Things I've noticed while visiting the ICU | Hacker News Reader

Things I've noticed while visiting the ICU

trevorklee.substack.com

339 pointsexolymph371 comments

I'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.

> 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.

I once had a week as a patient at the Mayo Clinic in Scottsdale AZ. There were many remarkable aspects of care there versus the impossible mess out here in the other world.

But the single most significant aspect of care at Mayo Clinic is that the doctors and nurses and techs get to read your chart before seeing you.

That's it. You write something in the chart, it doesn't get tossed. It might not get parsed completely, but the essential info is there. And the staff does not get penalized for reading it.

(The other big reveal for me at Mayo was the sheer scale and throughput of the system. Healthcare at Mayo did not cost more than healthcare in my small town. It. Cost. The. Same.

It took six months to get in, I had a week, then it was someone else's turn. I presume that the high paying "celebrity" customers can get seen more regularly. So it's not perfect. But holy cow I wish it were easier for healthcare professionals to do their job.)

In general for US healthcare providers there is little relationship between price and quality. They have to meet certain quality standards in order to operate at all, but outsides few limited areas they don't get paid more for delivering higher quality care. So quality (or lack thereof) tends to come down to organizational culture and management.

For someone that hasn’t heard of they Mayo Clinic other than through webite articles describing medical conditions, are they that desired/high-quality?

I'm not sure if you live in the United States, but Mayo Clinic is probably a top 5 hospital system in the US. It is legendary. Just read the opening paragraph from Wiki: https://en.wikipedia.org/wiki/Mayo_Clinic

    The Mayo Clinic (/ˈmeɪjoʊ/) is a nonprofit American academic medical center focused on integrated health care, education, and research.[6] It employs over 4,500 physicians and scientists, along with another 58,400 administrative and allied health staff, across three major campuses: Rochester, Minnesota; Jacksonville, Florida; and Phoenix/Scottsdale, Arizona.[7][8] The practice specializes in treating difficult cases through tertiary care and destination medicine. It is home to the top-15 ranked Mayo Clinic Alix School of Medicine in addition to many of the highest regarded residency education programs in the United States.[9][10][11] It spends over $660 million a year on research and has more than 3,000 full-time research personnel.[12][13]

A little deeper:

    Mayo Clinic has ranked number one in the United States for seven consecutive years in U.S. News & World Report's Best Hospitals Honor Roll,[19] maintaining a position at or near the top for more than 35 years.

IIRC, the Mayo Clinic invented the medical checklist. Like, people actually read the checklist and make sure that they tick off all the boxes they are required to tick off.

That's why they are number one. Because they actually use checklists.

My wife was diagnosed Devic's disease, a rare disease with a grim prognosis. Almost every paper we could find on it had the name of a doctor that worked at the Mayo Clinic in Scottsdale. We lived in Arizona at the time so we went there and found that doctor. He corrected her diagnosis as MS, not Devic's. They both suck but Devic's is much worse. We paid out of pocket and getting the correct diagnosis was worth every penny.

This is similar to problems that would often happen in car manufacturing. The person assembling the car the standard way finds a problem, but the problem doesn't get addressed, or information isn't disseminated correctly, so the cars go out with problems. Toyota developed a methodology whereby such problems are addressed immediately and fixes were disseminated immediately, and would not send a car out otherwise. That kind of obsessive attention to detail and "crazy" focus on quality is what made them the top automaker. But most businesses are led by management that refuse to believe that being slow or focusing on quality first will result in more profits. And none of their lower-level workers are trained on how to spot and fix quality issues, nor are they told to care.

Hospital systems are the same way. Moronic, scared management that is fine with these kinds of problems as long as the dough keeps coming in, ignorant of the fact that more dough would roll in (in addition to better health outcomes, which of course is not their first priority) if they would just focus on quality.

This is my favourite ever episode of This American Life, about NUMMI, the shop floor level and individually fraternal miracle that was created by workers at Toyota and GM in a CA GM plant, until management shut them down:

https://www.thisamericanlife.org/561/nummi-2015

This episode is incredible! I also listened to it a few years ago. It provided so much insight into (a) Japanese vs American manufactoring and (b) the impact of poor labour union relations. (Please do not read [b] as me being personally anti-labour union. Some of the revelations from union members in that podcast were shocking to me -- drinking and drugging while on the manuf line!)

Very cool point. In my ideal world a whole nursing unit or facility would be a self-correcting operation. There are problems that a nurse on the floor can fix but it takes up time. If those problems were prevented to begin with, it would be much easier. I would like a system where the nurse notices a problem and simply sends it up to a manager / supervisor who 1) finds a way to handle the immediate problem and 2) always writes up and enforces a new guideline to prevent it from happening again.

Good managers probably already do this, but healthcare has a very short supply of such people. It would be great if this type of improvement were the standard across the board. Let's say, for example, that you have latex and non-latex foley catheters mixed in the same bin in a supply closet. Your patients with latex allergies have gotten a latex catheter put in more than once and it now becomes a problem. Well, someone notices the issue, sends it up to someone above and now there is a new guideline to place the different catheters at least 3 feet apart, or something to that effect. It almost sounds silly, but people would be surprised how many of these mistakes happen over and over again due to equally silly reasons / lack of basic prevention.

> Moronic, scared management that is fine with these kinds of problems as long as the dough keeps coming in

That sounds like it’s the same in any sector? Especially IT.

Not lost, but I've had a lot of trouble with information being captured incorrectly.

Things like date are pretty commonly messed up. I've also had doctors and nurses put their own, incorrect, interpretation on information I've given them when they repeat it to others. When I say "my child wasn't eating and drinking normally and had half of what they normally do throughout the day", it's incorrect to say "the patient didn't eat or drink all day". That's the type of shit that can look really bad if it's recorded and looked at later. But it's like nobody cares if they record things correctly.

I've also had trouble with people not doing anything with important information. Like maybe you should slow down on the morphine and oxy if the patient is answering fewer basic questions correctly than when they came out of surgery. But it's OK if they can't tell you their own birth date - just give them more and later order a CT ro check for a stroke. Sorry guys, but it should be pretty obvious you're putting them into a opium stupor...

I've noticed recently that there are people out there who simply can't accurately listen to others and repeat back what they say. It's not about being stressed for time, the skill is just not there. You say ABC, they write CBD, and they have no idea it's not the same thing.

Add to that the people who reply to an email or other message without providing any response to the questions it explicitly poses.

I’ve found numbered lists of short questions helps a lot.

But with some people definitely only ask 1 question per email.

This can be intentional rather than a misunderstanding.

OpenNotes can help a little with this, but only if the patient or one of their caregivers has the time and ability to do a detailed review of every chart note.

https://www.opennotes.org/

This 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.

As 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.

> As a physician, shift length is honestly a red herring.

This is how the Stockholm syndrome feels. I manage a few T.A. in the university, and they barely can think after a 6 hours of teaching (two consecutive classrooms, with like half an hour of rest in each one for the students, and perhaps another informal half an hour in the middle). Sometimes they have to speak in the blackboard, sometime grade informal take home exercises, sometimes reply questions on the spot, and they get very tired. So we have a strict 6 hours per day rule. And if they make a mistake, nobody dies!

Thanks for sharing!

Even outside the medical field, it seems like most humans are pretty bad about both writing down and consulting notes. Even worse for the notes written by another human. We really aren't particularly good at transferring knowledge / experience and it takes a lot of effort to do a good job of it, so most people don't even make much of an effort.

This really seems like a problem that still needs a lot more attention, especially in critical places like hospitals and really any long term crisis response situation where there is important knowledge gained over time with a (poorly handled) hand-off to successors.

I had some exposure to formalized incident management[1] at a previous job. There, I learned a few formalities and practices that seemed valuable, especially assigning a single coordinator to be responsible for continuity of information and coordination between many independent actors over a long period. The coordinator role had explicit hand off to their successor where the stated purpose was to transfer important working knowledge and prevent the kind of problems you (and the article) describe.

1. https://en.wikipedia.org/wiki/Incident_management

I liked the way you framed this as something universal. Is there any field where one can quickly reference knowledge from your peers to just as quickly solve a problem in practice? Maybe it's asking too much. Though I suppose it wouldn't be necessary to get everyone on board with such an idea if you have that single coordinator who everyone knows as the reference point. Although, if you think about it, even then that person would have to be available 24/7, which isn't feasible.

With patient documentation specifically, what I would really love to have is a simple search mechanism for patient notes. This still wouldn’t solve the problem of getting everyone to capture the right information. But assuming the information is there, and I'm having a real hard time sticking that right arm, I would love to be able to search for "arm", "blood draw," "stick" and see what pops up. I hope it's not something I missed entirely, but I have never used an EMR with such a feature.

Indeed, seemingly simple functionality like you describe should be bare-minimum requirement for just about any kind of information system, and yet it's almost always omitted or implemented so terribly as to negate any practical benefit to users.

> a single coordinator to be responsible for continuity of information and coordination

Years ago I saw a talk by a VA (US veteran's health care) thoracic surgeon, who was trying to entice tech folk to address the following problem. A surgeon is both team manager and skilled technician. When heads down in the technician role, the management role suffers for lack of attention. Especially severely at the VA, which did randomized staffing of operating teams, so you don't get the "group mind" and practiced gap filling of team which stays together. So surgeons would say "do X", and being distracted, not notice the order was dropped, and then proceed assuming X had happened, with regrettable results. The VA surgeon envisioned a voice system which noted the request, waited, and then whispered a nudge in someone's ear "did we do X?".

I think this is a symptom of hospitals being understaffed, whether that's from a deliberate lack of hiring or an actual labor shortage. I feel like many of the problems in this aspect of healthcare could be solved if doctors, nurses, etc weren't run ragged with insanely long shifts and expected to care for a ton of patients.

I don't know how to respond to your post. I'll try: Money. Skilled people cost money, a lot of money. I disagree with both of these: <<deliberate lack of hiring or an actual labor shortage>> They are making do with the amount of money that is available. It would be wiser to focus on why healthcare is so expensive in the United States compared to other highly advanced countries -- France, Germany, Netherlands, Finland, Japan, etc.

I wonder if part of the issue is having to remember a bunch of random things about a bunch of different people so that you can apply the information at the relevant time. E.g. the left arm is easier to find a vein, but this information is only useful for 30 seconds a day during a blood draw, so it's hard for people to remember or even retrieve (how much notes do you have to read through to find this info?)

If the info were somehow magically there when needed, it would be used, right?

Like, google glasses but for ICU workers?

I was gonna say augmented reality, but there are probably low-tech options that could do the trick.

I would start with "sticky note on the relevant machine" type interventions first.

I have great respect for what people like you do. I've lived all over Europe and a have some first hand experience with care in different countries. Universally, nurses are heroes and it's just a very hard and often thankless job. Not to mention under paid in many places. But there's a big difference in what I would label as institutional stupidity between different countries. Some countries feature a lot of mismanaged health care facilities where things are bureaucratic, slow, etc. For example, Germany is hopeless on this front. Being in the health care system here means an endless sequence of forms that need to be filled in with the exact same data points over and over again and over worked nurses dealing with all that crap on top of their normal job. It's beyond stupid. Nobody shares any data. And it's inefficient and dangerous for patients because no doctor or nurse can possibly have the full picture.

My home country the Netherlands is very different. My father had a stroke quite recently and spent some time in a very modern hospital where they are applying some of the latest insights for patient care. So, he was obviously hooked up to lots of equipment and intensely monitored. However, this hospital has separate rooms for all patients. Reason: it's best for the patients and helps them recover more quickly. Basically, more privacy for the patients and less restless nights. There are no TVs in these rooms. Instead patients are issued ipads with entertainment options and access to various things like indicating dietary preferences. Nurses carry ipads as well. Everything is digital. There are no paper charts in sight anywhere.

The rooms were modern, clean, and clearly optimized for making patient handling easy and straightforward. What struck me was the attention to detail and level of pragmatism in this. For example, my father's room had wall mounted hangers for folding chairs. These are for visitors. And when they are folded they are not in the way. The room had a whiteboard and a locked cabinet for medication and supplies. The doors are sliding. So, it's easy to move things in and out. Like beds, wheel chairs, equipment, trolleys. Etc. And so on. Just a really well designed and thought through design and architecture. Well managed and efficient.

BTW. This is not a private hospital: my country has a mandatory private insurance system: they can't reject people, people must be insured, and they can switch insurer. So, insurers mainly compete on quality care. Miserable patients and inefficient hospitals are bad for business and they are working to fix any issues there with hospitals. Which is why everyone, rich or poor, gets the same quality treatment in this hospital. It's way better than the private insurance I pay for in Germany. Way cheaper too. My German insurance is about 5x the price. I've been in a hospital here a few times and they can learn a thing or two about efficiency there.

The only bad thing about Dutch healthcare is that, if you are not acutely in need, it can take months to get a spot.

I have heard similar complaints about UK and Canada. From a cost perspective, it makes sense to me. I also wonder: If you make people wait months, how many people skip/cancel the appointment? Probably many.

I have lived in two countries with very unfair healthcare systems. High income people get "health insurance" (whatever that term really means!) from their employer. They use it a LOT. Way too much. And their "health insurance" covers most of the cost. The number of times that I have seen high income people see a medical doctor for a runny nose (light head cold) stuns me. What an incredible waste of medical resources! As someone fortunate enough to have this "health insurance" at various times in my life, I am constantly saying "no" when doctors try to over-prescribe all manner of medicines. Obviously, they know my insurance will pay 100%!

The #1 duty of a public healthcare system absolutely must be "acute need". Everything else is second priority, else they go bankrupt. It's rough. I don't know a better solution.

Crazy idea: What if there was a kind of public auction system where people in the queue could set a price to sell their position? As long as it was fair and transparent, I might be OK with it.

I'd say that's universal across many countries. The flip side is that Dutch insurers do allow their patients to shop around for care. E.g. getting treated in Belgium or Germany for routine procedures is fairly common. Mostly these just are shortages of staff, equipment, etc. and being efficient sometimes also means that available care is fully utilized. Which just means people have to wait for non critical things sometimes.

That makes sense. When I worked shiftwork (8 hr days), you'd get good info from the people before you, but not about the people before them (after you), so you'd often have the same problem in that rhythm. But we would stay on shift for months on end, and obviously that helped with all the knowledge walking away all the time.

I 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.

I had a family member who wasn't even in ICU, and still experienced delusions simply from being sick and being in the hospital for a few days. He thought there was a group of family members around the corner waiting to jump out and surprise him and was insistent that I tell them not to disturb the other patients. I had to argue with him to get him to accept that, no, there is not a random group of family members waiting to jump out. He insisted he heard them talking and stuff. It was pretty disconcerting for me actually because he has always been a psychologically-bulletproof person. Definitely an eye-opening moment for me.

Now thinking about how this applies to the acute mental health wing.

Yes - 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.

I 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.

I 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.

My dad definitely got better care because both my brother and were assertive in our advocacy, but my sister’s aggressive, undirected badgering didn’t help at all.

As someone who has spent much more than my fair share of time in ICU and on "the floor" I can honestly say that being in the hospital is similar to being in prison in one respect. Having someone on the outside working for you is critical. Medical staff will almost immediately try to establish a power dynamic over you to keep you cooperative and docile. Having people from outside who are polite but inquisitive and questioning is key. I've also noticed that people who have frequent and varied family visitors get more attentive care than those who never have visitors such as the elderly whose family may all be gone and friends can't really travel.

> 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.

The 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.

Yeah, that's what I mean by the medical system just not being set up to allow this. I generally see a different doctor every time I make an appointment, because I'm assigned to a team in a clinic with constant turnover, the appointments are 20 minutes long, and the doctor easily spends more time on boiler plate stuff in the computer system than examining and listening to me. I don't even think they have time to look over the basic medical history, let alone have a whiteboard session to consider all the pieces of the puzzle and brainstorm possible explanations.

Jeez, 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.

You should check out The Resident. The first several seasons are about the doctor invested in a device that is a fraud, a private equity group buying the hospital, it eventually failing.

Chicago MD has some of the aspects you mention, especially overloaded, drug abuse, blame, police interactions.

New Amsterdam attacks it by the main character trying to solve the problems and running into bureaucracy.

Are all of these well-written shows? They all look terrible in the descriptions but I’m hoping I’m wrong.

Back when ER was a hit show, there was survey among medical professionals and hospital staff asking for their favorite medical drama series and the reasons for it. Grey's Anatomy, and similar series, constantly beat ER. The reason was that medical staff considered ER way too realistic. Makes sense, why would I entertain myself during my off hours with what is basically a documentary about my on-duty hours.

I’m half convinced the ER diagnoses everyone with no apparent issues with dehydration so they don’t feel stupid about coming in for no reason.

You would not. 5 doctors talking about your case wouldn't help much.

People really don't understand the dire and primitive state of current medicine.

We are in the dark ages. We don't know why most drugs work; we have some notional idea but it's often an after-the-fact fiction that we tell. We don't know what causes the majority of diseases. In many cases we don't have treatments for the underlying problems, we only have treatments for symptoms.

If you want to see House MD, then tell your congresspeople and senators to invest in funding medical research so we can one day maybe leave the dark ages.

Also, the cases are usually in desperate enough straits that “here, swallow this seagull poop!” doesn’t get hints thrown out of the hospital.

I'm sorry but curiosity and creativity are certainly the n°1 enemy of the patient, especially in ICU settings. Curiosity and creativity are grandpa's medicine, and a total antithesis to evidence-based modern medicine, that attempts (and largely fails) to be an application of science instead of the whims of the decision-makers.

What you should want is curious and creative _researchers_, but precise and totally unimaginative clinical staff. Those are often the same person. See the problem? You want protocols applied down to the last detail. You want nothing left out of standard operating procedure. That's what kills patients in practice.

You might mean creativity in the sense of "let's have guys who think about the right things, and search for rare diagnoses and analyze stuff to see what could work, like Dr House". But that simply can't be done in practice. You can't be testing for every rare thing, because the tail of low probability diagnoses is much too long! And believe me, you _really_ don't want creative doctors around...

Maybe you don’t want creativity in the ICU, but as a patient with chronic health issues, I do want creative clinicians. Over and over my entire life, I’ve gone to doctors with health issuesand watched as they mentally plug my symptoms into a flowchart that they learned in medical school, then they find that the symptoms don’t match anything that a standard protocol can treat, then they shrug their shoulders and say they can’t do anything. The latest case of this has been severe blood glucose drops in the middle of the night that wake me up with a pounding heartbeat. I waited four months for an appointment with an endocrinologist, then was told I don’t have “true hypoglycemia” because it’s not corrected by eating. End of story. No curiosity. No help. Goodbye. Again.

Sorry, this is not acceptable. The only time I’ve gotten decent medical care for my chronic issues was when I was making enough money to pay for a doctor who only worked fee for service. He would troubleshoot things like an engineer, because he was a former engineer. He improved the quality of my life immeasurably.

I think there’s a difference between “evidence-based” and using only 100% manualized protocols. If medical science was better and actually had answers for everything, sure, let’s stick to the manuals. But medical knowledge isn’t even close to being that thorough. Clinicians need to be able to think on their feet when they look in the manual and there’s nothing there. Otherwise, you’re failing patients.

Completely agree. Any educated layperson can figure out and follow a clinical decision tree. I mean it can work in your favor if you know you need something and know how to get the decision tree to give you what you want, but otherwise clinicians should definitely be actual experts and not just meat following something a computer could do

You still have the problem of writing a sufficiently detailed tree. I had a blood test last year and when I discussed the result with the doc, he asked me the clinic location where the blood was taken, because then he could estimate time between blood draw and lab test and interpret the result accordingly.

> Any educated layperson can figure out and follow a clinical decision tree.

12-15h a day, 6 days a week with not even a lunch break? You're sorely mistaken. It takes an expert to follow clinical workflows.

Yes, it's so tiresome and frustrating. I once had a period of a few months where my sleep was down to around 5 hours/night (normally I would get 8-9), I was exhausted and my body just wouldn't sleep more than that. Went to a doctor who offered a couple of thoughts "some people only need that much sleep" and "there's only one thing it could be, but that's not what it is". He wasn't even going to test the "one thing" until I asked if he would. Turns out he was correct that that wasn't what it was, but obviously there was at least one other thing. My sleep ended up returning to normal though I still have similar periods where I can't get enough sleep.

The only medical practitioners I've found willing to be more curious and to take a more holistic approach are naturopaths. I have had some notable improvements in my chronic health issues working with them, though I am a little uncomfortable with them given their general openness to things that seem pretty questionable to me (like homeopathy).

> n°

Since you’ve used a slightly fancy Unicode character: I found U+00B0 DEGREE SIGN unpleasant here, and it took a brief bit of thought to understand. (A capital N would probably have helped a little, but the degree sign is still disconcerting.) The character you want is №, U+2116 NUMERO SIGN. If you happen to be using a Compose key, `Compose N o`.

For less fancy options, “#” and “number ” would both be better choices and easier to read than “n°”.

not all of us live in the US

I don’t either but fully agree GP’s assessment, you chose a strange character to use there.

I appreciate your perspective as a professional in this area.

Yeah, I'm not really looking for doctors to demonstrate creativity (although House does), so I don't think I'm asking for anything at odds with evidence-based medicine. What I'm saying is that I think you need to get to the bottom of what's actually happening (i.e. why is the program outputting 5 when it should be 4) before you can know what evidence-based medicine to apply in a "precise and totally unimaginative clinical" way to actually fix the problem. As a patient, it just feels like the system, and therefore the doctors in the system, lack the curiosity to figure out what's actually happening. We often get the treatment for the most common issue even though it doesn't quite fit the real issue, or the common issue seems to just be a downstream effect of the real issue.

Curiosity is essential. Eg guy with chest pain and trop rise gets sold by ED as a NSTEMI. But why is the pulse pressure so high? Hang on what is that scar on his back? Oh he had an aortic root repair 20 years ago after a car accident... Ok I’m calling in the radiologist at 2am to do a CT angiogram. Sure enough, his aortic root repair is failing, and he has new onset AR. Curiosity saved that guy’s ass, following the protocol would have probably killed him.

Creativity also has a role for non-critical conditions when standard treatments aren’t working.

I guess this is why the hospital asks me to list historical surgeries.

So curiosity as a remedy for systemic failure to perform a full exam and actually do the job correctly in the first place? Not a very convincing argument.

Not really, the clinical signs were subtle, I couldn’t hear the AR. If you had a ‘protocol’ to pick up these edge cases, you would be doing a CT and echo on every chest pain that walks in the door. The workup was perfectly evidenced based and standardised.

I don’t think it is ideal to operate this way though, to be clear. Obviously this could have easily been missed by me or anyone else. But you aren’t arguing that point. You are approaching it from the perspective of minimising the variance in clinical quality. I don’t agree with you that this requires standardising how clinicians are, not just what they do.

If medical treatment was actually as formulaic and fully-solved as you imply, we wouldn't take the best students of every generation and make them spend ten years training to become doctors. We'd just have nurses, checklists, and diagnosis flowcharts.

Medical treatment is obviously not fully-solved, or anywhere close.

But it is just as formulaic as described above. The doctors aren't trying to solve your issue. They're following a flowchart, and if that doesn't work for you, that's your problem, not theirs. Next time, be a better patient.

I've had doctors tell me "Good news! You don't have a problem!" when they were testing me to see if they could explain the problem I have. It's good news for them, because their next step is to tell me to fuck off. It's not good news for me, but apparently they can't tell the difference.

I'm precisely not implying that medicine is currently "fully solved". I'm implying that we should strive to gather more information, synthesize it better and study how to make it useful.

As a clinician, I'd say yes to a bicycle for the mind. But currently, my job is already plenty full with worrying about applying what's known in a correct manner without seeking to break new ground while treating patients, which would be very dangerous and given the odds of success, very stupid. What I'm implying is that the general public has a completely skewed view about what really kills patients in the ICU: mundane infections and "medical errors", which are not really errors at all but in a large majority of cases failures and complications of usual procedures.

General Practice medicine seems to come close enough. No differences in patient outcomes between physicians and nurse practitioners.

> Randomised controlled trial comparing cost effectiveness of general practitioners and nurse practitioners in primary care

> Results: Nurse practitioner consultations were significantly longer than those of the general practitioners (11.57 v 7.28 min; adjusted difference 4.20, 95% confidence interval 2.98 to 5.41), and nurses carried out more tests (8.7% v 5.6% of patients; odds ratio 1.66, 95% confidence interval 1.04 to 2.66) and asked patients to return more often (37.2% v 24.8%; 1.93, 1.36 to 2.73). There was no significant difference in patterns of prescribing or health status outcome for the two groups. Patients were more satisfied with nurse practitioner consultations (mean score 4.40 v 4.24 for general practitioners; adjusted difference 0.18, 0.092 to 0.257). This difference remained after consultation length was controlled for. There was no significant difference in health service costs (nurse practitioner £18.11 v general practitioner £20.70; adjusted difference £2.33, −£1.62 to £6.28).

https://scholar.google.co.uk/scholar?hl=en&as_sdt=0%2C5&q=do...

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC27348/

More tests isn’t a good things. The doctor was significantly quicker and could see 3 patients for every two the nurse saw.

I’m not sure where this leaves us, as the cheaper training cost for the nurse is a factor too.

Yes talking about scientific method and citing a TV show. Logic

House is not real, it falls under "arguing from fictional evidence"; House's patients are written by a writing team to have obscure and surprising - yet easy to fix - ailments. They are generally young with acute short term symptoms leading to a race against time and a boolean toggle outcome healed/dead. They are rarely the 70+ year old ICU inhabitant with age related complications who is mentioned in the blog post with long periods of 'boring' illness to keep track of and treatment rotating between many doctors.

House gets to choose his patients, he pre-rejects any that he doesn't want to deal with or has no ideas about, or no interest in. Real world doctors can't do that. House gets to do basically any test for any cost without having to justify it or argue with insurance, scheduling, resource constraints, practicality or side effects. If he needs an MRI, it's available, if he needs his team to spend all night tonight on blood tests in the lab, they can do that and the lab is there and they have no consequences tomorrow of having no sleep.

House has plot immunity, the worst that happens to any hospital employees as a consequence of his behaviour is the loss of a lot of potential money, or some paperwork or audit. The show never focuses on the life of the patient who has to be on dialysis forever because of House's risky intervention before he knew what was really wrong. House blackmails and barters with and sleeps with the hospital administration to get away with things no real doctor could do.

House and Wilson are named as a play on Holmes and Watson, and the original Sherlock Holmes books were notable because Holmes walked the reader through deducing interesting conclusions by looking at evidence anyone present could see but with a fresh viewpoint, things like the height of scratches on a wall. Recent Sherlock TV shows and films, he's written to magically know things that nobody could know, by means the viewer isn't shown and can't participate in, and presents them as amazing accomplishments to wow the viewer. House is the latter, in an episode I saw recently (Series five, episode 1) he is absent all episode with the usual array of organ failures and suspected pregnancy and suspected cancer, then in the last five minutes he walks in, stabs the patient in the leg, declares she has leprosy because she looked youthful, and walks out. And of course she has leprosy. It's not even good storytelling, it's a background thread for House and Wilson's interpersonal problems and his assistant's own terminal disease diagnosis.

Or to put it another way, you read a blog post about heoric troubleshooting of some tech problem and it's good reading. That's self-selected from someone who had an interesting problem and the time and skills to diagnose it and the luck of it coming to an interesting conclusion. Most troubleshooting is not that, it's mostly the basics over and over, or it's above your skill level or outside your skills, or it might not be but you can't spend time on it, or it comes to a boring conclusion like "we never got to the bottom of it before the system was decommissioned".

In Series 3, Dr Foreman goes to be head diagnostician at another hospital, pulls a House move of risk taking treatment, saves the patient, and gets fired. The dean of medicine tells him the procedures work for 95% of cases, and everyone needs to follow them in all cases because everyone thinks their hunch is in the 5%. It works for House because that's the show.

Author 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.

I am going to repeat myself here.

Quick Google search for "icu beds per capita" finds: https://www.oecd.org/coronavirus/en/data-insights/intensive-...

US: 25.8 / 100K population

Germany: 33.9 / 100K

My impression as a Canadian resident was the bar seemed a lot lower to get into the ICU in the US. Unless they needed a tube to secure an airway, pressors, or CRRT we managed COPD with BiPAP, pretty profound hyponatremia, cirrhosis with& bleeds, DKA/HHS on the ward pretty regularly just as examples of repatriated patients I remember. I always figured it was due to an overly litigious culture and a money maker for the hospital. To be clear I didn't practice in the US.

It’s probably because we don’t have enough ICU (or step down beds) in Canadian hospitals than the fear of litigation in the US. Canada’s capacity is amongst the least in G20 nations.

A lot of patients we manage on the ward or step downs (i.e. pressors on step down, I’m unaware of any ward that will let you run these, very few tolerate central lines) really should be in a full ICU, or at least a high level step down unit like D4ICU at KGH (rather than the hilariously awful AMA units at TOH).

I am going to repeat myself here. You wrote: <<Canada’s capacity is amongst the least in G20 nations.>>

Not even close.

Quick Google search for "icu beds per capita" finds: https://www.oecd.org/coronavirus/en/data-insights/intensive-...

Canada: 12.9 / 100K population (slightly higher than OECD average)

For the record, it is usually better to quote "OECD" than "G20". G20 just means total GDP is large, but GDP per capita can be very low, like India, Indonesia, and China. OECD is always (democratic and) high-income -- high GDP per capita. For example: Nederlands, Norway, and Switzerland are all OECD, but none G20. All are very high income and high human development.

This number includes level 2/step-down ICUs inclusive of regional/community hospital.

This is not the bed count of units capable of having cardiac support or prolonged ventilation.

I can’t readily find the OECD figure but if you look at ventilator capable beds in Canada the number drops to ~9.7, again inclusive of community/regional hospitals mostly staffed by non-ICU trained physicians which are only equipped for short term ventilation.

Which center in Canada have you trained at where there isn’t constant pressure to offload ICU patients to the ward due to a lack of beds?

Can 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?

An 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"

To add to this, the costs the one area I understand are huge.

Radiology generally needs to have a CT ready to go when there is an ICU. It likely needs an MR too, and staff for running after hours. Portable X-ray and ultrasound, a PACS, a RIS, services contracts and a load of other smaller costs.

That’s several million in hardware costs.

The running cost is huge with MR service contracts alone into the hundreds of thousands per year.

Staffing utterly dwarfs that expense and getting skilled people to work out of hours requires a lot of money, and additional cover for when they sleep.

Staff need to be kept competent with courses and training, certificates and leave to get to these sessions. More money.

The consumables are silly expensive and expire fairly rapidly. Everything needs to be available and a few spares should be present.

Radiology can be a cash cow for day to day operations in a private clinic. But having staffing and equipment that can run 24 hours a day with 100% uptime is a massive cost multiplier.

So, they're complicated, they're expensive, they're necessary... why don't we have the state pay for them? We spend 720 Billion dollars on the military. Would it be useful to send a couple of those billion to make ICUs less expensive?

Where do you think state money comes from? Even if it’s the government that foots the bill for ICUs, in the end it will still be paid collectively by all of us regular people.

Yes it would, but in the US we have a for profit medical system so this is a natural result of that.

Most 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.

For one American medical workers earn absolute insane wages compared to their European counterparts.

This is a practical reality of the "we keep old people alive too long" category.

I'm not old but I have an Advance Directive on my file that essentially says if I'm fucked then they should let me go. (And I'm in the UK where treatment is free at point of use).

Wow, this is a great post. I never knew about this NHS programme. I wish I had the same where I live.

https://www.nhs.uk/conditions/end-of-life-care/advance-decis...

https://www.nhs.uk/conditions/end-of-life-care/advance-state...

At the risk of sharing some PII, are you willing to share some of the conditions that you set?

Compassion in Dying have some advice about advance decision making.

https://compassionindying.org.uk/making-decisions-and-planni...

It's important to get the right balance around specificity. You need to include some

It's not an NHS programme as such, just that the law recognizes these documents. It would work with a private GP too.

I used a template document but don't recall where I got it.

I’m old and statements like this are… interesting

We all will be old one day, if lucky. My comment was not about you because you happen to be old right now. But are you unfamiliar with typical end of life care in the US? Where the last few years is a constant stream of hospitalizations, rehabilitation, etc with no quality of life and no tangible benefit but a very substantial cost? I find that concept… interesting… as in, I don’t like paying the cost and I don’t intend on participating in it when my time comes. I think this feeling is growing with younger generations because we’ve witnessed what older generations are subjecting themselves and their families to.

I’m familiar with all those issues and have been for years. Have taken both parents through agonizing deaths. Doesn’t make comments like yours less unsettling.

How old should people be allowed to get? Why are the old less valuable to you? A life is a life, is it not?

Well traditionally, nobody allowed old people anything, except what their own family or checkbook could provide.

It had never been this simple. A child dying is pretty universally seen as worse than an 85 year old dying.

I feel like the greatest tragedy of them all is a 53 year old person dying.

Why 53?

No reason. No reason at all. I may change my view on this in a few months however.

It’s more about health and quality of life vs our capabilities to delay the inevitable. If you’re unfamiliar with the topic there’s plenty of information out there about how much money is spent and now low quality of life is commonly enough in the final few years.

Interesting 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.

I'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.

Cried a little reading that. What agony, losing a child in slow motion. My best to you and yours.

> What agony, losing a child in slow motion.

These words are both poetic and heart-wrenching.

There 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.

I 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?

For context see my comment here 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.

I 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.

> 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.

Hallucinations are one of the most common symptoms of sleep deprivation.

I 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/S073510972...

From 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.

A closer reading of the intervention shows that it wasn't _just_ "more calories".

But I think that is missing the forest for the trees, what this study showed is that when a patient is left on their own, they consume an inadequate diet that _puts their health at risk_ in a hospital. By a big margin!

I would imagine, though the study didn't show this, that the primary factor in recovery here was having a human (dietician) actually paying attention to your recovery. On intake they put together a plan, and followed up routinely to ensure that the patient has consuming their diet.

The GP's point is valid, hospitals are missing out on a 50% increase in health outcomes because they're letting patients fend for themselves with regard to nutrition. You're right that it isn't as easy as spending $6 per meal vs $3 to buy "better" food. But what it means is that hospitals are failing their patients because they aren't thinking and acting with a holistic eye towards patient outcomes.

I don’t think the problem is cost cutting. I think the problem is just the same problem that every human enterprise has.

Most people just don’t give a shit outside thier immediate responsibility.

Looking at the global view and actually making changes that require persuading other people is a hard and often thankless task.

Many people who do give a shit get this crushed out of them early in their career by the negativity you will face if you try.

Much easier to just accept the status quo.

Occasionally you get a group of people who really care and come together determined not to let things be crappy and they can form an organisation that is significantly more effective for a time. But once the rot of “We can’t fix things” sets in, it’s really really hard to turn things around.

I work in a hospital, and occasionally in ICUs. You're wrong. Most workers are very much jaded, but they do care. Problem is, the system crushes you to death if you don't set pretty harsh limits to protect yourself. In a lot of cases, that means de-humanizing your work, put your feelings aside and work like a machine. Good little machines are just what management wants, right? Now higher management... wow, those people really don't give a hoot about anything that's not themselves!

A second major contributor to inertia, is that the initiatives from lower echelons are usually set for failure by the intricacies of bureaucracy. And said bureaucrats are completely unimaginative about what they could do to fix things, because they never leave their office to see what's really happening in the trenches. So yes, in fine the problem is the extreme stupidity stemming from human collective behaviour. Complain, and suddenly _you_ are the problem!

What percent of patients have a medical need to be woken up every few hours then?

pretty much every patient in the intensive care unit - that’s kind of what the “intensive” is referring to.

If nothing else, you either take the blood pressure the normal way with a pressure cuff, which is going to wake you up. Or you put an intra arterial catheter, which reads continuously without bothering the patient, but has a small risk of damage to the vessel, infection etc

You'd be surprised to see what happens to staff going against waking up patients all night. You get the "dangerous sloth" sticker on your forehead real quick on the morning grand rounds.

Cost cutting is definitely to blame for how understaffed hospitals are. Then Covid happened and it got even worse. It's definitely not all due to Covid though. Even the "not-for-profit" medical group in my area has been pushing doctors and PAs to take more and more patients, well past what they're comfortable with. Nursing staff has been cut down to nothing compared to 10 years ago. Wages haven't gone up to match the increase in workload.

Again, this started before Covid, the pandemic just highlighted how much these cuts screwed over both healthcare professionals and patients.

Everything you said is spot-on, but, brining things full circle, the lack of “shit giving” could be due to cost cutting. People don’t have an incentive to care. The end result, vis-a-vis their personal situation, is unchanged whether or not they go the extra mile. Part of this is because they exist in a rigid corporate structure hyper-focused on value extraction and not at all focused on the development of human capital.

>"people need to sleep"

Sleep is almost impossible with regular check-ups... 30 min or 60 min, don't remember. Excepting the comatose and most medicated(maybe not?), a person's sleep cycle is unable to reach REM when a stranger approaches and fiddles on regular intervals. I would think monitoring from afar(sensors, cameras) would be more beneficial, but I was informed the liability factors preclude such remote monitoring.

edit: to add context, I slept in the room on separate occasions with 2 family members. While tests were not performed, the regular checks were mandated. I was exhausted after my shifts ended.

Last time I was in the hospital (in 2016 with a broken arm) it was very difficult to sleep because the bed had some device that pokes you every so often to make sure you don't develop bedsores from lying too still.

This makes sense for someone who might be in there for weeks, but I was barely there overnight!

Nightmarish yet darkly comical. Sort of torture adjacent…

More than 10 years ago now, I was in the ICU for myocarditis, leading to bradycardia, a very slow heart rate.

During the night, it would drop to 40 (which is still fine), but sometimes below 30, at which point my heart monitor would blare an alarm, waking me up and scaring the absolute bejesus out of me, raising my heart rate immensely. A nurse would walk in, see that I was fine, and leave again.

This occurred nightly for a few days.

I don't understand this post. It reads like "have your cake and eat it too". The the heart monitor did not blare an alarm, maybe you died. Which one do you want?

The alarm to go off in the nurses' station so they could investigate.

I don’t know why the haldol reaction didn’t go in his chart, but the whiteboard in the room (which is present in every high level hospital room I’ve been in) is exactly where the TV information and other patient preferences should be, and is the second best place after the chart to put a drug reaction. Cost cutting has nothing to do with “nobody wrote it on the place for writing it”.

>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.

Great, 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.

>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.

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.

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.

> 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.

These 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...

It's kind of amazing anyone chooses to go into healthcare having to work like this. It's the absolute last field I would ever want to go into, even as an engineer who wouldn't need to actually practice medicine. Seems like you need to practically give up your life to save countless others. Your wife, and those like her, are truly performing an innately critical job at an absurd cost to themselves - God bless.

It depends a lot on the specialty. Obgyn is particularly hellish.

But yeah, there's a good reason why suicide rates are so high for doctors...

The AAMC should increase the number of students they admit. The average medical school is turning away 95% of applicants. The top 10 schools in America are excepting <2.5%.

Doing this would make the problem worse by increasing the amount of unemployable newly graduated doctors that can't practice because they can't match into a residency program. Medical schools have exploded in number the past few decades compared to the actual amount of residency spots that have been opened.

The limiting factor isn't medical school admissions, it's residency spots. We'd need to increase medicare funding if we want more residency spots.

Why does medicare alone have to fund residency spots?

excepting?

Goofed that one up...

Accepting

That is insane. For some reason, airplane pilots have very strict rules about how long they can be in the cabin, how much they must rest, and similar stuff. (Also, they have checklists, plenty of checklist, but medical doctors don't like checklists.)

Even bus and truck drivers have a more sane maximal shifts restrictions.

That sounds illegal.

Nope, not where we live.

I have seen administration do some blatantly illegal shit around physicians with COVID, but I don't want to write that up here.

Doctors answer: yes. And?

And she is not a resident or in a training/certification program?

Not anymore, but she’s only two years out. Her hours are actually worse than most of residency these last two years.

Wow, 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.

What's cynical about stating the truth? Are you disagreeing with his observations, or just hoping he'd have the good taste to keep them to himself?

Saying ICU are overproportionally occupied by the lederly, abd very young also if this a different ICU, is a fact. Continuing to say that is reason "you" have to wait for getting a slot and asking whether or not the observed sotuation is actually hood is cynical.

I’m a layman with no knowledge of how ICUs work, because (thank God), I’ve never had to visit one.

I found this article informative, and not cynical at all. No system is perfect, and so with all of the significant benefits they provide, ICUs have some things they aren’t best for.

> Continuing to say that is reason "you" have to wait for getting a slot and asking whether or not the observed sotuation is actually hood is cynical.

I see you bashing the author, but you haven’t made a coherent argument at all. In fact, I’m not sure if this is even English.

If there’s something op got wrong, help us understand and make it a teaching moment. Just bashing them isn’t productive.

Exactly 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.

I 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.

Related, interesting anecdote: I was recently talking to a co-worker. We are both "third-country", so we can compare and contrast our current healthcare system versus "home". My co-worker made an interesting point: In their home country, patients are much more involved in their care, and doctors are willing to engage with well-prepared, intelligent patients. As a point of comparison: Our current country, not at all.

My point of this anecdote vis-a-vis high-agency healthcare systems: I like when I can ask questions to a doctor about their diagnosis and proposed treatment. Yes, I understand they are busy and there is a reasonable limit. I am equally annoyed when this is viewed (in the extreme) as an assault on their authority!

The observations of the comment about old people does however match the demographic data, and it shouldn't be simply dismissed this context is important and was not made clear during the COVID-19 pandemic.

The 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.

On why there are too few doctors:

https://www.theatlantic.com/ideas/archive/2022/02/why-does-t...

Although I agree with you on a distaste for the foolishness of central planning, lLet me provide an alternative perspective.

A huge proportion of US physicians are already mediocre; a shocking number are bad. (Source: I am a physician.) Given this, I am concerned that further relaxation of standards in an effort to train more doctors won't lead to better outcomes.

> Given this, I am concerned that further relaxation of standards in an effort to train more doctors won't lead to better outcomes.

The high standards certainly prevent people who are unable to meet the standars from practicing medicine, but they also prevent people who are able to but see the standards as unreasonably onerous and pursue something else. Some of those could have been great doctors but looked at the steps and said nope, I'm not going to go to med school, then hope I can get a residency, in which case I get to have a hellish schedule and little autonomy for at least three years, and then probably a hellish schedule and little autonomy for many more years.

"But I want my doc to have a degree from medical school not some 3 month anatomy bootcamp..."

Not making American doctors do 4-years of an undergraduate "premed" degree will not meaningfully lower standards. Nor will creating more residency slots.

We don't need better outcomes. We will happily take the existing outcomes but cheaper.

Is the point you're making here that removing the "premed" undergraduate degree (which doesn't exist) will somehow lead to reduced healthcare costs?

It’s unclear to me how removing the requirement for an undergraduate degree (side note, it is not actually required at many or most US medical schools) will lower healthcare costs.

> 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

Agreed, but I would go further and say that if demand by students for the training provided by residency exceeds the demand by hospitals for the work provided by residents, I don't see why residents couldn't pay for their training just as they do for medical school. The whole "residency funding" thing seems like a red herring as an explanation.

To be clear, I'm not saying that medical graduates should have to take on more debt to pay for residency, but rather that the reason this doesn't happen is not obvious according to typical economic reasoning.

If you've spent on average ~200K for medical school, how willing will you be to pay to work for 3 to 8 more years before you get a paycheck? Resident doctors already make less than nurses with 4 year undergraduate degrees.

So? People really, really want the prestige that goes with being a doctor. If they could pay for it they would. Physician compensation is heavily weighted towards middle and late career as it is and that hasn’t stopped people beating down the doors to get into medical school. Half the people who currently apply to medical school could look at how crap it is and decide not to and there would still be intense competition.

The below article on how awful medicine and medical school are was written a decade ago and nothing has gotten better. People really like social status.

https://jakeseliger.com/2012/10/20/why-you-should-become-a-n...

Just 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.

I 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.

I would argue that having onerous tests are not a great proxy. Not only do they not necessarily measure how good a physician a student would be, but it also encourages undergraduates to intentionally enter easier/less rigorous coursework to focus more on the exam aspect (though GPA plays a large role as well). I'm sure a psych major may make a fine physician, but I don't want doctors to only be educated in a rather dubious field. If undergraduate education is only a stepping stone towards medicine, then just integrate medical education with undergraduate studies, rather than adding a ritualized acquisition of a bachelor's degree.

> For now tests a a fair proxy for that

Is it? Is there a study demonstrating the correlation to pre med test scores to patient outcomes?

I get what you're saying, but I don't think more doctors is the answer. Hospitals will only hire the absolute minimum number of doctors they can possibly get away with, other than the ones who actually bring in new business.

This is the reason: as soon as the medical industry has established a consensus price for some procedure or other item of care, the hospital administration starts to work on figuring out how to do it for the least possible cost. The price has been set in stone, no need for further justification. Medicare or whoever WILL pay that much. The price is fixed so the only knob left to turn is cost, and cost will be reduced all the way down, until service is just above a level so poor that patients would decide to stay home.

Possibly part of the problem then is having a for profit medical system?

Totally agree. Also, let people open more medical care facilities. Right now "Certificate of Need" legislation is killing lots of viable options for care _outside_ hospitals.

It's not illegal for other entities to fund residencies!

I anticipated your argument in my other comment...

My 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?"

It’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

The author even mentions that a long term stay like their father’s is rare. A lot of the criticisms are about what is, and I apologize for the expression, an edge case.

My 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.

> 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

Congratulations! 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.

Father 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?

The 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.

I made do, so can you (and all the other dads).

I 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.

> 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.

Old 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.

It 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.

Having experience from emergency departments in two different countries with "Medicare for all", it seems pretty much the same everywhere. There are two cohorts that make up the frequent flyers: the old and the drunk/addicts. The former get sick often and when they get sick they don't recover well; the latter end up in problematic situations like falling asleep outside in winter, getting in fights, overdosing or similar.

ability 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

A 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-he...

[2] https://www.cnbc.com/2021/01/05/americans-fear-they-wont-be-...

[3] 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-...

That’s the patient choosing not to go to the doctor - how is that the ICU doctor’s responsibility? Are they meant to scour the streets looking for people who need intensive care?

What 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.

> 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.

his "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.

It’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]

For 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-di...

From 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.

It'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.

Yes, certainly people in medicine are aware.

> we let a 90 yr old with dementia/diatebetes/etc. pass with dignity.

Often it's a 4 week old baby.

For every 1 sophisticated family member, there are 19 unsophisticated ones, who toss a weighted coin and, if it's heads, they decide they want their dying, non-responsive relative - possibly their baby, possibly their mom, etc. - to be kept alive at all costs. I don't know if this is politically toxic as much as it is cultural, and possibly globally cultural.

Could you please stop creating accounts for every few comments you post? We ban accounts that do that. This is in the site guidelines: https://news.ycombinator.com/newsguidelines.html.

You needn't use your real name, of course, but for HN to be a community, users need some identity for other users to relate to. Otherwise we may as well have no usernames and no community, and that would be a different kind of forum. https://hn.algolia.com/?sort=byDate&dateRange=all&type=comme...

> Often it's a 4 week old baby.

You are stretching the word often, most people in the ICU are close to the end of their life. A lot of people don't realize but most of the time if you needed to spend weeks in an ICU you are probably not "living" in a dignified way. Almost all ICU doctors/nurses I've talked to would rather have a DNR in their old age than live like that.

It's pretty well know and often discussed that up to 1/3 of Medicare spending is wasted. Being fee for service doesn't help but neither does spending 13-25% of all medicare dollars on end of life care[1].

What's worse is how much of Medicare's wasted spending goes to harmful treatments.

[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6610551/#:~:tex....

Many of the top causes of death, per the CDC, are from diseases that can be prevented or naturally mitigated. We're all going to get old. We're all going to die. But carrying two or more "pre-existing conditions" into your later years is going to decrease your quality of life, as well as your use of healthcare.

My point is, what's not sociopolitically allowed is discussing how personal choice as well as normalized systematic issues (e.g., urban food deserts) are killing us, slowly. It's unfashionable to suggest someone's weight is (ultimately) unhealthy. But the USA wants to have its cake and eat it too, literally. That's not working out. It's not sustainable.

Finally, not to get off topic but over the last couple of weeks there's been a thread or two on HN based on acticles suggesting the GDP and similar "classics" economic metrics are hiding underlying social issues. That is, for example, healthcare care contributes to the GDP (or whatever) but that healthcare is for diabetes, opioids, faltering mental health, etc. We're falling apart but not to worry the economy is doing just fine.

It's complicated. But to your point, the fact that some important topics are ofc limits isn't helping. Until that changes the status quo will continue.

> My point is, what's not sociopolitically allowed is discussing how personal choice as well as normalized systematic issues (e.g., urban food deserts) are killing us, slowly. It's unfashionable to suggest someone's weight is (ultimately) unhealthy.

The recent push to try to re-frame obesity as healthy, fashionable and sexy seems particularly bizarre and unexplainable. It's the opposite of what happened with cigarettes, which started out as fashionable and healthy, then slowly became known as unhealthy and finally fell out of cultural fashion.

Any form of euthanasia runs into the legal and moral problem of who decides? And why?

You might think everyone wants to act in the best interests of their relatives, but of course that's not true. Some people will want to speed the natural process along because that inheritance looks really appealing, and no one is really going to miss the old guy/gal anyway.

Besides, that's not really the problem. The problem is profiteering by insurance companies and the hospitals they (effectively) run for profit, with patient wellbeing as a regrettable requirement they have to put some effort into.

I 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.

> 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.

We 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.

I 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.

Where do you draw the line? At what age, what illness do you refuse to treat a patient even though he may not want to die?

You could give a lot of people medical treatment with a proper healthcare and tax system. Why don't we try that first?

I assume we start by getting more information from patients about their wishes, and then following them accordingly. A large number of elderly people don't want hopeless and unpleasant medical interventions, but end up having them anyway because no one asked them.

> Where do you draw the line? At what age

30? or 21, if you prefer the book ;p

At some QALY/$.

Canada is actually moving in that direction with their medical assistance in dying laws.

Is it the same dilemma if we can kill one to save more?

This is an oft-repeated piece of received wisdom that is empirically untrue.

https://www.statnews.com/2018/06/28/end-of-life-health-spend...

Wow: just sample bias! We need to also look at the old people who had expensive care and survived (95% of costs in that article). Money does gets spent on hospital care just before death (5%), but predicting how to avoid “wasting” that money is hard.

For 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.

His 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.

If 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..

I 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.

A lot of old people have made peace with death. Not all, but many

Fox 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.

My 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.

> 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.

Here 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.

They 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.

As 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.

The 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#...).

I 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.

Probably assumed it was somatoform

It'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.

I'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.

Healthcare 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-o...

[1] https://www.cms.gov/Research-Statistics-Data-and-Systems/Sta...

[2] https://gs.statcounter.com/search-engine-market-share/all/un...

[3] https://www.statista.com/statistics/250577/domestic-market-s...

[4] 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).

As 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.

I 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%.

About 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.

RE: 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.

The single most important thing for anyone in the medical system is having a capable advocate. This story really drives that point home.

When 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.

Rich 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.

Very well thought out article, but I promise your life will improve if all you do is read the caption on the first image.

This 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.

I suspect it IS a real hospital, depending on if the show was set in a hospital or not. If they only needed it for a few scenes, you just rent out a hospital or something that looks similar enough.

Thank you

I’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.

I 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.

I 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.

I 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.

Something 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.

Elephant 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.

Heart 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.

https://web.archive.org/web/20221118233758/https://trevorkle...

With 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.

In 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.

From 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-he...

A 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...

I 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.

Surgeon 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.

From an epidemiological perspective, one of the hardest things about evidence for critical care is that ICUs are really, really hard places to conduct studies.

I 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.

You 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?

Interesting 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.

It'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.

ICU 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.

> 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.

I 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.

A 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.

Excellent 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)

I 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.

Hospitals make you sick. Intensive care unit make you intensively sick. What a tragedy that something we need so much is so bad for us.

> 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.

I had a strong reaction to that too. Of course we devote more health-care effort to people in the last 5-10 years of their life, which primarily (but not entirely) means older people. There is practically no world in which that wouldn't be the case, because everyone's health trajectory eventually trends downward. By the time someone reaches the ICU (other than as a result of trauma) not only the immediate problem but likely several others will have progressed to problematic levels. That's also where the most labor- and dollar-intensive treatments tend to be applicable. It's just basic statistics, really. Cars also cost more in maintenance late in their life cycles, and so do many other things. A flat age distribution in the ICU would be super weird and probably an even worse allocation of resources.

I don't think the author really meant that to come across as callous as it sounded. Probably just poor choice of words. I'm only addressing it because someone else reading it here might interpret it in more of an "older people stealing from younger ones again" kind of way for demographic or ideological reasons.

ETA: it already happened as I was writing this.

What's terrible about it?

I'm a younger (34) person with substantial healthcare needs (I have MS). Everything is always oriented towards the old, and I also pay taxes that are used to support them while getting nothing in return despite having similar needs.

> I also pay taxes

Do you really get nothing? And who is paying for whose care? You mention taxes, but they've probably been paying taxes even longer. And why do you think health care is a strict quid pro quo anyway? Some of us believe care should be allocated where it's needed, not where it's paid for. Put another way: why is it a problem that they are getting care? Isn't it that you aren't? This doesn't have to be a zero-sum game. If you feel that you're in competition with someone else for care, the problem is pretty clearly that there aren't enough providing it.

Saying others have less right to health care is pretty terrible no matter which way the finger points.

It’s painfully easy to start thinking in numbers when you’re paying six thousand a month to warehouse your grandmother’s body.

The number of tests people want to run on someone we all hope dies tomorrow is insane.

Funny, I pay even more than you mention to support my own mother in relative comfort in a nursing home, and I don't find it "painfully easy" to think that way at all. I certainly don't hope she dies tomorrow. You might want to reconsider saying such things in public.

Note: my mother, not my grandmother, and I have lived that ordeal for several years. Some interaction is still possible, but recognition has been beyond her for a while. As long as she seems to take some pleasure in her surroundings, no matter how dim or muted the signs, you won't catch me framing my thoughts about her in terms of dollars I could save.

Sounds like your grandmother can still recognize and interact with people. Mine was basically a warm body for the last five years of her life.

Prolonging that existence is not a kindness in any sense, and I hope you don’t have to go through such an ordeal.

I think a more generous reading of the comment you are replying to could be (and probably is reasonable): It is hard to pay a lot of money for somebody that is living in agony with no chance of getting better, where death might be a good option for them personally. I would not understand the comment to criticize supporting people living in relative comfort.

Before you jump the gun like that again: The context is most likely about the suffering of the patient in question from simply existing in that state, and there being no way to alleviate the suffering (only prolonging the life). Not about saving money.

So it’s a lose-lose: the patient suffers and society has to pay for their privilege to suffer (without recourse, most likely).

And maybe you disagree fundamentally with things like assisted suicide. But someone who posts something like what you replied to most likely do not.

Because of demographics this is a problem we will have to confront regardless - do you think medicare/medicaid spending will become 80% of government spending?

Maybe 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.

It's horrible but true. How do you budget for and prioritize access to scarce resources?

In a way I think this is ok though? Like, when I reach that age I sure as hell hope I'll have more access to doctors than younger people?

I didn’t read it as an indictment (why are we wasting all this money on people who are dead soon anyway?) but more of just a straight observation that makes sense if you think about it but probably isn’t what most people would expect if asked unprompted.

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