With regard to the medical management, the three-pronged matter as to who is the attending physician, who is writing the orders, and who are the available specialists and what are their specialties is sometimes a mystery to the patient in a teaching hospital. First, there is a distinction between private and service patients. The private patients are usually lucky enough to have a relationship with a board certified experienced doctor who will provide personal attention. The service patient has no such connection with the attending physician. Usually having Medicaid coverage or belonging to an HMO, service patients in many cases never get to talk to the attending physicians. Medical management is usually dedicated to resident physicians-in-training, with a signed note being placed in the record showing the physician's awareness of the case.
Second, the issue of who is writing the orders becomes a hitch when you, as the patient or visitor, find out that the nurse is serving up an unfamiliar drug. When this happens, it is time to demand a conference with the attending to find out if he or she is aware of the order and approves of it. Remember that for the most part, a post-pubescent medical school graduate is deciding your fate. If your doctor recommends an invasive procedure such as a spinal tap, find out who is going to do it and how many times that person has done it before. If you are the first one, and the attending is standing there directing the moves, it need not be a harrowing experience. I have seen many first-timers do an excellent job with good teachers guiding them. However, the teaching person should be a doctor who not only has the experience of doing the procedure but also has experience teaching it. If you do not feel comfortable with such an arrangement, you have the right to request an alternate who has done it a few times before. In any event, if the patient's body is going to be the object of a lesson, the doctors have an obligation to disclose that fact beforehand.
Finally, the age of medical specialization brings the average patient into contact with a number of different specialties of medical and surgical disciplines. When there is one physician in charge who is coordinating all medical orders, seeing one or more specialists should be beneficial. On the other hand, when different services take charge and then shift the responsibility, there is no single doctor coordinating care, and that is when the problems begin. There is often duplication of services, and, worse yet, the opposite occurs, whereby each specialist thinks that the other team is going to take care of a specific problem and no one does anything.
For example, when a patient suffers a crushing injury to a leg, two teams perform surgery. The orthopedic team reduces the fracture, while the plastics group does the skin graft. The question then becomes, "Whose job is it to change the dressings after surgery to assess wound healing and clinical progress?" If each team believes it is the responsibility of the other, no one will do the dressing change and medical follow-up.
This is exactly how a man I'll call Armand lost his right leg to gangrene at one of the teaching hospitals in New York City. This forty-seven-year-old taxi driver had gotten out of his cab to change a flat tire on the westbound side of the Queens Borough Bridge. While he was pulling his spare out of the trunk, another car hit him and crushed his right leg against the cab.
Nine hours later, Armand emerged from the operating room after arduous reconstructive surgery with bone and skin grafts. Two surgical teams were involved: orthopedics and plastics. For three weeks, no one bothered to follow up to change the dressings and evaluate the leg postoperatively, despite orders specifying that only a surgeon was to provide wound care. After the two surgical teams independently diagnosed Armand with compartment syndrome, they continued to pass the responsibility to each other. Every time the nurses asked the plastic surgeons to change the dressing, they responded with, "It's not our responsibility. Call the orthopedic residents." The nurses got a similar response from the orthopedic people, telling them to "call plastics."
When one of the nurses boldly removed the dressing because of the horrific stench of rotting flesh, the orthopedic and plastic surgeons agreed that the patient needed an emergency amputation to save his life. The leg was black at the operative site, and the diagnosis was necrotizing fasciitis (gas gangrene). If Armand and his wife had understood how the medical and nursing processes were supposed to work and that the treatment was unacceptable, he would be walking on his own two legs instead of having to use a prosthesis.
In summary, there are comparative milestones by which to differentiate between a reasonably safe hospital floor and a dangerous one. Those involve distance from the nurses' stations, emergency equipment, supplies, skill level of nurses, nurse-to-patient ratios, patient acuity, and coordination of medical specialty services. The table on the next page provides a tool for such a comparison.