Christmas at the Hospital

Christmas comes to the hospital in a manner far different from the shopping malls. Usually the patient census is lower because most attending physicians want to get their patients home for the holidays. It is a well-known fact that people heal much faster at home among familiar surroundings than in the hospital. Exceptions to this rule would be people who are incapable of caring for themselves or those who have no one at home to help with their convalescence. Sending any patient home to an empty house where they have no groceries or means of even preparing meals is not going to assist in their recovery. That being said, most people are happy to get home ,holiday or not, to their familiar routines.

I usually volunteer to work on Christmas. My family has a huge celebration to welcome in the New Year so Christmas generally takes second place to the New Year’s celebration. I also LIKE being in the hospital on Christmas. There are decorations and most people are in a festive mood even if they are hospitalized. Rooms are usually decked with little Christmas trees and and cards with loads of red and green. The staff is generally upbeat because by Christmas Day, one is over the grumbling and disappointments of not being home for the holiday. I have found that the folks who work the evening and night shifts have little disruption to their holiday activities. The folks who are working during the day shift are usually younger and have plans for the evening and night anyway. Christmas is a pretty nice day in the hospital.

In our departement on Christmas, or any holiday for that matter, the chiefs and one intern will take care of their services. We round on the patients and get needs taken care of. Since the operating room is only taking care of emergency cases, we can generally get most things done and get home unless we are on call. If there is an emergency case, the call team will take care of it. Most of the time, it’s something like an appendectomy or an occasional strangulated hernia that the patient has been trying to ignore over the holiday. On a couple of occasions, I have had things like a ruptured abdominal aortic aneurysm roll in though the door. All in all, you are not going to be operating unless something needs to be done in a hurry.

The Operating Room staff will make plans for brunch or dinner on Christmas. Usually one of the attending surgeons will have some food sent in for the folks who are working on Christmas. They are happy to share their food with the resident staff, which is a nice thing to do. Many of the larger surgical or medical practices will have sent gift baskets and fruit baskets to various floors in appreciation for the work that the nursing staff does. One of our thoracic surgeons has a catered party for all shifts on the floor that takes care of his patients. It’s pretty nice for the staff. Even as an intern, I was always invited to “share the chow” with the nurses. Usually, I wanted to rest in bed because the night might get busy and being rested was a good thing.

The week preceding Christmas was generally a time of holiday vacation for most of the clinic staff too. Patients were not scheduled unless they needed something that couldn’t wait. Usually there would be a party after we had seen a couple of patients that needed treatments on a regular basis. The week after Christmas would be brutal but some of the wiser office managers had developed the practice of making the schedule after Christmas a bit lighter and the week before Christmas a bit heavier. In either event, working the clinics around Christmas wasn’t bad. Some of the regular patients would drop off chocolate, which made the days even more pleasant.

Some of my colleagues started their annual “grumble” from Thanksgiving to Christmas. They wanted to go home (California or overseas) for the holidays and a week just wasn’t enought time for this kind of travel. Our program director was pretty flexible about time off around the holidays as long as services were covered. If someone wanted to take a couple of extra days, we worked out a schedule where we could accomodate everyone. Still, there are folks who would complain that the schedule is “unfair”. Again, I always volunteered for Christmas Day or Christmas Eve and was happy to be off New Years Eve and New Year’s Day. By my third year of residency, the holidays were a welcome break in my routine and I would “go with the flow”.

Our department would have an elaborate Christmas party. This would be held off hospital grounds (read alcoholic beverages involved) and would be a “dress-up” affair. It gave some of us a welcome change from the scrubs and minimialist atmosphere of our everyday life. It was also an opportunity to meet some of the spouses and significant others of my colleagues. Sometimes this affair turned into the “coming out party” for some of the couples that had developed from July to December. One of my favorite tasks was taking bets on who would last through New Year’s Day. Many times, the week off during the holidays took care of the relationships that had been so feverish right after residency started.

Christmas was not an especially heavy time for traumas. If the weather was bad (ice storm or heavy rains), we would get an occasional motor vehicle collision victim but most of the time, people stayed home and the bars were closed. I remember an very sad Christmas night when a family was returning home for a day trip. The father was driving and feel asleep at the wheel of the car. The mother ended up being declared brain dead and all three of the children were killed. Only the father survived. One of the children and the mother became organ donors so that many people were helped that Christmas by the generosity of this grieving father who had lost his entire family. It was’t weather or alcohol that had caused this collision, it was extreme fatigue. Christmas can be a day of tragedy sometimes too.

I remember one quiet Christmas evening. I was resting in my call room (half watching the Food Channel) with my eyes closed. I had told the charge nurse in the Intensive Care Unit that I was going to take a nap so just call into the room instead of paging (faster anyway). She would also make sure that her staff didn’t page for trivial things that could wait until I finished napping. When I am the ICU resident, I always round every four hours and take care of loose ends. Most of the nursing staff will keep a “scut sheet” at the bedside for things that they need or for things that they want to bring to my attention. I also check vitals, lab values and make sure that all of my orders are up to date too. This makes signout in the morning and round much faster.

On this quite evening, I napped for about 30 minutes and then got up to make my rounds. I got a call from the chief resident that he was bringing up a very unstable patient that was a ruptured thoracic aortic aneurysm. He was through the door with the patient within three minutes. The intern appeared and begged me to let her put in the monitoring lines (arterial and central) so we got to work. I put in a subclavian central line as she placed a radial arterial line. The OR called to say that they were ready as the attending cardiothoracic surgeon came through the door. While he was speaking with the family, the chief resident and I wheeled the patient into the OR, the patient was in full arrest and had little blood pressure according to our arterial line. The chief told me to scrub and get ready to open the chest.

This was my first median sternotomy and I shook as I opened this patient’s chest quickly. Once the chest was open, we saw that this patient was beyond repair. There was a 50-cent sized hole in his ascending aorta that had dumped blood into the chest. We examined the rest of the aorta, which was quite friable. At this point, we pronounced the patient and I closed the chest with one of the physican assistants. Our attending physician told us that he would dictate this case since it was a fatality. I had literally opened this patient’s chest and placed my finger in the large hole in the aorta. The heart was empty of blood and silent. We didn’t even have enough time to get the patient on heart-lung bypass which might have bought us some time.

When I had completed the chest closure, I changed into clean scrubs and slipped out of the back door of the operating room and up the elevator into the ICU. I told the nurses about the case and checked all of the patients who had been covered by the resident in the unit upstairs. Since neither of us was particularly busy, he had volunteered to cover my unit while I scrubbed this case.

Christmas can be a time of looking at life and death up close. It can be a time of learning for a fledgeling resident who was beginning to hone her craft. I know that that family will always associate Christmas with the death of their loved one. I had found out later that this patient had known about the aneurysm but had cancelled every appointment for scheduling repair over the past month. The patient wanted to schedule the repair after the holidays but had begun having chest pains on Christmas Eve. This patient didn’t want to “trouble the family” with their illness.

The Uninsured Patient

My fiance is a fan of green tea. I have been shopping for his favorite green tea and my favorite hot sauce at a small family-owned Asian market near my house. Since I am in the store at least once per week, I have been introduced to many new tastes and foods by its very-knowledgable owner. Having something of an advertursome palate and being a lover of travel and new cuisines, I always appreciate the discussions and tastings that the owner offers regularly.

The owner of this store is a 50-something gentleman from Korea. He has a wife and three children who are high school and college-aged. He and his wife take turns in the store and I have gotten to know them all in a neighborly sort of way. They are hard-working and offer a very wide variety of great items in their spotlessly clean market. They will special order items for customers at request too.

Some time ago, I was called to the Emergency Room after the intern on my service had seen a 50-year-old gentleman with abdominal pain. The intern had completed his patient history and physical exam and had told me that he suspected that the patient might need surgery (likely gall bladder problem). He had reviewed labs and wanted to discuss the case with me so that I could notify the attending surgeon on call.

When I arrived in the Emergency Department, I found my beloved shopkeeper in considerable pain and agreed with the intern, that the patient would likely need surgery. We ordered a some tests (Right Upper Quadrant Ultrasound) and I relayed the case to my attending who agreed with out plan. I informed the patient of our plans and what to expect in the next few hours. I also made liberal use of pain medication as indicated.

Our patient continued to have a significant amount of pain and the right upper quadrant ultrasound did reveal gallstones so we added the patient onto the end of the day schedule. He was in good health and had been having some indigestion from time to time but nothing that kept him out of the shop or that he felt the need to consult a physician for.

The patient was prepped for a lap cholecystectomy (the usual procedure) and was given IV fluid hydration along with pain medication. The anesthesiologist was happy with administering a general anesthetic and the patient had given consent for the surgery after all of his questions were answered. His wife arrived after closing the store and sat at the side of the stretcher in the anesthesia prep area. She said that she was happy that I would be doing the surgery and liked the attending surgeon very much.

As we proceeded with the surgery, we found that the patient’s gallbladder was gangrenous and friable. We converted from the laparoscopic procedure to an open cholecystectomy (happens in about 5% of cases anyway) so that we could get the gallbladder out safely under the conditions that we had found. The case went smoothly and I accompaned the attending surgeon out to speak with the patient’s wife while the intern finished closing the incision and writing post operative orders.

When we spoke to the patient’s wife, she told us that they didn’t have any insurance. They just poured all of the profits from their store into providing necessities for their family and college tuition and had dropped their health insurance. Both had been in good health but things like mammograms for the wife and regular exams were had not been done. (Not that these things would have prevented the gallbladder problem anyway).

My attending told the wife not to worry because we would keep the costs as low as possible and the hospital would pro-rate charges based on the patient’s ability to pay. My attending told me as we walked back to the recovery room, that he would not charge the patient for his professional fees under the circumstances but this would be an expensive illness for this previously healthy gentleman.

Our patient made an uneventful recovery and was released from the hospital, feeling better but walking a bit slower. He returned to our office the next week for a wound check and two weeks later, I saw him in the store helping his wife take care of customers. He was doing great even though we had asked him to not work for at least three weeks. He was worried about his business and wanted to at least work half a day.

Two months later, the store closed. The family was not able to make the payments for the hospitalization and keep up with the store. My beloved shopkeeper had lost his business and was in danger of losing his house had it not been for a business associate who had hired him to work in another store.

My patient lost his business because he was not able to afford health insurance for himself and his wife (his children were insured). He was hard-working and contributing to the economy of our locale and country by operating a store. Yes, he took a chance and lost but why not put out best and brightest folks on solving the problem of providing basic healthcare for the uninsured patient.

I am not an advocate of a “federal program” for taking care of this problem. One need only look at Medicare and Medicaid to realize that having the “feds” do anything is not cost-effective and more costly. Why not have an “Apprentice” type show where folks come up with solutions to this problem? It’s not as sexy as a multi-million dollar real estate deal but it’s a huge problem where we all could benefit.

There are millions of folks out there like my wondeful shopkeeper who contribute to the economy and provide a wonderful service in their neighborhoods. These are hard-working folks who want to provide for their families and keep a roof over their heads. They are not looking for a “government handout” but some kind of affordable insurance plan that would take care of their basic needs and emergencies.