Just over three weeks ago my brother suffered a brain hemorrhage while on vacation with his family in the Dominican Republic. After an emergency medevac and a few weeks in two different hospitals he has continued to get better and very thankfully is expected to make a full recovery.
As a result, I’ve been spending a good bit of time in hospitals lately.
What I never realized is how amazing hospitals are as organizations. It’s really fascinating. During the entire experience I couldn’t help but marvel at all of the different parts of the hospital working together to create their end product: health.
Here’s what I learned.
At the core, hospitals are really comprised of two systems working in tandem: Nurses and Doctors.
Nurses:
Each hospital is divided up to “floors” which are really just blocks of rooms. In the two hospitals where I stayed, there were about 15-25 rooms per floor and one or two patients in each room. At the center of the floor is the nurse’s station. The nurse’s station is home base for the nursing staff – that’s where all of the patients on the floor are monitored centrally. That’s also where the administrative staff for the floor sits. Each floor has one or two admins who answer the telephone and monitor who is coming and going on the floor. Although security is usually pretty loose, the doors to the floor are locked and need to be unlocked by the admin for anyone to enter or leave.
There are different types of floors throughout the hospital. Each floor is categorized by two factors: the specialty and level of care. The different specialties are, as you expect – cardiology, gastroenterology, maternity, oncology, etc. In terms of level of care, I only really observed three levels (in order of escalating severity): general care, intermediate care, and ICU (intensive care unit).
Depending on the specialty and level of care, there is a specified ratio of nurses to patients. This can be as high as 1:1 or 1:2 for ICU floors (evidently this ratio is mandated in some states), or as low as 1:5 or greater for general floors. This ratio dictates how many patients are assigned to each nurse. This number is important to keep in mind because it represents how much attention each patient will get from the nursing staff and how readily available nurses will be in case something goes wrong.
Organizationally the nursing hierarchy looks like this on each floor:
1) The Charge Nurse: the boss of the nurses. They are the escalation point for nurses on that floor.
2) The RN’s or registered nurses. These are the nurses that provide 24-hour care for patients. They work in two 12-hour shifts. They administer meds, monitor vital signs and they are the ones who come running when there is a problem.
3) The nurse technicians. These are the folks who do more of the dirty work in the hospital. They sponge bathe the patients, clean the rooms, help the patients go to the bathroom, and do more of the operational work.
Overall the job of the nursing crew is to keep patients alive and comfortable while they are receiving care at the hospital. They also provide some emotional support and motivation – often writing “goals for the day” on a whiteboard in the patient’s room (e.g. get to pain free, walk down the hallway on your own, etc.)
The second major system of the hospital is the Doctors.
Doctors are easy to identify at the hospital because they wear distinctive white coats, they often travel and packs and people get out of the way when they walk down the hallway. They are clearly the top of the social hierarchy in the hospital. However, not all doctors are the same inside the hospital – there are actually lots of different kinds and levels of doctors.
As doctors become more senior at the hospital, they specialize in one area of medicine. For instance, I spent a lot of time with neurologists. Here’s what the organizational hierarchy looks like (I personally found this to be one of the most important things to remember):
Attending Doctor: these are the most senior doctors at the hospital. They make most of the decisions about how to handle patients and when to do surgery or other procedures. They are very often the surgeons themselves and spend a lot of time doing surgery (and if it’s a teaching hospital, teaching surgery).
Fellow: this is the second most senior tier of doctor. These doctors are technically still in the process of their “on the job education,” but are very experienced. I think by the time they reach the fellow level, doctors have already specialized in a specific field.
Resident: these are the 3rd most senior (second most junior) doctors. They either have not specialized or are just starting to specialize in a specific area of medicine.
Intern: these are the most junior doctors. They have not specialized in any one area of medicine and they rotate through different departments at the hospital. For instance, we once had a sports medicine intern come talk to us even though we were being treated by the neurology Attending.
For complex or serious cases, when it comes to doctors, the Attending and Fellow are really the only ones who actually have real decision making authority. One of the most important lessons I learned during my time in the hospital is to make sure you know whom the information is coming from when you talk to a doctor. Although the Interns and Residents are the most junior doctors, they are also (logically) the most available to patients. Very often we were in a situation where a Resident or Intern was relaying information to us that had been told to them by the Attending. I found that it was important to try to cut down on the game of telephone and talk directly to the Attending whenever possible.
However, one important warning about Attending doctors – who are often surgeons. They are notorious for not really caring about follow up or recovery. Surgeons are the alpha-males or alpha-females of the hospital. They go in, fix you, and then send you on your way so they can fix the next person. When it comes to creating a rehab plan – talk to a Resident who may have more appreciation for some of the softer sides of medicine.
One of the most interesting things is that the nurses and doctors at the hospital work totally independently. For instance, nursing staff works 24/7, while the doctors really tend to work more on a regular work schedule (Monday-Friday). Doctors, especially the more senior ones, can be very hard to find on the weekends.
Another thing that really caught me off guard was the practice of Doctors doing “rounds.” Rounds are when a bevvy of doctors walk from room to room, spending about 5 minutes with each patient to give them an update on their condition and plan. Rounds are pretty much the only time patients get to talk directly to the doctors (unless there is an emergency) so it’s a very important time. Also – because it happens so quickly and at an unpredictable time (generally between 7am and 10am) it can be a bit of a scramble to figure out what’s going on and what you should ask the doctor. To help with this, I started writing down my questions in advance of the doctors showing up and (figuratively) blocking the door until they gave me all the information I wanted. It took me a few times to get really good at this. The first time the doctors did rounds, I completely missed what was going on and had to wait 24 hours to have another shot at it.
I suppose at the end of this experience I’m left thankful that my brother is ok, but I also have a brand new respect for hospitals, nurses, doctors and really anyone who has been through a long term hospital stay. Hospitals can be really scary places, but they are also beautiful, vibrant, living organisms.
Note: the entire content of this post is based on my observations and light internet reference. If there is something here that is wrong, please let me know! I will update the post.