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!