Most of my articles thus far have focused on what to expect from the outpatient medical world. Today, I want to share with you what you should expect from perhaps one of the most medically stressful experiences that you will go through: being admitted to the hospital. The inpatient world, as we call it, can be foreign, unfamiliar and scary especially if you don’t know what to expect.

I want to walk you through a scenario of a patient going into the hospital from the emergency room to his discharge to home. This scenario is meant to give you a framework for what you can expect from a typical hospital stay. This scenario will not necessarily be your experience, because everyone’s experience in the hospital is unique. Follow along with this story line to get an idea of what you should expect when you go into the hospital.

Let’s talk about John…

John is a 50 year old man living in Denver, Colorado with his wife Sarah. John takes medication for high blood pressure and diabetes. Over the past few days, John has felt tired and developed a cough. After dinner this evening, he develops shortness of breath with a fever and is now coughing up green sputum. Sarah is concerned and drives him to the nearby hospital.

John and Sarah arrive at the emergency room. Sarah explains what is going on to the person at the front desk, and they are checked in. John is then taken to a triage room to meet with a nurse who takes his vital signs: temperature, pulse oximetry, heart rate, and blood pressure. The nurse puts oxygen tubing into John’s nose because his oxygen levels are low. John is then taken back to an emergency room bed. John and Sarah have gone to a large academic hospital that teaches medical students and residents, so a medical student doing her ER rotation comes in to take a medical history and perform a physical exam. She then reports this to the resident physician who does the same thing, and then, shortly after, the attending physician will come in to talk with John and Sarah. The attending physician is the boss, the one who can actually practice medicine on her own and makes the final decisions regarding what should happen with John.

After some blood work and xrays are done, the doctors tell John that he has pneumonia. Because he is requiring oxygen, the doctors recommend that he stay in the hospital overnight. John gets moved up to the 8th floor and is greeted by a new nurse who will be taking care of him. Sarah decides to stay the night so she sleeps on a sleeper sofa next to John’s bed. The hospitalist is the internal medicine doctor who will be taking care of John for the night. He comes in to ask John his medical history and perform a physical exam again. He will make sure John is getting the antibiotics he needs and makes sure that he receives his blood pressure and diabetes medication while he is admitted. The hospitalist also asks John about his code status, which is standard for anyone being admitted to the hospital.

That night John does not sleep well because the nurse is coming into his room every 4 hours to check his vital signs. At 4am, the phlebotomist comes in to take a blood sample. At 6am, John is awoken by a new medical student. This medical student is a part of the daytime medicine team who will be taking care of John, completely different from the team of doctors that took care of him last night. John has to repeat his story again. At 6:30, the resident physician comes in to ask John about his history, his medications, and how he is feeling. John is not too sick so he can eat breakfast that morning. Shortly after breakfast, around 9:30, the daytime medicine team comes in to visit with John for their daily rounds. The medical student will present John’s case to the attending physician discussing John’s medical history, his medications, the results from the previous night, and his current treatment for pneumonia. The resident physician will add his piece and will discuss the plan for the day. Once all is agreed upon, they will ask John if he has any other questions and will hopefully give John an idea about how much longer he will be here.

Morning rounds are a critical time of day. It’s very important that Sarah is there so she knows the plan going forward. If you have a loved one in the hospital, it may be a good idea to ask their nurse if you could be contacted when daily rounds are going to occur so that you can be there in person or could perhaps listen in by phone.

John’s condition starts to decline

Later that afternoon, he starts to become confused and starts to breathe faster and becomes more short of breath. Although John is on the antibiotics, he has developed sepsis and John’s body is starting to react to it. Sarah calls the nurse into the room because she is concerned. The nurse agrees and calls the resident physician. The resident performs an exam and looks at John’s vital signs, which are not looking good. The resident decides that John needs a higher level of care, so he calls the ICU team to come take a look at John. ICU stands for intensive care unit. This is where the sickest patients in the hospital will go. In the ICU you can put a patient on a ventilator, and the nurses only have 1-2 patients instead of >5 patients per nurse on the floor. The ICU resident physician and the ICU fellow physician (a doctor training in Pulmonary and Critical Care) will come in and talk with John. By now, John is having trouble, breathing fast enough to keep his oxygen levels up. The team decides that he needs to be put on a ventilator for a short period of time while his lungs heal. The ICU fellow will sedate John and put a breathing tube in his throat so he can be hooked up to the ventilator. Sarah follows the ICU team and John as he is transported in his hospital bed down to the elevator and up to the 10th floor ICU.

After a couple of days John’s lungs start to improve. His oxygen levels look much better, and the ICU team decides he is ready to come off the ventilator. They will stop sedation and once he is awake enough to follow commands, they will remove the breathing tube. The next day he is sent back to the original day team of doctors that took care of him before going to the ICU. After another day, they decide that he is well enough to go home.

Day of discharge:

This is the day of discharge, the day that John gets to go home. A physical therapist will come by to assess John’s ability to walk on his own. We cannot discharge patients to their homes if they have become too weak while in the hospital. If going home is not an option, then going to a temporary rehabilitation center is usually a good option. Discharging someone from the hospital is never a quick task. It never goes as fast as the patient thinks it will. John was told he would be discharged during morning rounds at around 9am but he should not expect to leave the hospital before 2-3pm. This is also a very dangerous time for John. The doctors in the hospital have changed the dose of his blood pressure medication and have given him instructions to take further antibiotics by mouth for the next week after he goes home. The discharging doctor goes over these changes and instructions in detail, because it is hard for both John and Sarah to remember everything that happened during the hospital stay. Sarah is sure to ask plenty of questions in order to have a clear plan for when they go home. They already have a follow up appointment scheduled with John’s primary care doctor.

Take away points:

John’s story is just an example of what a hospital stay may look like. Everyone’s experience will be different. I think it is important for Wise Patients to realize these 3 things:

1) you will see many different providers while in the hospital and it may be disorienting. Be sure to ask everyone’s name and role to help keep them clear. You will repeat the same story over and over again.

2) When John started to look worse, Sarah advocated for him by getting his nurse. Certainly we can’t all have someone in our hospital room with us 24/7, but if you are visiting someone and something doesn’t feel right, be sure to alert the nurse right away.

3) Hospital discharge can be a dangerous time. Be sure to know exactly what changes were made, what new things need to be done, and what follow up is needed.