Wednesday, November 30, 2011

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.

Wednesday, November 23, 2011


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.

Saturday, November 19, 2011

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!

Wednesday, November 16, 2011

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!

Wednesday, November 9, 2011

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.