Saturday, December 31, 2011

Medicine. It's A Whole Other (Abbreviated) Language

A+A
VSS
MAE
D/C WS

Do these four lines make sense to you? If it does, then you must be a physician. During our recent TJC inspection, one of the things they were looking for was legible handwriting by doctors. Not only did the notes have to be easily read, they also had to make sense. No bizarre (nonstandard) abbreviations were allowed. If they came across one in your notes, you were tracked down and educated on the necessity of good writing. It has been shown that poor handwriting leads to medical errors. These errors should never happen because the physician couldn't bother to clearly differentiate between "mg" and "mcg" in his orders.

cc: BRBPR
87 y/o AAM w H/O CAD, IDDM, HTN, BPH, ESRF and CVA c/o BRBPR x 7D
PSH: CABG, TURP, AICD, AVF
Soc. Hx: 1 PPD x 30 yrs
NKDA

PE:
HEENT: PEERLA
CV: RRR, -m
Pul: BSE, CTA
Abd: Neg
Neuro: CN II-XII int.

A/P Admit to MICU. NS TRA TKO. NPO. CBC, BMP, ECG, CXR in AM

They don't teach this stuff in medical school. In med school we had a class on medical terminology. It was mostly a semester on learning the different Greek and Latin words that are the basis of medical terms. For instance, it was important to understand the difference between "hypercalcemia" and "hyperkalemia". However, nobody taught us that OLT is short for orthotopic liver transplant or that CLD stands for clear liquid diet.

Why do doctors write such cryptic notes? Is it some sort of conspiracy to keep nurses from doing their jobs properly and thereby blaming them for any mistakes? Of course not. Principally it's about saving time. The above history and physical would be three times longer if no abbreviations were used. We doctors are so inundated with paperwork and phone calls that anywhere we can save a few seconds is worth the trouble. For every patient I see for surgery I have to sign at least five different pieces of paper. Each signature requires a date, time, a printed copy of my name, and my hospital ID number. When the cases are short and the turnover is fast, there is little time to write longhand a patient's medical history, which typically looks like the one above. Frequent use of abbreviations makes the day run more efficiently. If everybody had to write all the words out by longhand, we would be even more bogged down by paperwork than we are now.

Incidentally, the first note at the top of post means:
Awake and alert
Vital signs stable
Moving all extremities
Discharge when stable.
Obvious, no?

An Angry Surgeon Publishes In The Wall Street Journal

"Get this thing out of my operating room!" The colon stapling device exploded into pieces when I hurled it against the operating room wall.

When I read those lines at the beginning of Dr. Paul Ruggieri's book excerpt in the Wall Street Journal, my first thought was, who is this raving lunatic operating in this unfortunate O.R.? When I previously wrote about out of control surgeons, it was done anonymously to protect the reputations of the surgeon and the hospital we were in. Now here is a guy who is so full of himself that he doesn't mind putting his name down in a national newspaper describing what a piece of work he really is. This kind of juvenile hysterics would get a disciplinary action from our hospital. I wonder how dismayed his hospital administrators must feel when they read about how the doctors who work at their facility don't know how to control their own tantrums.

I grabbed the scrub nurse's hand. "See, touch that thing.  Look how inflamed it is." When given the chance, scrub nurses love to touch organs in the operating room.

I don't know about Dr. Ruggieri's hospital, but around here nobody better be grabbing the scrub nurse's hands. They may feign fascination with the anatomy of the patient but they are too busy getting the next piece of equipment ready for the surgeon to use, before he throws another tantrum and shatters it against the wall.

Is it all a ploy to sell more books? After all, publicity is always good, even if it is bad publicity. But how would his patients feel now that they know he blames the patients and their diseases for his difficult cases and bad outcomes?

If the difficulties posed by Mr. Baker's obesity weren't enough, he had been steadily losing blood during the procedure.

Dr. Ruggieri readily admits that the hemorrhaging in the case is caused by nobody but himself. But he goes on to blame the patient's obesity and bowel disease for his inability to gain control of the situation. All the while he is mentally calculating how much money he will make for this difficult operation and ruing the day he didn't get an MBA or become a plumber. Meanwhile the anesthesiologist is busy behind the ether screen trying to pump in blood so the patient doesn't die on the O.R. table. Is there a word of acknowledgement for the O.R. staff who are busy helping this surgeon finish his case successfully so that the patient will live to see another day? Of course not. He is too busy racing home in his new Porsche. Embarrassing. And pathetic.

Thursday, December 29, 2011

The Law Med Blog

Many of you readers are entertained by the foibles of so called medical professionals. If you do a search under "medical malpractice" on this blog, you'll find a list of some pretty appalling cases of doctors gone bad. Unfortunately for me and the profession, there are just too many stories of doctors and nurses who show a dereliction of duty or just have questionable personal lives to cover. I recently found one blog that seems to report these tales pretty extensively. I've listed it under My Blog List. It is the Law Med Blog. Here you'll find multiple entries on doctors behaving badly, such as the North Dakota surgeon who is accused of using propofol as a date rape drug, or the North Carolina anesthesiologist who likes to expose himself in public to unsuspecting women. Horrible, yet fascinating at the same time. I'll continue to post stories about malpractice cases that I find particularly interesting and relevant but if you want the dirty laundry on medical care in America, head on over to the Law Med Blog. You'll wonder what kind of people make it out of our medical schools.

The Joint Commission Dementors

Fans of the Harry Potter books and movies are familiar with the characters called dementors. These are creatures who guard the wizard prison Azkaban. Their presence causes one to feel cold and lifeless, losing all sense of hope and happiness. Prolonged exposure to their presence eventually drives one into madness. That is what being inspected by The Joint Commission feels like.

Our hospital recently had its inspection by this nongovernmental agency formerly known as JCAHO. I commented before on the lunacy of some of the rules that TJC imposes on healthcare providers that don't seem to affect the quality of patient care. Many of us feel that in order to justify their existence, TJC kind of makes up stuff along the way in order to sound authoritative and put doctors and hospitals in their place.

For instance, while inspecting one of the operating rooms, one of the members of TJC told us that the trash basket has to be at least five feet away from the dirty laundry basket. Now what is the logic of that? Are there any studies to prove that a dirty laundry basket sitting next to the trash worsens a patient's health? So we dutifully pulled the baskets apart in each O.R. Another inspector decided that clipboards made from wood or particle board were verboten in the O.R. Why? Don't ask me, ask TJC. When word got out on that, the O.R. managers went rushing madly through all the rooms to make sure all the wooden anesthesiologists' clipboards were thrown out and replaced with plastic and metal clipboards. I was amazed how all those brand new plastic clipboards materialized so quickly. Is that insane? I could go on and on about these stories of random acts of lunacy. I can't forget to mention that our bulletin board had to be removed thanks to TJC. Apparently some of the clippings of personal notes and pictures that were stuck on the board were not secured properly. They were pinned to the bulletin board with thumb tacks causing the corners of the notes to kind of droop down due to that force called gravity. I guess TJC doesn't like gravity. They felt that those droopy paper corners could be a potential fire hazard and said all the notes had to come down. However if all four corners of the notes were stuck securely to the board, they were okay. WTF?

Some of the anesthesia related irritations by TJC include the perennial question about locking anesthesia carts. Our particular group of inspectors hadn't gotten word yet that TJC and the ASA had agreed on when it is appropriate for anesthesiologists to leave their carts unlocked. They wanted our carts locked whenever the anesthesiologist leaves the room, even though the O.R.s are considered secured areas of the hospital. They also suggested that we label our syringes when performing regional blocks. Sounds reasonable, you ask? Well how is one supposed to put nonsterile labels on sterile syringes while wearing sterile gloves during the performance of a block? Plus the syringes and medications never leave the sight of the practitioner so why is labeling required?

Our hospital spent months preparing for these "surprise" inspections by TJC. We rehearsed our time outs studiously. Our syringes were randomly inspected to make sure they were all labeled with the drug name, date, time, and initials of the person who drew the drug. Personal effects were banned from the O.R.'s or had to be placed in plastic bags. But you can't prepare for this kind of irrationality. It's a travesty that healthcare providers have to subjugate ourselves to these insulting inspections. They know we do a good job taking care of patients so they come up with these excuses to demoralize us. They are aware that if our facility doesn't get their approval, Medicare and insurance companies will no longer do business with us. How this organization acquired their monopoly on inspecting hospitals and the government's continued reliance on their seal of approval is beyond me. It seems that TJC has a conflict of interest in their business. They don't have a book of all the rules that a hospital has to follow in order to receive approval. If they did every hospital would follow it to the letter and there would no longer be a need for TJC. Instead they make up these random on the spot rules to justify coming to our facility and insult our patient care.

Don't laugh at our frustrations. TJC will soon be coming to your hospital soon. In fact, they are expanding internationally to inspect overseas hospitals thanks to all the medical tourists out there. Let's see if those doctors and nurses in Thailand, India, or Dubai give a darn about droopy corners on their bulletin boards.

Wednesday, December 7, 2011

Splattered


One of the workplace hazards of being an anesthesiologists is getting splattered by body fluids. Sure we are all keenly aware of needle sticks and drug addictions, but being splashed by contaminated fluids is a far more common occurrence. Somebody who has never been in an operating room naturally assumes that operations are nice sterile procedures where every surgical instrument sparkles and every surface pristine. But that is far from the truth. Once the knife touches the skin, all manners of human liquids can start pouring out. I've been doused by HIV contaminated water, blood, stool, urine, bile, pus, bone fragments, fatty tissue--virtually anything that can come out of a human being.

But aren't surgeons the ones who are most concerned about getting dirtied with human contaminants? Well yes, and that's why they are covered head to toe behind masks and gowns. In particularly bloody cases like orthopedic surgeries (pictured above) some surgeons even don astronaut suits to completely envelop themselves. The same thing with the nurses. The scrub nurse assisting the surgeon wears the same protection as the surgeon. The circulating nurse is usually sitting far away in a corner of the OR, safe from any bloody projectiles. We anesthesiologists however are right in the line of fire. You may think the ether screen separating the operating field from the anesthesiologist is to preserve the sterility of the operation, but it is really there to protect us from the mess the surgeons are creating.

Unfortunately that little ether screen sometimes is not enough. All manners of debris can come flying over the screen at the most unexpected time and direction. I can be innocently sitting at my anesthesia machine documenting my patient's vitals when a stream of blood drops can come shooting over the screen and land on my records or clothing. Unlike the surgeons, we don't usually wear protective gowns in the room to protect our clothing so this can get really disgusting. Some cases like hip replacements are particularly prone to getting spattered by blood just because of the proximity of the operating field to the ether screen and the impact of the surgeon's hammer on the patient's bone and soft tissue. But the spraying can occur in any operation. I had one colleague who was drenched from head to toe with blood during a carotid endarterectomy when the surgeon somehow lost control of the carotid artery. The force of the bloodstream showered her, her anesthesia cart, and the back wall of the OR before he was able to regain control. She was not pleased.

Perhaps one day we can perform our anesthesia from a separate room. We intubate the patient in the beginning of a case then retreat to a safe room where we will monitor the patient and control the vent settings. Preloaded syringes of drugs can be injected into the patient remotely as necessary. Once the case is finished we then reenter the room to wake up the patient and extubate. Until that fantasy comes to fruition, we best learn to wear surgical gowns or raise the ether screen to the ceiling.

Thursday, December 1, 2011

How Soon We Forget


I saw this commercial on TV the other day for the Edge of Glory knife sharpener. To prove how effectively it sharpens blades, the pitchman even runs a credit card through the sharpener then effectively slices through a tomato, which everybody knows is notoriously difficult to cut without a sharp blade.

Immediately I had a flashback to the 9/11 attacks on the East Coast. After the terrorist strikes, one of the security concerns at the time was how easily household objects can be weaponized. After all, who knew that a simple box cutter could be used to hijack a plane and lead to the murder of over 3000 people? Now of course box cutters are no longer allowed on airplanes. That's also why we have to take off our shoes before boarding, limit ourselves to three ounces of fluids that can be brought on board, and be subjected to invasive body screenings.

At that time I recall analysts discussing how a credit card can be cut in a way that turns it into a knife blade. It would be a dull blade, but if you cut it at the correct angle, it could have a very sharp point. Now with the Edge of Glory knife sharpener, that credit card can indeed be turned into a weapon. Should credit cards now also be banned from being brought on board the plane? How soon our society forgets the lessons we all learned the hard way about keeping terrorists at bay.

Wednesday, November 30, 2011

Occupy Orthopedics

Why would any medical student decide to go into primary care when procedurists are raking in all the dough? I already wrote about the incredible compensation of anesthesiologists in 2011. Now there is income data on two of the most lucrative fields in medicine, gastroenterology and orthopedic surgery.

According to MGMA, gastroenterologists on average last year made $496,874. GI docs in the Midwest did the best, averaging almost $540,000 a year in compensation. Orthopedic surgeons did even better, if that can be believed. Orthopods made a minimum of $500,000 yearly, with the exception of foot and ankle surgeons who came in just below that. Spine surgeons raked in the most money, averaging over $760,000 each annually.

We may deride orthopedic surgeons as a bunch of big lunkheads who don't know the difference between CAD and CHF, and are happy to hand off the treatments of such to the hospitalists, but they sure know where the money is. This also points to the long road for politicians who hope to attract more medical students into the primary care fields. Sure they may suggest raising physician reimbursements by 5% for primary care doctors while holding back on interventionalists. But as these huge numbers suggest, internests and other PCP's will still lag woefully behind their procedure oriented colleagues by a wide margin. Even if you cut the average compensation of GI and Ortho docs by half, they would still make more than most PCP's. Little wonder medical students with six figure school loans are still shunning primary care. They are making a rational decision based on market principles and what's best for their own livelihoods. Cause even the dumbest orthopedic surgeon still was smart enough to graduate from medical school.

Monday, November 28, 2011

Surgeons Are Overrated, But We Anesthesiologists Already Knew That

CareerCast.com has come out with a list of the most overrated jobs in America. While a corporate executive was ranked as the most overrated job, surgeons came it at number two. And physicians in general were ranked number three. The company produced this list based on compensation levels, hiring outlook, work environment, stress, and physical demands.

Sure surgeons make the highest salary in this unflattering list but they probably have the highest level of stress and physical and mental demands too. Nothing like a ruptured AAA at 2:00 AM to keep you on your toes and cause your cortisone levels to skyrocket.

We anesthesiologists of course knew that when we decided to go into our field. We saw how the surgeons all looked frazzled and discontented. Any honest surgery attending will tell his medical students and residents about the high levels of stress, lack of sleep, exorbitant medical malpractice insurance premiums, and little to no family life. While the public may be enamored of selfless, heroic surgeons based on Hollywood depictions like Hawkeye Pierce in M.A.S.H. and Richard Kimble in The Fugitive, these are fictional portrayals. The reality is much grimmer for surgeons. Yeah, I loved surgery too as a medical student and resident. I even tried it for a few years. But ultimately, once the haze of chronic exhaustion finally started to dissipate, I saw the light and went into the best field in medicine, Anesthesiology.

Sunday, November 20, 2011

The Beginning Of The End

This was going to have to happen eventually. Anesthesiologists in Ventura County, CA, just west of Los Angeles, have decided that they are no longer going to work for below market rate wages. According to the Ventura County Star, anesthesiology groups who work at St. John's Regional Medical Center in Oxnard, St. John's Pleasant Valley Hospital in Camarillo, and Los Robles Hospital and Medical Center in Thousand Oaks have refused to work with Gold Coast Health Plans, which runs the Medi-Cal program in Ventura County. Medi-Cal is California's version of the federal Medicaid health insurance for the poor.

Medi-Cal already has one of the lowest physician reimbursements in the nation. According to one study, an anesthesiologist will get $180 for a one hour C-section and $190 for a two hour hysterectomy. This is not enough to cover the overhead expenses. Medi-Cal patients who want elective procedures done at those hospitals are referred to other facilities where the anesthesiologists will still accept the insurance. A director at one of the regional clinics recalled a patient who had to shell out $550 in cash out of pocket in order to get a hysterectomy at St. John's. According to Denise Templin, "She went with a checkbook and paid out of pocket. She got money from her family and stuff to help. It's just wrong. No one should be put in a position like that."

Oh really? Nobody should be put in a position to do what, pay for a service they want? When the going rate for anesthesia services is $550 and the insurance is only willing to pay $190 but the patient expects to pay nothing so the service is denied, is that truly unfair to the patient or the doctor? What did California Governor Jerry Brown think was going to happen when he petitioned, and got approval, for a ten percent cut in Medi-Cal reimbursements to doctors last month? Does the government just expect doctors to accept the slashing of their livelihood without protest?

Since this is America, the land of the caring, we doctors will still treat emergency cases for almost next to nothing, out of compassion and the law. Nobody will be turned away from the ER who truly has a life threatening medical issue. Try asking a lawyer or an electrician to work for free in an emergency situation. They would be more likely to double their rates for waking them up in the middle of the night, if you can find them at all. But doctors are demonized for complaining about being forced to take on charity cases or asking patients for payments for services rendered.

The most frightening part of all this is that this scenario will soon play out across the entire country if ObamaCare becomes the law of the land. We'll suddenly have millions of patients, many who can pay for health insurance but won't because their iPads are more important than their health, seek medical care with Medicaid level payments. Hopefully by this time next year the U.S. Supreme Court will have given us a clear answer to the future of medicine in America.

Friday, November 18, 2011

World Toilet Day


November 19th is World Toilet Day. No I didn't know that either until just now. In America, we take clean functioning toilets for granted. Most of the world's population do their business into open pits or trenches. We on the other hand insist on a well scrubbed, sparkling clean, aromatically fresh loo within walking distance of anywhere in this country. We have toilets that wash and scrub your butt. We have toilets that will warm up your derriere when it's cold in the morning. We sell toilets that have a built in computer tablet. We even have supersized toilet seats like the one pictured above that can hold 1000 pounds. Think about that. American manufacturers have discovered a market for toilet seats that can hold a half ton human being while he's taking a crap. You wouldn't find any Japanese or Chinese toilets made to such sizes or tolerances. So as you go about your daily business this weekend, planning for your upcoming Thanksgiving holidays, remember to say a special thanks to the toilet. It's a luxury only a small minority of the world's population have access to.