Wednesday, June 13, 2007

Bureaucracy In Action

OK, I admit it. My subject header is a bit disingenuous. I let an errant "space" creep in there... It's supposed to read Bureaucracy Inaction. We've all dealt with the paperwork monster: the company HR department, the Division of Motor Vehicles, the IRS. But nothing, nothing compares to the bureaucratic Grendel that is the "health care" system.

Case in point. I had a recent... adventure... in which I enjoyed the delightful and pastoral ambience of my local hospital. Several times, actually, but that's another story... Suffice it to say that somewhere along the way some very skilled and saintly men and women cut my appendix into itty-bitty bits and extracted it through one of three itty-bitty incisions in my abdomen. (Laparoscopic surgery they call it, though when I reflect back on it, all I can picture are those creepy alien creatures with tendrils that they can insert into your body to suck out your vital essence. Wow, that's some pretty contrasting imagery there, eh? Skilled and saintly creepy alien dudes saving your life by inserting their tendrils and sucking out your organs. I think I've got mixed feelings about health care...)

But back to the point. This particular adventure began, as they all do, with Admitting. There's a misnomer for you. The admissions process consists of reading (ha!) and signing page after page of vaguely English prose stipulating that not only will your potential caregivers admit to nothing when it's all over, but in fact will disavow everything. The Consent For Treatment form (please sign this before we can proceed) absolves your Friendly Neighborhood Health System (FNHS) and it's medical staff, employees, independent contractors, placement agencies, providers, agents and assignees, ad infinitum, from any and all non-optimal results in gory and fascinating detail. Sort of like those FCC-mandated disclosures that the Pharma companies have to include in their drug advertisements now: Take Generis and feel better fast! Side effects include retching, belching, farting, fever, diarrhea, constipation, high blood pressure, weight gain, weight loss, swollen genitals, nasal discharge, bloody stools, delirium tremens, spontaneous human combustion, anal probing, energetic catastrophic disassembly of the cranium, and sudden death. Unlike the Pharma company ads, though, I don't remember the Consent For Treatment form mentioning anything at all about the desired outcome...

Next we have the obligatory Patient Information form: name, address, date of birth, medical record number, social security number, number of sex partners (ummm, lots... yeah, that's the ticket!), insurance provider, name of childhood pet, last ten bowel movements, registered political party, tetanus shot, polio vaccine, flu vaccine, family medical history, drug history, ancient history, American history, genetic profile, number of fingers/toes, declaration of goods and services purchased outside the country, arrest record, credit rating, mortgage payment, net worth, shoe size, hat size, coffin size, etc. The usual. This is in the ER, mind you. I was pale, clammy, and listing dangerously to starboard. I'd hate to speculate about the reams of forms to be completed if I were being admitted for elective surgery or an outpatient procedure.

As if the Consent For Treatment form wasn't alarming enough, now they hit me up with the Advance Directive form. This is the form where you specify what steps should be taken if, say, your cranium decides to undergo energetic catastrophic disassembly despite the best efforts and intentions of the FNHS medical staff, employees, independent contractors, et al: (Choose one) A) undertake heroic efforts and all necessary artificial means to preserve my life for the eventual legal struggle between those who love me and want me to die a dignified death and those who love me and want to keep me around to assuage their guilt over not treating me better while I could still appreciate it; or B) just kill me now. In the absence of a Durable Power of Attorney, please indicate who should make medical decisions on your behalf in the event you are unable to do so? My wife of course (Honey, I swear I'll get to those rain gutters as soon as I can, OK?)

Up next: Symptom and Triage form. At last, we're getting to the meat of the matter! Let's see, Please indicate why you are visiting the ER today. I think I managed to scratch out an almost-legible facsimile of "unbearable abdominal pain". When did these symptoms start? When did you last have anything to eat or drink (recent ingestion of food or drink may delay your medical treatment!)? Please rate your pain on a scale from 1 to 10. Please describe the nature of your pain (acute? sharp? distributed? other?). Finally, they're asking what's wrong! Can sweet morphine be far behind?

Admitting Clerk: Please have a seat in the waiting room and wait for your name to be called!


Eight or nine hours later (well, it seems that long anyway) they finally call my name. Now I get to face the triage nurse in her lair.

Triage Nurse: How are we today Mr. skitch?

Me: [incoherent gasping noises]

Triage Nurse: Good, good. Please fill out these forms Mr. skitch, while I encumber your arms with blood pressure cuffs, oxygen saturation sensors, pulse monitors, and IV needles. Oh, and open wide for the thermometer... do you have any questions?

Me: [weak whimpering noises]

Let's see, Intake Information form. Name, address, date of birth, medical record number, social security number... hey, isn't this the same form I filled out at the Admissions desk? Don't you guys talk? Ah, no, this one asks if I'm a smoker and if I'm allergic to any medications. No, and penicillin. I (re)enter all the information and let the clipboard slide from my weakened fingers.

Triage Nurse: Don't forget page 2 Mr. skitch!

Ah. Page 2. Please list all medications you are currently taking, including over-the-counter products and vitamins. Well, that's reasonable I suppose. Wouldn't want to take an energetic-catastrophic-cranium-disassembly-inducing combination of chemicals accidentally.

Triage Nurse: Mr. skitch, are you a smoker? Any drug allergies?

Me: ...

Triage Nurse: Good news, Mr. skitch, we finally have a bed available between a flatulent old man with dementia and a teenage skate punk with a nasty bleeding head laceration. Your ER nurse will take you back now!

By this time it has penetrated my pain-dulled consciousness that the nurses are passing around a fat folder with my name on the front stuffed to the brim with every form I've filled out in my entire life, including my Blockbuster Video rental card application and my High School Annual order form. But I don't care any more, the ER nurse has injected some morphine into my IV. Ah, blessed happy juice. The next few hours pass hazily with an endless stream of nurses, interns, physicians, and orderlies poking and prodding me in various ways that I might actually have enjoyed if only I weren't alternating between pain-induced amnesia and morphine-induced apathy.

ER Doc: Mr. skitch, you have an elevated white blood cell count indicating a possible infection and you are presenting with some, but not all, of the symptoms of appendicitis. We're going to send you over to Radiology for a CT scan.

ER Nurse: [grinning evilly] Mr. skitch, you have to drink this 5 gallon container of contrasting agent in the next hour! Good news, though! Instead of the old chalk-flavored agent we now have a choice of flavors: berry/chalk, apple/chalk, citrus/chalk, and beef/chalk!

Me: Do I have to choose my flavor on a form?

The next hour is spent in a frenzied attempt to ingest twice my body weight in viscous berry/chalk-flavored room temperature shake punctuated by frequent reminders from Nurse Ratched's evil twin that I have to finish the entire container. Finally the deed is done and they wheel my gurney over to Radiology. Meanwhile, the contrasting agent has expanded to twice its original volume and those organs not directly involved in digestion (including my besieged appendix) are feeling like passengers on a Tokyo Metro Rapid Transit car (by the way, who the hell decided it was a good idea to put raised expansion joints at every hallway intersection and every room door?).

Radiology Nurse: While we wait for the Imaging Tech, Mr. skitch, we have to fill out some forms!

Me: Huh? Wha?

Radiology Nurse: We need to fill out a Consent For Treatment form, a Patient Information form, and a Current Medications form!

Me: Wait, aren't those the same forms I've already filled out?

Radiology Nurse: Radiology is a different department sir!

The Radiology nurse is an improvement, though. I still have to sign the Consent For Treatment of course, but at least she makes an effort to streamline the form-filling-out process by wielding the pen herself instead of tying it to my rigor-stiffened claw.

Radiology Nurse: [winding down] Are you a smoker? Any medicine allergies?

For God's sake, how many times are you going to ask me if I have any medicine allergies? (PENICILLIN you Neanderthal, it says so 564 times right there in that very folder you're using to prop up the form you're filling out. Do you think I'm suddenly going to remember a new allergy the twelve hundredth time you've asked me?)

I'll spare you the boring details of the remainder of my adventure (too late, skitch!), but after the surgery and a pair of abscesses and their accompanying paperwork it's safe to say that a substantial portion of both the Brazilian rainforest and Pacific Northwest old growth forest have made the ultimate sacrifice and given their lives to document my latest journey through the health care system, leaving me to wonder: "who the hell actually reads all this stuff?" I don't remember my Dante very well... wasn't there a special circle of hell reserved specifically for the bureaucrats? Problem is, I'm not really sure how to punish these guys... would they be in greater agony forced to fill out forms for all eternity or PREVENTED from doing so?

Ah well, I can at least comfort myself in the knowledge that the worst is over. At least until I have to fill out all the insurance paperwork and short term disability forms.

Oh, yeah, on that Advance Directive thing? Will there be forms to fill out should you successfully revive me? Yes? Then I choose B) just kill me now.