On Consents and Foleys

As an undergraduate student, you take the MCAT. This test is bullshit for a number of reasons. It tests your knowledge of college-level biology, general and organic chemistry, physics, and reading/writing. I can tell you, categorically, that I have never been helped by this undergraduate preparation in my dealings with patients or in understanding my texts. At best, the test lets me know if you have the capacity to sit down, eat pancakes, and vomit when appropriate.

Eating pancakes - that is a useful skill. That is actually worth knowing about an applicant. But the MCAT could be so much better than a bullshit assessment. Instead, it should be an actual Assessment of Bullshit.

I say this because handling bullshit well will meaningfully contribute to the care of your patients. It may even save their lives.

***

Have you ever even seen a consent form? If you haven’t, and you’re having trouble imagining it, let me tell you that it is a legal document and is therefore designed to be incredibly explicit and, in-so-doing, is impenetrable.

“The following document asserts that you, Mr. Reading This And Nodding But Retaining Nothing, give Dr. WhiteTurk permission to perform a laparoscopic cholecystectomy with intraoperative cholangiogram, possibly open, for your diagnosis of gallstone pancreatitis. RIsks of the procedure include, but are not limited to: pain, infection, bleeding, swelling, bile leak, pancreatitis, hepatitis, damage to adjacent structures, failure to resolve symptoms, need for reoperation, sepsis, and death.”

These are the first two sentences of a document that is a full two pages long, single-spaced, with like 0.5″ margins (which wouldn’t fly for an undergrad English paper) in 10pt font (again, most colleges require at least 12pt) and is supposed to simultaneosly achieve the competing goals of (1) being understandable to your standard 12th-grade reader and (2) detailed enough to protect the hospital/doctor from lawsuit.

It aims so high, it falls so short.

And it’s fun and fine to poke fun, but I have to actually present this document to people and get their consent for a surgery that I think they need. I have to answer their questions. And there isn’t one biology or chemistry class that helps with that. What helps is being able to strip the bullshit away and tell this person what the document means.

“Mr. I Hope You Understand This Now, this is a complicated legal document. You can read it if you want and I’m happy to give it to you to look over, but if you trust me, I’d rather just tell you what the gist of it is. This thing says the following: You’re you. I’m Me. You have this problem – pancreatitis – which I think is being caused by stones in your gallbladder. You see, the stones are traveling down a small tube, blocking the tube, and then pissing off everything that normally drains out of that tube. Taking out your gallbladder tends to fix this, so I’d like to do that for you. If we don’t fix it, this is just going to keep happening and getting worse and worse each time. We’re want to take it out using three tiny cuts in your abdomen, each about as wide as my fingernail. Through those cuts, we’re going to put in some tools and a camera. Shouldn’t be any reason to give you a big scar unless things become complicated. We also want to make sure that, after we take out your gallbladder, there aren’t any stones in the tubes, so we’re going to look through the tube as well. After that, surgery is over. You’ll probably have to stay an extra day or two in the hospital, but after that you should get to go home.

“There are a bunch of other paragraphs here. They basically say that

“(1) There are risks with the surgery and that things can go wrong. Most of the time, things are fine. We are slow and meticulous during this surgery, and we do a lot of them. If something bad happens, we will detect it early and do everything in our power to take care of it.

“(2) If something unexpected happens during surgery, you give us permission to do everything in our power to help you, even if this means we have to change the operation.

“(3) You give us permission to give you anesthesia drugs so that you sleep during surgery, don’t move during surgery, don’t remember the surgery, and don’t feel any pain during the surgery.

“(4) People are going to be in the room that aren’t doctors. They are there to help us and we want you to know that.

“(5) We may need to take pictures of the surgery or send samples of your tissue to a lab for diagnosis.

“(6) We won’t tell anyone about you or your surgery that you don’t want us to.

“If you agree with all that, then you can legally sign this consent form. But before you do, do you have any questions about how the surgery works, why you need it, or about any of the other things we just talked about?”

I go through that spiel because that’s how I want a doctor to talk to me. But you have to understand bullshit and be comfortable enough with it to strip a legal document down to what it’s really saying. And just in case you think I’m trashing lawyers right now, let me correct you. I’m no fool. Masonry is a skill – swinging a sledge hammer at a brick wall is artless. But just because you put forth the effort to stack bricks of shit doesn’t mean I shouldn’t take a big long swing at them.

Who I am trashing are the doctors that have no understanding of bullshit, who just read the consent form to the patient and ask them to sign at the dotted line, knowing full-well that they are signing a document that they have been exposed to but do not understand. Those people are assholes.

But removing bullshit isn’t the whole story. No, handling bullshit means you can take and you can give. Never is this so clear as it is with foley catheters.

Surgeons often have to put people to sleep. When you’re asleep under the power of drugs, you tend to piss yourself. This sucks because (1) no explanation needed and (2) your nurse has to clean you and your bed each time this happens. When we know that we’re knocking you out or you won’t be able to move for a long time, we put a tube into your bladder so that the urine goes into a bag instead of onto your legs. There are also situations where monitoring your ability to make urine by the hour is critically important, but this is less frequent. For the purposes of this discussion, a foley catheter is an uncomfortable rubber hose I put into your penis or vagina that makes your nurses happy and preserves a measure of your dignity. Win win win-win-win.

But hospitals hate foleys. The more foleys you put in, the more often people get foley infections. The US Government won’t pay hospitals to take care of infections caused by foleys, so every infection is a money-loser for the hospital. Therefore, hospitals make rules that foleys can only be inserted for a small number of reasons and that all foleys have to be re-evaluated on a two-day basis to see if they are necessary. So the Foley Police make their rounds through the hospital, examining each tube and trying to take it out. The nurses beg you to manufacture a reason why the foley must stay in.

Announcer’s voice: “In this corner, weighing in at 3 tons of hell-hath-no-fury, we have the nursing staff! And in this corner, weighing in at 5 tons of faceless beaurocracy, we have the hospital! And in this corner, tied to a post with no gloves and everyone mad at them for who-knows-why, we have the doctors!” DING DING DING.

And before the blows begin to reign, you have your insight: I can bullshit my way out of this!

“Dr. WhiteTurk, why does this patient still need a foley after four days?” (real reasons in italics).

He’s knocked out, he’s going to the OR again tomorrow, and his nurse is already handling two other complicated patients. Taking it out and putting it back in isn’t really worth it. ”Please continue foley to monitor fluid resuscitation status as measures of CVP in current R Subclavian CVC have been unreliable.”

“Dr. WhiteTurk, this patient has had a foley for two days. Why can’t we take it out?”

She’s quadrapalegic, she’ll never control her bladder ever again, and her family isn’t ready to have the conversation about intermittently straight-cathing her just yet as this happened just a few days ago and they need a break. “Please continue foley to monitor resuscitation parameters in patient with new-onset neurogenic shock.”

“Dr. WhiteTurk, surely this patient who has been in the hospital for two weeks can have his foley taken out!”

What you don’t realize is that he is so fat and his penis is so small that we cannot put a condom-catheter on him. If we discontinue his foley, he’s going to piss himself, develop breakdown of his skin, get a raging infection because he’s an uncontrollable diabetic, and he’ll die from it. “Please continue foley for pity’s sake. For pity’s sake.”

I long ago forget how actin filaments assemble and disassemble intracellularly, but you bet your ass I could bullshit my way through convincing you that I hadn’t. That’s because, unlike an understanding of basic science, good bullshitting doesn’t fade with time. And though you don’t win every battle and you can’t help every patient, a solid grounding in bullshit will help you win more than a few and help quite a lot. An accurate Assessment of Bullshit would tell me a lot of useful information about a future doctor’s success in a hospital.

Can’s say that about the MCAT. Not by a long shot.

3 thoughts on “On Consents and Foleys

  1. Pingback: Grand Rounds: Giving Thanks! : DiabetesMine: the all things diabetes blog

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