Hospitals

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written by NAME DELETED, RN, CRNI

The following is a brief overview of hospitals in the United States (2008 note: This was written in 1997, so some things might have changed.) Once again, generalizations have been made, and undoubtedly what follows may vary a bit from place to place. But at least it should give the reader (and fanfic author) an idea of the administrative structure of the average hospital, who does what to whom, and what happens in certain areas of the hospital. Then I will use one of Mulder's frequent trips to the ER to illustrate this information.


Hospitals

First a word on hospitals themselves. There are two main types of hospitals in the USA: public and private.

Public hospitals are generally owned by the Federal Gvt (e.g. Veteran's Administration Hospitals, Bethesda Naval Hospital, Walter Reed Army Hospital), a state, or more commonly, a city (e.g. Boston City Hospital).

Private hospitals are owned by a corporation, university, church or other entity and may be For Profit, or Not For Profit. The size varies; some private hospitals can be as large as public ones. Public hospitals are almost always "teaching" hospitals, which means they take part in teaching clinical skills to future doctors, nurses and other clinicians. Private hospitals owned by universities are also always teaching hospitals. Other private hospitals may or may not be teaching hospitals. Most make arrangements to allow some students to gain clinical skills - especially nurses - but do not have residents and interns and medical students.

Not all hospitals - even big ones - offer all services. Some of the most common "optional" services are: obstetrics (maternity), pediatrics (children's services), and behavioral health (psychiatric services). Some hospitals do not have an emergency room, although this is less common. And some hospitals specialize: for example, all children; all women; all cancer patients; or all psychiatric patients.


Administrative Structure: Who's Who

ADMINISTRATOR - may or may not be a physician; these days, the hospital administrator is more likely to be a non-clinical person with a Master's Degree in Hospital Administration or Business Administration. He is responsible to the Board of Directors (prominent doctors, businessmen, community leaders) for the running of the hospital. He plans improvements and expansions, makes up the budget, runs meetings, and so on.

DIRECTOR OF NURSING - because nursing makes up the largest part of any hospital staff, usually the Director of Nursing is seen as the #2 person, after the administrator, in the hospital hierarchy. This person is always a nurse, usually with a Masters degree or PhD and it's usually been a LONG time since they actually provided any direct care to a patient.

Under the Director of Nursing are the nursing shift supervisors (in small hospitals, one per eight to twelve hour shift; larger hospitals may have also nursing shift supervisors in specialty areas such as Pediatrics, Maternity, Intensive Care/Coronary Care and the Emergency Room.

Each floor/area also has a Head Nurse, who is generally available just on day shift and handles the larger needs of the area - planning staffing, hiring, discipline, possibly some teaching, and budgeting. On each shift in each area is the Charge Nurse who directs the activities of the nurses on that floor, assigns responsibility for specific patients, and helps out with hands-on patient care as needed.

OTHER DEPARTMENT DIRECTORS - each of the other departments in the hospital will have its own director. The departments may be clinical (Lab, Radiology, Pharmacy, Therapy, etc) or non-clinical (Human Resources, Food Service, Materials Management, etc). Clinical departments invariably have a clinical person as director/manager. Sometimes it is a physician, especially in the case of Radiology, or it may be a pharmacist, therapist or technologist. Non-clinical departments have non- clinical managers, very often someone who has risen up through the ranks.


Physical Plan

It is surprising, but in many hospitals, the rooms that patients occupy take up less space than the rest of the facilities. These patient areas are usually segregated by specialty: Intensive Care, Coronary Care, Progressive Care (AKA PCU or "Step-Down" Unit), Pediatrics, Obstetrics, and then the Medical/Surgical areas, where the majority of the patients are. "Medical" just means that the patients are being dealt with medically - without surgical intervention, such as patients with diabetes, or congestive heart failure, or emphysema. Surgical means that they are having an operation (although trauma patients such as people who have been in auto accidents or who have been burned, etc may also be placed here). In very large hospitals these areas may be further divided; there are entirely Medical floors with the patients often grouped by disease process, and entirely Surgical floors, which may be subdivided according to the kind of surgery done (orthopedic, general, throacic, vascular, and so on).

Another large area of space in the hospital is taken up by testing and treament areas through which the average patient may or may not pass: the Emergency Room, operating rooms, radiology (X-ray, nuclear medicine, MRI, CAT scan, fluoroscopy, endoscopy, etc), sonography (ultrasound testing), laboratory (microbiology, histology, chemistry, blood bank, pathology, etc), physical/occupational therapy areas with specialized equipment, research facilities, and so on.

And finally, there are large areas of the hospital that never see a single patient: administrative areas such as human resources, accounting, payroll, billing, and medical records; staff lounges/changing rooms; offices; cafeteria and kitchen; laundry; stockroom/sterile supply; and teaching facilities and meeting/conference rooms.


Physicians

For the purposes of this page, I will not go into the differences between Doctors of Medicine (MD's)and Doctors of Osteopathy (DO's). My use of "physician" and "doctor" may apply to either.

Hospital Staff physicians

The number of physicians who are actual employees of the hospital varies greatly. Large public hospitals and teaching hospitals (public or private) will have the most, while small, private hospitals employ relatively few.

Most hospitals employ one or more specialized Emergency Room physicians, to ensure that there will be a doctor available around the clock. There will also usually be a Radiologist, a physician who reads xrays, MRI's, CAT scans; performs procedures such as IVP's, endoscopy and fluoroscopy; nuclear medicine procedures such as thallium scans where radioactive isotopes are injected into the patient and their progress followed by xray; and radiation therapy for cancer. And in the Laboratory, there will usually be a pathologist, a physician specialized in diagnosis using blood or tissue samples.

In large teaching hospitals, there is the whole network of hospital-employed physicians in various stages of their training. A person becomes a doctor when s/he has completed medical school. Prior to that, s/he is a "medical student". Though medical students spend time in the hospital, they do relatively (and mercifully) little with patients, as far as treatment goes. Mostly they observe and learn to assess.

Every doctor in the US must then go through their internship, a kind of "on the job" training under the direction of a doctor who has had more experience than they have. This consists of "'rotations" in each of the major areas in the hospital - Medical, Surgical, Emergency Medicine, Intensive Care, Trauma, Obstetrics, Pediatrics, Neurology, Orthopedics, and so on. This is an intensive period with long hours and relatively poor pay which lasts usually two years. After successfully completing this period, the doctors can then take the state Medical Board examinations and if they pass, they can practice medicine independently.

But many doctors decide they want to specialize in a particular area of medicine. It is at that point that they apply to hospitals to become "residents". Residents continue their education under the tutelage of a specialist in the field they have chosen (Cardiology, Family Medicine, Internal Medicine, Geriatrics, Obstetrics, Gynecology, Urology, etc) in the hospital. The specialist is a physician who excels in his or her field, and who may have patients they see privately at an office, and/or teaching duties at the university. At the same time that they are learning from the specialists, the residents become the teachers of the interns. The residency generally lasts three years.

Private Physicians

Most of the doctors you see in the hospital are private physicians. They have their own medical practices, but have admitting and practice privileges at one or more hospitals. Without these privileges, they would not be allowed to see their patients in the hospital, or perform procedures or surgery there. They must obey the hospital rules and, theoretically at least, practice their craft well in order to retain these privileges.

Many of the physicians in the hospital are there to visit their patients, review their progress, and write new orders for treatments or medications. Surgeons and anesthetists are there to perform surgery, and also to visit patients. Others are there to perform certain procedures (procedure is "medicalese" for a treatment or test that isn't as drastic as surgery, but probably isn't pleasant, either), or deliver babies and so on.

What they do: Anything their state and their level of training allows them to do under their license to practice. This may be surgery, procedures, daily or more frequent patient visits, lots of documentation and order-writing. Everything that happens for the patient is done on the basis of the physician's orders. If s/he doesn't order it, it doesn't get done. Patient visits may be thorough (actually checking under dressings, physical exam and assessment of the patient, all necessary documentation in the medical record, checking with other doctors who may have seen the patient on a consultlative basis, and so on). Unfortunately, they rarely are thorough. Usually the doctor pokes her/his head into the room, asks the patient how he's doing, and then s/he makes a quick getaway. Surgeons do tend to make longer visits. And all doctors spend more time in the ICU/CCU because of the severity of the patient's illness.

What they do NOT do: Normally doctors do nothing in terms of direct patient care. Except for interns, they do not start routine IV's, insert catheters, change dressings and so on. They tell the RN to do those things. And they NEVER pass bedpans, help a patient get to the bathroom, give medications (except sometimes in surgery or during procedures), and that sort of thing.


Nurses

In this section I will cover only Registered Nurses. LPN's/LVN's do roughly the same things as RN's but only under RN supervision, and the limitations on practical/vocational nurses vary hugely from state to state. And I will not get into the wrangle concerning the differences between an RN with an Associate Degree, a Bachelor's Degree, or a Nursing Diploma. All levels of preparation have their good points and bad points. What counts is that they all take the same exam and are licensed to do exactly the same things by their state.

Some nurses get further education and are then licensed to perform certain advanced skills. Examples of this would be Nurse Practitioners, Nurse Midwives, and Nurse Anesthetists, who, if they pass their board exams, perform some LIMITED doctor functions and work under the supervision of a doctor. Few hospitals, however, employ sizable numbers of these specialized categories of nurses, except for perhaps the Nurse Anesthetist.

The "elite" of hospital nurses are those that practice in the Critical Care areas - Intensive Care, Coronary Care, and the Emergency Room. These are the nurses who generally have the best assessment skills, best judgement, and most finely-tuned intuition (I have frequently seen a nurse's 'hunch' save a patient's life). They also tend to be Type-A personalities who thrive on responsibility and stress, because if they don't, they soon burn out. They are entrusted with the 24 hour care of the most critically ill of patients, or with patients who are fresh off the ambulance and at their most unstable. They can deal with more life and death drama in a single night than in a season of "ER".

Medical/Surgical nurses have to be the most dedicated, because their jobs are so difficult. Staffing is constantly being trimmed due to cost constraints, leaving too few nurses to do the job that needs to be done. M/S nurses rarely get to feel the sense of accomplishment of the Critical Care nurses, and usually have to deal with more of the frustration, pain and fear of the patients and their families.

Other nurses work in specialized areas such as the OR, Recovery Room, Endoscopy, Cardiac Cath lab and so on, assisting physicians as they perform tests, procedures and surgery.

What they do: As above. Start IV's, give medications, set up equipment, take blood samples, calculate patient fluid intake and output, change dressings, perform treatments, change sheets, bathe people, feed people, teach, document everything in the medical record, assist physicians on rounds (when they come in to visit their patients) and anything else that needs to be done. They also remind the physicians of things they may have forgotten to order, or orders that don't look right.

What they do NOT do: Surgery, stitches, diagnosis, or anything beyond their scope of practice or that the physician has not specifically ordered.


Non-licensed Staff

CNA's, PCA's - Certified Nursing Assistants, Patient Care Attendants - assist in the personal care of patients. Help make beds, bathe patients, feed patients, ambulate them in the hallways, Bedpan Patrol.

DO NOT: Depends on the laws of the state and the level of training. Generally speaking, they do not give medications, change sterile or operative dressings, do treatments or perform other functions which require licensure by the particular state. In some states, they might be allowed to insert urinary catheters or give enemas under certain conditions.

Med Techs - Usually a PCA with special training to certify them in giving oral medications. Would NOT give injections or IV's

Pharmacy techs - assist pharmacists to prepare medications for patients in the pharmacy.

OR techs - assist surgeons in the OR by passing them instruments as they are needed Monitor techs - trained in recognition of EKG readouts, they watch the monitors in Critical Care and Progressive Care Units, alerting the nurses when they see waveforms that could mean trouble.


Therapists

Physical Therapists - physical therapists and their assistants work with patients to restore gross motor skills like walking, standing, rolling over in bed and so on. Some specialize in patients with certain types of conditions, like brain injuries or prosthetic devices (artificial legs or arms). Like all therapists, they work with both inpatients and outpatients.

Occupational Therapists - OT's and their assistants work more with fine motor skills and their practical applications, such as helping a person learn to dress himself using an artificial arm, or helping a person who has lost his sight learn to care for himself. They often take over after PT has finished, teaching a patient who has just regained some use of an arm after a stroke to learn to write again, for example.

Speech Therapists - not just to help cure a lisp or stuttering, ST's (or Speech Language Pathologists as they now prefer to be called) work with patients who have had a stroke or brain injury to learn to speak, or read or recognize words and sounds. They also do swallowing studies to ascertain if a patient can safely eat without choking, or must be tube-fed.

Respiratory Therapists - perform breathing treatments on pneumonia or asthma patients and others; perform pulmonary function tests to determine the amount of lung damage done by exposure to smoke or toxic chemicals; set up oxygen for patients; check the ventilator settings for intubated patients in ICU; wean patients off ventilator dependence, answer Codes (see "Codes" section, this page).

Nutritionists - what were formerly known as Dieticians. Create diets as ordered by the physician for patients with all sorts of disease processes. The most common is diabetes, but many others also require specific dietary regimens. Nutritionists do a lot of patient teaching.


Technicians

XRay (including Nuclear Medicine, CAT scan, MRI, Fluoroscopy) - take XRays both in the Radiology department and portable XRays in other areas, especially ICU; assist with scans and with procedures such as fluoroscopy and radioactive isotope tests.

Lab techs - perform tests on blood and other body fluids and tissues for diagnostic information

Phlebotomists - draw blood from patients for different types of lab tests. The correct tube must be used, some of which contain special additives for preservation or to resist clotting.

EKG techs - run EKG tests to determine heart function and electroconductivity. Respond to Cardiac Arrest Codes (see below)

EEG - run electroencephalographs to determine brain function and the source of problems such as bleeds and tumors. Now largely supplanted by the more sophisiticated scans, but EEGs still have an active role in pinpointing the source of certain neurological conditions such as epilepsy.

Ultrasound (Sonography) techs - perform ultrasounds, painless tests which use sound waves to map body structures

EMT's - mostly used in the field in ambulances. Perform first aid and more advanced skills to stabilize a patient and move him from the place of injury/illness to the hospital.

Paramedics - Like EMT's but with more training. They start IV's and defibrillate patients in cardiac arrest and can administer drugs.


Codes

Every hospital has a code system to announce certain emergency situations where the help of other staff is necessary. Most hospitals have a color code. For instance, "Code Red" or "Doctor Red" usually means a fire has broken out. Certain staff members are pre-designated to bring fire extinguishers and help move patients away from the fire area Other codes may announce bomb threats (staff response is mostly to get patients evacuated), hostage situations/unruly patients or visitors (to which hospital security, the chaplain and others may be designated to respond), and even large scale disasters in which it is expected that the hospital will be flooded with large numbers of trauma patients, such as in air crashes or train wrecks or natural disasters like tornadoes. Disaster Codes trigger a response from every staff member. Off duty staff members are called in from home, and even other hospitals may send staff in to help.

The most common code is frequently "Code Blue". This is a fairly universally accepted code meaning a patient has suffered cardiac arrest and needs the immediate attention of the Code Team.

The Code Team is made up of a number of highly qualified personnel who are assigned at the beginning of their shift (or possibly for a week at a time). Members include: at least one physician (usually the ER physician and any others who may be in the hospital at the time. It is usually better to have just one doctor, otherwise they tend to issue conflicting and confusing orders), the nursing shift supervisor, the charge nurse of the area in which the patient arrested, the nurse who cares for the patient, a Critical Care nurse, a Respiratory Therapist, an EKG tech, and sometimes an anesthetist. Others are called in as needed.

When a patient goes into cardiac arrest, the Code Team acts as a well-oiled machine. The physician questions the patient's nurse to find out what happened and learn more about the patient, assesses his condition and gives orders for medications, IV fluids and so on. One nurse will act as recorder, writing down exactly what happens and the time it happens, what medications are given, the defibrillation attempts and so on. One nurse (usually the Critical Care nurse) starts IV's and gives medications the doctor orders. Another nurse performs CPR chest compressions and defibrillates. Another may be in charge of calling for extra help, such as Lab or XRay or the Blood Bank, and checking the patient's vital signs at intervals. The EKG tech connects the patient to an EKG machine and runs strips of the patient's heart activity to check response to medications and other interventions. The Respiratory Therapist "bags" the patient - uses an oxygen mask with a bag-like attachment to force air into the patient's lungs. If the patient's heart is revived but the patient is still not breathing on his own, the anesthetist will intubate the patient with an endotracheal tube, and attach the tube to a ventilator. If the patient is not already in a Critical Care area, once stabilized as much as possible, he is moved there, with several members of the Code Team in close attendence and with all the equipment and IV's to which he is attached.

Cardiac Arrest Codes can take from a few minutes to several hours. It all depends on the patient's response to treatment, how quickly he become stable, how persistent the physician is, and so on. The clean-up and documentation following a code can take another couple of hours. As their Code duties are completed, each Code Team member goes back to his or her regular duties.

Since Murphy's Law is as true in hospitals as anywhere else ("If something CAN go wrong, it WILL"), simultaneous Codes are not unheard of. Therefore there may be backup Code Team who will spring into action if another patient arrests before the first Code has been cancelled. The larger the hospital, the more chance there are several Code Teams which cover specifiic areas of the hospital.


Mulder goes to the hospital

Okay, X-Files fans: Mulder has done it again. He ditched Scully to meet an unknown source on the waterfront, and has been shot. He had just enough strength to call her on his celphone before losing consciousness.

First the ambulance arrives with the Paramedics. One will begin Mulder's physical assessment, while the other sets up telemetry - the vital link to the hospital from which he'll receive his orders to treat Mulder. He'll attach EKG leads to Mulder's chest to send a strip of his EKG activity back to the hospital. His partner has meanwhile taken Mulder's vitals, which are poor: BP 78/40, Pulse 134 and thready, respirations are shallow and rapid. From the vitals, Mulder's pallor and sweating, and the amount of blood on the ground around him, the paramedics correctly deduce he is in shock, probably hypovolemic shock.

The assessing paramedic does a head to toe assessment, noting an entry wound in Mulder's lower left chest. He attempts to talk to Mulder, to get him to identify himself, to ask him what happened. Mulder is unconscious. The paramedic listens with his stethoscope to Mulder's lung fields, and feels that he may have a pneumothorax (see Injuries page). An airtight dressing is applied to his chest wound by one paramedic, and an oxygen mask is placed over his face by the other. Then one of them will start a peripheral IV or two, while the other reports their findings back and receives the orders for the kind of fluids to give and how fast to give them. They open the IV's wide open.

Since the hospital is just a few minutes away, they will not bother to apply the anti-shock trousers which would force much of the blood in his body to the vital organs. Then they load him onto a Gurney (stretcher) and put him on the ambulance. One will drive, while the other stays in the back with Mulder, taking his vitals and running EKG strips and following any orders given from the hospital.

As the ambulance pulls up at the hospital, a Code Blue is announced for the ER. Scully sees with horror that the paramedics are performing CPR as they are wheeling Mulder into the ER at a run. In seconds, running footsteps tell her that the other members of the Code Team have arrived. Soon, Mulder is in the center of a sea of activity and noise.

After the Code Team defibrillates him and administers vasopressors and cardiac drugs, his heart starts again. The Emergency Room physician inserts a chest tube to let out the air in Mulder's chest cavity which is compressing his lung, and connects the tube to sealed underwater drainage. Mulder's breathing improves immediately. In the meantime, the lab has drawn blood for chemistry, CBC, and type and crossmatch for four units of packed red cells. Even before he is ready to be transferred to the OR, the first unit of blood and two liters of IV fluids are in. With their patient stable for now, the Code Team is dismissed. XRays are taken to determine the bullet's placement and a few minutes later, his stretcher is wheeled to the OR, with Scully, the ER physician and three nurses in attendance in case his condition changes significantly on the way.

In surgery the bullet and bone fragments are removed and repairs are made to his lung and major blood vessels. He also receives more blood and IV fluids, and antibiotics to prevent infection.

Because it is late at night, he does not go into the Recovery Room as he normally would after surgery. Instead he is moved to the Intensive Care Unit, where he is welcomed as a "frequent flyer" and the staff move Scully's own personal recliner (which she invested in during his last stay) to his bedside. It takes several minutes to untangle all the IV lines, blood lines, pressure bag lines, catheter tubes and chest tubes. As Mulder begins to rouse from the anesthesia, he is in pain, so morphine is adminstered via one of the IV lines. Throughout the night, nurses check hourly how much fluid he is taking in and putting out, change IV bags, and hang more blood transfusions and medications. Several times every hour they record the readout on his arterial line for his blood pressure and the cardiac monitor fro his pulse. They take more blood from his arterial line for the lab and for Respiratory Therapy to run blood gas checks to make sure he is getting enough oxygen. Toward the end of night shift, he is bathed and turned to his other side, and given more pain medication.

Mulder eventually regains consciousness later that morning. Respiratory Therapy comes in to work with him to keep his lungs clear, there are more Xrays and more IV's and visits from the surgeon who operated on him. He has been lucky - the bullet chipped his ribs, punctured his lung and perforated a couple of major blood vessels, but hit no other organs. His recovery should be complete.

Now stable, after two days he leaves the ICU for the PCU - the Progressive Care, or Step Down, Unit. Here, he has his own room rather than the ward-like setting of the ICU. It is much quieter, except for Scully yelling at him about ditching her again. He is able to get more sleep without the constant interruptions, but he still has the sticky, itchy EKG leads attached to his chest. He also still has the chest tube, which is very uncomfortable. He groans every time the Respiratory Therapist enters his room, knowing he will be forced to take deep breaths to encourage full lung expannsion, and inhale medications which will force him to cough up any secretions which could accumulate and cause pneumonia. He no longer needs IV's, but a heparin lock remains in his arm just in case of an emergency. He is eating - if you could call a clear liquid diet -apple juice, chicken broth and jello - food. He has been promised that the catheter will be removed the following day. The nurses aren't quite as ominipresent as they were in ICU, but he saw much more of them whan he would have down on the Surgical floor.

He spends three days on PCU. He could have left after two days, but with the chest tube, his surgeon wanted him to stay where he could be monitored more closely. The EKG leads are gone now, and on his final day in PCU the chest tube is finally removed. He is then transferred to the regular surgical floor.

The nurses are noticeably much busier here, and Scully spends more of her time taking care of him, helping him to the bathroom, helping him to walk to gain some strength. The Physical Therapist comes in and gives him a set of exercises to do so that he will not lose muscle tone while he recovers. Scully gets some revenge for his ditching her by seeing to it that he does his exercises, and continues to do frequent coughing and deep breathing.

By the end of his seventh day in the hospital, Mulder has had enough. He is no longer in pain, only moderate discomfort, and he longs to be on Scully's couch with Margaret feeding him some of her famous minestrone soup. His doctor wants him to stay in for another day, but over Scully's objections, he signs out AMA - Against Medical Advice. The nurses had expected this and had the forms ready for him. Scully reluctantly helps him to her car.

The nurses are sad to set the decorative Mulder leave, but they know they will be seeing him again - soon. They always do.


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