Why Good People do Dumb Things in Healthcare

 

Two years ago, I suffered a serious accident involving my right shoulder.  Because of Covid-19, I avoided doing anything about it for a long time.  There was a short window when it seemed that Covid-19 might be lessening, and I obtained a prescription for physical therapy.   I worked at it very hard but flunked out when my health insurance company determined I was not making progress fast enough and advised me to consult with an orthopedic surgeon for possible shoulder surgeon. 

I received a referral to an orthopedic surgeon, and he confirmed that my right should, and arm were very week, and he ordered a magnetic resonance imaging (MRI) procedure to determine if there was damage to my right shoulder that could be corrected surgically.

Yesterday I reported into my community hospital for my MRI, paid my $250,00 deductible and waited.  Like most people I tend to do what I am told when it comes to being directed by healthcare personnel.  I am quite differential. 

It turns out that the procedure is in two parts.  The first part is the injection of contrast material into my right should show up under the imaging of the MRI procedure.  There were two lovely people handling this first part and the only thing I was told to do was removed my shirt and put a gown.  I was also requested to remove my watch.

The technician put some lidocaine on my right should and proceeded to inject a need and induce a vial of contract material.  This technician was having difficult injecting the contrast material and blurted out, “Your shoulder is a mess.”  That comment was unprofessional.  I know I am not going to be given the results of my MRI procedure until I see my orthopedic surgeon in about a week.  Her clinical judgement should how have been shared with me and it certainly did not inspire confidence in what I was going through or my ultimate clinical outcome.

I should race to say that both individuals I was working with through stage one were lovely people, but it certainly could have been handled differently.

Stage two is the MRI procedure.   Again, there were two people handling me and the equipment.  I have worked in healthcare administration for over 50 years.  I am not expert at MRI, but I do have a minimal understanding of the dos and don’ts.  Remember, I called the MRI department a week in advance to find out what I should and should not wear.  So, we are close to starting and I shared with the technician just before she turned on the magnets that I wear knee braces due to a long period in my life when I was obese, and the braces were loaded with steel.  She was horrified and asked me to remove them.  I was only too happy to do so.  Also, I carry an Android cell phone in my right pocket, and I asked if I should remove it and she suggested I should do that.

So, the procedure last about 15 minutes.  I did what I was told to do and was advised that the imaging results were first class.

As I was getting off the MRI machine, the technician asked if I had anything in my pockets.  I said, “Yes, I have a wallet.”  She asked if I had any credit cards and I responded that I did.  She said, we probably accidentally demagnetized your credit cards and your will have to call the issuing banks to have them replaced.  I was not angry.  I just was stupefied after all my advance efforts to be properly prepared for this procedure at how many things could have been handled better.

Again, let me race to say that the two technicians in the MRI department were lovely people.

So, what do we learn?  Good people in healthcare do dumb things.  Why?  People get busy and fail to pay attention to detail.  God lives in the details because it is in the details where you find the truth.  

My experience is a microscopic example of what can happen in healthcare.  A systemic problem in hospitals is why we have failed to succeed to motivate middle class nurses to wash their hands.  Nosocomial infections in hospitals run rampant.

Winston Churchill wants said, “Americans always do the right thing after exhausting all of the other possibilities.”   We are still exhausting all the other possibilities.

 

Jan Ricks Jennings, MHA, LFACHE

Senior Consultant

Senior Management Resources, LLC

 

Jan.Jennings@EagleTalons.net

JanJenningsBlog.Blogspot.com

 

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