Thread by @hshanawaniMD

2 days ago, my dad got a VERTEBRAL COMPRESSION FRACTURE (VCF): a break in TWO of the 33 back bones.

Here is a normal scan and one of a broken vertebral body.

2things 2know:

1-when u break your spine, if u make the wrong move, u can be permanently paralyzed fr the waist down (or worse)

2-My dad is a brain/ spine/ nerve doc. He knows exactly what's happening. He knows he can be paralyzed forever-

He's in pain--worst EVER in 83y

So he can't get up 2 go 2 the doc & get checked. Only way is via 911/ ambulance.

So mom & fam call 911 & Emergency Medical Technicians (EMTs) come to house and caaaaaarefully lift dad up using special EMT techniques specifically to prevent paralyzing him (You rocked, EMTs)

& now, dear readers, is where the ludicrous, crazy, no-good, very bad story (1 of a dozen, more threads 2come, so follow if u want 2read more...)

I will only say he was taken 2 a medical center in the NJ/ NY/ CT tri-state area that is on the US News list of best hospitals

Some important info:

The ER isn't "part of the hospital," it's "outpatient."

This is important when you get your bill!

When you're ADMITTED, UR billed under a "DRG payment." So everything u get done is (sort of) one bill.

1 blood test, 101 tests, same price-saves u BIG MONEY

This is y some tests aren't done inpatient.

When your X ray/ Cat Scan/ heart test is done during an admission? part of the DRG--You don't pay extra.

But if it's done AFTER DISCHARGE? separate bill, higher price for you.

In the emergency rn, it's different. You're billed "a la carte," or piece-by-Godd***-piece.
So u get ECG/ Xray/ CT scan/ 600 blood tests in ED? separate bills 4 each one.

This gets into the TENS OF THOUSANDS fast.

I saw one emergency rm bill--AFTER INSURANCE--for 50 THOUSAND.

(so I'm new to twitter and I never did a twitter poll. Can someone do a poll asking "did you know this difference between DRGs and ER pricing?")

yes @goobermunch, UR right! But lucky 4 my dad, he's my dad & knows this inside out. He warns patients abt this EVERY DAY.

& he's got ME, who knows it even better, & who ALSO warns patients--"get it done inpatient!"
(hospitals don't like this, b/c they eat the cost ¯\_(ツ)_/¯ )

@goobermunch Remember the outpatient/ inpatient billing difference. This is important 4 the story soon...Foreshadowing--the key to quality literature--thanks high school english!

Next billing lesson 4 patients & the providers who should love them:
Ever hear of a thing called
OBSERVATION?

@goobermunch OBSERVATION was designed 4 people who doctors & hospitals didn't know where 2 care for them. They "didn't need 2B admitted," but no one felt they could go home.

When ur observation, (or "obs," as we hip docs say), you're "in the hospital," but you're GETTING BILLED OUTPATIENT

@goobermunch this was the mother of all macgyver duct-tape solutions to "2 many admissions," Medicare won't pay bill, so hospitals "should b more careful w/ admissions."

Instead, they keep doing the same care, except now they stick bill 2 the patient.

A *BIG* BILL.
(enjoy a visual dad joke)

@goobermunch to read more about observations, here's a few links:
Outpatient Observation Status medicareadvocacy.org/medicare-info/…

@goobermunch another link:
Understanding Medicare Observation Status via @forbes forbes.com/sites/howardgl…

"No issue generates more anger and confusion among Medicare recipients than observation status—that hospital stay that really isn’t a hospital stay."

Hospitals and Medicare abuse this pretty badly.

So badly, that a few years ago a class-action lawsuit was filed about abuse of observation status.

Hospital 'Observation' Status Prompts Federal Class Action Suit shar.es/amMgcP

Also, because observation is such a mess and SO EXPENSIVE, hospitals r REQUIRED 2 TELL YOU that you're "not being admitted," & explain the financial stuff.

This is supposed 2b told 2u in simple language that can b understood by someone with a 6th-grade reading level or less.

how many of you knew all this about "obs status," and getting hit with another big bill?

Back to my dad.

He's in the ER. We're pretty sure he has a broken back, but u need tests for that. EXPENSIVE tests. Cat Scans & MRIs.

He can't walk.
One wrong move: paralyzed.
Intractable pain, can't stay awake with painkillers.
No solution in ER.

Can he go home?
Here he is:

Another thing about obs:
If you meet criteria--you CAN'T BE PUT INTO OBSERVATION.

If you have severe pneumonia, a heart attack, or, say, a BROKEN BACK AND POSSIBLE PARALYSIS, you can't go home.

It just literally takes a click of a button by the doc.

So the ER at this "top-ranked hospital" is doing lots of tests, calling a spine surgeon, calling cancer docs. Lots of work.

And after 11 hours, they tell mom and dad: "can't send you home, broken back, you're being admitted."

But the next morning, 24 hours after he arrived 2 the ER, 12-13hrs after "admission," a hospital staff member comes in w/ papers 4 my mom & dad:

"we need you 2sign this paperwork saying u agree 2 obs status."

Dad's out from pain meds. Mom was ready though...She calls me.

this is how I'm feeling about this person right now...

but although I was born & raised in NJ, I have learned after nearly 20y in the midwest how 2b nice...until it's time 2b not nice.

And it's not time to be not nice yet. & everyone deserves benefit of doubt

(Thanks road house/ patrick swayze/ 80's toxic male reference...)

This is how it goes: (Me/Staff Member)
(BTW I don't tell people I'm a doc or what I do--it always comes up eventually)

Me: "hey thanks 4 coming. Help me understand--y isn't my dad a full admission?

SM: "well he's in this thing called obs"

& I get mansplained what obs is.

Me: "thanks, I understand the obs/ admit thing. Your hospital uses interqual or MCG for admission criteria, right? What criteria 4 broken back did my dad not meet 4 admission?"

...get ready for the duel, folks...

side note--Interqual & MCG are published criteria hospitals use to decide if you can admit a patient.

You can't see them b/c they're subscription-only. But I see them b/c I use them every day.

& dear reader, guess what I'm reading as I'm on the phone w/ said staff member...

So, IK what you're thinking:

I'm an MD

An MD who understands admission process/ criteria.

Who is LOOKING AT THE CRITERIA AS WE SPEAK.

I'm looking at criteria. We agree he meets them.

I swear-SWEAR! I'm being reeaally respectful

Can't go wrong!
(spoiler alert--it went wrong)

SM: "well, he's observation, so we'll send it 4 review."
me: "sorry-UR (review) is 2 make sure he meets admission criteria. Last nite, we were told he did. What changed?
SM: "IDK"
Me: "but u can find out, right?"
SM: "Well, he's obs"
me: "I understand. But he met criteria"

me: "I'm getting really frustrated. I'm sure you are, too. Bottom line: dad meets criteria 4 admission. We were told he's being admitted as a FULL admit. Obs was never mentioned & It's not needed. I'm instructing my family 2NOT AGREE 2 obs. So do we have 2go home now?"
SM: ...

Me: "Ok, we're not agreeing on this. The surgeon is offering surgery or a brace. What outpatient clinic can my dad get the brace?"
SM: "that's not possible"
me: "y didn't they do the brace in the ER?:
SM: "they can't put it on--it's an inpatient thing(!)"
Me: ...

Me(trying hard--SO HARD--2b nice:

"OK--I need your help here. We know one click in the computer & my dad's inpatient. I trust u2 fix this 4 my dad. My mom needs your help. It's the right thing 2 do. And I trust u.

(how I'm feeling on phone:)

SM (leaves)
*fin scene*

& we wait 24 hours, while they fit my dad w/ a brace

During which time he gets overdosed on narcotics, develops a condition called "hospital psychosis..."

& the unit mgr calls me 2re-explain obs status & "y wont we sign the paperwork..."

all in obs

In all stories of woe, you wish a hero would just SHOW up and fix stuff.

Personally, I hate that we need heroes

bc the SYSTEM--that I work personally to build all day--should just work for patients.

But after 6-8 hours of discussions, I was drained. I needed one.

In this story, I wish there was a hero.

we got two.

The 1st was the physical therapist (PT)

PT: "So I see they put u in obs 4 a broken back. I don't understand that. BUT IF I DO THIS TEST & U FAIL IT DOCTOR SHANAWANI, U AUTOMATICALLY MEET CRITERIA 4 ADMISSION."

I'M GOING TO DO THIS TEST NOW, LET'S SEE IF YOU PASS IT."

2nd hero...

who wants to guess the letters after the name of the 2nd hero, that personally sent in the PT, who addressed my dad's pain, & who called me & talked me off the ledge, saying "this is crazy--stop worrying, THIS IS MY PROBLEM NOW."

The palliative care nurse provided ME palliation: of my own anxiety, and handled it.

She took care of me, the hospital, my DAD--like a BOSS.

1-FIND OUT WHAT THEY NEED
2-GET IT FOR THEM

So despite my knowledge, skill, wealth, communication skill, literacy, assertiveness...

my dad & I were helpless in a system that wasn't PATIENT CENTERED, EFFICIENT, TIMELY, EFFECTIVE.

PEOPLE were, but the system--MY system! still failed.

So, my dad got his brace, and after 2days, got a decent pain plan.

The only "cure" for hospital delirium/ psychosis is GET OUT OF THE HOSPITAL AS SOON AS YOU CAN, so we brought him home.

His obs got changed to a full admission.

And I didn't smack anyone.

My story isn't new--I have personally addressed this w/ 100s of patients. Since my tweet 2d ago, dozens of friends have told me similar ones.

As a doc, who works 2 improve patient-centered care 4 a living, I thought, maybe we're on mile 14 of the marathon

But are we on 1-2?

Fundamentally, it's an issue of justice.

& other docs (@RanaAwdish ) have literally written BOOKS on their helplessness as patients.

Not every patient has me in their corner. How do we provide advocacy 4 every patient, w/o having a brilliant gorgeous doctor 4 a son?

@RanaAwdish That's all for now. Off 2C avengers & see my dad.

Follow 4 my next thread in a few weeks, when I relate how a #1 hospital in America gave my dad drugs that make your heart PUMP FASTER while he was in the middle of a heart attack*

*for non-docs--that's bad.

Thanks for reading!

Me: "Ok, we're not agreeing on this. The surgeon is offering surgery or a brace. What outpatient clinic can my dad get the brace?"
SM: "that's not possible"
me: "y didn't they do the brace in the ER?:
SM: "they can't put it on--it's an inpatient thing(!)"
Me: ...

UPDATE
Dads story getting tremendous support, likes & retweets

Your support 4 my dad got attention of @NJDeptofHealth & NJ health commissioner @ShereefElnahal

2 early 2tell, but maybe some good will come from sharing this w/ u all.
THANK U GOD BLESS!

https://twitter.com/hshanawanimd/status/1122343968338063360?s=12

More calls...

I got a call fr hospital CEO!

They r inviting our family 2 come debrief their leadership!

Meanwhile continued support fr twitter. Sadly, dozens more stories of good people w/ resources struggling 2 navigate hospital care.

Now an invitation from NJ state health commissioner

We want to work with @CMSGov and @SeemaCMS to make navigating the complex finances, and can they use the story and can i help

I dont know what 2 say.

I was powerless in the deeply flawed system of my own design, that isnt caring 4me despite my own best effort, all my wealth, privilege, knowledge.

Only when I surrendered did i find new allies & supporters from strangers who also continue 2 suffer

Whats helping my family is the humanity of good people in the hospital...

...& the humanity of thousands of GREAT people, also struggling, who amplified my voice!

im crying thinking of all these people most of who i may never meet, who made this happen

So

Many

Thanks