Wednesday, November 25, 2009

Double the work, to increase efficiency?

Right in time for the huge increase in "I met my deductable and want my surgery now season", the medical center decided to implement a new computer charting system in the ORs to increase efficiency and decrease costs. So far it has caused every case to run late and a has caused the hospital to double the circulating nurse staffing. The system is supposed to help the OR be more efficient by not only charting but by tracking all the supplies, meds, implants etc. The only ones who can enter data in the system are the circulating nurses. So here is the problem. The circulating nurse is the one who is there to make sure the patient is safe and the surgery runs smoothly. So, now the circulating nurse has to sit infront of the computer, away from the patient and enter page after page of data. We still need a circulating nurse to do what the circulating nurse is suppose to do, so guess what? We now have to have two in each room. One to actually take care of the patient and one to take care of the computer. Thats increasing efficiency and decreasing costs!

Monday, November 23, 2009

Naval stalagtites

I know that the old story is that you should always wear clean underwear in case you get in to an accident, but we just cut those things off with big bandage scissors and toss them on the floor when you come in with a multitrauma. The real problem is when you have a patient that you have to take to the OR to do a trauma lap. You spread paint on the abdomen and right next to where you are going to make your incision is this mass of unidentified fibers, sweat and sebum full of bacteria and often the occaisional piece of gum or french fry. You grap it with sponge stick and pull and it wont come out. The patient is crashing and you just pour betadine on it and cut around it hoping that it doesnt fall out into the belly. I dont care what kind, how clean or even if you are wearing underwear, please just keep that crud out of the belly button!

Oh, wait a minute. I have got an idea. I just have to come up with a special, single use disposable naval smegma extractor. Then I write a paper in which I show a Press-Gainey study that it potentially could cause improved survival and get JACHO to mandate a three page chart document that shows who and how the goo was removed, its color, clarity, palate and aesthetic qualities making sure that it in no way is discrimatory and make a fortune. We will have to charge a lot for the extractor to cover the lawsuits where people claim loss of consortium for all the pain that they have had post lint extraction and those that claimed that we participated in a class action against all those who have navels. I wonder what portion of the population are outies vs inees?

Oh, while we are at it, could you also trim those toenails?

Sunday, November 22, 2009

BS Check!

The State of Tennessee has instituted several tort reforms in the area of medmal. The two big ones are that plaintiff attorneys must file a pre-suit notice and the have a certificate of good faith from a physician that attestst that there was a possible deviation of the standard of care (BS check!). Tennessee saw a huge rush of suits filed before the law went into effect. Since the law has been effect however, medmal suit filings have dropped 65%. John Day at Dayontorts ( has a great piece on it. In my little group of docs, most of carry malpractice insurance because we want patients who are harmed because we screw up to be taken care of. What we dont want is to be dragged into court because we are seen as a cash cow for some plaintiff and their attorney who figure that all they have to do is be a big enough pain in the neck to get some money. I think it will be interesting to see what the effects are of these reforms. Will the number of judgements against physicians be the same? What will be the total defense costs? I hope that injured patients get what they deserve and frivoulous filing attorneys get what they deserve.

Friday, November 20, 2009

The Government Insured

This was a letter to the editor on August 29, 2009 in a Jackson , MS newspaper.

Dear Sirs:"During my last night's shift in the ER, I had the pleasure of evaluating a patient with a shiny new gold tooth, multiple elaborate tattoos, a very expensive brand of tennis shoes and a new cellular telephone equipped with her favorite R&B tune for a ringtone. Glancing over the chart, one could not help noticing her payer status: Medicaid. She smokes more than one costly pack of cigarettes every day and,somehow, still has money to buy beer. And our Congress expects me to pay for this woman's health care? Our nation's health care crisis is not a shortage of quality hospitals,doctors or nurses. It is a crisis of culture -- a culture in which itis perfectly acceptable to spend money on vices while refusing to takecare of one's self or, heaven forbid, purchase health insurance. A culture that thinks "I can do whatever I want to because someone else will always take care of me."Life is really not that hard. Most of us reap what we sow. Don't you agree?

Physician Name Deleted at my discretion, MD Jackson , MS

Halstead is Dead!

I was called to see a patient urgently. Of course I got there and started to take care of the emergency and once things had calmed down, I went to the chart which of course meant logging on and slowly making my way through all the HIPPA screens and then the whole thing crashed. About this time the resident of the service of whom the patient was on came in and I started asking him what her labs were and her past history. I got a shrug and he said that he would get the intern as he might know. It was all I could do to no take his head off right there. (It is the kinder more gentle era of medical education where incompetence is met with, please do better next time and I hope that your feeling were not offended!) This is the new"team" way of teaching medicine. You only have to work a certain number of hours and no one is really the boss or responsible, the patient is "the teams" not a specific doc.

I know I am dating myself but we trained under the halstead principles. We were expected to know everything about our patients and be able to recite their labs, history etc from memory. We drew their blood, we pushed them to the OR and got to know their families like they were ours. For all intents and purposes, we lived at the hospital. Everything about our pateints was our responsibility. If we failed in that responsibility, punishment was harsh and instant. We weeded out surgical residents with only a few surviving to the top of the pyramid.

Now we have a scary trend of shift workers and a mentality of not being totally invested in patients that is slowly creeping into medicine. The Halsteadian code of ethics and responsibility is being eroded by "its not my responsibility or someone else will do it". We cant reprimand or even fire bad residents because they can claim to be ethnically, sexually, intellectually discriminated against. When I am sick, I want an old school doc, not one of these time card pushing, Union docs.

Saturday, November 14, 2009

Homicidal Family Members

We review all the codes that occur in the medical center to see what happened and do determine how best to improve our responses and to prevent the events that lead to the code. One code this week involved an elderly patient who had a stroke and and as result had severe dysphagia. They had a feeding tube in place and were strickly NPO. The patient suddenly had a respiratory arrest and when the code team went to intubate they had to remove a large portion of fried chicken from the glottis. The family though that since the patient loved fried chicken, that a little bit wouldn't hurt. The second case was in one of the units. The sedation was decreased to allow the patient to start to wake up to begin a weaning trial after bypass and valve surgery. While the patient's family was visiting the nurse went to do her charting outside of the room. Appartently, the family saw the patient was starting to move his arm and decided to undo the restraints. No sooner had they started to release them than the patient reached up and pulled out the ET tube in one swift motion with the cuff up. Luckily the team was able to get the patient re-intubated before laryngeal swelling made it more difficult. The famlily immediately blamed the nurse and the hospital for "poor care" and "letting this happen" and denied that they did anything. We were fortunate that we have each ICU room on CCTV and the whole event was caught on tape. Of course I am sure that the tape is a HIPPA violation but we were able to show the family that it was their fault.

Wednesday, November 11, 2009

Thank you for your service!

You have got to love how our government shows its support for our troops. The health insurance for our soldiers and their families is called Tricare. Tricare pays on average the same amount as Medicaid, which is 60% of Medicare and comes with a lot more governmental headaches. It pays so low that our military families often have to travel out of state to find a hospital or doctor that will accept it. Tricare mandates precertified and approved appointments for all specialist care and outpatient visits. Federal Employees and Congress on the otherhand, have BCBS which pays top dollar, do not need referrals and can go wherever they want.

Welcome to the world of government dictated single payor healthcare, and the first people to get the shaft are the ones who actually are the ones fighting for out country.

Friday, November 6, 2009

Angels fly home

We lost an angel today. We watched her grow and fight infection after infection, endure numerous days in the ICUs and pic lines after hickmans. Everyone in the hospital was her friend, she was our family. The nurses were her teachers, mothers and sisters. Each infection and episode of pancreatitis brought her pain which she endured with a smile. She would joke that she like sherbet ice cream even when she could only have it through her g-tube. Her cystic fibrosis made the hospital her home and her life. She was hoping to get a lung transplant but the flu was too strong. We miss you Lindy and know that you are not in pain.

Local and Vocal

We are in a medical crisis. On top of if all there is a severe shortage of propofol. There are two companies that make it. One had a contamination problem with metal shavings and I am not sure about the other but it has been recalled. The side effect is that is is scarce. So instead of a little bump of propofol for the needle sticks and the infusion of the lidocaine, you get some versed, fentynl and a bit of "just a little poke", "stay still"! I dont know about you but I will wait until propofol is back before any colonoscopy!

Thursday, November 5, 2009

Signing out AMA

I hear that the American Medical Association claims that it represents Americas doctors but I sure cant find any in our town who believe it. From what I can tell, they may have about 13% of the physicians. Anyway, I cant figure out for the life of me why the AMA would even support Pelosi's healthcare bill. I know that many of us are scared of the SGR thing and it would decrease Medicare payments by over 20%, but man selling your soul?

The same goes for AARP. Did they even read the thing? Anyway, at least the docs I know are signing out of the AMA.