Sometimes I feel like the business of healthcare is one huge conspiracy. If you really think about the “things” we do to people in the name of “taking care of them” you might come to the same conclusion. Take an elderly stroke victim, Joe, for example. He is seen in the emergency department, mildly slurred speech and left sided weakness, but he is alert, oriented and his vital signs are stable.  He receives IV fluids, a Foley catheter, lab draws, EKG, chest x-ray and CT of the head. After lying on a hard gurney in the emergency department for over six hours, he is finally admitted to the medical floor. Because Joe is weak, and slow, members of the nursing staff pull him over to the bed using the draw sheet; in the process his Foley catheter is pulled, but not discontinued, and his IV is dislodged. Nursing staff start another IV, and bandage the skin tear on his left arm that was caused when the IV was dislodged. The nurses’ aide enters the room with a clear liquid dinner tray for Joe. Joe is propped up in bed, and the tray placed in front of him. He is able to use his right arm well enough to lift the glass of cranberry juice to his mouth. Joe soon aspirates the 120 ml of cranberry juice, his nurse alertly comes to his rescue and informs the physician that Joe aspirated, and has blood in his urine. The physician tells the nurse to make Joe NPO, orders a speech and swallow study in the AM,   IV fluids at 100ml/hour, and replacement of the Foley. Through the night, Joe is turned every two hours;  the nurses quickly enter the room, bend Joe’s hips and knees, place pillows at his back and crick his neck into an uncomfortable position.  Joe develops pulmonary crackles, increasing hematuria, and severe restlessness as the night goes on.

In the morning, the physician arrives to find Joe confused, febrile, tachycardic and short of breath. He orders a chest x-ray and a set of blood gasses. The tests show Joe is hypoxic, and the chest x-ray shows CHF and aspiration pneumonia. Joe is placed on oxygen, but because he is confused he will not leave the oxygen mask on; wrist restraints are placed on both arms, and sedation is given. The physician orders a feeding tube; places Joe on tube feeding at 50 ml/hr to be advanced to a goal rate of 100 ml/hr and discontinues his IV fluids, but starts IV antibiotics. Joe’s hypoxia worsens and he is placed on a ventilator through the night.

The following day Joe develops severe diarrhea, requiring frequent clean-up. Joe’s bottom becomes red, and irritated. The nurse’s aides decide to place adult diapers on Joe to control the incontinence. The RN reports to the physician the problem with the diarrhea. Joe has had minimal feeding tube residual, so the tube feeding has been increased to goal rate. A fecal management tube is placed in Joe’s rectum, to control the stools. And special perineal wipes are used to control the dermatitis and breakdown caused by the diarrhea.

Do you recognize the conspiracy? Pulling the Foley catheter with transfer, caused hematuria; and hence an order to re-catheterize poor Joe. Rushing to move a fragile patient caused dislodgment of the IV a skin tear and the need for another skin puncture.  The IV fluids caused the CHF and hypoxia leading to confusion and the need to sedate and restrain Joe. Severe bending of the hip, knee and neck during every two hour turning caused an increase in ICP exacerbating the symptoms of the stroke. Allowing a compromised patient to drink a thin liquid led to aspiration pneumonia, requiring intubation, the need for antibiotics, and tube feeding. The tube feeding and antibiotics caused severe diarrhea. The diarrhea and placement of adult diapers caused perineal dermatitis and subsequent skin breakdown requiring another tube be placed rectally, as well as the need for specialized skin care.

Don’t get me wrong, everyone in this patient care scenario had good intentions, everyone did their job, but poor Joe seems to be the victim of a healthcare conspiracy, and may have been better off at home resting in bed, recovering from his slight stroke. What do you think?