Saturday, November 9, 2013

Doppler Effect Turn Around Times

It seems that the closer you get to the setting sun, specifically closer to about 3 o'clock, the OR turn around times get longer.  The exact opposite happens once the sun sets as the times get shorter.  Looking into this phenomenon I found that it had nothing to do with space time but rather laziness.  The morning OR shift knows that if the case starts before two, they will have to do it and get the room set up.  If they drag their heels, there wont be time to set it up and then they can leave it for the second shift.  Since the second shift comes in at 3 the morning shift will push all the work on to the them.   They then have to set up everything and now you have a 2 hour delay.  The second shift then wants to get everything done and will hustle to get any follow on cases done so they can have the rest of the night to chill.  Rule to the wise, if you are NPO and have surgery scheduled for 2 or 230, remember the doppler effect and be ready to be hungry for at least 2 additional hours.

Friday, November 8, 2013

Code Green!

Every now and then I would hear a code green called overhead and really didn't pay much attention to it.  I know what a code brown(pooped in  bed) and a code yellow ( peed in the bed) are, but a code green was one those that I just didn't know.  Was it bile? Tube feeds?  Now it seems that a code green is being called every few minutes.  Finally, I had to ask one of the unit clerks what a code green was.  She looked at me and said it was a press ganey!  I asked her what she meant.   She explained that if a patient was belligerent or if their family members were belligerent or stealing or drug seeking they could call a code green which is security.  Once security is called, the patient never will receive a press ganey survey!

Monday, October 14, 2013

No Care Dispair

It is always hard when a patient cries.  You want to comfort them and do all you can to ease their suffering.  Today was one of those days but their was no comforting.  Three separate patients broke down in tears today.  Each has a chronic medical condition and just found out that their employer can not afford to pay the increased cost of their health condition and as a result, they have to go out on their own and purchase Obamacare only to find out that they cant afford it.  I did my best to try to help them and assured them that I would take care of them no matter what.  That didn't comfort them because they didn't know how they were going to pay for their meds and the hospital costs.  So much for the affordable care act.

Sunday, September 22, 2013

"It costs more to provide less"

Just for grins I looked to see how much it would cost to get my family health insurance through one of the Obamacare exchanges.  Turns out that for about 40 percent more cost, I can get a higher deductible plan that covers less.  What a great deal! I hope the medical center doesn't decide to drop our coverage.

Dope Flu

20 y/o male in the ED brought in by his parents because he was nauseated, vomiting, tachycardic, sweating and gnawing abdominal pain. Parents are convinced that he has appendicitis.  They said that he got sick right after they pulled him out of college last week because of his bad grades.  I asked Mom and Dad to step out while I examined him.  Yep, its been a week since he had his last fix of Oxys.  Good ole dope flu.  We checked an US of the belly to be safe.  Gave him the numbers of AA.  HIPPA says we cant tell his folks.

Monday, September 16, 2013

Pop tops and blow holes for Dummies

I think I am going to have to call the publishers of those "Dummies" books to see if they would consider a series on medical issues.  There are already tons of books about caring for cancer, "what to expect when you are expecting", and dealing with grief but I think the post-trauma market is untapped.  Especially for the "I took Vodka and Molly and then drove my car into the overpass" crowd.  There could be Dummies books for "pop tops" (PEG tubes) which if you are going to shot gun beer into them let it go flat otherwise, the top pops and you spray all over.  "Blow holes for Dummies" (what little cigars fit into the trache tube), "Keg taps for dummies" (suprapubic catheters), and last but not least "Bung holes for Dummies" for the colostomy bags.  Hey, you know how they have those anti smoking commercials with the people who lost their voice box and legs and stuff on TV.  Maybe they could have some that say "I'm cool, I joined a gang and now I have a pop top, blow hole, a keg tap and this great bung hole!

Reconcile This!!

As part of yet another JACHO mess, we are supposed to reconcile all the patients medications when they leave the hospital.  This means that we are supposed to say what medicines they are to take and not take regardless of what we are threating them for. We are then responsible for those medications both medically and legally.   This is hard enough because they might be in the hospital for a hernia but all the meds are cardiac or psyche meds.  Now we have to reconcile all the herbals and all the other things that they take.  "Lets see they take gin sing, oral silver, and a powder from the flea market".   On the computer I cant find a way to check the button that says "call the person who told then to take this stuff", or the button that says "sue someone else" so I just click "do not continue". 

Sunday, September 15, 2013

Action Hero

I was driving home from a trip and traffic on the Interstate started to slow down.  I saw the sign that said "right lane closed ahead, merge left".  I moved to the left lane and joined the other cars that were already there slowed down.  After several minutes of slowly moving ahead, car after car sped past on the right to see how far up they could get and then barge into the line.  Of course they slowed the whole thing up and made everyone have to slam on the breaks.  One almost caused and accident. Suddenly the pickup in front of me moved into the left lane.  He didn't speedup, he just stayed even with me. I made sure I left his space in front of me open.  Car after car flew up behind him, honking and honking.  He just stayed even with me.  The line moved steadily without incident.  When the right  lane closed he slipped back in front of me.  I gave him the best thumbs up and salute I could!  You sir are a true hero! By the way, his license plate was from Texas and had a combat wounded veteran symbol!

Friday, September 6, 2013


It was early morning rounds before surgery and one of the medical students was presenting a case that came in during the night.  She explained that it was a 24 y/o male with severe abdominal pain that was out of proportion to exam.  I stopped her right then and asked what his race was.  She said that they were told not to mention race as that is "prejudicial and stereotyping".  Before, I could saw anything else, one of the residents said, Asians don't get sicke cell crisis.  I cant wait until we cant mention sex in the evaluation of pelvic pain.

Monday, August 26, 2013

Bathroom Oragami

I though I was imagining things.  I double checked, yes the toilet paper in the hospital was getting narrower.  I checked at home, it was narrower as well.  I didn't measure but I had the distinct thought that my bottom was getting bigger. This is a problem!  A Conspiracy!  before I could dwell on the possible regulations and profit motivations of decreasing the toilet paper by a half inch I went into problem solving mode.  How do you fold something to make it wider.  It turns out that you can fold the paper on itself in kind of a star rosette pattern that makes it at least 6 inches wide but it takes alot more paper. I decided I have two choices, be in the lavatory longer and have people yell "what is taking you so long?" and yell back "origami!", or just go in with a roll of Brawny.

Bumper Sticker Lib

I had an older patient who had afib and a stent and needed surgery for a malignancy.  Anesthesia saw him and wanted the opinion of his cardiologist in regards to his cardiac status.  The cardiologist then stated that they no longer accepted Medicare and that he would be happy to see him if he paid his usual and customary charge without any discount.  Needless to say the patient could not afford it.  I got on the phone and found another cardiologist who worked him up and we were able to do the surgery.  Today I was walking though the parking lot and saw the cardiologist who no longer accepts Medicare.  On his bumper were two stickers.  "If you have Medicare, thank a Democrat" and "Change".

Saturday, August 24, 2013

Chicken Little Bang Bang Bang

In order to create more jobs and provide less patient care, the Medical Center has decided that all orders will be done through the Computerized Patient Oder Entry "CPOE" or F+++ing Piece of S""" "FPOS" system.  As a side note, the medical center also has posted signs saying that "carrying of handguns in this facility is prohibited" to keep the staff from shooting the computers.  Anyway, when you go to order a medication the FPOS doesn't let you order it without giving you at least a dozen warnings that you have to go through and mark "seen and approved", or "noted", or something.  Of course all the warnings are the legalese, mumbo jumbo ones that have no bearing on what you are actually doing.  One of my favorites is "insulin has been shown to decrease levels of blood glucose".  Ive looked, when you try to get rid of the warning there is no "No Sh@@" button.  As you can imagine, after fighting this for a while you go out of your way to find someone else to do it for you.  I think this is why the medical center had to hire so many PAs and RNPs and why so many of the hospitalists quit.  As an attending, I make the residents put in the orders.  The residents make the interns do it.   They new interns are at least trying to make a sport of it.  After every one of those stupid alerts they hit the desk.  The call it banging the head of Chicken Little.  Of course, with warning fatigue, sooner or later there will be a real warning that will be missed.  If only we could combine those warning alerts with an electronic version of "whak-a-mole" or you could fling the warnings like "angrybirds".

Friday, August 9, 2013

Mommy's Little Helper

Last night I got a call from the surgical unit regarding one of my partners patients.  The nurse explained that the patient was not having good pain control the "10 out of 10" thing.  I asked what she had for pain and it seemed very adequate for the surgery.  I then asked what the patients home meds where.  The patient  had admitted that she had "fibro" and was taking oxycodone 4 times a day and had been for years.  My partner who is very astute had ordered a drug screen as part of the pre-op labs.  This was positive for benzo's and amphetamines.  I had to go in and have the talk where I explain that chronic narcotic use causes your pain receptors to go bezerk and that even the slightest pain will be amplified and that it is essential to seek treatment to come off the narcotics.  I also had to explain that because of this it will be hard to keep her pain under controlled.  We later found out that the patient was taking her kids adderal and what was worse was that she was a teacher!  We have no idea where she got the benzos.


We are in a crisis in regards to Medicare patients who went with the AARP supplement.  With the Medicare cuts and now the poor reimbursement by the United Health AARP plan the medical center and all the surrounding hospitals are not accepting it for chemotherapy or radiation oncology.  Patients have to pay the out of network costs out of their pockets, that is if they can afford them.  I wonder if AARP is still glad that they supported Obamacare?

Sunday, June 23, 2013


With many of the EMRs, docs are using Dragon software to dictate.  Dragon is amazing but you "have to train your Dragon" and some dragons are not well trained.  On top of it, there is now pressure to have  a complete note for the patient to have when they check out, as this is another one of those "mandates".  The result is that the note is made entirely of macros with a small Dragon dictated blurb at the bottom that you don't have time to proofread.  As you can imagine, the notes are not very useful but can be quite funny.  Some of my favorites are " the incision was opulent", (instead of purulent), "the patient was singularly pathetic", (the patient was on singular and patanase).  The best is when someone is dictating and then answers the phone, so the Dragon starts typing what he said on the phone. I had one note that ended, "fine, love you too!"

Copay "Triple Pay"

I had to have a prescription filled at the local chain pharmacy.  The pharmacist handed me the script and it was only for 30 days instead of 90 days.  I asked why they altered the script for a smaller amount.  He got a little nervous.  I then said, my copay is 10 dollars for this generic, how much is the cost if I pay cash for all 90?  He got more nervous then said $14.  So, to get it straight they will break a 90 day script in to three 30 day scripts so they can triple the copay.  At first, the people in the line behind me were annoyed because I was taking so much time, after hearing what had transpired it was game on with each of them checking to see if their scripts had been altered.  This is the same chain pharmacy that is so determined on electronic scripts so that people cant call around to see who has the cheaper prices!

Tuesday, June 18, 2013


It is near the end of the year and the interns are a bit burned out.  We had an avid medical student here on an audition clerkship and overheard two if the interns talking about which one of them was going to see which of the "artists" in the Emergency Department.  After a few minutes he approached me and said something to the effect that there are a lot of artists here in this area.  I didn't want to burst his idealist bubble of sculptors and painters but I finally had to let him in on the meaning of the term.  I explained that "Artists" are those who are really good at drawing.  They are good at drawing disability, social security, Medicare, Medicaid, food stamps, Obama phones and everything else while they sell drugs and sponge off society.

Thursday, April 18, 2013

Bolus of Common Sense

We had a patient that was aspirating.  The concern was whether or not it was tube feeds.  Before we would add some food coloring to the tube feeds and then see what color the mucus was that the patient coughed up.  Now we cant because somebody wrote a paper that it might cause a reducing agent problem.  I tried to explain to the nutritionists that we were just going to use the same stuff that was in the cupcakes in the cafeteria but they wouldn't hear of it.  All they said was the potential danger of the dye.  In my own retaliatory manner I flooded them with case reports where tube feeding was accidentally run into central lines because it is the same color as the lipids in the TPN.  They didn't think it was funny.  I solved the problem by putting Gator Aid in the tube feed and sure enough he was aspirating!

This led me to wonder.  We are always trying to be sure the wrong medication is not given to the wrong patient.  Why don't we color the medications so that even when they are in the syringe of the bag we know that something is wrong.  After all, patients take pills that are different colors.  Make morphine blue, decadron yellow, ancef green and so on. That way when you walk into the room you know hey these are the meds he is on.  Oh, never mind, that makes common sense.

Thursday, March 21, 2013

Hand Caught in the Cookie Jar

We set a new record last month in the medical center.  Six  times maintenance had to be called to cut the top off a sharps box to free the hand of someone who was trying to get the used syringes for the last drops of the narcotics contained within them.  They were all "family members" or "visitors".  Two claimed it was an accident despite the fact that the patient was on seizure precautions and they were on camera for the whole thing.  We also have had over 12 sharps boxes go missing.

Wednesday, February 13, 2013

Hour-glass sign

Technology is amazing.  Before, I would have to roam the halls of the hospital to try and find the chart of my patient.  It might be in the rack, with the ward clerk, back with the case manager or left in radiology.  I probably spent several hours a week not to mention walked miles to find those darned things.  Now, I just have to find a computer, log in and sit there for hours looking at the little hour-glass sign while the computer locks up, stalls and then blue screens itself into oblivion.  Technology is awesome, it lets me at least sit down?

Sunday, January 13, 2013

White Lie Pneumonia

I know that often people will tell little white lies because they want to tell you what they think you want to hear.  We see it all the time. "Sir, do you use any street drugs or pain pills?"  "Oh, heavens no!" We run the tox screen and it is pan positive.  "Do you use alcohol?" "No." DTs on the way.  I try to get people to be honest with me and try to explain that we are asking these questions so we can better help them.  It still doesn't work.  "Sir, did you have anything to eat or drink after midnight?", "No".  The bronch after the aspiration that occured during induction for the elective surgery sucked out what appeared to be bread, egg and either sausage or ham.  Talking with the family, they all hit Hardees on the way to the hospital.  The patient thought a couple of biscuits wouldn't hurt.

Macular degeneration (cant see the disc)

We see patients from all over several states.  No matter how hard we ask, most of them forget to bring their xrays.  They will bring the report but not the actual films.  Our schedulers call them and specifically ask them to go to where they had their xrays and have them put the images on a disc and bring it with them to their appointment.  When they don't have their xrays the patients get mad because we really cant do anything until we see the films and blame us.

Saturday, January 12, 2013

Curbside Contagion

One of my partners biggest pet peeve is when she is on the OR and one of the staff comes by and asks if she can look at their throat or listen to their lungs because they think they are coming down with a cold.  Of course, if they are, it is a cold and their is not much to do about it.  Secondly, you will get the cold.  Sure enough, someone came by and asked her, she tried not to but did not want to look bad.  Despite the flu shot  she got the flu.  Now she is out and so are her patients.

Friday, January 11, 2013

Negative fecal matter on the slide Dr. Sherlock

I know that you will find it amazing, but the recent Rand study (the same people who promoted EMRs) shows that Electronic medical records did not reduce medical costs nor did they improve care.