Editorial

Perspectives from the other side of the ocean: A Croatian hospital experience

Copyright © 2007 Society of Hospital Medicine

When I went back to Croatia this summer to visit family and friends, little did I think I would find myself standing in the hospital where I trained as an intern. At 1:00 AM I took my father to the ER for an acute episode of nausea, vomiting, dizziness, chest tightness, and dyspnea. Earlier that day, he had been watching the World Cup, not moving from his chair for several hours. The ER saw him promptly and transferred him to the main hospital in town.

Hours later, I was alone in the middle of a wide, marble corridor. Memories flowed back to when I was a young nursing student and later an intern, full of life, energy, and dreams. Now the walls were yellow and darker than I remembered. They were barren, almost sad: no pictures, no art, no life. On my left, patients were taken to a room for procedures such as thoracentesis and lumbar puncture. The next door led to a balcony where cigarettes glowed like orange fireflies. Dark shapes murmured to one another as they nursed their habit. At least smoking wasn't allowed in the patient rooms.

On my right were alternating male and female patient rooms: up to 7 beds per room. They would add an eighth and potentially squeeze in a ninth bed when needed. There were no private rooms, even if you had money or status. There were no dividers or curtains between patients. With no privacy and nothing else to do, patients entertained each other. Some were young, others older. Some had fought in the last war; others were tourists who were visiting. They shared their stories. They overheard each other's plans of care during morning rounds conducted by physicians and nurses.

Each hospital bed had a little nightstand, but that was about it. If you were lucky, you got pajamas. My dad got warm flannel pajamas in the middle of the summer, but at least he got something. We left the house in a hurry and didn't bring anything. No towels? You had to bring your own. No toothpaste or a toothbrush? There was running water but no cup to drink it in. There was not even toilet paper. You had to bring your own.

Everything was nice and clean but something was missing in this former military hospital, as if the life had been drained out of it. It was once a premier facility. Maybe it was getting older or worn out by the war, or lack of maintenance. The best equipment (including new ventilators) were reportedly stolen and sent to another city.

There was no army of people serving you. No medical assistants, physicians assistants, nurse‐practitioners, or technicians. No physical therapists or occupational therapists or even a front desk where people were greeted. No case managers. The hospital population was so much younger than in the United States. There was only 1 patient on the ward who was 90 years old, as opposed to the usual 10 patients on my service in their 80s and 90s. Most patients were discharged home with their families; very few were sent to nursing homes. There was no length of stay to worry about. There were no insurance hassles, preapproval for a test or for an additional day of hospitalization.

There were no daily blood draws. They are not watching him closely enough, I worried. The ER physician apparently ruled out cardiac causes before admitting my father to the neurology service for presumed vertebrobasilar insufficiency. Was the ER physician's history, cardiac bedside exam, 2 normal EKGs an hour apart, and CXR enough to assure him there was no need for a CPK or a troponin? I was told the CPK was normal but never saw the result. They used to do troponin but had stopped because it was too expensive. I cannot imagine admitting a patient in the United States with chest tightness without ordering cardiac enzymes. Are we scared we'll miss something or afraid of litigation? There was no such fear that I could detect in Croatia.

The inpatient workup was otherwise thorough, and everyone was courteous. Nonetheless, the money was tight. If a patient needed over the‐counter medications, a family member would be asked to buy it, sometimes at significant cost. Almost every patient had a peripheral IV but there were no unnecessary IV infusions, unlike the occasional TKO IVs we see here to justify hospitalization for a little old lady who didn't have a place to go or whose insurance would otherwise refuse to pay.

My father seemed dehydrated.

Could you put some normal saline in? I asked.

He already got some, the charge nurse replied.

What did he get?

Metoclopramide infusion in 500 cc of normal saline. He is not vomiting any longer, he can eat and drink, and he doesn't need any more IVs. It is expensive. Go buy some water and juices for him, the charge nurse said.

The meals were served 3 times a day. No snacks in‐between unless friends and family brought something.

Visiting hours were 2‐4 PM daily. Information time for families took place on Tuesday and Friday afternoons. I arrived 30 minutes early to speak with the neurologist. In less than 20 minutes the room was filled. Everyone patiently waited their turn. The time spent with the doctor was brief but was better than nothing. As hospitalists, we spend a significant amount of time on the telephone tracking down family members, talking to them, or arranging a meeting to accommodate their schedule. On the other hand, there are family members who become frustrated because they have difficulty catching the doctor. I wonder if it would be helpful for us to have a dedicated information time. It could prevent frustration, unnecessary phone calls and pages, and perhaps save us time. Given our shorter length of stay, information time only twice a week probably wouldn't be enough.

What are you doing here? Dr. T., a friend of mine, exclaimed. Come on, a doctor from America waiting for the information! Come here, you don't need to wait! Your father is already better. We did a head CT, and we'll do a cervical spine x‐ray and carotid ultrasound tomorrow. Although I was hesitant, my brother, a medical student, tried to question the current treatment.

Why are you giving him diazepam and diclofenac intramuscularly? he asked.

What do you mean why? Because this is how we do it, Dr. T. said.

You already have an IV access. Couldn't you give it to him IV? my brother persisted. Dr. T. looked at him like he had fallen off the apple cart.

I had never seen it done this way in Austria or Germany, my brother continued. Why cause unnecessary pain and complications?

What complications? said Dr. T., now impatient. We use it intramuscularly. This is how it is done. It is only 10 injections. That's nothing.

Ten injections? You can injure a nerve! my brother exclaimed.

What nerve? Not if you do it right. We've been doing it this way forever. Your dad had dizziness and vomiting, and now he is better.

My father was better. Something had worked. Was it the medications or that he had slept and was rested?

The night had sneaked up on us again. The ward was quiet. No call lights. No patient telephones. No TVs. No IV machines and their beeping. No vital signs were taken in the middle of the night. No early‐morning blood draws. No pagers. The hospital was a place to get some rest.

The following day I spoke to the on‐call physician. The head CT and labs were normal. After 4 days in the hospital, I needed to know what the weekend plans would be.

How much longer will he need to be in the hospital? I asked.

Oh, about 10 to 14 days.

Ten to 14 days? I couldn't hide my surprise. What for? I might have as well asked if pigs were falling from the sky. This is how it was done.

Documentation was scanty. No worries of audits to justify the work done. How much time was saved this way? No wonder each physician saw 20 to 30 patients or more. There were 2 forms at discharge typed into a computer by the physician: a short one containing discharge medications and follow‐up plans and a long one to be completed later. We got the short one immediately and made follow‐up appointments. But many weeks later, we are still waiting for the long one. Apparently not all the lab tests are back.

Looking back, I see that when I tried to push for more information, I was viewed as pushy. So I stopped pushing. When I asked some logical questions, I felt like I was showing off. So I stopped asking too many questions. When I asked dad to tell me what happened during the day, he did not know. He did not remember the name of the consultants or what they said. When I asked him to try harder, he refused. When I asked him to write things down, he hesitated. It would mark him as a troublemaker. He was concerned that he would be labeled as an outsider, despite having lived in Croatia his whole life. Years after the war, a person's last name could still conjure up barely concealed hatred or suspicion. My father wanted to be seen as a good and compliant patient. He felt too vulnerable to be pushing for answers. Somehow, against my better judgment, I fell into the same mode.

Coming back to my hometown curiously hampered me. I still don't understand why. Was it sadness in my heart and nostalgia? Or emotional remnants of the recent war lingering in the air? Or a more patriarchal mentality and the unwritten rules of thinking and behaving that I had forgotten about? I was both a daughter and a visitor. I grew up in Croatia, but I left 2 weeks before the fighting broke out, and my prewar memories were still pristine. I was both a native and an American physician with all the expectations of stateside care. When I was a student there, physicians were authoritative and almost never questioned.

In the end, my father received care that was professional and thorough. The hospital lacked some basic necessities. They were on a strict budget for medicines including IV solutions. On the other hand, they kept my father in for 9 days, consulted an internist, an ENT. and a urologist. They also did numerous studies, including a head CT, cervical spine x‐ray, carotid ultrasound, hearing test and vestibulogram, CXR, and abdominal ultrasound. He had only 2 blood draws: CBC and Chem 7 (one time, one stick) and thyroid tests and PSA (one time, second stick). If he had been my patient, I would have probably tried to discharge him within 2 days and have him complete the evaluation as an outpatient. They gave him 9 days of diclofenac and diazepam intramuscularly and 7 days of 500 cc of normal saline and metoclopramide IV. My father was released from the hospital several days early at his insistence and mine. He had no more nausea or vomiting, no chest pain or shortness of breath. He was calm and relaxed. He was well rested. He felt better. And he is fine today.

Acknowledgements

The author is grateful for S.R.C. and his support in writing this manuscript.

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