Things I've noticed while visiting the ICU • Hacker News Board

Re: Things I've noticed while visiting the ICU

#261

Post by barry-cotter » Sat, Nov 19, 2022, 9:56 AM UTC

titanomachy wrote: post #110

rscho wrote: post #88

Earlier quoted context omitted.

I'm sorry but curiosity and creativity are certainly the n°1 enemy of the patient, especially in ICU settings. Curiosity and creativity are grandpa's medicine, and a total antithesis to evidence-based modern medicine, that attempts (and largely fails) to be an application of science instead of the whims of the decision-makers. What you should want is curious and creative _researchers_, but precise and totally unimagi…

If medical treatment was actually as formulaic and fully-solved as you imply, we wouldn't take the best students of every generation and make them spend ten years training to become doctors. We'd just have nurses, checklists, and diagnosis flowcharts.

General Practice medicine seems to come close enough. No differences in patient outcomes between physicians and nurse practitioners.

> Randomised controlled trial comparing cost effectiveness of general practitioners and nurse practitioners in primary care

> Results: Nurse practitioner consultations were significantly longer than those of the general practitioners (11.57 v 7.28 min; adjusted difference 4.20, 95% confidence interval 2.98 to 5.41), and nurses carried out more tests (8.7% v 5.6% of patients; odds ratio 1.66, 95% confidence interval 1.04 to 2.66) and asked patients to return more often (37.2% v 24.8%; 1.93, 1.36 to 2.73). There was no significant difference in patterns of prescribing or health status outcome for the two groups. Patients were more satisfied with nurse practitioner consultations (mean score 4.40 v 4.24 for general practitioners; adjusted difference 0.18, 0.092 to 0.257). This difference remained after consultation length was controlled for. There was no significant difference in health service costs (nurse practitioner £18.11 v general practitioner £20.70; adjusted difference £2.33, −£1.62 to £6.28).

https://scholar.google.co.uk/scholar?hl=en&as_sdt=0%2C5&q=do...

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC27348/

Re: Things I've noticed while visiting the ICU

#262

Post by retconn » Sat, Nov 19, 2022, 9:58 AM UTC

throwaway892238 wrote: post #224

ler_ wrote: post #161

I'm a nurse and I find the 7th point on the post especially relevant. I will add a disclaimer that I never worked in the ICU so I can't speak for what happens in that type of unit. There is a serious issue with the flow of information in healthcare, (or at least in the U.S, I never worked elsewhere to know if it's any different). But If you find something during your shift which will be important to know later on, it…

This is similar to problems that would often happen in car manufacturing. The person assembling the car the standard way finds a problem, but the problem doesn't get addressed, or information isn't disseminated correctly, so the cars go out with problems. Toyota developed a methodology whereby such problems are addressed immediately and fixes were disseminated immediately, and would not send a car out otherwise. That…

This is my favourite ever episode of This American Life, about NUMMI, the shop floor level and individually fraternal miracle that was created by workers at Toyota and GM in a CA GM plant, until management shut them down:

https://www.thisamericanlife.org/561/nummi-2015

Re: Things I've noticed while visiting the ICU

#263

Post by m463 » Sat, Nov 19, 2022, 10:06 AM UTC

With respect to sleep, I think that being disturbed (and/or medicated) might affect REM sleep. And if you don't get your REM sleep eventually your body will try and do it while you're awake. This means lucid dreaming aka delusions.

I think an interesting possibility for an ICU would be to add EEG monitor along with EKG and others. You could not only measure heart rate, but the type and amount of sleep each patient gets. And then use the information to make the ICU better.

Re: Things I've noticed while visiting the ICU

#264

Post by joenot443 » Sat, Nov 19, 2022, 10:23 AM UTC

rscho wrote: post #259

chrismorgan wrote: post #243

Earlier quoted context omitted.

> n° Since you’ve used a slightly fancy Unicode character: I found U+00B0 DEGREE SIGN unpleasant here, and it took a brief bit of thought to understand. (A capital N would probably have helped a little, but the degree sign is still disconcerting.) The character you want is №, U+2116 NUMERO SIGN. If you happen to be using a Compose key, `Compose N o`. For less fancy options, “#” and “number ” would both be better choi…

not all of us live in the US

I don’t either but fully agree GP’s assessment, you chose a strange character to use there.

Re: Things I've noticed while visiting the ICU

#265

Post by hef19898 » Sat, Nov 19, 2022, 10:23 AM UTC

Wow, that first paragraph is as cynical as it gets: " The ICU is filled with old people." It ends with people now knowing why it tales so long to get doctors appointments, and saying the author is not sure whether ir nit this is a good thing, that we (the articlee is about the US but is pretty much the same everywhere) spend so much of our health care resources on the old. While his dad, also not in his twenties, was cared for in the same ICU. Maybe he should visit an ICU for infants and babies next time...

Staffing. Well, what can I say. Patients are there 24/7, staff is obviously not. That staff works in shifts, great realization. I am almost surprised that the author wasn't surprised ICU staff has vacation and sick days.

And finally "The ICU is a good place to not die, but a bad place to recover.". No shit, Sherlock, tgat is basically what an ICU does, stabilizing patients enough to transfer them to a "normal" station for recovery, or, worst case, to a paliative unit if death is the only possible outcome.

Oh, not to forget: "It really makes me think about how the hospital might be organized differently. If the hospital focused less on pure survival, might their patients recover faster?" What makes a emotionally involved amateur think that the people running ICUs, after sometimes years if nit decades of training in that exact field, don't think about this question constantly? And tgat the current state of ICU care represents the current optimal solution?

I am so fed up with articles from people judging things by looking at them from the outside. Mind you, the articke in question here is one of the better ones.

Re: Things I've noticed while visiting the ICU

#266

Post by incone123 » Sat, Nov 19, 2022, 10:25 AM UTC

opportune wrote: post #218

dimal wrote: post #214

Earlier quoted context omitted.

Maybe you don’t want creativity in the ICU, but as a patient with chronic health issues, I do want creative clinicians. Over and over my entire life, I’ve gone to doctors with health issuesand watched as they mentally plug my symptoms into a flowchart that they learned in medical school, then they find that the symptoms don’t match anything that a standard protocol can treat, then they shrug their shoulders and say t…

Completely agree. Any educated layperson can figure out and follow a clinical decision tree. I mean it can work in your favor if you know you need something and know how to get the decision tree to give you what you want, but otherwise clinicians should definitely be actual experts and not just meat following something a computer could do

You still have the problem of writing a sufficiently detailed tree. I had a blood test last year and when I discussed the result with the doc, he asked me the clinic location where the blood was taken, because then he could estimate time between blood draw and lab test and interpret the result accordingly.

Re: Things I've noticed while visiting the ICU

#267

Post by [deleted] » Sat, Nov 19, 2022, 10:26 AM UTC

conductr wrote: post #236

duffpkg wrote: post #124

Author of Hacking Health for O'Reilly, managed operating companies for hundreds of hospital facilities, etc... One widely under realized aspect to healthcare costs in the US (there are many) is the very high number of ICU beds per capita, ~35 per 100,000 people. While it gets a little complicated to compare apples to apples, a reasonable person could say we have 30% more than germany which is the only european contry…

This is a practical reality of the "we keep old people alive too long" category.

[deleted]

Re: Things I've noticed while visiting the ICU

#268

Post by incone123 » Sat, Nov 19, 2022, 10:41 AM UTC

conductr wrote: post #236

duffpkg wrote: post #124

Author of Hacking Health for O'Reilly, managed operating companies for hundreds of hospital facilities, etc... One widely under realized aspect to healthcare costs in the US (there are many) is the very high number of ICU beds per capita, ~35 per 100,000 people. While it gets a little complicated to compare apples to apples, a reasonable person could say we have 30% more than germany which is the only european contry…

This is a practical reality of the "we keep old people alive too long" category.

I'm not old but I have an Advance Directive on my file that essentially says if I'm fucked then they should let me go. (And I'm in the UK where treatment is free at point of use).

Re: Things I've noticed while visiting the ICU

#269

Post by hef19898 » Sat, Nov 19, 2022, 10:44 AM UTC

coding123 wrote: post #74

jmhmd wrote: post #52

Earlier quoted context omitted.

The main thing that House MD has, that no other doctor in the world has, is not so much his superior intellect. It's that he and five other doctors spend 100% of their time on a single case, and can sit around all day discussing it, trying different things. If real world doctors had even a fraction of that luxury, you would see a lot more of what you describe.

Jeez, no kidding. I imagine if they made a realistic doctor show they'd be constantly showing the doctor at the bar (on days off) trying to make money on side gigs like health startups. Stumbling in a hangover to appointments on "work days" and giving everyone the same diagnosis as the last (and likely whatever sickness they themselves had recently). Also giving everyone fluids and an ativan so the patient says - "i…

Back when ER was a hit show, there was survey among medical professionals and hospital staff asking for their favorite medical drama series and the reasons for it. Grey's Anatomy, and similar series, constantly beat ER. The reason was that medical staff considered ER way too realistic. Makes sense, why would I entertain myself during my off hours with what is basically a documentary about my on-duty hours.

Re: Things I've noticed while visiting the ICU

#270

Post by barry-cotter » Sat, Nov 19, 2022, 10:49 AM UTC

haldujai wrote: post #196

rscho wrote: post #159

Earlier quoted context omitted.

You're right that silencing alarms is strictly forbidden in anesthetic territory only, not ICU. I'm biased bc I'm in Switzerland, and here the coverage ratio is usually 1:1. The country is so rich, that many things are different here... they really are near the patient at all times. To give you an idea: the day COVID really hit, we received 180 shiny new Hamilton respirators complete with additional staff overnight,…

I want to clarify two points given the language used in your response: 1. I used the possessive “my” in reference to nursing staff for simplicity in writing and clarity to the reader rather than to indicate ownership, we are on a team. This is akin to saying “my goalkeeper wears Nike soccer cleats”. 2. I do not “order nurses around.” I verbally communicate and leave medical orders in the chart that nurses act on. It…

Any doctor who says they treat nurses as valued professional colleagues should be presumed to be lying unless you have seen it yourself, in person. Doctors treating nurses like shit is the norm, not the exception. How badly varies a lot.