Category Archives: Surgery

Staring Down Dragons

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Every crisis chooses its heroes. The heroes do not volunteer for the role. Brave souls do not rush to the front line to save us. The heroes, ordinary folk until now, are plucked from their previous lives without warning, whether they are willing or not, whether they are ready or not. In this crisis, there are many heroes (see Heroes in Masks with Mops). Everyone who shows up for their shift—whether they be nurse, houseman, security guard, food service worker, physician, or one of the countless other individuals needed to care for the tsunami of sick COVID-19 patients overwhelming our hospitals–is truly performing an act of courage each and every day. The heroes for the history books, though, the heroes who will be remembered by their colleagues long after this plague passes, are the anesthesiologists, nurse anesthetists, respiratory therapists, and ENT surgeons who find themselves staring down this monster every day–some many, many times on a really bad day. These are the special people whom we will always remember with an admiring nod and a tear of appreciation.nurse-anesthetist-vs-anesthesiologist.jpg.5c6db5df59cf2f07619cd04bbc39f0c1

The AIDS epidemic was the last plague that truly threatened US medical workers. While Ebola and H1N1 challenged us, neither of these crises presented a general threat to the health of our practitioners in this country. AIDS, however, during the terrible years of the late Eighties and early Nineties, killed our practitioners as well as our patients. We forget now, because of brilliant scientists like David Ho and countless others, who have given us effective treatments for HIV. But for several years, AIDS actually was the leading cause of death of people under age 40 in this country, the only time any disease displaced trauma from the top of the list. AIDS killed EVERYBODY it infected. And if the medical professional caring for the critically ill AIDS patient suffered a significant exposure, there was a definite possibility that they would die–horribly, because everyone with AIDS in those days died, horribly. Whole wards were filled with young people dying, horribly. Many AIDS patients developed severe intra-abdominal crises that required urgent surgical intervention. Surgery on these patients was fraught with the possibility of killing the surgeon, because these patients generally had extremely high viral loads at the time of their surgical crisis. This was the first time in memory when we had a national discussion about whether a doctor or nurse was morally obligated to care for an ill patient.

Doctors and nurses were dying. General surgeons, resident surgeons in training, orthopedic surgeons, surgical techs, and scrub nurses were at risk from needle sticks, blood splatters, intra-operative incidents of all kinds; significant or seemingly mundane, but now mortal injuries. Some surgeons refused to operate on HIV positive patients, hiding behind the argument that the patients were all dying anyway. This left the rest of us scrubbing on more and more of these dangerous procedures as others subtly deferred consults. Scrub techs and nurses willing to operate in dangerous conditions were increasingly called upon to fill in for those who declined. NY state entertained a law requiring surgeons who seroconverted to notify all patients of their status in the never-proven concern that a patient might contract the disease from the practitioner. So we stopped getting tested after every needle-stick, we even stopped donating blood, because we were not only risking our health, but also our ability to practice. It was a double-edged sword, with both edges pointed toward the practitioner. We stopped telling our spouses and colleagues about every torn glove or needle stick during an AIDS patient operation, because we stopped thinking about it as soon as we left the OR. But we kept operating on HIV patients, trying blunt-tip needles, extra-thick latex gloves, even chain-mail gloves—none of which helped in the least. Be careful, assume every patient is positive, universal precautions, we were told—all of it went right out the window with the next trauma patient in shock.

This plague has picked a different hero. Now, the riskiest moment for the health care practitioner is the intubation of a deteriorating COVID infected patient. In every hospital, anesthesiologists, anesthetists, and respiratory therapists, as well as many emergency medicine physicians and ENT surgeons, are placing their heads in the maw of the dragon as they insert an endotracheal tube needed to save a patient’s life. There is not a more dangerous maneuver in our current practice. Even worse than the surgeon operating on the AIDS patient, our modern knights staring down this dragon are not protected with chain-mail gloves, cannot even see the enemy, because it attacks—not in a spray of blood or with the pain of an errant needle—but in an invisible miasma. The risk of each individual intervention may be less, but the anxiety so much greater, as no one knows as they pull off their mask if, on this occasion, the dragon’s breath got past their shield. There is no choice but to take a deep breath, say a little prayer, and go on to the next patient.

When our anesthesiologists, anesthetists, ER docs, and respiratory therapists applied for training, none of them took a moment to ask themselves if they were brave enough to do this work. The job interview didn’t include a question about courage. No one signed up for this. They just do the work we need them to do to save our lives. When this is finally over, we will not forget that.

Heroes in Masks with Mops

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The physicians and nurses facing the onslaught of this pandemic are undoubtedly heroes. We salute them for leaving their homes and families every day to face the risk of personal illness and death. Their bravery is an inspiration. That bravery is a product of the oath that each swears upon entering this profession. There are others in this struggle, however. Others who never swore an oath to use their skills to care for the sick and injured. Others who are every bit as critical to these efforts, but who are not receiving accolades and applause as they make their way to hospitals every day, to work another shift at great personal risk. I am speaking of the janitors and housemen and women who work in our hospitals all day, every day.

These brave individuals serve an indispensable role in caring for patients and keeping the medical system working. They transport the patients to the ICU’s, and in so doing, are exposed to the same risks as the treating physicians and nurses. During the painful learning process of caring for the sickest of the COVID-19 patients, it was discovered that the technique of prone ventilation, in which the patient is positioned on their belly while on a ventilator periodically every day, is the only consistently effective therapeutic intervention so far. But this treatment requires the careful repositioning of a sedated patient in critical condition, a process that requires a team of nurses, physicians, and other health care workers to effect safely. Those other health care workers are often Physician Assistants, or Surgical Techs displaced from the now-idle operating suite, and Housemen and women. This oft-repeated therapeutic maneuver puts all members at an equal risk of infection. And while nurses and physicians, PA’s and NP’s are carefully trained and experienced in how to minimize their risks, these other critical team members have–until this moment–not prepared professionally for this effort. Nonetheless, we expect this, and much more, of them. They have stepped into the battle without hesitation.

Janitors also are unsung heroes in this crisis. They are required, just as the physicians and nurses, to don PPE and masks to perform the critical duties of cleaning the rooms and care spaces of the contagion which is pervasive in their work. Our janitors are no less courageous in their efforts. Indeed, maybe more so, as the physicians and nurses are almost always working as a team, with particular monitoring for the proper removal of protective garb and other concerns to minimize risk. Janitors, however, are often working on their own, with no such assistance. Every ICU room, every ventilator, every ER bay, must be cleansed and prepared, else risk injury of the next patient. Without the critical services of the janitors, the system cannot provide care.

These brave health care professionals, the janitors and housemen and women in every hospital, are working just as hard and at just as great a risk, as our physicians and nurses. They never swore an oath. They don’t get the same benefits, or the same pay, or the same accolades. But they deserve at least as much of our gratitude.

 

Please Ring Your Callbell

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Ten minutes into a redeye on JetBlue to JFK, I pull out my earphones in the middle of Nathaniel Rateliff and the Nightsweats’ “Son of a Bitch” to ask my wife why she’s reaching over to ring my call bell. “They just asked for any doctor on board,” she explains. “You’re a doctor,” I point out. “Yeah, I don’t think any of these passengers is looking for an emergency mammogram,” she explains.

The senior flight attendant appears at my elbow. “You’re a doctor?” I nod. “What’s up?” I ask. “Do you have some proof? An ID of some kind?” Geez, this guy is pretty demanding. He scans my surgeon’s club card like a Manhattan bouncer. “Great,” he pronounces. “Follow me.” No problem, I think. I’ve done this drill a few times before. Almost every time, it’s a hyperventilating passenger with more anxiety than pathology.

Senior flight attendant introduces me to my fellow passenger, who is standing and clutching the seats on either side of the aisle in obvious distress. Oops, I’m thinking, this lady looks like a real sick person. She’s trying to breathe at about thirty times a minute, shrugging her shoulders with every breath. She looks scared; like a person who can’t breathe, scared.

“Hi,” I say. “I’m a doctor. What’s the problem, ma’am?”

“I–Can’t–Breathe!”

Got it.

“Let’s get you sitting down,” I suggest. Before you fall down, I don’t add. Because if this lady passes out in the aisle, it’s going to take me and about twelve of my fellow passengers to pick her up. Not gonna be a pretty picture.

“Can’t–sit. Can’t—-breathe.” She shakes her head. Okay then–let’s talk here. “What’s your name, hon? Marie? Great, Marie. Are you having any pain?” She nods vigorously in time with her rapid breathing. “Where is your pain?” She lets go of a seat to tap her chest, then grabs on again to keep from toppling over. “Okay, pain in the chest. Got it. Do you have heart  problems?”  She nods enthusiastically. “Diabetes?” She nods. “Emphysema?” She nods. Well, maybe she’s just agreeable. “Anything else?”

“Sugar.”

“Do you take insulin?” She nods. “Did you take your insulin today?”  She nods. “Did you eat anything before you got on the plane?” She shakes her head. Great. Not just  being agreeable, then. “Any other health problems, Marie?”

“Kidneys.”

“Kidneys?  Kidney failure? Are you on dialysis?”  She nods vigorously. “When was your last dialysis?”

“Weds–breath–day.”

Great. She’s probably on a Monday-Wednesday-Friday schedule. Today is Sunday. Which means her last dialysis was over 3 days ago. Which is a long time to go without dialysis.

So far I’ve diagnosed this lady as probably being in respiratory distress due to florid congestive heart failure, probably having an MI (heart attack), and likely to lapse into hypoglycemia at any moment.  I’m thinking anxiety is not the main problem this time around. I’m going to need to do some kind of real doctor-stuff, not just my usual professionally reassuring murmuring. Which is sort of a problem, because I’m a surgeon, not an internist. But I’m a general surgeon, and we all think we know everything about everything, anyway. So there is that going for me.

With flight attendants’ help we clear the back row and get my patient semi reclined and out of the aisle. Oxygen mask applied and helping–as in her lips are no longer purple. Reassurrance. But patient still expressing distress, feeling of impending death, invoking need for Jesus to save her; none of which are considered ‘good signs’ in this setting. Most important, she is still having chest pain. I break open the completely inadequate first aid kit.  The kit is composed of many, many sealed plastic bags with various drugs and things, poorly labelled and completely unorganized. A bag of saline with no catheter to connect it to the patient. Helpful.

I find the blood pressure cuff and get some vitals. It takes me three tries to convince myself that her pressure really is sky-high, as in ‘impending-stroke’ high. Her breath sounds are even noisier than the aircraft engines and her heart is going so fast I can’t tell if she has a murmur which is just as well because I was never any good at hearing murmurs anyway. My exam does reveal that she has a dialysis access fistula in her left upper arm which has a bounding pulse–which is good, I think.

So at this point I tear open all the little plastic bags and start giving drugs to my patient. Glucose gel under her tongue for hypoglycemia, nitroglycerin for angina, aspirin for the acute MI. I’d love to start an IV but, again, no angiocath in the kit. Great.

The patient looks better but not great–as in, she now looks like somebody who may die soon rather than at any moment. I call over the flight attendant and mention to him that this lady may die at any moment. She is almost certainly not going to hang on like this for the five-plus hours it’ll take us to get to JFK, not to mention the additional half-hour taxiing to the gate. Time to land, buddy. He gives me his shocked face and mentions that maybe I should talk to the pilot. Good idea. He gets me on the little intercom thing and I introduce myself to Captain Pilot.  He asks me about my patient. I explain the situation and tell him in no uncertain terms that she needs to get to a hospital as soon as possible. To my chagrin, the pilot is not enthusiastic about my recommendation. He’ll check in with “MedCon” and get back to me. Really?

More drugs, more oxygen and Marie is alive but still having chest pain. Not good. Blood pressure is better, though. And her breathing is much better. At this point, helpful flight attendant informs me that I’m only allowed to use one more oxygen cylinder. “I’m sorry, why’s that?” Turns out that the plane only carries three cylinders and if I crack open the third one, I’ll violate safety protocol since the attendants need oxygen in case there is a decompression emergency. I inform him that if we are that fucked to have a decompression on top of what’s going on here, he’ll have to hold his breath. He doesn’t find this funny. So maybe, I suggest, he should get the pilot to land this plane like I said twenty minutes ago.

The pilot calls back to inform me that MedCon doesn’t feel the patient’s condition merits diversion. They recommend I continue current therapy, monitor vitals, and report back in thirty minutes with an update. I am pissed. I don’t know who “MedCon” is but I’m no fan. I inform Captain Pilot that if he doesn’t land this plane soon he’ll have a corpse in the last row of his plane. He promises to get back to me. I crack open the third–and last–oxygen cylinder. Flight attendant gives me a very concerned look.

Captain Pilot calls back twenty minutes later to inform me we’re diverting to Denver. Hallellujah! We’ll be down in 40 minutes. Hold it–what? Forty minutes? Captain Pilot lectures me that this is “not easy”, that Denver has “weather”, that it’s going to be “pretty damn bumpy” and he needs to get off the intercom so he can do pilot stuff so I should take care of the patient now, Bye. I’m hoping he’s smart enough to call ahead for an ambulance. Attendant assures me he is.

Half an hour later, I look past my patient and see lights out the window which is the first good time on this whole damn flight. “You’re going to be fine, Marie.” Woo-hoo! Celebration is short lived as pilot instructs everyone to buckle up for an unscheduled landing because the doctor in the back row is making us do this and by the way it’s going to be pretty damn bumpy because there’s a thunderstorm over Denver airport where we’re about to make an unscheduled landing so good luck with that. I’d be pretty pissed at the tone of the overly detailed announcement except I’m busy trying to keep my patient breathing and the last O2 cylinder has been on fumes for the last 3 minutes. I strap in and strap in Marie next to me across two seats and position myself to keep my hand on her pulse as the gear and the flaps come down and we’re bouncing all over the dark stormy skies of Denver, a flash of lightning illuminates the plane and I see a few folks from the back rows looking at me like, “If we crash and die, it’s all your fault, asshole.” So I smile except at that moment I realize that I can no longer feel a pulse on my patient. I attempt to discuss this problem with Marie but her eyes roll up in the back of her head and she slumps over as she stops breathing and proceeds to die.

“Oh, fuck! Really, Marie? Now you pull this?”

I unbuckle and stand up so I can lay my patient across all three seats. Helpful flight attendant yells at me that I must remain seated, we’re landing. Yeah, right. I start doing CPR which of course causes everyone in the last four rows of the plane to start screaming, which makes it tough to hear the automatic external defibrillator announce that “No, your patient does not have a shockable rhythm so, sorry, I’m not going to be much help. Just keep doing the chest compressions. Click.” Which I do while alternating breaths with the Ambu bag hooked up to the empty oxygen cylinder when a very pleasant young lady appears next to me as the plane jounces onto the runway and she asks, “What the hell are you doing?” I explain that I’m doing CPR, are you a doctor?” “I’m a family practitioner, can I help?” “Well, yeah, lady, where you been the last few hours or are you an Leprechaun Family Practitioner that just magically arrived on this airplane?” “Sorry, I was asleep, I didn’t know.” So she starts doing compressions so I can give drugs. Of course, I don’t have a working IV so I shoot an amp of epinephrine transtracheally into her windpipe and shoot another one into her fistula followed by an amp of bicarb because, well, what the hell, it can’t hurt and just might help. Mr AED still isn’t going to shock anybody but there is a pulse which is a definite improvement. Late Arriving Family Practitioner and I alternate doing chest compressions as several of our fellow passengers helpfully record our efforts on their cellphones. A kid leaning on the back of his seat keeps asking if that lady is dead and I’m impressed by my colleague telling him to shut up and go back to playing video games. At this point, the plane arrives at the gate and quite suddenly a squad of EMT’s arrive and somehow get not-entirely-dead-Marie on a gurney and up the aisle to the concourse. Well-Rested Family Practitioner and I follow and see that Marie really does have some type of rhythm on the monitor just before they package her up and speed away towards Denver General. Vaya con dios, Marie!

Well, that was fun–not!  I walk back to my original seat next to my wife and realize that my hands are shaking. I’ve done surgery for over thirty years, including a lot of pretty crazy trauma stuff, and I’m sure that this is the most shaken I’ve ever been after taking care of a patient. I was planning on discussing these feelings with my empathetic and supportive spouse, but I’m shushed by her so we can listen to the pilot announcing that, no, we won’t be taking off shortly to continue our voyage to JFK. Rather, he explains, this emergency diversion required by the doctor sitting in seat 6B has eliminated any chance of making it to JFK to be home with your loved ones or to make all those connections to lots of fun places because the doctor used up all the oxygen and the crew is traumatized and not allowed to continue so we’ll all be spending the rest of the night here in Denver International and we’ll try to get you seats on a plane in the morning to New York or somewhere, probably. Thanks for choosing Jet Blue!

At this point there is a general groan and many pointed stares pointed pointedly in my direction.

As we all gather up our carry-ons and make for the exit, I see Captain Pilot leaning against the doorway to the cockpit. I stop to chat. I introduce myself as the doctor who was on the other end of the intercom. “Oh,” he says without a smile. “That was you.” I agree that was indeed me. Just because I’m curious and still a bit pissed off, I reveal to Captain Pilot that I was surprised that there was such reluctance to land the plane even though it was my professional opinion that his patient was going to die otherwise.

Captain Pilot looks at me with a steely gaze and, in that Southern pilot drawl that they all have, says, “Doc, you got one life to worry about back there. I gotta worry about 186 lives. You do your job, I’ll do mine.”

I guess that’s pilot talk for “thanks for your help.”

 

 

Difficult Doctors

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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.

Dread_Pirate_Roberts_by_bryanhumphrey

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.

Sincerely,

[name deleted]

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.

Seriously.

 

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

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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

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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?

Electronic Medical Death

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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

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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

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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.

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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.