Coal in the Stocking

I really, really wish insurance deductibles ran on the fiscal year instead of the calendar year! It seems all too often people put off things until the holidays hoping to meet their deductible or just give up on meeting it and wanting to get things done before it starts all over again. Soon after thanksgiving, people flock to the office to get that CT or MRI or endoscopy that they have been putting off, or to have that funny pain when they eat checked. They absolutely want it done before Christmas. Sure enough, we then get to spend the holidays being BAD SANTA telling them and their family that they have some horrible ghastly cancer. Cant we just make deductibles end on April 15th so all the bad news is at the same time?

The Otis Effect

We had to cancel our study of the Otis effect early because the data reached such a statistical preponderance so early. We found the following things to be true. The elevator that is the farthest from you will always be the one to open the doors. the time that the doors are open is exactly 2 seconds less than the time it takes to get to the elevator. This is especially true in the middle of the night when there is not anyone else on the elevators. When you get in the elevator and have to be somewhere in a hurry, all the floor buttons between you and your destination will be pressed. This effect is enhanced when your destination is the parking lot to go home. If your arms are full, however, the only button not pressed will be the one that you need pressed. Further, when you ask for help, someone will press the wrong button. Flatulence is immune to the ventilation effect of any elevator fan. Lastly, the person who wants to get off first will always be the one farthest back.

Bobcat

My back is killing me. Sometimes it doesnt matter how many people you have to move a patient, especially when they have all their monitors and drips. Just trying to push a wieghted down ICU bed is a struggle. I was at the local lumber yard and saw someone moving a bunch of heavy duty carts. He pulled them along with a bobcat, put them where he needed them and then filled them with the bucket. It was awesome. I wonder if you can get a Bobcat into the hospital. I was thinking about a fork lift as well but with a Bobcat you load and move all that other stuff. Better yet, what if hospital beds where made by Bobcat? Each bed would be like an industrial hover-round with a winch, scoop bucket and a hydrolic lift system that you turn around real quick and easily. Press a lever and you could load and unload. When the pateints are alert they could drive themselves around.

Jelco, I Miss you!

Yet another JACHO inspection is coming. Someone found my stash of Jelco's. Over the years I have learned to put these into about any vein, use them artlines and even drain abscesses. As part of a "safety program" the medical center has been replacing them with these crazy expensive things that you have to push a button or slide a snap or do something else other than just put in the IV. Worse, you then have to unscrew the darned things while the blood drips on the floor tyring to insert the IV line. I guess to improve "safety" we have to stick the patient more times and use these impractical things.

I have heard we can get some on the black market. With the drug shortages maybe I can swap some anectine for a case of 18Gs.

Flame Out!

Back in the good old days, the internists, pediatricians and family medicine docs woould come to the hospital and round or even have their office next to or attached to a hospital. The doctors lounge was a place to grab a cup of coffee and run into each other to discuss cases and keep peresonal contact to see if that other doc was someone you wanted touching your patients. Now there are hospitalists. The referring docs dont want to step foot in the hospital becuase they will be forced to sit on committee after endless JACHO/CMS committee, not to mention fight yet another computer system. So, they dont even apply for hospital privaledges anymore. To keep in contact and to help build good referral relationships, we periodically go out to their offices and say hello. Last week I went to a group of awesome internists. As we were sitting down over coffee, one of them said that they were closing their practice at the end of the year. I asked him why, and said it bluntsly, he and his partners are Bingo on the fuel to practice and they were having a flame out. He said that they all find that they have loss of autonomy, loss of control of their practice conditions and their time is being more and more wasted due to all the administraction and paperwork crap. He said, in fact they were going to shut down last year but with the stock market tanking they were hanging on to see what wass going to happen. They figure it isnt going to get better so its better to just fold up. I left their office dejected, and went to the next one. Their practice is breaking up, 2 of the three are calling it quits. I wonder how much of this is happening accross the country!

What you need to know and why you need to know it

Medical records used to be a helpful tool to communicate to others what was going on with a patient and how to help pass on their care. The same was true when we signed patients out to each other. A mantra that we used was to be sure we told each other what they needed to know about each patient and just as importantly why they needed to know it. What was different about that patient was immediately passed on. Ms. So and so had a colostomy after a perfed tic, she is stable but she has been on steroids! Nuff said, you knew what to watch for and where to go when things went bad. Her medical records had the pertinent positives and pertinent history. You could pick up the chart, know what was going on and get down to business. Now it is just the opposite. We will have a patient sent in from somewhere. With them will be their records. A multitude of pages that list negatives like "No family history of travel outside of North America. Page after page. You have to sit there and play "Where's Waldo" to catch a glimpse of what is going on with them and pray you find the needle in the haystack. Of course it is all computer generated so you know that someone just clicked on a template so all that is written is BS anyway to comply with some CMS thing and to have "it documented in case of litigation". Its bad enough that it was happening in the paperwork but now it is creeping into direct communication about patients. One of the residents was seeing a patient in the ED and called me to run the case. They started with all the things the patient didn't have. I cut them off and said, "What do I need to know, and why do I need to know it?" There was a pause, then more of the BS about fibro and pain scales. I finally said, "Do they need to go to the OR?" A feeble, yes was the reply. Then I asked "why do they need to go to the OR?". Severe abdominal and back pain with free air and dependent fluid on scan was the answer. "Ok, then. What else is important that I need to know?". Crit is 30, they are probably septic and have afib with a recent stent and an EF of 30%. Crisp, clear, concise. Time for a Bard-Parker Scan!

Gremlins in the wiring

I just saw that the company that makes most of the surgical robots is being sued when one of the robots stopped working and the surgeon had to convert to an open case. First, I was surprised that this was a lawsuit because it is commonplace to have consent to convert to open if necessary but anyway, the suit is claiming damages because the robot broke. Like many surgical tools, the robots are designed to shut down before anything bad can happen, apparently they are supposed to be indestructible and never fail. I hate to say it, but stuff breaks. Sometimes it is the new stuff, sometimes it is the old. I have had a harmonic generator basically melt down, microscope bulbs blow, drills chew their bearings out, tourniquets explode, anesthesia machines fault out, lasers just become possessed. You don't want to know about what the perfusionists have to deal with. The point is, things break, Gremlins get into the wiring. This is the risk of surgery. That is why in addition to using all the high tech stuff, we learn to use our hands, scalpels and silk ties.

Net Loss

Had to go to one of those dreaded third quarter status meetings of the medical center. Here is the breakdown. Patient volume, up. Reimbursement down. Overall costs up. Termination of 54 nurses (rns/lpns). Hiring of 71 "data management specialists". (they make more than the nurses do!)

So, in order to take better care of patients, we have had to fire those that take care of patients and then hire more people to take care of the computers. On the brighter side, we have more people to take care of who cant pay with less people to do it.

The Elephant in the Room

In an effort to decrease the widespread shortage of medications, the President today ordered the FDA and the CDC to increase the things that he ordered them to do that caused the problem in the first place. Here are some of the generic, life saving medications that are in short supply due to the mandate that all older drugs go through millions of dollars of testing that new drugs go through and as a result, no one can affort to make them: fentynl, succinyl choline, etomidate, propofol, decadron, and phenergan. Before you need that life saving surgery, better call ahead and reserve some of these meds!

Is there anyone else who would like me to do their Job?

We just got word that two of the biggest pharmaceutical chains as well as the national organization of pharmacists will no longer fill any prescription that does not have the quantity on it. The reason, they dont want to be responsible for having to figure out the quantity and therefore be responsible for any errors. This is on top of the fact that almost none of them will do any coumpounding. Where this is an issue is that many medications come in different doses and forms. These very big time in price. A classic is prednisone. 5 mg tabs are the same price as 10 mg tabs. So a patient can ask the pharmacist for the 10s and take 1/2 and save 50 %. Of course, the pharmacists does not ever want to substitute a suspension for the tablet because they have to do math. The governement wants us to eprescribe so they can keep track of all the scripts and your personal information. Part of this is that the script goes straight to the pharmacy instead of the patient. The result, the patient cant call around to see who has the best price! In our area, some of the smaller non chain pharmacies beat the others by a substantial amount. This is a big deal for those in the donut hole! I guess pharmacists just want us to be sure we send electronic scripts so they can charge the most, not have to be responsibe, while the government wants us to be their stool pigeons and rat out our pateints.

Un-Meaningful Use

I think I almost have my computer fixed. I threw it accross the floor doing the G+D<<< Electronic Medical Records. These record systems are all build backwards and are geared towards what the government wants and not what is best for and how to take care of patients. My favorite is that they automatically report to the government the patient's use of tobacco and their body mass index! That is just the tip of the iceberg. They also record other demographic information and send it as well, such as race, sex, etc. Medical charting which at one time was used to help you take care of the patient, is now something that is done to the detriment of the patient. The patient comes in and you do your best to take care of them and then generate a computer driven bundle of initelligible drivel that no one can read, much less understand why the patient is there, thats only purpose is to comply with government mandates and by way of such what the insurance must have.

Next time you go to your doctor for that rash, just think, your BMI is being sent to the FEDs!

The Seven (deadly sins) Entitlements

It slowed down a little bit last night in the ED, at least in terms of the "real Emergencies". There was still the late night cohort of the STDS, low back pain, you know, the usual. At the window was a man in his early thirties screeming at the triage nurse that he was disabled and how dare those others go back before him. I dont know why but somehow all the protestors who are in Wall Street popped into my mind. This guy is screaming that he deserves and is entitled to things because of his (deadly sins). He is envious of other going before him, he is drunk and morbidly obese, he is definately full of wrath, turns out he had a STD. Watching the Wall Street protestors, it seems almost the same thing. They are full of wrath, they dont want to work for things, rather they want it given to them, their gluttony is that they all have laptops and iphones, they want it all!, they are envious of those who have achieved, their pride is that they believe that they are entitled to what they lust after.

Locutus of Borg

Just like the others, we are being forced to be assimilated by CMS with the mandate to go to electronic medical records. I have named ours Loki after the norse god of discord and mischief because it has pretty much destroyed our practice and ability to practice medicine. With out embelleshment, so far the EMR has decreased our productivity by 45%, doubled patient wait times and cost over 92K/physician to implement. Worse, it is still not running correctly. The touted improvement in the ability to take care of patients is not there, nor is improved office efficiency. All it seems to be able to do is create thrirty page reports to comply with the Federal Governments "Meaningful Use" demand.

I though we were the only ones who felt this way but then I started the whole conversation in the lounge at the hospital. There was not one doc who liked the things. On the average, they all have seen the same thing. Thank you Fed Gvt.

The Go To Light

I was called in to see a patient in the middle of the night. As I was checking on them a code was called on the floor I was on. With great concern I poked my head out of the room hoping to see someone else in a white coat looking like they knew what they were doing going to the room where the code was happening. No such luck! I went over and started doing the doctor thing. Airway, tube in, pump chest, push drugs, pump, pump. In the middle of it all, it was pretty dark in the room. Someone recognized that fact and hit all the switches. There over the bed was an exam light that was stronger than a landing light of a 747, I mean it was blinding. Soon as it turned on we all had to squint. Someone in the back said, "dont go to the light"! We got the patient back, PEs suck! I couldnt help wonder how many of those "I saw a white light" stories where those darn exam lights.

Phone Solicitors

One of the hardest things about being on call, is all of the phone calls. Our answering service does a great job telling patients that we can not diagnose over the phone or call in prescriptions after hours. It also tells patients that if it is an emergency they are to go to the nearest ER. Lastly it tells then that we are on call only for acute post-operative problems. So, what happens? They lie to the service and we get called. Many are drug seekers, many hope to call when the office is closed so they wont have to come in.

Here are some of the latest. A patient called stating that he had surgery and one of the doctors was supposed to call in an antibiotic and that he had just called the pharmacy twice and it had not been called in. I asked what kind of surgery he had and it wasn't the kind that doctor even did. I then asked for the pharmacy number and he said he didn't know it and would have to look it up. When I reminded him that he said "he just called it twice" he hung up.

Another person called and said that they had surgery two years ago and now they were having a bad headache, could we call in some percocet?

Three were calls from people who thought they were getting a cold, could we call in an antibiotic. (two of these were after midnight!)

I had two calls last night from people who wanted to set up an appointment at some time during the month.

I know I have talked about this before, but I just had to vent.

Rule number two

I was doing rounds and right next to me one of the critical care attendings was also doing rounds with his posse of fellows, residents and medical students. He is a very brilliant, quite person who I had never heard crack a joke or even change his expression. A young intern was explaining that the patient came in with sudden mental status changes and fever. They had done a spinal tap which was bloody but did have some white cells. The attending asked what the next tap showed, the intern explained that they only did the one. The attending looked right at him and said, always remember "rule number two!". I cracked up. He looked right at me and grinned, I explained that I had better run, "you know, rule number one!" Only the medical students seemed to know what we were talking about when one said that he knew where there were some twinkies!

Cyber Staph

I knew it was going to happen sooner of later, but I was surprised how fast it happened. Ive heard about computer viruses but now we have computer bacteria. We had an uptick in the number of nosocomial infections on the first floor to have computer order entry mandated. Most of these were staph. After an exhaustive search we found the source. It was of course the computer keyboards that were used to enter all the orders. It appears that once the keyboard is contaminated it is rapidly spread because people have to keep going to computers to do anything and before you know it, the staph is spread everywhere. Worse, there is no way to clean and sterilize the keyboards. The touch screens were worse because they seem to keep a static charge that attracts all the floating dust and bacteria to the screens! One of our administrators suggested that all computers becovered in one of those keyboard plastic things, but when I mentioned the tough screens he blew me off. I saw him later sneeze and cover his computer with mist!

Kobayashi Maru

We are now in the third month of our government mandated electronic medical records system. It is amazing, not only does it require more staff, it also allows us to see half as many patients in twice as much time! On top of it all, patients complain that the computer is being takencare of instead of them. For the patients who are really lucky, it Eprescribes their prescriptions to one place so they cant shop around for a cheaper price. On a side note, we have just learned to break into the system so we can at least bypass some of the government mandated stuff to at least try to take care of some patients.

Butt sweat

Every now and then there is something that happens that no matter how hard you try to keep your composure, its all over. Today was one of those times. I was doing a history on an older patient who was being admitted. His family member was trying to recall all his medical problems when one of the things that was going on was "something that sounded like butt sweat". I couldnt figure it out until at last it made sense. The patient was having problems eating. Then I got it "AS-piration!"

Surgery cant cure phantom symptoms

Every now and then there is a patient that makes you just sit back and know that it is going to be a hard case. Not because it is technically difficult, but that the patient will be difficult. What I mean is, there are some who make up symptoms to be put into the hospital for the attention that it gets them. This is far more than the fibro patients. These patient complain of everything, but on careful questioning their symptoms wander all over and they cant quantify or localize any specific complaints. Unfortunately, sooner or later, someone will do a diagnostic study for one of the most rare conditions that exist. In the study, something incidental will show up. The patient then focuses on that and we are off to the races. Well, we had a patient like this show up in the ER. They were admitted and started their whole history. When the resident called me, the first thing I said was call every medical center in a four hour radius and get all her records and charts. Sure enough, the patient had been in every one and had every test known to medicine. At each hospital was a psyche consult that showed the patient was not right. This patient had years ago complained of vague abdominal pain. Unfortunately, someone went and did a laporoscopy. So every time she comes into the hospital, someone else decided that since nothing is showing up she needs another laporoscopy or open exploration to look for adhesions. As a result, we are off to the races. It is going to be a long call week.

Anton's Syndrome

In true wisdom the administration decided on a computer order entry system and then mandated that the whole center go live with it last Saturday. They turned their blind eyes towards all the problems that were pointed out in the system and did not bother to discuss it with the physicians. It lasted 71 hours. Even with all their manadated training and PR the system crashed the whole medical center and increased medical errors 10 fold. There had to be an emergency halt placed on using the system and an immediate reversal to go back to the old charts. Still allowing their Anton's Syndrome to override all logic, the administration now states that it will be back on line once the small bigs are fixed. The biggest medical errors were of course, people paying attention to the computer instead of the patient!

"I love the smell of Play Doh in the morning!"

We had a JACHO inspection of the Childrens Hospital last week so all the things that really matter to the kids were hidden. Of course with JACHO you cant have toys for the kids to play with because they might have germs or be racially/socially incorrect. Crayons are right out becuase they are a choking hazzard. Now that JACHO is gone, we can bring out the one thing that helps every child in pre-op as well as their parents. Play Doh! Sure it is against JACHO, but you can hand it to any child and they immediately start playing. For patents, the mere smell brings them back to their own good childhood memories. It is a sorry state of affairs when we have to smuggle Play Doh into the hospital!

Digital Neglect

I'm having a bit more time to write as I wait for meds to come up from the pharmacy. Before we could call down and they would tube them up. Took about 5 minutes. Now it has to be entered into the computer where it vanishes and you wait and wait and wait. You then call down to the pharmacy where they reply that they have to log in to see if it has made to them. If it has, they have to do all kinds of other stuff on the computer before they can go get it, mix it and finally send it up. Takes about an hour. Isnt efficiency great! Anyway, as you can tell one of my pet peeves is taking care of the paperwork instead of the comouter. I have been collecting incidents where this has happened but some of my favorites are when the family memebers take matters in their own hands becasue the person who is supposed to be taking care of their loved one is too busy on the computer to come and do their job. the latest is when a patient had accidentally disconnected his feeding pump from his NG feeding tube. I happened to come in and saw the wife put it back on, reset the pump and sit back down. I was impressed. She saw my look and said, that she knew how to change the IV bags, reset the IV pump and zero the lumbar drain. I asked if she was a nurse. She said no, she had to learn becuase the nurse was too busy to come in and fix these things. She added, "God help those pateints who dont have anyone with them!"

Scavenger Hunt

We do our best to share the pain of who takes call during the holidays. This year it is my turn to take call during the great medical center wide scavenger hunt called the first week in July. This is when all the new interns start. They are doing their best to find their way around while learning to take care of patients. Of course, the new "patient centered focus" means that instead of actually learing to take care of patients they are learning how to navigate their way through the hospitals new Computerized Order Entery system that was also started this first week of July. (note to self, dont get sick the first week of July). Where we used to have interns lost trying to find interventional radiology and the microlab, they are now lost in cyberspace trying to figure out why insulin is listed in the computer under "adult" instead of "insulin"! Before, interns and residents all had Washington Manuals in their pockets so they had a quick reference on what to do when the patient s/p xlap for dead bowel went into vtach. Now their pockets are full of notes on how do you log in and make your way through all the HIPPA screens to find out if the patient already had been given his K. I was called in to consult on a gentleman and when I sat down and talked with him, he said "I hope that d*** computer is doing better because I sure aint!"

CPOE DOA

I just had the opportunity to see what happens when you mix hospital administrators with computer geeks and accountants. You get computer order entry. This is basically where instead of writing orders in the chart, you have to find a computer and then enter them. This seemes like a great idea to the people above who have never been in the ED, OR or a hospital unit. It kind of goes like this. You go up to see your patient. Of course, to find out what has happened and their labs, you have to log into a computer. You then walk in to see the pateint, do your exam and then have to relog into the computer to enter what orders you want as well as to review what other orders others have written. Of course, you have to do this to every patient. Wait a minute, the nurse and the CNA as well as speech, nutrition and everyone else has to enter everything into the computer as well. What, their isnt enough computers? So now you have to wait to find a computer. Since it logs you out because of HIPPA, you just print everything out so at least you have some of the information. You then write your orders down on scrap paper until you can find a computer to enter them. This is what administrators,accountants and computer geeks call efficiency. Yet another great example paperwork (now computerwork) over pateint care.

Foxhole Faith

Several years ago I took care of a college professor. He had sent me a letter saying that he did not like my manner. Spefically, he did not like that I said God Bless You at the end of each encounter. He had written taht he did not believe in God and that may saying that was offensive to him and therefore wanted all his records and was finding a new physician who was in tune with his beliefs and was not forcing their faith upon him. Anyway, he showed up in the office this week with a stage 4 tumor and asked me to be his surgeon to remove it. I still said God Bless You, he replied, I need it.

Maimonideen Moment

We had a dinner to celebrate the retirement of a great doctor tonight. Like many doctors, he really wasnt retiring just scaling back to one day a week. Throughout his career, he never asked if people could pay, infact, many times he never charged. He never turned anyone away. As we spoke of our esteem for him, someone said something that just struck me. It summed up what we are and who we are. To paraphrase: " As physicians, we see all regardless of their race, income, predjudice, social class. Those we see entrust and share with us their souls in the form of their fears, aspirations and worries. We see all as equals in gods eyes and we never see a patient anything but a fellow creature in pain. We are entrusted with the souls of our patients, to provide comfort for their pain and to watch over them. This is our calling, a calling that exists forever and can not be recended, it can only be passed on with greater understanding of its dimentions."

Cooties Jump both ways

When I go to examine a patient, I always put on a pair of those purple gloves that I despise. Today, I went to see a patient and said hello and put on the gloves when the patient said that he did not want to be touched because Drs carry all kinds of germs and spread them from patient to patient. I paused and thought about it for a second. I had to see this gentleman because he had a huge abscess that he got from drug abuse. He was unkempt and had a rash all over that looked like a cross between meth skin and scabies. I dont think he had bathed in a while as the odor in the room reminded me of a gym bag that had been left in the trunk of a car in a hot day covered with all the old laundry that a football team could muster. Politely, I accommodated his wishes but I have to admit I was the one who was more worried of catching something.

Air Getting to Cancer

Three times today I had to explain the same thing. In each case, a patient had a lymph node that was suspicious and I was asked to remove it for a biopsy. In each case, the pateint at first refused because he/she had heard that once you get air to those, cancer goes everywhere. I try to explain that cancer does not behave that way and that in those cases that they heard that about the cancer was everywhere and the biospy just proved it. It is hard because I dont want them to think that the cancer is everywhere becuase we hope that it is just in the single lymph node but you can never tell. It always seems that no matter what, if the node is positive, the pateint will think that you spread the cancer because you got air to it.

EPA Job creation

I have a large group of patients that I take care of to the best of my ability who have lost their jobs and insurance. Most have had cancer, some chronic conditions. I had one come in today. He was both happy and sad because he now had a great paying job and good insurance but it was temporary. He is an Iron worker. He explained that suddenly he and his collegues have more work than they know what to do with. They are taking apart factories that had shut down hoping for the economy to improve. Apparently there is some new EPA regualtions that will make it very costly in the future to dismantle factories so any factory that thinks it may not be able to reopen in the future is in a rush to tear it down. In my patients case it has created jobs cutting up the steel and breaking up the boilers into scrap that is then shipped to China. Of course, all the jobs that the factory had were lost, and now the whole factory is lost and can not be re-opened, temporary jobs were created because the EPA regs, but once the factory is gone, so will the jobs.

JACHO/HIPPA free Zone

It was so refreshing. I saw over 400 patients and did not have to worry about JACHO or HIPPA. Of course it was on a medical mission trip to Guatemala. We saw and treated patients. We saw vitamin defieciency causing blindness, parasites killing children, simple infections devastating families and treated them all. Some we treated in mud huts, others on the floor of simple churches. The pateints were thankful. I wonder what JACHO would say about the hospital that was made of mud? Would we have to get HIPPA waivers for all those who formed a circle and prayed over our patients? I think JACHO needs to go on mission trips.

Throwing in the Towel "Time out Towel" to be exact

Ok, I understand the need to do a Time Out when starting a surgical case, but what happened today just blew me away. There in the room was a Registered Time Out Safety Towel! It is just an Orange towel that says time out. Of course it is trademarked and no doubt created and owned by someone who works with JACHO because these just showed up before our latest JACHO inspection. I had to ask how much these cost. Well, since they are in the OR they must be sterile and have a thread count that makes sure that they wont leave lint on the instruments. Of course, they are disposable. So, guess what. A box of 24 individually wrapped, sterile Time Out (r) safety towls is $112.00. So, instead of just having the time out, we know have to have the JACHO approved and probably wholly owned useless towel that just ads even more cost to the health care system. I hate to admit, I took the towel and wadded it up and threw it as hard as I could at the hamper only to be told that they couldn't be reused!

Gamer's

I have been noticing that alot of the patients that we see who are on Medicare and Social Security Disability are rather young. Many are under 45 years old. Being rather a cynic personally, I asked the front desk to keep track this week if they could how many patients I saw who were on Social Security and Medicare/Caid who met the following criteria: under 45, able to drive, talk on the telephone, and walk. The last three I included because I figure that if you can do these, there is at least some job that you can do. The answer they gave was a bit shocking to me. It was 18! I dont know if this was a high weekly number or a low weekly number. But still, 18! I am not sure what the truw dollar amount of full Social Security Disability and Medicare/Medicaid is but I can imagine both combined might be about $20,000.00. This is probably a very low ball estimate as these folks are receiving care that normally would have been covered by private insurance. Anyway, 18 time 20K is $360,000! This was in one week! No wonder Medicare and Social Security are going broke! I shouldn't have gone back up to ask the our front office staff anymore questions but I couldnt help my self. When I asked them about the number of people who met the criteria, they said "oh, yeah the Gamers". I asked why they called them that. They explained, "oh, they know how to game the system, they all are on disabilty for fibro". I said, "no, way, all of them?". They answered, "not really, two were on it for chronic fatigue". I asked why and they looked at me like I was a moron. "they have fibro and chronic fatigue because it gets you free money!" Great, we are all screwed!

Pine Box Warning

I had to give a pine box warning to one of our pharmacists last night. The patient had a deep rapidly spreading infection and was allergic to penicillin and all cephalosporins. The infection appeared to be gas forming and we needed to jump on it in a hurry. He had already failed Flagyl. I wrote to get him started on 900 mg of cleocin every 8 hours asap and made arrangements to go to the OR. When the patient got to pre-op, he still had not received his cleocin. I called the pharmacy to see what was up and immediately was told that it had to be appoved by the pharmacy supervisor on call because cleocin had a black box warning. After I told them that I didnt give a ***it and that I wanted it now, I asked them what was the "lack box warning" It turns out that it can lead to C. difficile diarhea. I told them that I hope they do get diahrhea, that means that they will still be alive! Right now there is a Pine Box Warning, without it, they will be dead!

I got the cleocin and the patient did ok. Anerobic infections are no fun. Anyway the head of the pharmacy called me and apoligized for the delay. She told me that from the administratosphere and edict came out that to decrease complications that may lead to extended stays in the hospital (CMS) unfunded and possible litigation issues, they had instituted this Black Box Warning policy!

Cant you see I'm Charting

One of my biggest pet peeves is when more attention is paid to the chart than to the patient. Boy, today I got peeved. I was seeing a patient in one of the units when their asymtomatic tachycardia became very symptomatic with the sudden accumulation of a large amount of blood with froth in the chest tube. At first I thought it was something even more worse than it appeared but I managed to press down on the chest and twist off the chest tube hoping the bleeding would tamponade the lung. While all this is going on I am yelling for help. After four or five yells and trying to use my foot to hit the code alarm I finally heard the nurse yell, "can somebody get that, Im charting!" The RT popped in when the vent alarms went off and helped me. Finally the nurse showed up. After the patient was taken care of, I though about what had happened. If I hadnt been there, the chart would be perfect but the patient would have been dead.

Federal Reserve Blood Bank

I know it is a scary thought, but what if the Federal Reserve ran the blood banks? At present, one unit of packed red cells is 220 ccs and intended to raise the hemoglobin by one point and the hematocrit by three. To make it look like there is more blood available,the Federal Reserve would increase the number of unit bags that the blood comes in, so each new Federal Reserve Unit would be diluted and maybe only contain 110 ccs of blood and the rest of the bag would be filled with saline. Sure, there are now more units available, but now each unit only raises the hematocrit 0.5. So, in each transfusion you need twice as many units. The real amount of blood available is the same, all you did is make each "unit" less effective.

I guess it is a good thing that the Federal Reserve does not manage blood banks, too bad they manage our nations life blood.

Non-essential functions

I saw on the news all these different governmental administrators explaining that a government shut down would only affect non-essential functions and that they were working on plans to operate in this way. They also said 800,000 people would be placed on furlough with the shut down. Doesn't this mean that we have 800,000 people who are government workers doing nothing important and therefore why do we have them anyway? For that matter, why do we have things in the government that are not essential anyway?

What's good for the goose killed the gander

I was just sent an email from a friend. A senior National Health Service Administrator in the UK passed away from gastric cancer. It was diagnosed earlier but she had to wait 9 months before her surgery. The surgery was even done at a hospital that she was in charge off. Of course it was way to late. I then thought what if it was over here in the US? You come in to the ED with stomach pain or nausea. They will get a ct regardless of your ability to pay. If UT shows a mass the surgeon on call then has to see you as well as the gastroenterologist. Before you know it you have the egd done, biopsy read and most likely surgery and the first round of chemotherapy before you even left the hospital. Sure you may get bills but if you don't have insurance the hospital writes most of it off and the doctorsa have to suck it up.

So, who has the better system if you are the patient?

There is always more than one patient

I had just finished a case and went to talk to the family. When I got back, one of the residents asked what took so long. I paused and then thought a bit and tried to explain. I told him that the person that went to the recovery room was not the only patient. While we were operating and dictating, someone is sitting in the waiting room worrying. There the clock seems to stand still. They are worried about their loved one, worse, they are helpless to do anything. Every time the phone rings, they jump. When the surgery is over, they have to face the news of what was found and what happened. Is there cancer? Are they going to be OK? What happens next? The person that had the operation is still asleep. The family and friends have to face the news wide awake. They are your patients too. Time and answers to their questions are the medicine that they need. Surgery takes as long as it takes, so does meeting with the family and friends.

Medical Ductape

I think there ought to be a medical hall of fame somewhere for the people who have contributed the most to medical care but who have not had their name placed on their invention. One of the most awesome things is that Mefix tape. It is like medical duct tape. It will hold in chest tubes, NG tubes and hold pressure on wound until you can pigure out what to do. Another cool thing is that artificial snot stuff that is on the back of EKG pads. It sticks, but you can pull it off later and it is like the rubber cement you used to put on your hands and play with in grade school. I dont know who invented it but I like how you can cut the end of the tube that chest tubes come in, and then use it as a blow gun to shoot those oral care sponges on a stick. Pillow packs. These are cool, besides being a convient way to get saline to lavage a plugged ET tube, they are awesome one shot sniper squirt guns. Opsites (tegaderms) are cool too. See through self stick sterile saran wrap. I wish I would have though of it. I think there should be a special place in the Hall of Fame for the person who can come up with a way to open all the sterily packaged stuff with gloves on. I hate having to open some of that stuff with my teeth!

Air Traffic Controller Lapses

I just saw on the news that the air traffic controller at Reagan National Airport fell asleep and as a result two aircraft low on fuel had to make landings. The Air Traffic controller's union in perfect form blamed the issue on staffing and not on the fact that the gut was asleep on the job. It is a good thing no one was injured. I guess unions are a good thing. If we decide that we are going to take a nap and ingnore the emergencies coming in to the ED, we are going to get in huge trouble. I guess that is why docs cant form a union, its not like we are responsible for bunches of people who could be in danger.

Ball Park Amnesty

I just had the opportunity to go to a professional Spring training baseball game. On the ticket and also announced in the stadium was the statement that "Baseball is an inherently dangerous sport and baseball, bats and other objects may cause injury, the stadium, team or its employees are not responsible for any injuries that must occur." By entering, you assume all liability for any injury. So, in other words, if a highly trained professional accidentally slips and lets hits bat fly into the crowd, he is not held responsible. I kept thinking about this. Medicine is an inherently dangerous activity, perhaps we need Ball park Amnesty! If a surgeon has an accident, he is sued. Oh, wait a minute. We cant have accidents, only malpractice.

Toll Free Calls?

I think the thing that takes the biggest toll on me while taking call is the constant barrage of phone calls. I understand the calls from the hospitals and the ERs and the patients who are recovering from surgery. It is the other types of calls which is the majority and the biggest pain in my side. We have an answering service that does their best to screen the calls and the phone system even says "if this is an emergency, hang up and dial 911." It doesn't make a difference, people lie to the answering service and you get calls like this. "text message: patient had surgery by Dr. (partner x) and now has severe nausea and vomiting." Of course it is 2 am. You call the patient, he is drunk. Turns out the surgery was a small office procedure 2 years ago. The patient is drunk and wants nausea medication called in because he doesn't want to still be puking in the morning. I give him the speech that we do not call in medications after hours and that we are on call for emergencies for which he calls me every name that would get my mouth washed out with soap as a kid. After he hung up and I dealt with other people calling for zpacks and antibiotics for their colds, I decided to look up the drunk guy on Google. Turns out he owns a bunch of car dealerships. I so wanted to call him back in the middle of the night and tell him that I had a headlight changed at one of his dealerships and want him to call in a new muffler for me at Autozone so I wouldn't have to have my car make so much noise in the morning.

Parachute Paper

About once a year I give the medical students and residents a talk on how to read and analyse research papers. I do my best to explain that just because there is a paper that says something, it might and most likely is just BS. We go through whether the study has a proper design, statistical analysis and if its conclusions are supported by the reaseach. At the end of the talk, I always finish by saying, when push comes to shove, trust your experience and your own observations as this is the best BS test of any paper and them I give them the Parachute Paper!

Parachute use to prevent death and major trauma related to gravitation challenge: systematic review of randomized controlled trials.
BMJ 2003;327 number 7429


As an aside, I was called to give a deposition when there was a lawsuit against one of our docs. The plaintiffs attorney kept showing me papers that he got off the internet. I gave him a condensed version of my talk and gave him a copy of the paper. They dropped the case.

Environmental Crisis of non-epic proportions

Warning, this may contain some actual scientific postulates.

I'm stranded in the airport. We have a plane but no crew. This leaves me with more time and very little to do to settle my ADD. So here is some of my rambling.

Somehow I got to thinking about the gulf oil spill and remembering how all the environmentalists were screaming about how bad it was and how many microbiologists were saying it was no big deal and that there were microbes in the ocean that were going to eat that stuff right up. In fact, it was adding to the microbial food chain. As it turns out the microbiologists were right. I then started to think, well perhaps oil is part of the food chain. I mean, we have bacteria that have evolved to eat oil so it is part of their food chain, that means perhaps something else eats something and excretes oil. I know that there is a bunch of research trying to use recombinant technology to get algae to excrete oil, but I got to think that there is already microbes that do it. All microbes need a metabolic fuel. Well, plant and animal tissues contain amino acids as their building blocks with some carbohydrates thrown in. Amino acids have by definition amino groups. These amino groups contain a large amount of energy which could be used to power microbes. This would allow the decomposition of bio-organic materials, producing free nitrogen and splitting off hydrogen to allow it to combine with methane moieties to create hydrocarbons. This would also explain why we have so much nitrogen in the atmosphere as it would be in circulation just as the CO2 and O2. How long do you think it will be before someone discovers a ammonia loving microbe that lives deep in the soil that eats coal and secretes oil and natural gas with free nitrogen as a byproduct? What will the anti-oil environmentalists do when they find out that oil is a natural part of the world food chain?

Non-union

I was just sitting at home listening to all the talk about the Wisconsin teachers union and how many democrat politicians are all about the rights of unions and collective bargaining. I was wondering then, why is it not legal for physicians to form a union? For that matter, if we as physicians form too large of a group, the Feds force us to break up. Here is something. I am a teacher ( in a medical school). Does that mean I can join a union?

Attorney PSA

As a general rule, it is not wise to stop your medication because you saw an add for an lawsuit clearing house on TV. I know its hard to believe but it probably was the plavix that was keeping your coronary arteries from clogging despite it being on 1-800-BAD-DRUG. I hope that you recover from your massive MI and have a chance to watch some of the other lawsuit seeking commercials.

I'm sorry to vent but it is getting ridiculous. We really did have a patient today who stopped their plavix because they thought it was banned after seeing a commercial on TV.

The Anti baffle with BS EMR Tab

It took many meetings and a ton of phone calls but we finally have our medical centers EMR equipped with a feature that lets you actually see on the same screen what you need to take care of the patient. Better yet, it can be printed out and placed at the patients room so you can see the patient and then check everything without having to find a computer, log in and wade your way through all the sections of pure computer generated BS.

Originally, the patients chart was a way to keep track of important lab values and information that let you take care of the patient. This was its whole purpose and its most important purpose. It is now a billing, government compliance checking monster in its own right. More time is spent on the paperwork than the care. The actual stuff that you need to take care of the patient is lost in the sea of BS.

I was so happy that we were able to get it so the nurses could print off the single page review of the recent vitals, I/Os, meds and labs. Unfortunately, the medical centers attorneys are afraid that if this is left at the bedside where we used to keep the patients charts it would be both a JACHO and potential HIPPA issue so they made it so you can not print it! So here we go again, Ms. Jones is coding, someone please find a computer and log in and make their way through all the HIPPA screens and all the other BS to find out what meds she is on and what has been going on!

Obama-innovation

I listened to the President talk about how he wanted to promote innovation. The problem is that he and his team have so alienated the pharmaceutical industry that many of our drugs are in short supply or no longer can be found, and here is the latest. Phizer announced that it is laying off thousands of its research and development personnel and moving its whole antibiotic research facility to China. Maybe we can use Obama-innovation and move our whole health care system to China?

(Dumbing Down)(Dumbing Down)

One of the concerns that we have had in the surgeons lounge is whether the new resident work hour limits have "dumbed down" the residents education. It is hard not to think that by decreasing the work 50% that you wont decrease the experience by 50%. On top of this, is that concern that we are further dumbing down our care by replacing residents with NPs. In one of the most ironic episodes, I was in the lounge last night waiting for the patient to have an artline discussing this very thing with another doc waiting for his post op film when I got a stat consult. The patient had come in through the ED where they were seen by an ARNP who consulted pulmonology. It was another ANRP from pulmonology who came and saw the patient and then arranged for admission who then called for the stat consult. The consult was for acute shortness of breath, decreased breath sounds on left! When I got to the room, the patient was pulling a chair over to see if he could stand on it to adjust the picture on the TV. He had a slight wheeze. I asked if he was short of breathe, he answered," Oh, yeah". I asked how long had he been short of breathe, to which he answered, "ever since they removed my left lung". I thought either I am being set up or this is candid camera. I asked what brought him to the hospital this evening to which he replied that he was having some abdominal pain from his old ventral hernia. Being paranoid, I checked him over and then went to the chart. There in all the best EMR was a six page history and physical of computer generated mumbo/jumbo. No where could I find anything that mentioned his hernia or the fact that he was missing a lung. I went to call the resident who had approved the admission but he had already left and signed out to another. This resident stated that the patient was having severe SOB and pneumothorax and that surgery had been called to place a chest tube! I then tried to call the pulmonology ANRP, but they had also finished their shift and left!

Welcome to the world of "not accountable" "Shift" "Dumbed Down" medicine.

Those who cant, teach!

In medical education, the apprentice principle is in high regard. That is to say, you want to get your residents out working with those in the field who are actually working. It is one thing to have lectures by researchers, but it is much better to be out in the field working with those in the trenches. This has led to the attitude that the ones who are good at the actual job are the ones doing the job. Those that suck, sit in auditoriums and teach. That little bit of Dogma got me thinking. Our President taught Constitutional law, but the law that he proposed, pushed and signed was declared unconstitutional. I guess, the principle that "those who cant, teach!" is true for attorneys as well

Squad 51, Squad 51

On call, one of the hardest things to get used to is to be in the deepest of sleep and then have to wake up and immediately run in to the hospital and perform something complex at a moments notice. The littlest things help ease it though. Instead of using beepers, we now use our cell phones. Before you would get the page, roll over and see the number of the ER. There would be a groan and then you would dial it not knowing is they needed and order for Zofran or that you had to get there stat because someone was bleeding out. Each time the beeper went off, there would be that little bit of anxiety. One of the big problems it that quite often, it was enough to make it hard to get back to sleep. With our cell phones, the text message goes off and right there is what is the problem.

Now, the fun part is when the ED calls or another part in one of the medical centers, we can assign them a ring tone. The ED is the Squad 51, Squad 51 from the old TV series Emergency. The patient placement/transfer office which is where they tell you another dump is coming in from somewhere is "Incoming tactical NUKE" from the Transformers Movie. Hospital Administration is "Run Away, Run Away" from Holy Grail. Fast track, which is like a mini-ed why are you here place is a Siamese cat whining. There are a bunch more but is Sunday morning and like always we are of to the OR for something that was elective 2 months ago but is now urgent!

Push pull the Pyxis

I remember when you went to round on a patient and the nurse would be right there to update you on what was going on and any of their concerns. If you had to pull a drain or chest tube, all the supplies would be right at the bedside. Not anymore. First, you cant tell who the nurse is. Most of the time the patient does know either. When you do find out who the nurse is, they are stuck somewhere entering stuff into a computer and cant seem to be made interested in anything else. When you finally track down the drain amounts and see you can pull the drain, you have to go to the locked medication/supply room. They all have these key locks, and of course you then have to track someone down to find out the code. Once you get in, all the supplies are locked into the Pyxis thing. This is like one of those big vending machines where you put your money in and coil spins and you hope what you are trying to buy drops into the chute where you can get to it. The Pyxis makes you enter a code, which of course is another step to track someone down to get, then you enter the supply that you need, and just like that bag of chips it sticks. You stand there and after a few seconds of making sure no one is looking start to push and pull the whole thing back and forth hoping that your suture removal set drops before the whole thing crushes you and puts you out of your misery. The suture removal set is all set to drop, you are eying it like a midnight secret snickers bar when all of a sudden the alarm goes off and the whole thing locks up! You then go to the ward clerk and borrow the scissors they have to cut the arm bands off the discharge patients and take the sutures out with them!

Federal Working Hours

We had a big incident at the medical center where one facility who could have taken care of a patient instead chose to transfer them on to another. I had to discuss this with our regional CMS office. I went to return their call. It was 8:00am. I was told that the person I was trying to reach usually doesn't come in to about 9 or 930. Not that they were in a meeting, just that this was the time they choose to come to work. I got busy and then called at 11:30. They had left for lunch. I called at 1:30. They were not back from lunch yet. I called at 3:45. They had already left for the day. I asked to speak to the supervisor. Turns out the supervisor was the one that I had been calling for all along. I decided to call the main office. It was 4:15 their time. I got the message that their office was open 9 to 5, and that I should call back the next business day? Got to love the Feds.

Real World Lesson #2

I just had a patient tell me that his generic colchicine that he takes for gout used to cost $18. It now costs $154. Turns out that the Feds have placed regulations that all old meds have to meet these new testing and other criteria. No one can afford to pay for all these new tests for the meds that have been around since the dawn of time, so guess what? The generics are either vanishing or getting more costly. Real World Lesson #2: Regulations make things cost more.

Real World Lesson 1

It has been the usual week on call with lots of un insured patients coming to the er instead of stopping by a walk in clinic and paying cash. What has been unusual is that three of the first real cases were patients who had great health insurance until the 1st of January when it became so costly, their employers asked the employees to pay some of it. Of course, they didn't, so here they are now without insurance. Real World Lesson 1: Obama care costs more and results in less people with health insurance.

Bubble Belly

There is a great book that you can give to pregnant ladies called "What to Expect when you are Expecting". I wish that there was a whole series for other things in life, and especially a "Dummies" version. That way, instead of having to come to the ED in the middle of the night, they could just had the book to the person and send them off. Last night, the "Dummies Book" would be "Things you shouldn't put in your PEG tube".

One of our local citizens who has severe esophageal stenosis because he drank some of his meth making chemicals by accident when he was high came in after he was found down by the police. He had severe abdominal distention. On exam, it was found he had a G-tube, so they uncapped it and it sprayed like a fire hose around the room. Somehow, he had found a way to fill his stomach with beer before it had a chance to clear the carbonation and had capped his tube. Talk about a mess. (Blood alcohol of 0.29 so no record).

Plethor-orders

I got the nasty call again. It was from medical records demanding that I sign all my delinquent charts or I would use my admitting privileges. I couldn't believe my luck, I was just starting to go on call. If I could not admit patients, I couldn't take call. Or so I though. The medical records person figured out quick that I was way to happy and then told me that the privileges would be suspended after my call. Dejected, I went to do my records.

It used to be that when you did your medical records, you went into the bowels of the hospital with a big cup op coffee and charts after charts were piled in front of you will all these little sign here stickers. After you signed all the places you would toss the chart into a bin with thud that was Pavlovian kind of like the ding ding of a slot machine. Alas, this is no more.

Now you sit in front of the computer and it shows you the chart. They tempt you right away with this feature that lets you hit one button that says, sign all. Oh, it is so tempting! I couldn't do it. Instead, I went to each document that the computer pulled up. There were hundreds of them. There were things in there that I had never seen, much less agreed to or even knew about. It was like the hospital attorney had hidden every possible thing in the record to make me the fall guy if anything happened. Most of it was in what was called the physician attestation statement. There were pharmaceutical risk documents so if someone got a reaction, the hospital would not be sued, there were restraint orders that I never ordered. I found several on patients that I had never heard of much less been their doc.

I brought this up at the medical executive committee, still trying to convince them to never put me on these committees. When I showed them what happened when you hit the sign all button which all of them had, the room went quiet. There was a definite air of hostility and the flurry of Blackberry activity ceased. A sign that people were really listening. Suddenly, there was a motion to "get the GD F+++ hospital attorney down here state" that got unanimous driving finger seconds and votes. When the attorney came in, the silence was deafening. Finally, there was the standard, some of those forms are JACHO and CMS defaults with the EMR system. No one bought it. I asked who approved the forms to be in the chart. We got the lawyer talk delay, I am not sure but will research it and get back to you.

I motioned that no one sign any charts until this is resolved. Driving finger approval all the way around. Our first doctors strike is on!