Reflections from my hips.

One surgeon, two hips, and three hospitals within four months, what's the story?

As the medical director of a community hospital that has been one of America's Top 100 Hospitals for three years in a row, why did I go to two out-of-town academic medical centers to get my hips replaced? The short answer: privacy and politics.

The orthopods at my own hospital were either my close friends or my "enemies," and you should have neither operate on you. Sometimes it is better to be anonymous.

Upon my return to my own hospital many wanted to know which hospital did I think was better, which hospital was higher quality, which one would I go back to again? As a physician patient, people wanted to know, how did I judge the hospitals' quality?

For this article, we'll refer to the hospitals as Hospital A and Hospital B. How I ended up having surgery in two different hospitals in and around Boston was more a result of the vagaries of operating room schedules and rapid symptom progression than any deliberate planning.

Pre-op

There are 40 operating rooms at Hospital A, and to describe the central pre-op area as a veritable beehive is to grossly understate it. No one bothered to draw curtains around the gurneys. The reduced sight lines would probably just lead to collisions at the many intersections, and the curtains would have been in constant motion from the passing waves of rushing people.

From my gurney, I could see the OR pharmacy which looked just like a NAPA Auto Parts store counter. The counterman handed anesthesiologists pre-mixed, presorted medications in a case-specific zip-loc bag from the stock shelves behind the counter.

In the midst of this maelstrom of everyone going somewhere else at significant speed with great purpose, my wife was performing some last minute Reiki (spiritual healing) on my hip while my oldest daughter appeared to be massaging my feet. She was actually protecting my feet from unforeseen jostling by the passing crowd.

"And what do we have here?" asked the attending anesthesiologist as he entered our little oasis of relative peace. Actually this was not a bad question, since my wife's hands were under the covers right over my operative site.

"Would you please read this Prayer of Light out loud as you put my husband under?" my wife said, as she extended her hand holding the 3x5 card.

"Is it in English?" was his immediate response. "When I have to be coached in the correct pronunciations of Native American, Hindu, Chinese, or whatever words, I want to make sure that we can make the time for it."

My wife and I had had some long conversations about the extent of our efforts to enlist my physicians' participation in complementary medicine. I wished to minimize it. You could call it a "sense of inner peace" or just plain stubborn denial, but I approach these events in my life with the unshakable feeling that everything is going to be all right ... even without the benefit of incantations.

I was open to some of these new treatments and actually received Reiki and acupuncture in a failed attempt to delay surgery until after the summer, but many physicians feel that complementary medicine is, at worst, unsafe, and at best, useless. I did not want to do anything that might throw off the balance of my patient (doctor) to doctor relationship.

My wife, on the other hand, as an asymptomatic four-year survivor of metastatic breast cancer, made extensive use of various forms of energy work, meditation, and psychological preparations. Fortunately, this anesthesiologist had no problem reconciling the two viewpoints.

The anesthesiology resident arrived at this point carrying a bulging zip-loc bag and exhibiting a severe case of "stuffed pockets syndrome." The attending anesthesiologist nonchalantly draped his upper body across my abdomen and began to describe in reassuring detail all that was going to happen.

While talking with me, he watched like a hawk everything the resident was doing unseen above my head. This was July 9 in a teaching hospital and all interns and residents had assumed their new positions on July 1. So if this resident was a second-year resident, he really was a one-year and eight-day resident.

I had earlier declined the amnesia-producing Versed for sedation, so my last memory as I went under was being the focus of the undivided attention of a senior attending anesthesiologist. It is a comforting memory.

Compare that pre-op experience to the one three months later at Hospital B.

I checked into the much quieter, more sedate pre-op area in Hospital B for my second hip replacement. I was led past the nurses' station complete with computers, cups of coffee and nurses discussing work schedules. I was placed on the last gurney on the left in the pre-op area.

At Hospital B they draw the curtains. That was the only possible way to establish a separate space in this small, narrow room. For the next hour, elbows, heads, and other human body parts of people taking care of the patient next to me repeatedly poked the green curtain into my space, only to retreat as quickly, often accompanied by an appropriate sigh, grunt or other sound from my neighboring patient.

I have no memory of the trip to the OR or of my induction this time because I received Versed sedation in the pre-op area. This was either because I was less vigilant in a quieter setting, or because this was my second hip, or because the choice of not being sedated was never explicitly offered.

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My last memory is of the anesthesiologist accepting the 3x5 prayer card from my wife and slipping it into the front sleeve of my chart without a comment and barely a glance as she wheeled me toward the OR.

Post-op

The first thing I remember in Hospital A's recovery room was a clock that said 4:30 p.m. I went in at 10:30 a.m., was supposed to be awake by 2:00 p.m., and in my room by 4:00 p.m. They finally shoehorned me into my room (luckily I was in the bed nearest the door so that my roommate's bed didn't have to be moved to let mine in) by 9:30 p.m.

I vaguely remember excuses being made about a shift change and a supper break delaying my transfer, but my wife laid the blame squarely on the battle-ax control-freak nurse in charge on the floor.

As a trained physician, I, of course, took exception with my wife's parochial view and reminded her about all the system problems that might have delayed my move upstairs. "It is wrong to blame the floor nurse," I preached.

But then that same nurse had me rollover in bed, and I changed my opinion of her immediately. "Off with her head!" I thought.

I had been in this new bed for all of 20 minutes and the nurse decided that it had to be changed.

"Just grab the sidebar there and roll over on your un-operated hip, and I'll slip these sheets under you."

That may sound reasonable, except that at this stage your operated hip feels and acts like it weighs about 3,500 pounds. Movement in any direction is highly unlikely, and movement against gravity is darn near impossible. When movement does occur it is accompanied by the gnashing of teeth and serious inhalations of life-giving breath that end in exhausted sighs.

About a half an hour after my rollover, my roommate, still nameless on the other side of the green curtain, was told they were going to change his bed. His new hip was only two hours older then mine and his immediate response was a loud and clear assertion, "You are not going to do to me what you just did to him? No way!"

At Hospital B, by comparison, I never had to roll over. Whether by plan, tradition, or task sharing with physical therapists, they always managed to change my bed when I wasn't in it. What a blessing!

The truth

My experiences at both hospitals reaffirmed for me the universal truth: It is the caretakers who spend the most time with you that make the biggest difference in your care and comfort.

At both hospitals, the entry level nursing assistants and patient care assistants took my vital signs every four hours, responded first to my call button, emptied my urinal, and most importantly, helped me (and my hip) up, out, and back into bed the first post-op days.

As far as any hip patient is concerned, that operated leg is so tender, so precious, and requires such gentle support that only certain people are allowed anywhere near it when it has to be moved.

At Hospital A, I was particularly wary of the nursing assistants who often appeared to be confronting the intricacies of an automatic blood pressure machine or electronic thermometer for the very first time as they slowly and deliberately took me through the vital signs drill.

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Barely awake, I could not imagine how these quiet, slow moving women in blue uniforms could possibly understand or meet my needs as a patient in pain with a nearly two-ton leg. These nursing assistants hardly ever talked.

Consequently, for the next two days, I made sure that one of the "real nurses" helped me move about. On the third day, I stayed up in the chair too long and in desperation at the end of a shift asked one of the young nursing assistants to help me move my leg back to bed.

Well, my beliefs about nursing assistants were proven wrong. That transfer was the sweetest, gentlest and smoothest I had ever experienced. Her touch was exact. Her timing was perfect. I was so relieved that I wisecracked that if she kept up the practice she might get it down pat yet. She looked at me with a sweet smile and responded, "You're only my one thousandth, eight hundred, and forty-third transfer this year."

The next night my roommate and the nurses were waxing eloquent about a rare and beautiful rainbow seen that afternoon over the city skyline. Poetic metaphors and metaphysical analogies were reaching a truly nauseating peak when I remarked that the rainbow was probably a galactic celebration of my first bowel movement since surgery.

The nursing assistant taking my blood pressure at the time slowly rotated her entire body and face toward me, tilted her head just a bit to the side, and stuck her tongue out at me! After recovering from my laughter, I decided that these nursing assistants with their calmness, unhurried pace and dignified competency were one of the best things about Hospital A.

At Hospital B these same entry-level caretakers moved faster, but responded more slowly to calls, talked more, gave more directions, and lacked the quiet calming effect of those at Hospital A. To be fair, the call-bell system at Hospital B was basically your "car-dealership-service desk" model. No matter what you said to the speaker on the wall, the speaker reply was always "I will tell your nurse."

Unlike at the car dealer, the nurse (or other "technician") actually does eventually talk to you face to face so that good communication about your problem and its resolution does eventually occur. It is probably the best way to handle patient requests in this large, linear inpatient unit, but I thought that response time suffered and I worried about information being lost in transmission.

Pain management

Patient autonomy, pain management and other current politically correct jargon does not adequately describe the action in the trenches (or at the bedside). My patient controlled analgesia morphine pump gave a reassuring beep in response to my push of a button. The machine is silent and you get no morphine if you push the button during the "lock-out" period after the last push.

My machine was preset for a dose of 1 mg per seven minutes. No one told me this. I learned this by direct questioning of the nurses during a particular time when I found myself watching the clock intently trying to time my button pushes most efficiently for maximum relief.

"What happens if the pre-set lock out is incorrect for a particular patient and adequate pain relief is not accomplished?" I asked innocently.

"Oh, the machine records your button pushes and totals them up in terms of milligrams of morphine delivered", the nurse responded confidently.

"Who reads it and changes the frequency or amount if necessary?" I asked with genuine interest.

"The nurse at the end of each shift records the amount used per shift in your medical record," answered the beginning-to-sound-official nurse.

"Who reads the chart and makes changes?" I asked persistently.

"The surgical resident ... or maybe the anesthesiologist ... or perhaps the pain management team," she answered tentatively. "Why, didn't you get enough?" she asked sympathetically?

"Oh, no. No problem. Everything is just fine," I responded gratefully.

I did, in fact, receive excellent pain relief. The oral pain medication is given to you after you answer a nurse's question: "On a scale of 1 to 10 what is your level of pain?"

My roommate and I quickly learned that to get the "good stuff" (opioids), which assured a full night's sleep, you had to answer at least a 6 or higher out of 10. A 4 got you nothing more than Tylenol.

A cynic might describe the current implementation of patient controlled analgesia as merely just another form of standing orders delivered by an electromechanical pump. The pain scale is an excellent device, but clearly favors those patients who catch on to the rules of the game quickly.

Also, the patient really knows only half of the rules of the pain relief game, since I suspect that nurse responses to the pain scale numbers may be floor-specific, if not shift- or nurse-specific.

In fact, one nurse trying to be particularly helpful brought me and my roommate two tablets each of the "good stuff" at 6:30 one morning because "this place is going to get crazy in about half an hour, and I thought you might be asking for them."

As a liberal optimist, I celebrate that the balance of power in the pain relief control game is now much more tilted toward the patient, but the reality remains that adequate pain relief still depends on an aware patient (or family member) who appreciates that the delivery on political slogans and campaign promises may still require an insightful and activist citizenry.

Staff shortages

Both hospitals had staff shortages that affected patient care.

At Hospital A there were six budgeted physical therapy positions for 100 orthopedic beds in four units of 25 beds on two floors. Three physical therapists were out on maternity leave and had not been replaced because either "the PT director is so picky about experience that no applicant has passed her screens," or "they are just muddling through in order to avoid additional cost and going over budget." I only asked two people, so I only got two opinions.

Consequently, the remaining therapists had to be fast on their feet, and they did an excellent job. At the end of five days, hip replacement patients could get out of bed, into a chair, on and off a toilet, and into the shower because of the good work of these "physical terrorists," as we patients called them.

But as my roommate discovered the day he was to be discharged, he had not been instructed in dressing and undressing, use of personal assistance devices (the "picker-upper" and the "sock donner"), going up and down stairs, or entering and exiting a car.

He pointed this out to his surgeon and requested that he be discharged to a rehab facility instead of directly home. To avoid the cost of this action to his HMO, his attending orthopedist cracked the whip over the therapists and ordered double sessions that day for his patient to receive the additional training.

With the short staff, some other patients must have been neglected that day. The physician was an appropriate advocate for his patient, the patient got the appropriate care that he needed, a part of the system saved some money appropriately. But the balloon being pinched bulged out somewhere else to affect some other patients and caregivers. This natural consequence of years of zero-sum budgeting and maximization of cost-benefit ratios is not surprising.

Over at Hospital B, the shortages hit on the weekends. Hospital B doesn't have an emergency room. The patient census drops over the weekend. The nurse census drops, too. I suspected that the two decreases may not be entirely proportional.

Nurses on the weekend seemed very scarce to us. The response time to call bells increased greatly and the frequency of nurse sightings in our room plummeted. My roommate had more nursing needs than I did, and I know that his opinion of the weekend staff shortage would be expressed in stronger terms.

And the food?

At Hospital A they no longer rationalize, apologize or try to explain anything about their food. The orthopedic unit was on the 16th floor and the standard comment was, "Well, it was fresh (or hot, or cold, or solid, or crisp, or moist) when it left the kitchen."

Hospital B's food was better, but only if you could convince the nurses to remove you from the "surgical progression diet" so that the "soup and Jell-O" would stop by the third day.

The best food was from the Au Bon Pain in Hospital A's lobby and pizza delivered by Domino's.

The bottom line

So which hospital did I like best? Which had the best quality?

Both had superb technical care, so in the end it was the "little things" that made a difference. I have to give the nod to Hospital A by a hair, primarily because of those nice nurse assistants. They were great.

Based on these reflections, what criteria would I suggest using in evaluating a hospital for an elective stay?

* How much does the nurse-patient ratio change on the weekends?

* Will your anesthesiologist and/or surgeon collaborate with complementary medicine modalities?

* How many inches are there between you and the next gurney in the pre-op area? (It makes no difference in the recovery room. You are in no shape to care, and your family probably won't be allowed in there anyway.)

* Who is designated to monitor and adjust the delivery of morphine by the patient controlled analgesia machines?

* What is the generally accepted pain level at which you will receive oral opioids? (You don't actually need to know this to pick the hospital, but the earlier in post-op that you know this, the better.)

* How far is your floor away from the kitchen?

* Will Domino's deliver?

In the end, one of my legs ended up a half an inch longer than the other after both hip replacements.

One day while walking without a lift in my shoe, my gait was a little off and a nurse at my own hospital asked if I had hurt my leg. When I told her about the double hip replacements she remarked, "Oh, you should have gone to Boston."

Enjoying the irony of the moment, I smiled and said, "I did."

Herbert O. Mathewson, MD, is medical director of the VNA of Cape Cod, a branch of Cape Cod Healthcare, Inc., in Hyannis, Mass. He can be reached at [e-mail].

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By Herbert O. Mathewson, MD