste, but Heaven forbid there should be a nurse's aide to bring a bedpan.
  Alas, the taxes beckon.  Perhaps I can clean out my refrigerator...

Costs A Lot and Not Worth the Price

My last post was called "It don't cost nothing and it's worth the price." The EMR (electronic medical record) industry is quite another matter, an example of where most things cost a lot and are worth much less. I must exempt Amazing Charts, the $999 little guy, which is an incredible value. I tried it and considering the cost, it was good despite some limitations. But the other EMRs, some of which I've worked with in previous settings, have limitations too, and they cost much, much more.

As pointed out by the owner of Amazing Charts, Dr. Jon Bertman, on his own blog and on the Amazing Charts website, the availability of federal ARRA (American Recovery and Reinvestment Act) stimulus money has corrupted the EMR marketplace such that EMR vendors are trying to get their product to cost exactly as much as the maximum amount that physicians can get from the federal government to support the installation of an EMR. As he pointed out astutely in his blog, some conflicts of interest are at work related to connections between the Obama administration's advisors and EMR vendors. All this frantic activity with hundreds of vendors and investors in the vendors trying to sell over-priced record systems to physicians makes me glad that I don't take Medicare. I'd rather just practice medicine. Medicare and insurers generally don't pay for what I provide, that is, in depth, extensive, thoughtful internal medicine consultations and research about your medical condition.

As readers of this blog already know, I believe in the patient-centered model of medical record keeping, with patients having their own personal health records, (PHRs) to which providers such as doctor's offices and hospitals have portals and upload data about the patient. This achieves true "interoperability" (fancy word for doctors' records talking to each other and to other health care facilities), with the patient as the hub. Therefore, my main concern with an EMR is that it easily upload electronic data to a patient's personal health record. I'm waiting for Peoplechart (the PHR I recommend to many of my patients because of the availability of staff to help with the inputting of and indexing of the data), or Google Health, or Microsoft Vault, to create a physician EMR, that speaks easily to their PHRs as well as to other EMRs. I've been trying to get an EMR vendor to collaborate with a PHR vendor to do this, but so far there hasn't been any incentive for them to do so.