Sunday, February 5, 2012

Poor Medical Care in Hospitals

     I recently was hospitalized on a non-medical floor for a procedure at a hospital which is directly affiliated with a major teaching hospital. I can only say that the nurses are wonderful, the medical support staff poorly trained, and the medical consults on my ward no more than casual and somewhat rude and impersonal. What I observed also further deepened my belief that hospital computer systems waste a lot of the doctors' and nurses' time, especially the time of the nurse who dispenses medications. I will just list the examples of poor medical care that I received, with additional comments for those of you who are not doctors.

1)  You should NEVER listen to the patient's heart and lungs through his/her hospital gown. The gown is an additional sound filter and the amount of sound that reaches the doctor's stethoscope is reduced. It is somewhat akin to driving at night wearing sunglasses. A faint I/VI murmur would  never be heard through a gown.

2) The patient's heart should be listened to in three different positions: sitting erect, supine, and then with the patient rolled over into the left lateral position. The latter position is sometimes the only position  in which the examiner can hear a faint S3 gallop, which sound is almost always indicative of heart failure.

3) You should never take the blood pressure through the patient's shirt. You will invariably get a falsely high systolic and diastolic pressure.

4) The digital BP machine that is so ubiquitous (because  anyone can use it) is set to read falsely high: typically 10 mm systolic and 5mm diastolic. Also, the proper method to measure the systolic pressure is to palpate the ipsilateral radial pulse as you manually pump up the sphygmomanometer: the systolic pressure is the pressure at which the pulse vanishes. This is even more accurate than listening with  the stethoscope.

5) If a patient has borderline or true hypertension, you must measure the BP in BOTH arms, because the two arms always have different pressures, and you want your treatment to be guided by the higher of the
two pressures. This occurs because the heart is situated in the left chest, so that  the path of blood and therefore the path of transmitted blood pressure is longer to the right arm than to the left.

6) The consulting internist never asked me when my last complete physical was, or did a rectal exam (forget about prostate cancer---you don't want to miss rectal cancer, which is both treatable and potentially fatal). He only listened to my heart sitting up. He did not palpate for a thyroid nodule, or listen to the carotid and femoral arteries for bruits, or palpate for my tibialis and dorsalis pulses. He checked one ankle for edema, but not both. He didn't even have the common courtesy to leave me one of his business cards, so I could call him if I had any questions.

7) He made several changes in the medicines I was taking. He NEVER told me that he was making these changes, so of course he never explained the reasoning behind the changes. I never miss a chance to educate my patients, and it is rude and counterproductive not to discuss the medication  changes with the patient.

8) Because I take a water pill to reduce my blood pressure, I also take a daily supplement pill of potassium chloride, since diuretics (water pills) accelerate the loss of potassium in the urine. He canceled my potassium, telling me that my potassium was normal when I questioned him. Duh----of course it was normal because I was taking supplemental potassium. He told me not to worry because they would check the potassium blood level in three days. This is just very bad medicine, and at the very least he should have discussed the planned change with my family doctor.

9) He ordered a chest Xray. This is just plain bad medicine, and would have exposed me to the increased cancer risk that any Xray does. The guidelines are very clear that if  any heart disease or lung symptoms exist as determined by examination or history a CXR is indicated, but in the absence of any such symptoms or findings, all the medical societies and groups strongly recommend that a chest xray NOT be done routinely. Perhaps the hospital just wanted to make some extra money.

10) An admission EKG, or electrocardiogram, was taken. A new medicine was added when I developed a complication from the procedure. I happen to know this medicine has a FDA mandated warning that the medicine could cause cardiac conduction problems, but a follow-up EKG to look for the development of a cardiac problem was never done.

11) And of course a PPD (skin test for tuberculosis) was never given, nor did I receive the pneumonia vaccine booster that I told them I was due to get.


  1. I forgot to add that I was given folic acid (folate) 1 mg/day. as a vitamin. This is a serious error, because daily doses of folate can mask the change in red blood cell and white blood cell morphology that would be caused by a deficient Vitamin B-12 level. In other words, too much folate (which you urinate right out) can prevent early recognition of Vitamin B-12 deficiency, which deficiency can lead to irreversible damage of the central nervous system (i.e. your brain).

  2. Robin -- this is pretty astonishing -- i hope it is not a hospital that i stumble into -- BTW i have never had a doctor check the heart in all three positions.


  3. You probably never had a physician listen to your heart carefully because the last time I witnessed and criticized a residents cardiac exam technique, he replied:"What's the difference? You can always get an echocardiogram."!!!!!

  4. Since upper-frequency hearing deteriorates with age (and nowadays may be compromised in younger people by exposure to loud music in clubs and via mobile equipment) many or most physicians may not do much worse by listening through clothes, so that the procedure has become more ritualistic than diagnostic. I don't understand why computer-aided analysis of microphone-acquired heart sounds has not become standard of care. Then again, much of physical diagnosis seems to have become obsolete (e.g., dorsalis pedis pulses and thorough breast palpation).

  5. But some patients have a congenital absence of the DP pulse, and it would be important to note this in the chart, lest following MD's think the pulse suddenly vanished. And with electronic amplification, is there agreement on what a I/VI murmur would sound like? I don't think there is a standardization. Of course as your ears and hearing deteriorate, maybe you should write a I/VI murmur as II/VI, etc.

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