Tuesday, August 19, 2008
I chose Emergency Medicine to be a white-hat cowboy.
Now 'cowboy' has connotations within medicine that entail being overly aggressive with patient management or taking silly chances or making wild guesses, but this is not what I mean.
I wanted, within the walls of the ER, to be in charge. I figured that, being Board Certified and subject matter expert would allow me to be benevolent King in the ER. Oh how wrong I was!
The real power in medicine today and the ability to effect meaningful change is not vested in practicing physicians. It is vested in the clipboard carriers... the makers and enforcers of policy and procedure, and the 'owners' of the 'business'.
Example: Three years ago at my current institution the method for performing urinalysis was changed from the simple dipstick method (with dedicated lab confirmation and culture when needed) to the whiz-bang (nice pun eh?), can't miss, lab-run urinalysis.
Besides being a huge waste of money this extended patient stays in the ER for no good reason as the lab UA takes longer.
Add to this an administrative decision that all urinalyses had to be ordered by the nurse in charge of the patient, not the unit clerk (who orders all other labs), and we now find ourselves waiting hours for a urine result. It is often the last thing we get back, even after the CT scans are read and resulted, the blood results are in, the EKG is interpreted, and the disposition is almost made. Often, when I am waiting on a urine, I just cancel it and make an educated guess that the urine is normal OR I go ahead and treat a urinary infection based on clinical presentation.
Simple fix right? Bring back the dipstick UA or have the clerk order them with the other labs or SOMETHING for the sake of humanity!
But no. The answer, from el jefe supremo, the nurse manager and the lab manager, is that it can't be changed because if we did change it back it would cause the earth to stop spinning on its axis and we would all fly off into space.
The people with clipboards have also decided the following...
1. We have enough nurses (we don't).
2. Nurses should be happy to work for less money here than at the place down the street (which is hiring by the way).
3. Good nurses can either like it or lump it... their resignations are accepted the minute they are delivered, but bad nurses, kinda easy to get at our rates and in our busy ER, can not be fired on the spot even for committing errors that a first year nursing student would not make, but must be 'mentored' and, if, after five years or so, they are not firmly part of the team, a 'termination process' must occur which in itself takes five years and must be given the seal of approval of Al Sharpton, Louis Farrakhan, the Ku Klux Klan, la Raza, and Hillary Clinton.
4. There are no ICU beds. Ever.
5. We do not need to fully staff the OR... surgeons should be able to operate by themselves, and, in a pinch, perhaps with an anaesthesiologist.
6. We do not need patient transporters... this is a duty best performed by RNs.
7. When we are short-staffed (every day), we are short-staffed. The nurse manager will NOT come in to fill the gap as he is long past his clinical days, and besides, he is in Aruba.
8. Our hospital is a success, just look at the numbers!
9. The understaffing is not a problem because "no one has died yet".
10. Doctors are not good at administration. It's really complicated and best left to the professionals... you know, the folks that have a hospital administration degree or something that looks vaguely like it. Doctors mess things up by insisting on things that aren't needed... you know, like OR nurses.
More brain-busters follow directly related to our subjugation to administrators...
11. TOFKAJCAHO rules! My favorite rule... "there is to be no food in 'patient care areas'." These areas are specifically where patients are not. In other words, there is no food or drink allowed in the nursing or doctor areas, only in the patient's rooms. If followed to the letter, this means that physicians and nurses need to leave the ER to eat or drink. Good idea. They don't really need to be in the ER anyway, they don't need to eat or drink while on the clock, and what's the worst that could happen?
12. EMTALA. Need I say more? If we make a law that everyone has to be given a 'screening exam' and definitive care of 'emergency medical conditions' (whether they can pay or not) the system will not be crushed, doctors and nurses will not quit, and the money to pay for the free care will magically appear. If it does not appear it will be made to appear. Duh.
13. HIPAA. I can't tell you about this.
14. See this.
15. Deborah Peel.
16. Clipboard Satan decided that REGISTERED FREAKING NURSES, can not administer certain 'dangerous' medications anymore. So what ends up happening when I choose to use, say, propofol for sedation, is that the nurse hands me the syringe full of propofol and I ask them where it hooks up and how much to give to equal the dose I ordered and they end up doing doing it anyway. Or I let them give the medicine while touching them with my index finger on their shoulder thereby taking advantage of the old 'electricity' rule from the game of 'tag'. Then the beleaguered nurse charts that I 'pushed' the medicine. Absolute fucking insanity.
Today's doctors are just like yesterday's. We are professionals with thorough training and skills that are unique. We are, to draw an analogy, like a professional boxer being told, prior to the first punch, that we have to fight blindfolded and with one arm only. Thankfully, one of our national organizations has finally got of its butt and started a petition so that we may do what is right for our patients without the clipboarders interrupting us. You may see it here (Docs, please sign this if you will).
HIPAA, EMTALA, and TOFKAJCAHO could all be trashed if folks on our side would simply follow this rule... DO WHAT'S RIGHT FOR THE PATIENT RIGHT NOW. Of course, this would put a lot of people with clipboards out of "work", but I would happily hold the door for them on their way out.
Posted by 911DOC at Tuesday, August 19, 2008