Society punishes those who improve it. Emerson observed this fact when he gave up a promising Christian ministry career to instead minister to all of mankind. Don’t expect awards and accolades from the psychiatric profession for bettering it. The awards go to those who maintain the status quo, not to those who change it. Freud never won a Nobel prize; they gave it to the fellow who introduced frontal lobotomy.
Nassir Ghaemi, MD, MPH
Difficult doctor (def): a physician that disagrees with, or fails to immediately and graciously comply with, the expressed directive of any nurse manager or hospital administrator. [cf., Policy relating to the Reporting and Disciplinary Procedures for Difficult Doctors]
Many of you are painfully aware that our work environment has recently become–how best to phrase it? Silly? Unpleasant? Challenging? Flat out, batshit crazy? Yes, let’s go with that last one. (See Doctors Without Barbers). And I’m not even going to grace these new policies with any discussion, because they are so imbecilic as to not merit even this amount of attention.
(Doctor, you can’t leave the OR without a jacket. The short, paper one. No, no, no, doctor, not the full length disposable one. Oh my god no, not the full length disposable yellow one, that’s only for isolation and an alarm will go off if you walk out of here with that on. Wear this one, it’s required, but make sure to take it off and replace it with the full length disposable one you had in your hand a minute ago if you step into the hallway with the brown guardrail to tell the family that your patient survived their operation, then take the full-length but not yellow one off and put the short coat back on when walking between the brown railed hallway and back to the OR, then remove the short coat before scrubbing for your next surgery but you can’t don a surgical mask after donning your coat because that would lead to shedding of dangerous skin cells onto the coat, rendering the entire environment a potential health hazard but you can’t go into the OR without a mask and you can’t walk down the hall with a mask dangling on your chest and you can’t walk down that hall to get a mask without the coat on so I guess you’ll just have to not operate any more today, okay? Sorry, doctor, it’s the policy. Have a nice day.)
Those in the business know that I’m not making any of that up. Really.
So, I received the following email recently from our hospital administrator:
Dear Surgical Physicians, Nurses, Techs, and all Operative Colleagues:
As you are aware, our policy for Surgical Attire is based on National Standards, and was developed to ensure our commitment to Patient Safety , which remains our core value. In addition, proper surgical attire continues to be a major focus for both CMS and the State Department of Health. Unfortunately, many of our sister hospitals (as well as hospitals in other systems) have found themselves in a position where physicians and staff members were not following policy to the specified level, and were subsequently placed on periods of Immediate Jeopardy, in which they were at risk of losing their Medicare and Medicaid funding.
We are doing everything we can as a hospital to follow our policy and avoid situations such as that. I am attaching our Surgical Attire policy as a refresher of the expectations at [our hospital]. At the current time, I will remind you that ALL hair is to be covered, including sideburns and hair at the nape of the neck, as well as any facial hair (i.e. mustache). Our strongest recommendation is that to make it most easy for you to comply, surgical hoods should be worn, often in conjunction with a surgical cap, to allow maximum of hair coverage with minimal effort. Mirrors have been added around the operating theater to allow each physician and staff member to best police themselves.
You are all professionals, and your professional obligation is that you will comply with hospital policy. We will be conducting periodic observations to make sure we are compliant. I would ask that all staff please look to help any other physician or staff member who has not noticed that there is errant hair, or other non-compliance with the policy.
I am confident that we, as a hospital, and YOU as the Operative team, will be compliant and successful.
Vice President Medical Affairs & Chief Medical Office
So much of what is wrong with our current OR work environment is summarized in this completely nonsensical email. Let’s discuss:
“As you are aware, our policy for Surgical Attire is based on National Standards”–actually, no, it isn’t. It is an ungrammatical, unscientific, ad hoc mash-up of AORN policy recommendations, in-house silliness, and a good bit of complete nonsense. It has no basis in JCAHO or Department of Health standards. It directly contradicts recommendations by many national and international scientific organizations, including the American College of Surgery Manual of Perioperative Care and a recent policy statement by the ACS. There is nothing about it that even approaches a rational scientific basis or accepted standards, national or otherwise. It in no way represents any form of consensus of surgeons, nurses, or surgical technicians, either within the institution or at the level of representative organizations. It was authored by a couple of nurse administrators who haven’t seen the inside of an operating room in decades while sitting in a hospital conference room with a few administrators lacking any clinical insight whatsoever and absent any physician, anesthesiologist, or surgeon who might contribute rational insight into the process; i.e., dissent. The resulting policy was then filed in the Manual of Procedures and Policy without benefit of review by the Chief of Surgery, his designate, the OR committee, or as an agenda item at the surgical departmental meeting. Or by the Chief of Anesthesia, or at the anesthesia departmental meeting. Or by the Chief of OB/Gyn, or at their departmental meeting. Or by the Chief of Orthopedics, or at the ortho departmental meeting. Of course it wasn’t, because the physicians affected would’ve pointed out that the document was nonsense. They would be “difficult.”
“developed to ensure our commitment to Patient Safety , which remains our core value”–unfortunately, your core value has been repeatedly demonstrated to be maximizing revenue. Capitalizing the phrase “Patient Safety” in all official emails does not make it your priority. You have an amazing capacity to re-interpret your institutional commitment to Patient Safety if this proves too expensive. It just so happens that arbitrary rules regarding surgical attire costs the hospital nothing. And by the way, if you truly believe that the type of hat worn by a surgeon or OR nurse is an issue of patient safety, you really shouldn’t be allowed to come to work as a hospital administrator.
“Our strongest recommendation is that to make it most easy for you to comply, surgical hoods should be worn, often in conjunction with a surgical cap, to allow maximum of hair coverage with minimal effort.”–of course, this recommendation makes no sense, which is obvious to anyone who has actually set foot in an OR, and creates a situation in which you will be unable to operate, or keep from sweating into your patient’s wound (recent policy change takes away the ability to control OR room temperature without contacting an administrator), or breathe. We’re just interested in making it “most easy for you to comply.” Comply or die, whatever. Minimal effort.
“Mirrors have been added around the operating theater to allow each physician and staff member to best police themselves.”–I have no words.
“I would ask that all staff please look to help any other physician or staff member who has not noticed that there is errant hair, or other non-compliance with the policy.”–Please report your fellow workers to the authorities. You may be awarded the coveted “Employee of the Month.”
And more recently, yet another hospital email regarding this same subject ended with the following threat:
Please review the attached Guidelines for Operating Room Environment and Surgical Attire Policy.
Non-compliance with our policy will compromise the Hospital’s position with the DOH and may lead to financial penalty for the Hospital. For physicians who are found to be in violation of our policy, a ‘non-adherence to policy that compromises patient safety’ note will be placed in the credentials file as part of their OPPE.
So, it’s okay that the OR nursing supervisor is “surprised” to realize that my hospital has no CO2 cylinders available when the tank goes empty halfway through my laparoscopic procedure, which results in no incident report, meeting, or repercussion of any sort, but if I fail to wear a disposable short coat while walking between the OR and the recovery room I will be cited as “compromising patient safety.” A note will be placed in my permanent record.
“Finish each day and be done with it. You have done what you could. Some blunders and absurdities no doubt crept in; forget them as soon as you can. Tomorrow is a new day. You shall begin it serenely and with too high a spirit to be encumbered with your old nonsense.”
― Ralph Waldo Emerson
And now, a rare foray into the political landscape:
And now, for something much more to the point:
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…
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.
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.
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?
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