Anesthesia is Pretty Difficult (5)–and Reading Can be Hard, too

Anesthesia is the scientific study of the subtle screw-up.

Same anesthesia rotation, different day, same inappropriately confident practitioner (me) today assigned to the gentle care of an eighty-two year old gentleman scheduled to undergo a routine hernioraphy.  Did I say routine?  Why yes, I did.  Hell, people, we do this shit a thousand times a day, let’s put this truck in D and get this done…BgicidBCQAAGm96

First case of the day, I’m a little late arriving to the break of dawn party that is the OR at this fine Midwestern University Hospital (17 year old Vega only starts by popping the clutch as I roll downhill), surgeon is annoyingly early and already pacing about, giving me that smile and saying, “Hey, take your time,” which means “Move your ass or I’m filing out this ‘Reason the Case was Delayed form.’ ”  I’m moving my ass, but this eighty-two year old ain’t a spring chicken, he’s taking about twenty minutes just to assume the position on the OR table so I can put in my obligatory spinal.  (Because, remember, everybody here gets a spinal.)  As Nurse Slowly Helpful helpfully but slowly helps patient curl up on his side “just like a baby or a comma” I’m marveling at her mastery of the mixed metaphor as I run in my mandatory liter of IV saline.  This eighty-two year old is on beta-blockers (who the hell isn’t?) and has the essential hypertension.  I’m about to relieve him of his spinal-cord mediated vascular tone with my spinal anesthetic, so in goes the vascular volumizer in anticipation of this physiological phenomenon.  An ounce–or liter–of prevention, you know.

Finally, the patient is positioned with Nurse holding him with maternal tenderness in fetal/comma position, I’ve got my gloves on and precalculated dose of magic local anesthetic drawn up as I notice Surgeon With No Home Life filling in the blanks of the “Case Delayed” form, but before he can sign illegibly I’ve done my Modified Taylor Technique thing and say, “DONE!” as I dramatically strip off my gloves, standing up to help Nurse  Nurturing reposition elderly widower patient with murmured sweet kindnesses (“See, that wasn’t so bad, was it?”) onto his back and crank the bed into the crazy angle that will give my man here just the right level of unilateral hernioraphy without hurting, perfect regional technique.  I’m thinking that, ‘Not so bad at all, no sirree. Damn, Geller, that guy was calcified and old and scoliotic and that was pretty sweet, first try and boom, baby, I could probably give a spinal to Michelangelo’s David if somebody could get him off that pedestal and lay him on his side for thirty seconds.’ Or something along those lines as I do my post-spinal first set of vitals-BP 176/90-well, you knew the old geezer had the hypertension going in, no problem, spinal will fix that, too.  I check my level and, of course, it’s perfect, so I pointedly announce to Surgeon Suddenly that we’re all set, he can scrub if he wants to get things started, big day of surgery ahead, wink, wink.

As the nurse is prepping the patient, I ask him how he’s feeling as I lovingly apply nasal cannula and he smiles at me upside down and says “Good,” like he knows that he’s in the hands of someone who’s taking really good care of him and he really  appreciates me, so I turn smiling to my drawer of a million medicines and select my little glass ampule of ephedrine from the neat little cubbyhole that is its special home, glance at the label as I crack the top and draw up my “just-in-case, never-hurts-to-be-ready, hell-it’s-not-my-money” pressor and dilute it 10:1, labelled and leave it lying on my little work space.

I’m humming to myself and glancing at the schedule to see if I can use a spinal on the next case (of course I can) as surgeon checks for effective anesthetic by pinching patient with pointed Adson tweezers, I nod at him with a smile as my patient remains oblivious to this assault.  Surgery ensues.  I recheck ancient patient’s BP, now 110/72.  See, I knew that the spinal was working and his hypertension is now normotension and what’s better than that, huh?  I look down fondly on my patient, now realizing that he looks just like the grandfather I never knew as he softly snores in contented comfort.  Sigh.  Isn’t anesthesia great?

“I think I might be sick,” patient mutters and I ask him “Excuse me?” noticing the slight sheen of perspiration on my Grandad’s forehead.  “Just a little queasy,” he says, smiling apologetically and I nod sympathetically as I recheck his pressure and-what do you know?–BP now 98 over don’t bother to notice because obviously it’s on its way down so I spin and push a little ephedrine, because I knew this was going to happen, I’m prepared.  I lovingly dry sweat from my patient’s brow with gauze and give him my reassuring smile but I’m noticing he’s looking a little pasty in his pallor.  Let’s just recheck that BP though it’s only been two minutes since the last one and–what the hell?– his pressure’s eighty?  That can’t be right, I pushed the pressor, should be working by now, let’s try that BP again and now it’s 70 and now I’m the one suddenly nauseous and I feel sweat appear on the back of my neck as I push half the remaining syringe of ephedrine.  I lean over my Poppa and ask, “How’re you doing?”

He looks me straight in the eye and says, “I think I’m dying.”  He seems sincere about this.  I check his BP, which is now somewhere south of seventy and I’m forced to agree with his clinical judgement.  A cold trickle of sweat runs down my back as I call my attending.

Kindly attending anesthesiologist appears and is immediately concerned when he sees the abject fear in my face.  “What’s up, Geller?”  Well, I explain, not my patient’s blood pressure though it should be because I’ve given him all this ephedrine (I hold up nearly empty syringe) but his pressure just keeps dropping and he thinks he’s dying and he looks like crap and I think he might be right and–

“Hold on.  You gave him ephedrine?’  I nod.  “Show me.”  I hand him the syringe.  “No, show me the vial you drew this up from.”  I look around and find the vial in the little plastic can attached to my cart and hand it to him as I sweat semicircles under my arms.

“Everything okay up there?” Surgeon asks, looking over the drape at our little tete-a-tete.

“Sure, no problem,” Anesthesia Attending reassures.  He turns to me and shows me the vial.  Sotto voce, he says to me, “This isn’t ephedrine.  It’s chlorpromazine.”

“WHAT?  Of course it’s ephedrine, I looked at the label,” I stammer as I look at the vial that says “Chlorpromazine” pretty clearly right there on the label.  No way, I’m thinking as I scan my drawer, noticing for the first time that even though every little vial is color-coded for safety, chlorpromazine and ephedrine just happen to be the exact same color and hey, look at that, they’re also right next to each other in the little cubbies, isn’t that just great, maybe the person who stocks this shit just missed a little in his underpaid, rushing through his job stocking my damn drawer.  Stop, Geller, just think–but I’m having a hard time thinking because the OR just turned to shades of gray and I’m hearing a roaring sound in my ears as I recall from Pharmacology For Fools Like Medical Students 101 in a sudden flash that chlorpromazine is an alpha blocker, strange the little facts that come rushing back from memory, especially since alpha blockade is the exact opposite of what my patient needed, OH MY GOD I’VE KILLED GRANDPA!  I drop heavily onto chair reserved for incompetent anesthesia wanna-be’s and seriously consider throwing up.

Meanwhile, Anesthesia Attending (a man who can actually read a label, not just pass that ampule in front of his face and seem to see it) has swung into action and is giving my patient real ephedrine straight up and wide open fluids and turns to me, saying “Go take a break, Geller, you look like you’re going to puke.”  I nod and take his advice.

When I return, only a little relieved that there’s no code cart outside the door, Anesthesia Attending is smiling.  “He’s fine, Geller.  Actually, I charted your chlorpromazine, he was nauseous, not completely out of line, there,” but I know he’s just trying to be nice.  Actually, it was exactly the wrong thing and it’s only by the grace of God Almighty that I didn’t kill this man.  “Pressure was low there for a while, I think he should stay overnight, maybe check some enzymes, make sure…”  Make sure I didn’t give the guy an MI, he’s kindly not finishing in his sentence.  I nod and thank him as I take over my case again.  Anesthesia Attending gives my shoulder a reassuring squeeze as he leaves with a smile that clearly says, “You fucked that up, Geller.”

I stayed the night with my kindly old grand-dad.  He thought it was a little weird, I’m sure, that this twenty-something year old wanted to hang out and play cards and kept looking at his bedside monitor as he told me about what he did in the war and his kids and a lot of other stuff I don’t remember because I was just so damn grateful the old guy didn’t die on me.

Doctors Without Barbers

Barbarians at the Gates of the OR

It is time for pervasive panic and generalized pandemonium in my little hospital.  We knew we had been fortunate these past few years to remain sheltered in our backwater, unnoticed in the shadow of the huge academic medical center just down the road.  Other hospitals, we know, have faced these trials in recent years, but we had been spared.  We had been a small island of sanity, a redoubt of reasonable people caring for patients with reasonable ways.  No more, however.  Today, wild-eyed administrators are running amok in the hallways.  Nursing supervisors are lining up the cowering minions for inspection of hand washing efficacy like so many orphans from Annie.  Surgeons with heads uncovered are being challenged and so are surgeons with heads covered when the OR nursing administrator explains that all heads must be covered but head coverings must be removed.  Lose that lanyard or lose your life–you’re going to kill somebody with that thing.  I don’t think I saw you wash your hands just now, did I, doctor?  It’s the regulations, doctor.  Please, don’t be difficult, doctor.n

Trouble is at our gates–trouble in the form of the JCA (formerly the JCAHO, formerly the JCAH, the bastard devil-spawn of the lascivious American College of Surgeons and that harlot, the AHA) and the CMS (formerly so many different acronyms as to be unnameable).  Two hospitals in our realm (one being the aforementioned high-towered University Hospital) have been invaded, inspected, and decimated by the event.  Hospital administrators are left weeping and broken in their wake, clutching reams of citations and deficiencies.  Oh, the horror, the inhumanity–the lost revenue.

We will not be taken so easily!  We will be ready. Every effort will be made to put down this new plague.  We will wear garlic necklaces if there’s an article in the Journal of Medieval Medicine  (vol. 3, Sep 1199) that says that such efforts are laudable.  New regulations will be promulgated, old regulations rigorously enforced and any lack of enthusiastic compliance will be judged to be a threat to patient care and dealt with aggressively.  Those who do not comply will be reported to the committee we have for just this sort of thing.

There is only one problem–none of this zealous response has anything to do with the care of our patients.  Just the opposite, unfortunately.  Patient care is compromised amidst the capricious, unsubstantiated and unjustifiable new policies; policies that are conceived and become doctrine at administrative levels carefully removed from the influence of those difficult doctors who just won’t go along with anything.  New policies appear as dogma based upon AORN guidelines–but now that they are written down on hospital computerized stationary, take on the rule of law.  No matter that none of these guidelines approach the level of standards or regulations, that the JCA never required compliance with these phantom statutes, that there isn’t the faintest whiff of science or rationality behind them.  All hair is to be covered, so, yes, doctor, you are going to have to shave that off for the good of the patient. Do you want your patients to suffer a horrifying septic death and skew our hospital statistics?  Is that what you want?  I’m sorry, doctor, but if you’re not willing to put the welfare of your patient above all else, well–I’m very sorry to say that I must report your lack of enthusiastic compliance to the Committee to Deal With Combative, Aggressive, and Inappropriately Behaving Physicians Who Have a Bad Attitude.  Isn’t your ex-wife on that committee, doctor?  Are you sure you wouldn’t prefer to just wear one of our ‘full-coverage hoods’ and sit quietly in the OR lounge?  I thought you would, doctor.  Smile, doctor–the patients get upset if the staff isn’t happy, you know, and patient anxiety has been proven to have a negative effect on wound healing.  I know, nobody can see you smiling in that hood, but it’s really your entire attitude, doctor, that is really the important thing.  Don’t you agree?

Don’t Buy This Book

Well, it seems that I’ve been on a bit of a rant lately regarding Electronic Medical Records.  The subtitle of this blog, however, says “Life, Writing, and Surgery”: or something like that.  So I feel compelled to move on, at least for the moment, to something other than Surgery.Bulldog (small)

It has been a very long time since I posted on the subject of Writing, so I don’t think it is too much of an imposition to provide the following post.  What follows is Chapter One from the second book in The Claddagh Trilogy, entitled The Problem With God.  It is, in my opinion, the best bit that I have written in this series to date, featuring the best dog character in a novel since Toto (my opinion again).  Feel free to try it, with the idea being that if you don’t like this, chances are pretty darn good that you won’t enjoy the rest of my novels.

Excerpt from The Problem with God:

Chapter 1

Father Julius Zimmerman was in Hell.  Hell, it turned out, looked and smelled an awful lot like Helmand Province in Afghanistan.  He wasn’t surprised.  He was dripping in sweat.  Of course he was, it was hot as Hell in here.  He sat in an armored personnel carrier with his squad.  It was stifling, as usual.  He turned to smile at his squad mates, noticing that they were all dressed in the same cowled woolen robes he had worn as a novice.  As his buddy next to him turned to smile back, Zimmerman saw that the other man’s face was a skull, smiling.  Julius started to scream.

The explosion lifted the APC straight into the air.  It crashed back to earth with a grinding shriek.  The air in the small vehicle became a stifling, putrid miasma that smelled of death.  Julius twisted violently to free himself of the wreckage entangling him.  His eyes snapped open and his breath caught in his throat.  Jack, his English bulldog, was staring at him, muzzle drooling on the bed and nose a half inch from his own.  Dog breath.  Julius screamed again, for real this time.  Jack almost blinked.

“Shit, Jack,” Julius yelled, “You scared the crap out of me.”  Julius fought to disentangle himself from the blankets that had twisted around him as he thrashed through his nightmare.  He finally succeeded and swung his feet over the side of the bed, sitting up.  He bent to scratch Jack’s head

“Ready to go, huh?”  Jack just stared back, unblinking.  Julius didn’t think the dog ever blinked.  Julius went to get up, putting his hand in the small pond of drool Jack had left on his bed.  “Aww, shit, Jack.  I just washed these sheets.”  Jack just stared back.  “Don’t get so upset,” Julius continued.  “It’s okay. I’ll take care of it.  Don’t be so hard on yourself.”  Jack just stared at him. Julius scratched the dog’s head again and went to the bathroom.

Zimmerman came out in his Georgetown hooded sweatshirt and shorts.  He grabbed his phone off the charger and dropped it in the waterproof bag with a handful of dog snacks and a bottle of water.  “Let’s go, buddy.  You got point.”  The dog shuffled out as Julius held the door open.  Zimmerman followed outside into the predawn darkness, carrying the bag.  The early morning chill was refreshing, dew on the grass stretching down to the river.  Julius forced himself not to check his six as he followed Jack’s waddling ass down to the boathouse.

Jack just sat watching on the dock as Julius flipped the two-man scull off the rack.  “Two-man scull, two men’s skulls,” Julius muttered to himself as he lowered the craft into the water.  It was heavy, almost a hundred pounds and ungainly, but Julius expertly flipped it into position next to the dock with a soft splash.  He dropped the bag into the back of the boat and held it steady to the dock. “What are you waiting for?” he growled at the dog.  Jack twisted his head quizzically for a moment, then padded over and dropped like a bowling ball into the boat.  The dog took a seat behind the bag, facing front.  Julius slipped into the front seat, facing backwards towards Jack, stretching arms and legs as he slid the seat back and forth on its silent mechanism. Julius had just greased the tracks and oarlocks yesterday.  He liked quiet.

“Clear to the rear,” Zimmerman announced quietly.  “Clear to the front?” he asked the dog.  Jack stared past Zimmerman and said nothing.  “Good to go, then.”  Zimmerman pushed off from the dock.  He fitted his long graphite oars to their locks and began an easy pull upstream to the middle of the Potomac.  It was still dark, but a lighter purple over the Gothic towers of the university hinted at the dawn to come.  Zimmerman started to pull harder, settling down to his warm-up cadence.  He stared back at the dog staring at him.  “When are you going learn to row?  I’m getting a little tired of hauling your fat ass up and down this river.”  Jack tilted his head.  “You know what I’m talking about, dog-breath.  Getting a little jiggly around the middle.  No snacks until we clear the Chain Bridge.”  Jack laid down on the ditty bag, settling his muzzle on his paws. He looked sad.

Zimmerman began to slowly increase his cadence, sliding and pulling in concert to the soft splashing of the dipping oars.  Despite the cold, a sheen of sweat appeared on his forehead.  He concentrated on his breathing.  He was an “empty-lung technique” guy, inhaling steadily during the power stroke, emptying his lungs slowly during the recovery, his chest empty and his knees tight in, squeezing every bit of air out at the catch, then the cadence beginning again, his powerful chest filling with air as he pulled with his back and shoulders, pushed with his legs and felt the trembling boat shoot forward through the glassy water.  He was a human metronome, a sweating piston pumping within the scull’s smooth cylinder, watching his wake curve smoothly downstream.

Jack’s head came up off his paws.  He made a thrumming sound with his throat and looked at Julius.  “What?” Zimmerman asked between breaths.  “You say something?”  A second later they passed under the Chain Bridge.  “Oh.  You said bridge, huh?  Fine, go ahead.  Lard-ass.”  Jack chose not to reply to this, instead nuzzling into the ditty bag and coming out with a dog treat.  “Just one, lard-ass.  It’s Wednesday, we’re going for distance today.  Better make ‘em last.”  Jack made his sad sound and settled into chewing on the snack.

Julius settled into his endurance cadence.  He no longer wore a heart monitor or brought along his little electronic metronome.  After four years of rowing three times a week, his body knew what to do.  He didn’t think.  That was the best part.  He pulled, the oars splashed, the water slipped by.  He felt a trickle of sweat travel the length of his spine.  He kept to the middle of the river, somewhat narrower here as he headed north, the yards and yards drifting behind him marked by the little whirlpools left by his curved oar blades.  Silence, if you didn’t count the loud snuffling of Jack polishing off his treat.  Jack looked into his eyes, head tilted.

“No more.  Not until the next bridge.”  Jack made his sad sound again, a deeper thrum ending with a higher note that always sounded to Julius like his ex-wife saying “Fuck you.”  Pity, that.  He breathed, pulled harder but no faster.  The water flowed past, the river making its slow turn to the west.  Julius could see the dawn threatening to break behind them as he fought to race away.  Sweat started to drip down his nose.  Pulling, breathing, pulling, breathing.  Jack started to snore.

Jack’s head came up and Zimmerman knew he must be nearing the Beltway bridge.  How long had he been rowing?  He didn’t know, didn’t wear a watch.  Pulling, breathing.  A drop of sweat rolled into his eye and he tried to blink it away as the huge mass of the bridge passed darkly overhead.  Julius could hear the early morning traffic noises as he shot like an arrow out from under the bridge.  Sweat in both eyes now and it wouldn’t blink away.  He couldn’t see, was blinded by the sweat and the sun rising like a searchlight over the bridge, straight into his eyes.

“Dammit,” he said out loud, shipping his oars and rubbing at his eyes with the heels of both hands.  He had been in a trance, moving at speed like a perfectly tuned machine, hadn’t been thinking or feeling or anything and then—stupid sweat, stupid sun, he thought.  He looked back at Jack, who was waiting to be told he could get his snack.  Something caught his eye, however, something about the bridge.  He looked up, squinting into the sun which was intensely bright, exactly behind the bridge.  Something on the bride—a person.  Standing on the railing, a person, silhouetted by the bright sun behind.  A girl, he thought, the light streaming through a loose white dress or something, her figure in dark relief within.  He stared, transfixed, his eyes watering from trying to squint into the sun.  It was a vision, he thought. An angel, an angel from heaven.  He could make out a ring of red fire, a halo, about her head, lit from the sun behind.  Everything else about her was in shadow. As Julius watched, she raised her arms, outstretched.  Jack barked, once.  An angel, he sees it too, Julius thought.  Just then, the vision started to shrink.  Zimmerman stared, confused, until he realized that she wasn’t shrinking.  She was falling, pitching head first over the side of the bridge.

“Holy Shit!”  Julius snapped out of his trance and struggled to unship the oars.  His boat was whispering away from the bridge, farther and farther as he watched the figure fall silently, slowly.   She hit the water with a sickening splash and disappeared.  Jack made his sad sound.  Waves lapped at the boat.

“Shit, shit, shit,” Julius said as he struggled to bring the scull about.  This was exactly what the small boat was designed not to do.  He fought the craft, backing one oar and pulling hard with the other, the graphite bending and locks creaking with the strain.  It seemed to take forever to bring it around, to start the pull back to the bridge.  “Do you see her, Jack?  Is she there?”  Jack barked, once; now hopping past Julius to the bow, front paws on the gunnel, staring ahead.  He barked again, his stub of a tail wagging.  Julius kept shooting glances over his shoulder to try to see ahead but could only see Jack’s butt wiggling emphatically side to side.  “Get down, Jack.  Down, dammit!  If you fall in, you’re gonna sink like a rock!”  Jack turned to look back at Julius.  He made the ‘fuck you’ sound.  Then he returned to looking forward.

Julius thought he was getting close, but wasn’t sure until Jack started barking.  Jack almost never barked, almost always in the context of pizza.  He was barking like a crazy dog now, though.  He kept looking back to Julius, then to the water.  Julius used the oars to brake the boat to a stop.  He got up on his knees and scanned the water.  He saw nothing.  Jack was hopping up and down with his front paws on the gunnel, barking.  Jack never hopped.

“Dammit, Jack!  Get down here, you’re gonna fall in.”  Julius wished again that the stubborn animal would wear his life jacket once in a while.  Jack had always refused, making the sad sound whenever Julius had put it on him.  Julius had made him wear it once, despite Jack’s complaining.  The next morning he found it chewed to shreds.

Jack was looking just ahead of the boat now, steadily alternating barks with thrumming sounds, not hopping anymore.  Julius was trying to think what to do, not even sure he had really seen the girl.  But Jack had seen her, too, he was sure.  As he stared at the same spot in the river as Jack, her white figure rose to the surface.  Silently, her inert form surfaced, face down, her arms outstretched.  A formless white dress clung gauzily to her.  She didn’t move.

Without a thought, Julius rolled over the gunnel into the river.  The boat rolled as he dropped smoothly underwater, knocking Jack off the gunwale.  Julius came up, suddenly realizing that his jump must have rolled the boat.  He looked from the floating girl to the boat.  No Jack!  “Oh my god!”  Julius stretched for the boat as Jack’s head came up.  He had been knocked into the bottom of the boat, but now stood with paws on the gunwale again. He barked and looked at the girl.  Julius just shook his head and turned to swim for the girl.  Julius was a strong swimmer, most ex-Navy Seals were.  He was at the girl in three strokes and rolled her face up, treading water.  He brought his arm under hers and around her chest.  He could feel her breathing.  She’s alive.  He turned with her, twisting to see where he was, where was his boat.  Where was his boat?  He turned and saw his boat, and Jack still standing on the gunwale, looking at him.  The boat was moving downstream, moving with increasing speed away from him.  Jack stared, twisted his head questioningly.

“Stay, Jack!  Stay!  Don’t jump!  Stay in the boat!”  Julius looked at Jack, at the receding boat, back down at the girl in his arms.  He looked back to Jack, now moving more swiftly downstream.  “I’m sorry, Jack.  I’m sorry.”  The boat was moving faster.

“Fuck you.”

Julius swam for the riverbank, carefully holding the girl’s head above water.  By the time he had pulled her ashore, the boat had disappeared downstream.

End of excerpt from The Problem with God

Now, if you did enjoy that somewhat, don’t buy the book!  But you should go ahead and buy the first book in the trilogy, entitled God Bless the Dead.  Works out much better that way.  Oh, and by the way, all proceeds from sales of GBTD go to charity to support research concerning mental illness.  So there’s that, too.

Buy God Bless the Dead at Amazon

Electronic Medical Death

Implementation of the Electronic Medical Record in a hospital or office setting carries inherent risk.  Like all medical technology, there is danger as well as benefit to the patient.  Unfortunately, this aspect of EMR implementation has been woefully neglected.  Our approach has been to consider the EMR no more risky than the doctor’s pen it replaces.  This could not be farther from the truth.  I refer the interested reader to the following blog post as an introduction to this fact:

How Medical Tech Gave a Patient a Massive Overdose

This type of manzanita grows in the San Luis Obispo region of California

Next time, we’ll explore this aspect of EMR implementation further.

Let’s Have an EMR That Doesn’t Suck: Part 4

 

It is not difficult to envision a better EMR than already exists on the market, because they all suck.  And they all suck for the exact same reason:  They were designed by software developers, not health care professionals.  They should all carry a label–Caution:  This product was never intended for actual use by a doctor or nurse in the care of a live patient.  This fact is obvious to anyone who is forced to use one of these programs while sitting in front of a patient, as opposed to running a demo of the product in front of a group of naive physicians.  Gee, we all think, it looked like it worked when the guy was clicking through all those “uniquely designed, personally templated, specialty specific and easily customized” screens.  Which, in case you still haven’t figured it out, weren’t really running the program but were just carefully choreographed prescripted, preloaded, dummy demo’s.  You figured that out after you bought it, right?Minolta DSC

Step One and Only in designing a real EMR:  Make the EMR fit the health care professional, not the other way around.  Doctors do not sit in front of fixed monitors with a mouse and keyboard.  They sit in front of patients.  We reach out and touch the patients occasionally (well, some of us still do, anyway).  We make eye contact with the patient and family members, not with a computer screen while we ask questions of the patient over our shoulder.  Doctors and nurses do not click radio buttons.  We don’t do “drop-downs.”  I decide what fields are mandatory, not some hospital IT guy who gets told by the CFO that the hospital reimbursement will go up if we can make the doctors document the reason the patient is in the hospital on every note, every day, every time he tries to type anything into the medical record.  The medical record is to serve the health care professional’s goal to care for the patient.  Let’s repeat that:   The medical record is to serve the health care professional’s goal to care for the patient.  It is not, therefore, to be designed to maximize hospital reimbursement, regulatory compliance foibles, or translate efficiently into some midlevel administrator’s Excel spreadsheet program to make his quarterly report easier to format.  Because you are screwing up the patient’s quality of care just so you can make it easier to run a report on how screwed up the quality of care has now become.  Are you with me here?

The following has been proven by multiple, reproducible, double-blind, multicenter clinical trials published in the best peer-reviewed journals:  There has never been a system more efficient in accurately documenting patient care than a doctor or nurse dictating their findings and plans into a hand held recording device that they carry with them, the results of which get accurately transcribed, reviewed, and signed.  This is the way we document our office visits with patients.  This is the way we document discharge and transfer notes.  This is the way we document our operative care.  It is not helpful, accurate, or appropriate to replace this with a single check-off box that describes my operation as “Repair hernia, inguinal.”  But now we can do even better than a simple dictaphone and transcriptionist.  Every nurse, doctor, and health care professional in practice for more than a month falls into certain documentary habits, certain turns of phrase, that he uses over and over again.  These can be templated, triggered by certain verbal or tactile cues, then easily augmented and modified on the fly to suit the individual patient experience.  Reviewed, proofed, and corrected in real time, then electronically signed, sealed, and delivered.  Poof!  The technology exists.  It has existed for twenty years.  It’s just that nobody cares enough about the way we actually do things to design this form of input into the multimillion dollar boondoggle that is your hospital EMR.  They need to implement this form of input.  Mouse clicks and managed care don’t mix.  Are you a seventy-year old primary care physician who has always handwritten his notes in illuminated manuscript grade calligraphy with a gold-nibbed fountain pen?  Fine, use your nib on a handwriting recognition tablet running Evernote.  We’re not trying to put a man on Mars, here.  This isn’t a technology problem.  It’s an attitutude problem.  And the EMR providers attitude is “Screw it, Jack, just write the code.  They have to buy it because the government says so.”  I’m sorry, I digress.

Doctors and nurses don’t sit down much.  We can’t wait until we find a convenient open work station to write the orders that will save the patient’s life.  “I’m a doctor, Jim, not a damn transcriptionist!”  Or something like that.  Your hospital ER will never have enough computer workstations to allow you to provide timely care to your patient when the patients are lined up in the hallways on a busy Saturday night.  I need to do my doctor thing on my handy, personalized tablet that I carry with me whenever I am playing doctor.  It contains all my personal professional documenting tidbits.  It has wireless access to the hospital medical records database, the laboratory database, the radiology database with images available for my review when the radiologist reading of my patient’s CT scan sounds a little–oh, I don’t know, a little ‘intoxicated’ perhaps–and access to  my office server with all my personal patient records. It turns on and trusts that I am me because it recognizes my fingerprint, so I don’t have to keep coming up with a dozen new passwords every ninety days to keep some IT guy happily HIPAA compliant.   It even can play me the basketball game that I’m missing while I wait for the nurses to come in to do my emergency case.  I can talk to it, and I can write on it, and I can tap on it–I can do things that make my care of the patient easy,and efficient, and better.  And I can decide how I want to do that, not the hospital administrator who got taken to that “conference” in Vegas on EMR implementation just before deciding which vendor to sign with.  Do I sound bitter?  Sorry.

I can write orders on my personal little tablet and they get sent to the hospital order computer thing.  No more verbal orders.  No more orders appearing in my electronic inbox screaming to be signed when I’m sure I was no where near drunk enough to order that stuff last night.  But hell, got to sign it or it’ll just bounce back anyway.  If it isn’t on my personal tablet, I didn’t do it.  So there.  My customized order sets, entered with a finger swoosh.  Because I write the same orders for patients over and over again.  I don’t want to have to make my own special sauce at every hospital, ambulatory surgery center, clinic, nursing home, homeless shelter, and my office.  Then rewrite my personal note templates and order sets every time the IT guy decides to trip over the mainframe plug or  do “mandatory system maintenance.”  I’ll just keep that stuff with me, thank you.  You figure out how to make it easy for me to jack my pad into your system, or I’ll go to a hospital that will.

All of this new electronic, streamlined patient-centric data input is to be automatically, consistently, and reliably entered into my personal database, not just yours, hospital administrator.  I need to keep an accurate record of how many gastric resections I performed in the past 10 years and how many of those patients died within 6 months of surgery.  I need to be able to easily upload my data to the various Boards, Colleges, and regulatory agencies that demand I prove that I’m a good doctor on a frequent basis. The data automatically and easily transfers to my billing software, not just yours.  I’m the one generating the data, I think I should be  benefitting from the effort.  Harrumph.

I could go on.  I’m sure you have lots of even better ideas.  It’s a start, at least.

Exorcising the Demon of Digital Documentation: EMR Part 3

The almost over half-dozen regular visitors to this blog know that I much prefer “snarky” over “wonky.”  However, this is serious stuff (see parts 1 and part 2 of this discussion), and I’m sorry to say that we’ll be eschewing the alliteratively amusing yet enlightening parable on this one for the tediously technical.  Non-physicians are encouraged to move on to this entertaining dog video:

entertaining dog video

Seriously, it’s a great video, where these dogs are dressed up as US Supreme Court Justices.  Even if you think you’re going to read this wonkishly tiresome tirade, take a moment first.  It’ll make the process more palatable.  Or whiskey.  That works, too.

As you may have gleaned from Parts 1 and 2, I believe the current state of the EMR mandated implementation to be no less than a public health crisis.  Over the top?  I don’t think so.  Please ask any physician, nurse, or health care practitioner in the country.  I’ll wait.

.Minolta DSC

See?  We have to take meaningful, immediate actions to save patient lives and stop the documentary disease that is degrading medical record keeping even as we speak.  My recommendations, therefore, are simple and immediate.  Here they are:

Step 1:  CMS is to immediately suspend the “meaningful use” mandate.  Financial bonuses for those practitioners who implemented EMR should, of course, remain in place.  These folks laid out a lot of good money based on this expectation.  But we should immediately lift the threat of financial penalties for those practices that have not yet fallen down this well.  This will also come as a great relief to the hundreds of practices that paid tens of thousands of dollars to install an EMR and have, in practice, chucked it into the closet because they found it unworkable, and therefore have not been able to meet meaningful use criteria.

Step 2:  Immediately charge the Bureau of Weights and Measures to develop, in a timely fashion, minimum standards for electronic medical record keeping.  Believe me, I would never have thought this up on my own–this was the plan back in the day when we were all talking about how great it would be to have an EMR.  Seriously, the Bureau of Weights and Measures.  These standards should be developed with input from the hospital industry, physicians, midlevel providers, nurses, and database engineers specializing in intercommunicability and security.  This standards-making process should actively exclude representatives from the current EMR companies.  The process should pay no mind for backward compatability concerns.  These are the assholes who jumped the gun in the first place and forced us to buy dangerous, flawed products at exorbitant prices.  Screw ’em.

Step 3.  Require commercially offered EMR programs to be tested and certified by the FDA as a medical device.  You think I’m kidding?  I’m not kidding.  The EMR is a medical device, a device that affects every single patient care interaction.  A bad EMR is dangerous to patients.  If the FDA requires that my felt tip skin marker be certified before I use it to mark a patient, yeah, I think they should check to make sure that the EMR doesn’t systematically screw up my orders. Not such a crazy concept.  Oh, and the current multibillion dollar products already on the market should be retroactively required to pass this testing.  No grandfather clause here–these programs are flawed and dangerous.  Let the FDA sort it out by soliciting open comments from the consumers (that would be us).  They will be swamped with helpful information.

Step 4.  Governmental funding of a standard EMR to be made available to any and all practioners/healthcare facilities at no charge.  This whole EMR idea began when a bright young (or maybe not so young, I wasn’t there) physician stood up (might have just raised his hand, not sure) and pointed out in a committee meeting during the early ’90s that the VA system had this pretty cool computer system that was better than paper charting.  Say what you want about the VA, they were the first and the best at this EMR stuff.  Then we all said, yeah, that sounds great, let’s do for the country what the VA is doing for our vets.  Which, of course, we completely screwed up.  So I propose that the federal government pay the money to improve upon the VA program to develop a simple, effective, broadly applicable, safe EMR.  Then the federal government should make this program available as the minimum default option for any and all health care practitioners and facilities for free.  Because we paid for it already with our tax dollars through VA funding.  This program, of course, wouldn’t be the “bells and whistles” pretty thing that private industry will provide for profit.  But having this free product would establish a baseline that all the other manufacturers will have to exceed if they expect us to lay out a lot of our hard-earned cash.  Because right now we’re paying for a grossly inferior product.

I can already hear my Malthusiastic colleagues and trade group lobbyists saying that these recommendations are bogus, just more government regulation/interference with the free market, blah, blah, blah.  Hey guys–we tried that, and we got this.  So no, it didn’t work.  Mandating purchase of a product immediately disrupts the free market.  Believe me, if we weren’t forced into it, very few of us would’ve purchased the grossly defective products currently on the market at extortionist prices.  The free market will be effective at leading to competitive pricing of an improved product if we take away the threat of near-term penalties and establish standards for this medical instrument. Then, and only then, can the free market work its magic.

I urge my colleagues, representatives, and medical societies to take up this challenge.  Nothing in our current practice of health care is more important.