Thursday, April 21, 2011


MAFAT as any surgeon will tell you very early in your career means Mandatory Anesthetic Fzcking Around Time. They will tell you this with great glee when they should be scrubbing, prepping or actually operating on the patient.

About a year ago when I took over as Department Head or in newspeak Site Leader I had a farewell interview with my predecessor, who is a living legend both in the anesthetic and medical communities. I was expecting some very insightful words to inspire me to reach the heights of notoriety that he had reached, however most of the time he spent telling me to make sure that I never let certain anesthesiologists do certain lists or work with certain surgeons. "They just cannot handle the work", was the way he put it.

I consider myself to be a pretty efficient anesthesiologist. I remember a few years ago an older nurse who had been trained by the nuns telling me that she had been taught by one nun that, "the biggest sin is wasting somebody else's time". I had never really thought about it, but I hate to wait, I hate to have my time wasted why should I waste other people's time. I was fortunate to be mentored in my residency by three role models who just happened to have the same first name as me.

The Samurai warrior was a Japanese Canadian pediatric anaesthesiologist who was always in a hurry but at the same time incredibly compulsive. Very stressful as a junior resident to work with but at the same time in retrospect a great education.

The Bull was an English anesthesiologist, very much less compulsive than the Samurai, but still hard driving wanting to get the cases started and finished as quickly as he could.

Dr. Gadget loved monitors and other toys which he of course applied quickly to the patient. One day one of the nurses remarked, "One day he is going to catch up with himself". I remember as a resident working with him and finishing two CABGs by 1430, a record that will never be broken.

All three of them taught me that you can be fast and still be safe.

In anaesthesia we typically work alone so the only insight I get into the work habits of others is when I work with a resident. Usually when a resident is doing something stupid, I figure that they must have learned this from somebody because no rational person could have figured out how to be so stupid on their own. The first case I did with a resident at the CofE I remember several times having to tell him to "get on with it", an expression I learned from the great Ernie Hew during an elective at Mt. Sinai. The epidural is not going to get done by you staring at the patients back!

One annoying habit that residents have which I can only assume someone is teaching them is what I call the appetizer approach. This is where the resident will give a little of the fentanyl du jour and then ask the patient several times, "are you feeling it yet?". OK this is not a restaurant, I am about to have surgery, I am in a cold room, if I look to one side I can see the weapons being prepared by the nurses, and now some idiot is making me dizzy and nauseous and asking me if I am feeling it. For the love of God, put me to sleep.

Some things like art line, central lines and epidurals take longer; they are going to take a lot longer if you don't think about them until the last minute, don't tell the nurses and the techs you are doing them and to quote again the great Dr. Hew, don't get on with it.

A lot of MAFAT is of course beyond our control. Surgeons especially those in teaching hospitals live in a delusional universe where after they scrub out and leave the room, the wound closes itself, the patient awakes immediately, the room cleans itself, the next patient arrives on time with his consent signed and the IV starts itself. All with no time elapsed. To their dismay the rest of us live in another universe. Long turnovers frustrate me too. When I have to wait 30 minutes between cases, I feel I have to rush and cut corners to make up for everybody else's inefficiencies. I call it "wait and hurry up".

At the same time our fee schedule has devolved into a situation where for the most part we are paid by the hour. This means if I do 5 cases in 8 hours, I get paid the same as if I do 4 cases in 8 hours. Or if I do 5 cases in 8.5 hours because I am less efficient, I actually make a little more. Multiply that 0.5 hours by 250 work days and we are talking about some serious cash. Not that this ever crosses the mind of some of my colleagues. Never.

Periodically administration approaches us about extending the day or working on Saturday to clear up a perceived backlog of cases, total joints are the current cause. I have learned that the best way to shut them up is to suggest that they first look at using the time they have more efficiently. End of discussion.

As I am reminded, patients don't come to hospital for an anaesthetic however we are only part of team. As my band teacher told us over and over again, a band is only as good as its weakest member. I try not to be that person.

No comments: