Short-taped in the OR

As a routine precaution during cataract surgery, we normally tape the patient’s head to the operating bed.  Our patients are sedated (wouldn’t you want to be sedated if someone was working on your eye?) but sometimes they wake up at unpredictable times.  Everyone metabolizes drugs differently.  So to prevent them from suddenly sitting up like the Cowardly Lion and quipping, “Unusual weather we’re having, ain’t it?” we gently but firmly run tape across the forehead and under the head rest.

May be a bit low tech, but IT WORKS.

In the past, we had this big ass roll of tape to make a couple of passes around the head (or more if the patient seemed likely to be a problem child.)  A typical roll might last for eight cases.

More than enough tape to get the job done!

Enter UPMC (the acronym for “U People Must Comply.”)  Someone, somewhere, in the vast corporate mind of the beast decided or calculated that  “single use” rolls of tape were more economical.  Or maybe they ordered 10 million rolls of the wrong tape.  Whatever, the reason, this is what we have to work with now.

The picture can be deceiving.  One roll of this single-use roll just barely makes one circuit over the head, so on most cases, we are now using TWO rolls of single-use tape to protect our cataract patients from their own involuntary movements.

Never mind the insanity of making rules to govern every situation as if every situation is identical, but isn’t this terribly wasteful?  At two rolls per case, we’re using about 8 rolls for every one of the larger multi-use rolls.  Is that environmentally conscious?

Rather disgusted, I told the nurse to just order the old rolls for us to use.

I was informed that we can’t do that.  This is what we are required to use.  Silly me.  This isn’t the United States of America.  I can’t be allowed to do what I think is in the best interest of my patients.

I’m going to go off on a rant right now (and several run-on and poorly structured sentences) so you might want to grab a Snickers and an English teacher.  Okay.  Do not grab an English teacher.  Unless you are Donald Trump.  Or you are married to said English teacher.

I am getting rather tired of people telling me, the surgeon, how to do my job.  I am told that I have to mark the patient’s eye.  (That is a good idea.  We always did it before, but . . . )  I am told where I have to mark it (in the holding room instead of the operating room where my chart is and with the patient in the proper position for the surgery–I know that sounds weird but when I operate I sit behind the patient’s head so his right eye is my right and his left my left, but when I face them in the holding area, my right is his left and vice versa–for someone who had operated for years the other way, it took some getting used to and I tried carrying my charts around, but now I have two charts, the previous patient and the next patient and of course I wrote on the wrong chart shortly into this new experiment which quite frankly made a simple but important safety act more cumbersome and difficult with no definable benefit), and how I am supposed to mark it (on the cheek below the correct eye, marker that won’t rub off easily (patients have to scrub, often with alcohol, to remove my initials tattooed on their face), and I have to include THREE initials, because I might forget who the fuck I am after following all these god-damned insane regulations.)  I am basically told what medications we can use because if it’s not in the hospital formulary, it ain’t happening.  I am supposed to date and time my orders–this is an outpatient procedure that takes 10-20 minutes in most cases.  How is dating, and worse yet timing, my signature of any benefit to patient care???  Anything I sign in the chart has to be on that date and within a fairly definable time frame.  I’m not supposed to wear a watch in the OR, yet I am supposed to time everything.  What the hell did I go to medical school and residency for?  I could have saved EIGHT years of my life and just had the federal government (The Joint Commission) and UPMC tell me what to do.  Maybe Trump will wipe out the Joint Commission after he’s done erasing the EPA.  And I am done digressing.

But I heard this single use tape experiment has been so wildly successful at improving patient care and cost-efficiency that UPMC is going to roll out their next great idea:  single-use toilet paper rolls.

Because you shouldn’t be pooping on company time anyway!!!!

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What’s That For?!

So after trying to pick the golf ball off my sweater this morning, I still go to work.

As I am giving pre-operative instructions to my patient who is scheduled next week for cataract surgery, I get to the point in the discussion where I inform them what medications they should or should not take the morning of surgery.

In the good old days, I could just glance down at the list on my paper chart and know exactly what medications a given patient was taking.  (Or at least the ones they remembered or told us, but patient’s memories don’t improve with computerization anyway.)  But good old Uncle Sam has shot to hell the good old days of practicing medicine, and I must now click on a different tab to bring up medications.  The computer does not always respond right away, so sometimes there is a delay before any useful information can be gleaned from among all the “meaningful use” crap clogging up the health record system.

And instead of waiting for the computer to unfreeze, I ask the patient what medications they are on.

Generally speaking, they should only take “essential” medications such as those for heart, breathing and blood pressure the morning of surgery with a little sip of water.  Not every patient knows what their medications are for, so I like to review the list with them.  And some medications should still be taken even if they don’t fall into those categories, such as anti-seizure medications.  Others, like Flomax, should be stopped a week before surgery.

I am still waiting for the list to pop-up and I couldn’t understand what the patient answered as to what medications he was taking.  Three sets of ear tubes as a child and multiple infections have left me with a modicum of hearing loss.

So I ask him again what medication he is taking.

He answers again, but I still can’t quite understand what he is saying, and what I think he said, isn’t a drug I am familiar with.

Still no answer from the Obama-care computer.

And then I make a fatal mistake.  I am embarrassed to have to ask the patient a third time to tell me the name of his medication.  I am also impatient because my computer is useless to me at this moment.  So I think that trying a different tactic might help facilitate me finishing this discussion and moving on to the next embarrassment patient.

If I don’t know what the name is, I can still make a decision based on what he is using it for.

So I calmly ask him what he takes this medication for.

Fortunately, he either didn’t hear me, thought I was a complete idiot, or wisely chose not to answer.  At this moment, the computer manages to find the list of medications and display to me that my patient is taking Viagra.

And I, his eye doctor, just asked him why he was taking this.

EPIC FAIL.

So what would you say in this instance?

I stammered, as my tech tried not to laugh out loud, “I guess you can skip taking that the morning of surgery.”

Stamping out blindness is never easy or for the faint of heart.

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Patients are a Virtue

Perhaps it might be deemed unprofessional for a doctor to talk about his patients in a public forum–and certainly, if I were to divulge personal information it would be a violation of ethics and a HIPAA violation–but studying the doctor-patient relationship in general can be enlightening.  And amusing.

Early on in my career–as a medical student as a matter of fact–I was interviewing a patient admitted to the hospital.  I had on my short white coat, stethoscope jauntily draped across the back of my neck, a blank history and physical form which I needed to complete and the patient herself.  I was tanked up on my second gallon of coffee for the day and steeling myself for what was then an intimidating encounter.  After all, I was a third year medical student–NOT A DOCTOR.  But I was expected to act and perform like one.

As part of the history and physical, we ask questions regarding general health, that may be completely unrelated to the problem for which a patient is admitted.  It is called a Review of Systems.  The textbooks and mentors try to teach us to be thorough–you never know what seemingly unrelated symptom may provide a clue for the real diagnosis.  And the best way to be thorough is to be systematic.

So as I went down the list of questions . . . do you have headaches?  Do you have sinus problems?  Any vision problems?  And so on.  I came to the auditory system.

“Do you have any trouble hearing?

The patient responded, “What?”

I kept my nose down in my notes.  Bedside manner is a fourth year elective.  Actually looking at the patient at this point in my training might have made my head explode.  I repeated the question, louder.

“What?” she responded again.

I asked her a third time, even louder than before.  Now remember, I had already asked her questions in a normal voice and she answered.  She was obviously joking around with me, but I hadn’t realized that at this point.  Fortunately for me, she started to laugh and I realized what she was doing.  I hope it made her feel more comfortable, because it didn’t do much for my confidence.

Another patient–in my internship year–called at 2:00 AM  (that is early in the morning in case you didn’t know) and told me that he had dropped an aspirin tablet on the floor.  Could he still take the pill?

I’m pretty sure the three-second rule applies here.  Apparently germs and dirt need more than three seconds to invade any object dropped on the floor.  Was it covered in dirt or lint?  Could it be washed quickly and then taken before it dissolves in your mouth and not in your hand or in the sink?  Do you have enough in the bottle to simply sacrifice this one tablet and take another?  Do you know what freaking time it is?????

As an ophthalmologist, I don’t get many of those calls anymore, but I still deal with people.

I had a patient with cataracts and I asked him if he had any trouble driving at night?

“No.”

His vision was actually not good enough to pass a drivers test for night driving, and after looking at the cataract, I couldn’t believe he could see well enough to drive at night.

With a sudden spark of inspiration, I then asked, “Do you drive at night?”

With a perfectly straight face, this gentlemen who had just told me he had no trouble driving at night now tells me: “Oh, no!  I gave it up.  I can’t see well enough to drive at night.”

It’s all in how you ask the question.  I guess it isn’t a problem to just give up driving.

Another gentlemen told me that he was able to read without any problem.  His distant vision was fine, but he was at an age when reading glasses or a bifocals would have been necessary.  I queried him again.  Again, he insisted he could read and he reads the newspaper every day–without glasses.

So I went out to the waiting room and brought back a newspaper.  I asked him to read it for me.

This man stands up out of the chair, unfolds the newspaper, and lays it on the floor.  He then stands over it and starts reading the paper.  I guess he doesn’t have a problem after all!

Another patient, a diabetic, was losing vision progressively from diabetic retinopathy despite numerous laser treatments.  I always ask our diabetic patients how their blood sugars are doing.  Each visit, she answered, “good.”

Finally, exasperated, I asked her, “what does your medical doctor say about your diabetes?”

There was a long pause, and a deep sigh.  She then said, “He yells at me every time I’m in there.”

I guess her sugars weren’t as good as she thought they were.  Maybe there’s a reason your doctor’s yelling at you.

But most encounters go well.  It’s always nice to give patients a good report, especially when they have diseases which could adversely affect their vision.

“Everything looks good,” I’ll say cheerfully.

The patient then squints at me and blinks his eyes a few times.  “I can’t see anything!  I can hardly see you!”

Thanks to the dilating drops and the bright lights we shine in your eyes, if you didn’t have trouble when you come in, you have trouble when you leave.

But that will go away shortly.

You just have to have some patients.

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