Red Cap Society

As I was entering the surgical center where I do cataract surgery, I was greeted by a sign on the door to the locker room . . .

If you follow my blog with any regularity–or my new sister blog, The Silence Dunwell Letters–you know that I am a bit of a cynic when it comes to arbitrary regulations–rules that seem to be in place only to justify someone’s job–proof that they are doing their job, even if it isn’t very well.

So apparently these rules are designed for VENDORS.  I’ve always known them as sales reps, but tomato, to-mah-to.  Vendors makes me think they’re selling hot dogs or drinks.

SO CLOSE!  Red Cap, but not BOUFFANT!

Red Bouffant Cap.  I’ll come back to that.  You know that I will.

Badge clearly visible.  Good rule.  No problem with that.

Current with requirements.  I have to maintain my license.  I don’t have a problem with everyone else in the operating room maintaining their credentials.

Long sleeve warm-up jacket?  What about summer time?  Is it possible the coach may want to put you in the game, so you better keep your arm warm?  There may be a good reason to require this, but I have FAILED to come up with any remotely logical reason to make this a requirement.  Leave me a comment if you think of something.

NO UNDERSHIRTS.  Seriously?  How will you know if they are wearing one under the already mandated LONG SLEEVE WARM-UP JACKET?  Are you [bleeping] kidding me?  Who’s going to inspect for this?  Do they have to undergo strip searches for illegal under garments?  Can anyone show me a medical study that even remotely suggests that the undershirts of non-operating personnel worn underneath an official warm-up jacket have been shown to increase the surgical infection rate?  Anyone?  McFly?  We are just a few sieg heils away from regulating the type of socks and underwear we use.  Oh wait, I think they do regulate the type and color of socks and shoes of the nursing personnel.

UPMC stands for U People Must Comply.  We will wear only their scrubs and have no other scrubs before thee.  We are the Stepford Doctors.

Shoe covers?  Not a problem for me.  As long as I can wear whatever shoes I want underneath.

And no problem with requiring that visits be scheduled.  We don’t want the operating room to resemble a flea market or bazaar.

But . . .

What in the wide, wide, world of medicine prompted this fashion faux pas?  I searched high and low but couldn’t find the big red noses or the clown shoes to go with them.  What are they vending?  Happy Meals?

I will assume–always an unwise thing to do, but this is my blog dammit–that they want these “people” to be readily visible.  Mission accomplished.  You could pick them out from a satellite image.  I guess the ID badges are simply not enough.

Seriously, is this necessary?  For the record, we never had RED CAPS before, so now we are spending health care dollars on this fabulous headwear.  (Hashtag #whyamericanmedicineisgoingtohellinahandbasket)

In all my years as a surgeon, I have never had an instance where there was someone in my operating room that I did not know, or was not introduced to (such as a nursing student, inspector, repairman, etc.)  And if there was someone in my room and I do not know why they are there— I ASK WHO THEY ARE AND WHY THEY ARE THERE.

I don’t depend on the color and coordination of their outfit to satisfy my curiosity.

Because any idiot can put on a red cap.  I did.  I wore that thing all day!  I’m operating and I’m vending!  Oh, I’m vending, Jerry.  I’m vending!  And I hear that UPMC allowed a VENDOR to perform surgery!  (Psst.  It was just me.  In the red hat.  Don’t tell.)

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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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Making Out in the OR

Most people are unaware of the myriad government regulations and documentation that goes on behind the scenes in the medical setting.

In the operating room, one of the items that must be documented are the times in the room and the times out of the room.  Time in or time out.  But, we also have to take a “time out”–actually two time outs–where we verify the patient and the procedure before starting surgery.  The terminology gets confusing.  But I digress.

Anyway, both anesthesia and the circulating nurse must document these times in different locations in the medical chart.  AND THE TIMES MUST MATCH.  I don’t know what happens if they don’t, but I imagine it would be like matter meeting anti-matter.  The very fabric of our universe would be ripped apart if these numbers are not exactly the same.

So to avoid a universal catastrophe and destroy civilization as we know it, the circulating nurse and anesthetist verify their times before documenting them in the medical record.

From http://www.shitamandasays.com/2011/12/01/she-wants-to-do-what-to-the-dog/

Now so far, none of what you have read about has actually TREATED the patient.  Apparently the government hasn’t worried about that yet.  Right now, we are spending an inordinate amount of time treating your medical record.  The outcome of your surgery is irrelevant as long as all the times match up correctly.  But, I digress again.

So a given interaction to coordinate these times might go like this . . .

Circulating Nurse:  “Do you want to make 11:13 time in?”

Anesthetist:  “Sure.”

And then they dutifully document that in their respective areas of the chart.

Today, at the end of the case, though, the anesthetist phrased the question slightly differently . . .

Anesthetist:  “Jane [name changed to protect the innocent], what time do you want to make out?”

He meant to ask what time she wanted to document for the time out of the room.  But that is not how it sounded to everyone else.

Always on the ball, she responded, “Not right now, but I’m free later.”

For the non-medical record, Jane, who really isn’t Jane, didn’t actually say that.  But she should have.  We all had a good laugh anyway.  And the universe is safe for another day as our times all matched.

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The Little Piggie That Should Have Stayed Home

As a runner (25-35 miles per week for the past ten years or so) I have gone through the gamut of running-related injuries including Achilles tendonitis, plantar fasciitis, sore knees, shin splints, ankle sprains, hip pain, and perhaps the most famous of all, the runner’s toe.  This latter is probably the least painful on the list, but there have been nights after a fresh bleed under the nail that the incessant throbbing has kept me awake.

Over the course of time, I have suffered purple toenails in three toes, all on the same foot.  Only the piggie that went to market and the one that cried wee, wee, wee all the way home have been spared.

After a brief consult with a podiatrist, I decided to have the nails removed from the three offending piggies.  She wanted to remove them permanently, but that sounded, well, so permanent.  I mean, what if I become a cross dresser some day and want to wear open-toed stilettos?  How will I paint my nails if there are no nails to paint?  I couldn’t take that chance.

So I opted for simple surgical removal.  Simple and surgery should never be used in the same sentence, although technically, I used the word surgical instead of surgery.

The podiatrist in question operates in the same surgery center that I do on the same day.  So we agreed this past week to do this simple procedure after I had finished my slate of cataract surgeries.  I’m thinking she will use some really sharp scissors and cut them back much the way I would do at home with nail clippers.  Wipe away the blood clots and I would be good to go.  Probably just do it in the surgeon’s lounge as long as no one was trying to eat.   I’d probably be running later that afternoon since the sun was finally shining here in central PA. 

I was mistaken about the simplicity of this procedure.

I was told to go to room six, which is the room where I normally operate.  I feel comfortable there, but I’d still rather just have it done in the lounge or in the hall.  It was done by the podiatrist, in the hall, with scissors.  It’s not that big of a deal.

They wheel in this big operating room table–the kind you do orthopedic or neurosurgery on, not the kind you use for eye surgery.

“What’s that for?” I ask innocently.

“For you.  Hop on.”

Really?  I’m just having a couple of nails cut off.  I can just sit in the chair over there.

No I can’t.

My staff is busy with gowns and gloves and setting up a table of instruments.  I don’t know whether I’m in for a lobotomy or a nail removal, but from the sheer volume of instruments, it looks a lot more complicated than I thought.  I’m starting to fear for my appendix.

Fortunately, before I can think too much about what is going on and change my mind, the surgeon comes in.

She asks for the anesthetic.  I’m just having the nails removed.  But you are going to want them numbed before I do that.  The way she said that made me want them numb.

“Can I have a smaller needle?”  She laughs.  They gave her an 18-gauge needle.  We’re in the eye room–I’m sure we have smaller needles.

“Can I have some morphine?  Or Fentanyl?   Or Propofol (Michael Jackson’s drug of choice)?”  I hope I didn’t sound too whiny or pathetic.  I am.  But I don’t want to sound that way.

“Don’t you have anything smaller?  This is a one and a half-inch needle.  I’d rather have a one.”

“Will somebody get her a smaller needle?!”  Now I just sound scared.  Or desperate.  Or both.  Scary desperation.  Desperately frightened.  Throbbing in my toes every few weeks isn’t so bad, is it?

They didn’t have to hold me down, per se, but I think someone sat alongside my legs and leaned over.  They said it was so I wouldn’t be tempted to watch.  Or move.  Or run away.

Now I’m paranoid.  Scarily, desperately paranoid.  I want to hang on to my appendix and my spleen but I’m afraid they will just make fun of me.

“What are you doing down there?”  I think I may pass out.  I’ll probably fall on the floor and break my nose.  I think the ENT guy is in room three, lucky for me.  Maybe he uses Fentanyl.

“We’re just cleaning the skin with a little alcohol.”

Can I have some to drink?  Is the Fentanyl here yet?

But alas, all I was going to get was a series of injections at the base of my toes with a short, sharp needle.  The medication burned a little at first.  I was being injected with tabasco sauce.  I don’t remember much after that.  But they didn’t need to call ENT so apparently I didn’t fall on the floor.  Well, at least I didn’t fracture my nose.  I take an aspirin a day because of a history of atrial fibrillation, and so I bled like a stuck piggie.  Three stuck piggies truth be told.  By the time they finished wrapping my numb hemorrhaging toes, I couldn’t fit my shoe on.  They got me some kind of boot to wear home.  Thankfully, no one called a stat type and cross to room six.

I figured if I got pulled over by the cops for speeding, I could blame it on the boot.  My foot is numb, officer, I couldn’t feel the pedal on the floor.

I made it home just fine and elevated my foot as I was told to do.  Initially she had recommended no running for two weeks, but I think we both knew that wouldn’t happen.  That was also when she was planning on permanently removing them by cauterizing the nail bed with Phenol.

So after three days, I jogged 4 miles today with no pain and no bleeding.  Probably could have run sooner, but my wife frowned on that.

My doctor was wonderful, but all the same, I hope they grow back normally and I never have to go through that again.

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