Monday, January 10, 2011

Downregulation of Stat

The most overused word in medicine has to be "stat". This is supposed to mean "right away because harm will come to the patient if something isn't done" but has come to mean "I do don't really know if this has to be done right away but it would be much more convenient for me if it was done right away" or "I don't really think this has to done right away but I know if I want to get the results in a timely fashion, I have to order it stat".

I have been thinking a lot about this lately because of problems I have been having with my friends over in the respiratory technology division. Lately arterial blood gas machines have evolved so that they now give results such as hemoglobins, electrolytes, calciums and blood glucose in addition to pHs etc. This has been extremely helpful for those of us in anaesthesiology and ICU who occasionally actually need the results. For example when a patient is bleeding, a 30 minute old hemoglobin is of little use. Likewise your TURP who looks funny in the recovery room after his 2 hour TURP, you would feel a lot better starting your next case or going home knowing what his sodium is, not to mention getting the phone call from the lab 45 minutes after your patient with the double figure sodium had his seizure is pretty useless. The problem is of course when you order a stat Hb because your patient is bleeding, it gets queued behind all the other stat Hbs which were ordered for other reasons (baseline, patient seemed off etc). Don't get me started on trying to get a stat PT, PTT. Phoning the lab to explain that your test really is STAT is a useless exercise.

Unfortunately our friends in the ER have cottoned on to this. Lab work in the ER is as I remember a huge hassle when you are trying to juggle multiple patients and the lab values are important in your decision tree (and to going home when your shift is over). Consequently my friends in the ER also started using the blood gas machine to get what they considered to be stat blood work. Rather than do an arterial stick however they (as do we) were sending these as venous blood gases.

This has predictably caused more work for the respiratory techs who have to run these blood gases. Blood gas machines aren't that difficult to use. In my residency we ran our own gases as did the ICU nurses. Part of this is a turf issue with the RTs not wishing to lose control of the blood gas machine but at the same time not really wanting to work to hard. Our respiratory departments solution to this workload however was to unilaterally announce that they would no longer run venous blood gases from the OR (not however from the ER). This is not a problem during the day when our techs can do the gases but in the evenings and on weekends we cannot get our "stat" blood work. This has lead to me having to make a number of increasingly pointed phone calls, letters and emails to various people.

I am not a big fan of blood work anyway as I have blogged. Even when I have an art line, I do ABGs infrequently. I have a pulse oximeter and except when it is really important to control the CO2, I use the ET CO2. Hemoglobins are different matter. With routine "preventative" transfusions being quite correctly out of fashion we now allow our patients to flirt with hemoglobins of 7 or 8. This is a delicate balance requiring frequent and most importantly timely hemoglobins. When I know the patient is going to bleed, I usually have an art line. I of course cannot anticipate when the bowel resection or joint revision is going to go south and for those I usually draw blood from whatever vein is available so I can see where I am. The other day when one of our backs started bleeding profusely, mindful of the ongoing problem with venous blood gases I drew some blood and sent it stat to the lab. After 30 or so minutes we phoned the lab for the results and were told it would be another 20 minutes (and another 30 minutes for the stat PT, PTT we had sent at the same time). I think next time I am just going to fight with RT.

Of course stat is egregiously misused in the surgical setting especially by our obstetrical colleagues. Every non booked C/S is of course stat. These range from prolapsed cords to patient wishing to have her baby today for astrological reasons (we have done at least one such stat C/S). Attempts to ask the person who phones you just how urgent this case is (i.e. do I need to call in the second call) usually gets a rude response.

The OR has of course been burned by this in the past and classifies cases by urgency. Our hospital uses E1,E2, E6 and E24, the number refers to within how many hours the case should be done. This system is susceptible to gaming as well. I find it amazing that appendectomies are only E1 or E2 after 1600 on weekdays and on weekends of course. I have of course never figured out whether an E24 becomes an E1 after 23 hours. The surgeon would say so, unless of course he is already operating or has a office ( or is baby sitting).

Where I used to work all the surgeons also booked their booked cases as urgent rather than elective. As a surgeon explained to me, if he booked his cases elective they would be continuously bumped by his and everybody else's urgent cases. The cardiac surgeons where I trained booked all their CABGs as urgent, which also helped to inflate their wait list number so that they could point out that the wait time for an "elective" CABG was 9 months. Problem was that they never did any elective CABGs, they were all emergencies (and usually done within 2 months of symptoms onset).

Part of the whole system is our unwillingness to triage patients; to say what truely has to be done right away, what can wait a little while and what can be done whenever (or never). Individually we may be willing to do this but we don't trust our colleagues to do the same and as we all use (and pee in?) the same pool of resources we try to get the best for ourselves and our patients.

I am however getting tired of all of this and am awaiting a resolution. STAT of course.

Another reason why Healthcare Costs are Soaring

Our department is trialling new machines this month. Our old machines are still functional but according to the manufacturer will not be serviceable in three years time.

Just before Christmas, I learned that we would be getting 8 new machines. As department head I was a little confused because no one had approached me about these machines. Worse I was told that we would have no choice about what machine it was and that we would not be able to trial the machine. The reason I was given was that money was now available for the purchase of these machines and it had to be spent now or it would be lost forever.

Worse still was that the machines that had been chosen for us were the Draeger Primus machine. Our department bought two of these a couple of years ago for use in Obstetrics. Unfortunately as I blogged about, these machines if unplugged have a 30 minute boot up which of course makes them unsuitable for obstetrics (or for anaesthesia in general for that matter). In addition they have a tiny work surface, do not have the modes of ventilation some of us have come to love and of course they have Draeger's annoying wolf-crying alarms.

About a year ago my predecessor was faced with a similar demand. Get new monitors or the money disappears. He replaced our perfectly good monitors with new monitors from Philips which have been disastrous.

I wasn't too happy about being rail-roaded into buying machines that I certainly didn't want and the rest of my department didn't want so after a few few phone calls my reasoning was thus: when if three years we actually do need new machines, what are they going to do? shut down the OR?. Of course not, the money will come from somewhere. I also got the strong impression that we were being railroaded into taking machines that somebody else had already rejected.

So I phoned up the lady who is in charge of purchasing these machines. She is as it happens a nurse who was in charge of the neurosurgical ORs at the Centre of Excellence when I worked there. I told her that we did not want the machines, that we realized that we were going to "lose" the money; that we did not care and that we would let the chips fall where they may. She just said, "I hope you know what what you're doing BH". I said I did.

One hour later I got a phone call from the same person, asking if I would be willing to trial a different machine.

BH 1 Administration 0.

Seriously though, in twenty years I have seen so much perfectly good equipment thrown out because the capital budget had to used up. Some new equipment has been an improvement over what we had before, quite a lot of new equipment has been a huge step backwards.

As an aside, it now difficult to find a machine that is not completely electronic, which of course makes them susceptible to software and hardware problems and of course a software glitch could easily disable an entire department's computers. This usually requires a tech from the company to come in from out of town. I long for the old mechanical machines with their simplicity and easy serviceability. I challenge anybody to prove that our newer machines are anymore safe than the old mechanical machines people of my vintage trained on.