Wednesday, July 31, 2013

Ways To Improve The Operating Room Environment

A recent post in Becker's ASC Review discussed strategies for improving communications and work environment in the operating room. Using ideas as outlined by a colorectal surgeon, it lists five methods that he felt should be implemented. The plans include using a preop huddle to make sure everybody in the OR is on the same page and taking the team approach during surgery because, you know, the anesthesiologist might be too intimidated by the superior surgeon to speak up.

Blah blah blah. What do you expect in an article that uses a surgeon as its source? They should have asked an anesthesiologist who will give the true low down on how to improve the atmosphere in the OR. This advice is directed to all the surgeons out there. You may think you're perfect, but there is always room for improvement.

1. Show up on time. Stop feeding us B.S. about how you weren't paged when the patient was ready to leave preop. If the schedule says 7:00 AM start, be here at 6:55 AM. Not 7:01, 7:05, or 7:15. We're not your mother who has to remind you that you'll be late for school if you don't get up soon. If you're not sure if the case will start on time, CALL. We'll tell you if we're running late. Don't make us chase you around on your cell phone, pager, and office numbers, none of which you will answer. And please man up about your tardiness. Don't feed us baloney that your secretary didn't tell you what time your case is supposed to start. It's your schedule and you're responsible for checking it before going to bed each night. I do. Why can't you?

2. During an operation, don't ask me to answer your pager or cell phone. That's not my job. I'm too busy making sure your patient doesn't die on the OR table. Frankly, it's nobody else's job in the room either. The nurse is as busy as me keeping the case going smoothly. If you have a resident, use him to answer your calls. Or your PA or  NP. My medical degree was not obtained with a rotation in answering phone calls.

3. Be quick about it. We know the difference between being meticulous and dawdling. We understand the former but won't put up with the latter. Even though I get paid more for longer cases I don't want to face the angry surgeon who is waiting to follow you in the room. He'll yell at the OR staff but will rarely confront the surgeon who is the major offender for why his case is starting an hour late.

4. Don't drag me into a faux emergency operation. It's not an emergency if the only reason the patient needs to go into the operating room stat is so you will make your dinner date that evening.

5. Stop acting juvenile. While this encompasses the previously listed suggestions such as showing up on time and not lying to get your case into the room, it also includes things like not throwing a temper tantrum if you can't get exactly what you want. Don't complain that your procedure card falsely listed a 3-0 Vicryl suture when you always use a 4-0 Vicryl suture when the OR has been using the same card for you for the last ten years. Stop throwing a hissy fit because your headlight isn't shining as brightly as you think it should be. Deal with it. Grow up!

6. Don't tell me how to do my anesthesia. If there is one thing that really, REALLY annoys me, it is a surgeon who emperiously tells me what kind of anesthesia to give. I have my own plans and I'll be happy to discuss them with you but you better remember I have the last word on this subject. As a corollary, don't tell your office patient beforehand what kind of anesthesia she will receive during an operation. You may think that the morbidly obese patient with severe obstructive sleep apnea and pulmonary hypertension only needs a MAC sedation for a case but I may completely disagree for the patient's own safety. I don't want to have to fight with the patient in preop to get her to agree with my plan for her anesthesia. If a patient asks, just tell her she will meet with the anesthesiologist before surgery to talk about it. That's all you need to say.

7. Don't cancel cases without telling anybody about it. Few things are more frustrating than preparing for a case and the patient never shows up because it had already been cancelled by you and you never told the surgery scheduler. It is a waste of my time and a wasted opportunity to use precious operating hours for legitimate cases. One simple phone call. That's all we ask.

8. Stop harassing me if I need to take a little break between cases. Don't page me incessantly if I need to take ten minutes to take a crap in the bathroom. If I need to get a cup of water, don't have the OR call my cell phone every thirty seconds to ask where I went. I cannot and refuse to be leashed to my anesthesia machine all day like a dog on the sidewalk. You get a nice break between cases while the rest of us are hustling to get your next case ready. It's only humane if we are shown a little consideration too.

These are some of my rules for improving the relationship between the anesthesiologist and surgeon. If you follow this guideline, we will get along just fine.

Tuesday, July 30, 2013

How To Prevent Childhood Obesity. Stop Reading To Your Children

My wife and I try to maintain a healthy diet for our kids. We rarely ever eat at fast food restaurants unless it is a special occasion. We don't keep bags of junk food in the pantry, tempting little hands to snack between meals. Consumption of candies and chocolates are strictly monitored. Therefore it is quite dismaying for us when we read children's books to them each night before they go to bed.

Any parent who reads to their kids knows what I'm talking about. Books for young readers are filled with depictions of children eating sweets. When kids come home from school, what do the stay at home moms do? They bring them a plate of freshly baked cookies and a glass of milk. When the children go to a friend's house, they are more likely to sit around drinking punch and eating cupcakes than they are going outside to toss a football. One version of "Wheel On The Bus" has all the bus riders ending up at a picnic, with the table loaded with cakes, cookies, punch, and ice cream.

Even Harry Potter is not immune. He and his pals are forever tempted by sweet desserts like chocolate frogs, treacles, and pumpkin juice (vomit flavored jelly beans don't count). Their favorite store to visit when they are allowed out of Hogwarts is a candy shop. I don't remember reading the Hogwarts's banquet table, with its endless supply of food, having ever served a crisp green salad or a slice of whole grain toast.

Consequently, at every activity where children are present, somebody always brings bags of empty calories for them to eat. After soccer practice, a parent may supply silver pouches of sugary fruit punch. After Sunday school, a teacher will hand out bite size candy bars or M&M's. The sweet temptations bombarding our children are ubiquitous.

Maybe the stories of the Brothers Grimm got the right idea. When Hansel and Gretel started chowing down on the witch's house made of candy, the sweets served as a bait to lure them in. The shingles made of chocolates and windows of spun sugar were not there to signal a party was awaiting them inside. The writers knew the treachery of junk food on children's health, even over two hundred years ago.

I implore modern children's books authors to do the same. Stop writing books showing how much fun it is to pig out on ice cream and cake. All these books give a false impression that unless kids are eating sugar, they are not having a good time. Cookies and cakes have a place in the diet, but not at every play date or after every meal. Nobody really needs that slice of apple pie after dinner when a fresh apple or a bowl of strawberries can be just as good. If we can alter the mindset of our youngsters, hopefully this will be a small step towards fighting the obesity epidemic in this country. I think I'll read to my kids "The Hunger Games" from now on.

Thursday, July 25, 2013

Why It's Better To Be A Doctor Than A Rock Star

Remember the days when you were in high school and you were spending your nights and weekends at home cramming for the SAT's? Meanwhile the cool kids were living it up playing in garage bands and getting all the girls. Then you got into a prestigious university and medical school through hard work and diligence. In the meantime your former rock band classmates were playing gigs as cover bands at the local bars and getting phone numbers and underwear from the floozies in the front row. Was all that stress and intensity worth it?

You bet your Top 1% income bracket it is! While we all envy the riches and lifestyle of megabands like U2 or Aerosmith, they represent the absolute cream of the crop of rock bands. Reaching that peak is like winning the lottery. Probably 99.9999% of all groups will never amount to more than a weekend part time bar mitzvah band. Even if an act makes it big, it is extremely unlikely it will have the longevity like The Rolling Stones with their 50th anniversary tour. Most will be a one hit wonder, if they're lucky.

Take for instance, the 1980's new wave band A Flock Of Seagulls. I bet you didn't know they were still playing did you? I know I didn't. I thought that hairtastic group flew off into the sunset when Nirvana arrived on the scene and pretty much took over rock. But lo and behold, they are still around and making news. Unfortunately it is not news that will land you in the Rock and Roll Hall of Fame. The band, whose lead singer's do was so iconic it was even parodied in an episode of "Friends", had just played a gig in Bellflower, CA last weekend. They went back to their Comfort Inn luxury suites afterwards to crash when their equipment van was stolen overnight. They lost $70,000 worth of instruments, clothes, and even the band's demo for a new album.

A Flock Of Seagulls
Not to make light of other people's misfortunes, but I find it rather sad that there are so many musical acts out there still playing for dollars and faded glory as nothing more than a cover band of their former selves. Their rock star dreams have devolved into a zombie like existence as they drive in their rented vans from one small town to the next. Now I have nothing against Bellflower, a middle to lower class suburb of Los Angeles. But playing there certainly doesn't have the glamor of headlining the Staples Center.

In the end, all your hopes and dreams have come true. You worked your ass off your whole life and now you're in medical school or a practicing physician, ready to cash in on some the rewards you have coming to you. Those garage band kids, on the other hand, can only show up at the next school reunion and thumb wistfully through the yearbook, reminiscing about how they were once awesome but now have nothing to show but a beer belly gut and a receding hairline. The girls won't be screaming for them anymore. All eyes will be on you, the responsible hardworking high achiever of your class. Rock On!

Monday, July 22, 2013

Even Doctors Can Be Insensitive Jerks

You would think that of all the people in the world, the most egalitarian and racially sensitive ones would include physicians. After all, we doctors know that under the skin, everybody is virtually identical. We all have nearly the same physiology whether we are white, black, or brown. We treat people equally regardless of ethnic identity. Unfortunately that understanding isn't as universal as I thought.

This past week, a former UCLA medical school ENT surgeon successfully sued the University of California alleging racial bias. Dr. Christian Head charged that he was frequently humiliated in front of his colleagues. He was also passed up for promotions and told not to complain if he wanted to get a tenured spot. At one faculty and resident banquet, Dr. Head, who is African American, was depicted in a slide show as a gorilla on all fours being violated from behind by his white superior. While not accepting any fault, the U.C. regents admitted there was "an inappropriate slide shown". They decided to settle the lawsuit for $4.5 million.

It saddens me to see such frat boy shenanigans are still considered amusing even in the learned halls of a medical school. It's obvious that Dr. Head was never considered an acceptable partner within the department. If he was well liked and treated better, perhaps he would have taken this faculty roast as a case of poor judgement and shrugged it off. But it seems like none of the other faculty or residents knew him well enough to realize that he would not find this slide humorous. And when he tried to complain through the proper channels his career was threatened.

Hopefully this is a wake up call for all involved in realizing the prejudices people still hold against each other. I don't think these feelings will ever be completely eradicated. However, knowing that it is still lurking inside all of us, no matter how much we say we don't have them or express them, will make us better doctors as well as human beings.

Monday, July 8, 2013

We Let Our Residents Grab The Yoke Every Day

As the investigation into the crash of Asiana Airlines on a picture perfect day in San Francisco continues, the focus is now on the pilots running the cockpit. According to the black box voice recorder, a junior pilot with a scant 43 hours of operational time on a Boeing 777 was in the captain's chair at the time of the crash. Though he has thousands of hours of experience with other jumbo jets, this may only have been his third or fourth international flight on that particular model, and the first time he has ever flown into San Francisco. More senior pilots could be heard in the background instructing him on the approach. Unfortunately for them and the passengers, they did not suspect disaster was about to strike until seconds before the plane hit the sea wall at the end of the runway.

I can't help but empathize with the experienced pilots on that flight. With the start of the new academic year this month, our operating rooms are swarming with brand new inexperienced residents, ready to grab the yoke and start taking flight with our patients. This is one of the most stressful and harrowing times of the year for the attendings of every specialty. It is a daily tug of war between allowing the residents to expand their skill sets and reining them in to protect the patient and their medical reputations.

An anesthesiology resident learning direct laryngoscopy can be one of the most trying times for an attending. The only person with a view of the oropharynx is the resident holding the scope. Everybody else can only stand by to assist by giving verbal directions and possibly holding cricoid pressure. We attendings are on pins and needles while the resident seems to take forever and a day to find the epiglottis and the vocal cords hidden underneath. When the resident complains he can't see anything, what does that mean? Is he too deep and thus posterior to the cords? Is he too high and looking at the roof of the mouth? Are the cords extremely anterior and he just needs more cricoid pressure? As the seconds tick by, everybody, including the circulating nurse and maybe even the surgeons start to wonder what's going on. This is where experience counts. One has to know exactly when to step in and rescue the hapless resident. Perhaps the patient does have an unexpected difficult airway that will require more expertise to perform successfully. Or more likely the resident just hasn't intubated enough patients yet to feel comfortable inserting the laryngoscope properly. It's a guessing game with the patient's life on the line.

The same is true for any procedure a resident performs under my watch. A trauma patient comes in and needs an arterial line. How many times do I let him poke around in the wrist, potentially ruining the only site for a good line, before I have to wave him off so I can get it myself. How can I explain to a resident the different sensations she should feel when inserting an epidural needle and catheter? The resident may claim she feels the sandpaper like scratching upon hitting the ligamentum flavum, but how do I know for sure? Maybe she's millimeters away from entering the epidural space and should slow down to prevent a wet tap. Or perhaps she's still in the wrong layer and we could be sitting here all day with a screaming laboring patient demanding pain relief. As attendings, we really don't know. We can only guess, through years of experience, what is happening and take over before any permanent damage is inflicted.

So I feel sorry for the pilots of Asiana Airlines Flight 214. To me, it seemed like they were allowing a junior pilot to take the plane's controls for the first time in San Francisco International Airport because it was a beautiful blue sky, perfect weather ideal kind of day for learning to land a jumbo jet. Anybody who has ever lived in the Bay area know how rare that is with its frequent fog and gusty winds. Cumulatively the pilots had tens of thousands of hours of flying experience to guide them. But one reckless move caused millions of dollars of damages, killed two passengers, injured hundreds of people, and ruined their professional careers. We attendings are on the same tenterhooks every day.