NPO

One of our staff emailed the whole group about a problem he encountered recently.  Our hospital does a lot of ureteroscopies for stones.  This is because we have the only lithotripter so we get the failures from there.  Despite having one room a week free during the day for urgent stones, we do a fair number after hours.  This is highly urologist dependent; 3 individuals account for about 90% of our after hours work.

Anyway one of these urgent stones presented to the OR in the evening having just eaten a full meal.  I didn't find out why this happened but I suspect the patient thought he was coming to the hospital to consult with the surgeon about his stone, NOT to have surgery.  It could have been that he got faulty instructions from the surgeon's office or that he is just stupid but he admitted to having eaten supper.  "That is too bad," said my colleague, "I guess you will have to have your surgery tomorrow."  "But" replied the surgeon, "he needs to have the stone done or else he might get septic!"  "Fine," says my colleague, "After a solid meal he will need to fast for 6 hours."  "That is way too late," said the surgeon, "he is going to get septic, can we do him under local with IV sedation."  "You can do what you want," replied my colleague, "But you are on your own" and went off to cool his heels.  The surgeon according to seemed shocked.

Kidney stones do get septic, I have seen one case in my medical career but as even the urologist who is chief of surgery at our hospital acknowledged, this is rare.  I suspect the urologist in this case was more concerned about getting home to tuck in his kids and have sex with his wife than any impending sepsis.

It does bring up the interesting topic of NPO.

When I started my residency a 6-8 hour fast usually written as NPO after midnight was the rule which meant patients frequently fasted for 16 hours or more.   The 6-8 hour fast was not based on any real evidence.  Up until the late 1950s fasting guidelines were much more liberal including things like tea and beef broth right up until surgery.  The introduction of longer fasting intervals coincided with other things like better anaesthetics (like halothane instead of ether), more use of endotracheal intubation, better trained anaesthesiologists and intensive care units, so any attribution of decreased morbidity with aspiration is more multifactorial rather than just due to longer fasts.  There also emerged a dogma of a gold standard of a gastric volume of less than 0.4 cc per kg and a pH of greater than 4 based on research on Rhesus monkeys extrapolated to humans.

Further we were told that narcotics delayed gastric emptying as did a myriad of other medical conditions including pregnancy so that those patients all had to have their airways protected with a rapid sequence induction and an endotracheal tube.  We asked every patient about reflux.

Many patients of course needed their surgery immediately and we managed them with rapid sequence inductions.  It was also apparent that one could use the NPO interval to manipulate emergency cases.  If you thought you could get the case put off to the next day, you quoted a longer fasting time, if you knew you were going to have the do the case anyway, you accepted  a shorter fasting time.  I played that game fairly recently.  Surgeons also clued in. When I was a resident, I was on call and one of the older surgeons booked an appendectomy.  "He ate lunch," said the surgeon smirking, "So how about we do him at 7 pm?".  What this really meant was he wanted to go home and have supper and then come back to do his case.  I on the other hand was more interested in following the list with the case. As I told the staff anaes firstly the patient had to be treated as a full stomach anyway and secondly if he was actually able to eat lunch, they didn't have appendicitis.  It didn't work, staff surgeon and anesthesiologist ate supper at home, I ate supper in the hospital cafeteria after which the patient was relieved of his appendix.

Already as I started my residency, brave anaesthesiologists were actually doing research to challenge the dogma of NPO after midnight.  One of them who gave a talk at rounds described how some of his fellow anaesthesiologists were horrified and refused to even be in the room while he did the studies.  It became clear however that patients could actually have clear fluids right up to the time of surgery and now the Canadian Anesthesiologists Society recommends allowing clear fluids up to 2 hours pre-op.  Administration asked about 3 years ago if we would relax our NPO standards at our hospital, I looked at the guidelines, asked my colleagues and we agreed that people could have water up until 4 hours pre-op just in case the case before them was cancelled.  We chose water because of the confusion over what exactly is a clear fluid.  The hospital ignored us and rolled out a 4 hour clear fluids policy with huge fanfare this January, however most patients seem to be fasting after midnight.

Exactly what a clear fluid is, has never been clarified.  If you look at the variety of fluids that are considered to be clear fluids, you see a variety of fluids with different pH and often pharmacological properties on their own (tea or coffee).  Many patients think that a large milkshake is a clear fluid.  I suggested just telling patients to drink Gatorade (any colour except red)  which is what my surgeon told me I could drink before my colonoscopy.  I am not endorsing Gatorade, it could be Poweraid, Kool Aid or Tang.  Coffee was verboten until they found it actually raised gastric pH and lowered gastric volume so black coffee is now back in.  I still am not sure what adding a few mls of milk or cream does to make coffee any less safe.

A few years ago, one of colleagues at the C of E announced that she had just cancelled a patient for chewing gum.  "Whats wrong with gum?'"  I asked (as long as they spit it out).  She looked at me like I was an idiot.  "Gum increases gastric volume," she said the voice one uses when trying to explain something to a child.  A few months later a study showed this wasn't the case.  I should have copied it and put it in her box but I didn't.

To sleep perchance to dream

The accusations against Dr. George Doodnaught are as disturbing as they are bizarre. The Toronto anesthesiologist has pleaded not guilty to molesting 21 female patients, who range in age from 25 to 75. While the women lay consciously sedated on the operating table, the 64-year-old allegedly kissed them, groped their breasts and even forced them to perform oral sex, all while hidden behind the sterility drape that divides the anesthesia station from the surgery.

Anyone who has spent time in an operating theatre knows there are nurses, cleaners and doctors buzzing in and out of multiple exits and entrances. So far, with few exceptions, witnesses who worked with Dr. Doodnaught testified he was a sought-after specialist with a good reputation. The prosecution is charging the hospital was engaged in a coverup.

Dr. Doodnaught’s defence: that the medications used to anesthetize his patients caused “sexual fantasies.” The drugs—including midazolam, ketamine, propofol and sufentanil—were given to patients in different doses to allay their anxiety and produce amnesia. The side-effects: the erotic and violent hallucinations these patients are confusing with reality.

It turns out there is an entire literature dedicated to the study of hallucinations and dreams during surgery—particularly sexual ones. “Sexual hallucinations have been reported since the advent of anesthesia,” begins a 2003 review article in the journal Anesthesia. In the late 1800s, the authors write, the use of chloroform in anesthesia was prohibited because of cases where women used “obscene language” while on the drug.

For decades, the medical community agreed that witnesses should be present when doctors give patients mind-altering drugs to avoid false harassment allegations. A 1992 review article in the dentistry journal Anesthesia Progress looked at the effects of benzodiazepines (such as midazolam) for sedation during surgery. The author, a Northern Irish doctor named John Dundee, discussed case studies in which female patients vividly recalled being sexually harassed by their dentists. “In 13 of 16 of the reported events, where patients and attendants were questioned closely, nothing improper could have occurred. In 11 of these, others were present throughout, while two events were physically impossible.” Some of the dentists who were working alone—that is, without witnesses—lost their licences.

The 2003 review article outlined a series of allegations and convictions involving “wandering hands,” “fondling” and forced oral sex. In Ottawa, in 1986, an emergency doctor was acquitted of a charge that he asked a patient to squeeze his penis while she was coming to after a surgery. A Norwegian plastic surgeon was tried in the Oslo High Court for masturbating nine patients who were on midazolam and fentanyl while he performed breast surgeries. A nurse who witnessed the surgeon at work helped to get him acquitted.

While the medical community doesn’t know exactly how anesthesia works, or why it causes hallucinations,, the authors point out that patients may be confused by routine touching during an operation. “Stimuli to the chest such as the removal of ECG electrodes, elbows rubbing the chest while the operator is working in the mouth or on the face have resulted in accusations of breast fondling.” Most cases on record involved female patients and male practitioners, though there are reports of the inverse. Most articles conclude that sexual hallucinations or fantasies are an infrequent, though noteworthy, side-effect of a range of drugs in anesthesia and sedation.

Erotic dreams under the effect of many anaesthetic drugs including Propofol have been known anecdotally if not formally studied in anaesthesia.  This is more likely if drugs are used in sedative rather than anaesthetic doses; patients do not usually  (should not) dream under anaesthesia.  It is possible that patients may dream while coming out of anaesthetic given that most of us lighten up patient while the residents are watching the wound heal, in the hope that the patient will wake up quickly  and we can empty our bladders and have a coffee.  Given low level of most of conversation which occurs in the OR which patients can sometimes hear, it is not surprising that they may have sexual fantasies.

The case against the unfortunately named Dr. Doodnaught raises some questions.

1. If the patients are just dreaming about sexual assaults, why was he the only person in the hospital accused.  Is there something innocently different about his technique?
2. There is a mention of him attempting oral sex with a patient during an abdominal hysterectomy.  Given that most people intubate their hysterectomies which involves muscle relaxation that is relaxation of ALL the muscles it is how to see how this happened?  It is possible that this could have been a spinal with IV sedation but this is stretching things.  Maybe I am not enough of a pervert but I am stumped as to how one would accomplish this.
3. Is he such a nice guy that everybody in the OR is willing to cover up pretty disgusting behaviour by him or did he just piss off the wrong OR nurse?

Don't know all the facts and like most cases involving the legal system and the press, I suppose I never will.

Bullying, disruptive physicians and thoughts on administration

One of my fellow physician administrators forwarded this post from Kevin MD.  I have pasted it at the bottom. 

I was talking with the same physician a few months ago and we were discussing how bullying was going to be next club with which physicians were beaten.  In addition the disruptive physician label has become the latest Scarlett A.  Both are perfectly valid concepts, many physicians were or still are bullies.  It is unfortunately the culture in which we were raised if you want to commit sociology.  Likewise there are many disruptive physicians and many of them have continued to be so in part because the system nurtures them.  It is the extension of the terms to legitimate disagreement or dissent that is the problem.

I have to attend a lot of meetings, which we all know are way to deal with any problem.  These include meetings specifically to deal with problems and regular meetings such as what used to called the OR committee and Medical Advisory Committee among others.

The MAC which is supposed to be a meeting of the department heads with senior management is no longer a forum where policy can be discussed or modified, assuming that was ever the case.  About two days before every meeting, I receive by email a massive document dump which I am supposed to read before the meeting.  There is of course no way I can ever read the whole package let alone figure out what parts of the package I should read.  Assuming I did read the whole package, I would find it full of incomprehensible flow charts and neologisms. This is what is called consultation.

Occasionally you may be asked to give feedback into a particular policy during the planning stage.  The meetings will be scheduled in the middle of the day when you can't get to them because you are working.  If you think it is important enough to take an (unpaid) day off, the meeting will be cancelled at the last minute because one of the "stakeholders" can't make it.  They of course never cancel the meeting because you can't make it.  Or they will invite you by the hospital email address you never use because it is too cumbersome to access.  When the policy comes into force, they will say that they consulted you.

Most policies are then presented to the MAC as a fait accompli.  The medical director, now called the Vice President - Medicine may actually have had some input or not.  It was at meeting about a year ago that I realized that there must be a secret administration running the hospital.  We were presented a policy on standing orders made by our quality department that was completely illogical and was going to hamstring care as we knew it.  Despite the fact that our administrator, both medical directors and all the department heads were present, the policy was presented as something we would have to live with and could not be modified.  Discussion did become a little heated and both sides made some edgy comments.  The policy went ahead however and we are gradually learning to live with it.

My father served in the provincial government for over 30 years rising to fairly high levels and attended multiple meetings.  He told me that every committee should have somebody on it whose job is just to say, "BULLSHIT".  He told me that people get irrationally attached to ideas and need somebody to bring them down.  Keep in mind it now almost 30 years since he (or people who think like him apparently) was involved in decision making.  This is not a new concept.  The Vatican when considering somebody for sainthood actually has an individual known as the Devil's Advocate whose job is to argue why the individual should not be a saint.

Nowadays if anybody is brave enough to object to or suggest modifications to some policy or plan they are told one or all of:

1. It is an accreditation standard.
2. It is a Zone/Regional/Provincial/National standard.
3. Administration is committed to the project.
4. People have already been hired and it is too late to stop.
5. You have no right to comment on this issue.
6. You are an asshole. (While it would be nice if they actually called you an asshole, they never phrase it like that, they just make you look like an asshole).

Pointing out how impractical implementing the policy with the resources that you have or that it won't work in the real world is useless.
In three years I have learned a few things about administrators.  I refer to nursing because I deal with them the most but this applies to most of the heirarchies in the hospital.

1. Administrators are usually hamstrung by how much money they have to work with and the political agenda of the people who decide how they spend the money (this includes the secret administration).  This is true by the way in both the public and private sectors (the private sector just has more money but also has to make a profit).
2. Administrators have the best job they have ever had in their life.  Why would they want to risk it by standing up to the people above them.  This is as opposed to physician administrators who are often doing this out of a sense of duty or because it is their turn and either already have a good job outside of administration or could go back to clinical practice and be a lot happier and quite often better paid. Non-physician administrators know this and resent this.
3. In the health care sector many administrators actually rose up from the trenches.  In a lot of cases this is on merit.  In quite a few cases it is just a case of having been in the right place at the right time.  There is also nepotism.  In one hospital I worked at, most of the nursing supervisors were relatives of a former administrator (she was fired, they stayed around).  The organizational chart resembled the genealogy of the Habsbergs.  Those who rose up on merit usually rose up by virtue of a non-administrative job for example a nurse may become what we used to call a head nurse by virtue of her good work on the floor or by seniority.  Her skills as a nurse however have very little to do with what is required of her (or him) as an administrator.  Frequently nurses who were quite good (or remember themselves as being quite good) have unrealistic expectations of their now subordinates.  Nurses also frequently become administrators for the "wrong reasons", better hours and more pay and who can blame them.  It is of course reasonable to expect anybody to be good as an administrator based on their skills as a clinician.  How many hockey stars became good coaches.  This was called the Peter Principle where people rise to their level of incompetence.  
4. Lower levels of management have shifted.  When I was in medical wards were run by head nurses who wore uniforms just like the floor nurses and some of them actually helped out when things were busy.  Over them were nursing supervisors who also wore uniforms and helped out on nights and weekends.  In essence head nurses were, to use a military analogy, sergeants   Head nurses are no more, they are now called supervisors and wear plain clothes.  Supervisors now have a different title and are not seen in the hospital after hours.  Essentially it is like the sergeants have been replaced with second lieutenants and anybody who has been in the army (I haven't) knows what that is like. 
5. Unlike most industries many of the top administrators and almost all the lower administrators are women.  This of course shows that women can be just a arrogant and out of touch as men can.  They also do stupid things, just like men.  It also creates an interesting dynamic for a male physician who has to deal with a female administrator (not that female physicians have any more luck).    It just seems easier to stand up and get into a battle with another man.  

Anyway here is the post from Kevin MD's blog.  I may just try some of his strategies although I know they won't work.

Become a disruptive physician: How to do it right

DIKE DRUMMOND, MD | PHYSICIAN | MARCH 21, 2013

“Disruptive physician” is one of the most misused terms in healthcare these days. In many organizations, those two words have become the c-suite’s trump card to quash any physician resistance to new administrative programs. These programs are often have purely financial motives or are a brazen attempt to dump additional tasks on the physicians with no regard for their workload or stress levels.

The doctor’s legitimate concerns about quality of care don’t matter. They are lost in the politics of the silos of the administrative and clinical sides of the organization. They are quickly seen as not being a team player. The disruptive physician label comes flying out and the doctor is deftly tossed under the bus so the meeting can move on to the next topic.

Often, this is bullying, plain and simple. It can create permanent consequences for the physician, including diversion into any number of treatment programs and not uncommonly losing their job.

However, sometimes the disruptive name calling is just a consequence of a fundamental clash of communication styles between physicians and administrators. In this situation, the skills inside the disruptive physician’s toolkit will allow you to do the following:

• Air your legitimate concern
• Be heard by the administration
• Avoid being labeled disruptive in the process

Physician vs administrator communication clash

Physicians are highly trained experts at finding a unifying diagnosis, the crux of the problem, the thing that is likely to go wrong. We see clinical issues administrators are completely unaware of.  We do all of this at lightening speed, because in our diagnoses often must be made quickly.

When we see a problem, we point it out without hesitation and we are not used to having to explain ourselves. And we shoot from the hip, without regard to the social setting or the politically correct thing to say in the given situation. One word for this is “blurting.”

This is not how you make your point in the midst of a meeting to a group of administrators. They do not think or communicate in this fashion. It is not what you say, but how you are saying it. Disruptive physician labeling can be the result of this clash of communication styles.

The disruptive physician’s toolkit

If you have a concern, talk to as many people as possible before the meeting where this program will be discussed

To raise a concern for the first time in the midst of a meeting is the definition of rude to an administrator. Discovery and building of consensus is best done before the meeting occurs – much like the work in politics is done in conversations before they vote on the bill on the floor. You want your concern to be discussed, shared, understood and at least a partial consensus on what to do about it. All done before any committee meeting.

Always ask questions, rather than making statements

Ask questions of everyone involved in the proposal and everyone who will be part of the decision on whether or not it goes forward.  Always start your questions with the word “what” or “how.“ This guarantees an open ended question that will draw the maximum of information from the person to whom you are speaking.

Here are some very simple and powerful examples:

• “What are your thoughts on program “X”?”
• “How do you see program “X” affecting the quality of care?”
• “I have some concerns about “X”. How do you see we might be able to address them?”

Channel Columbo

Do your best to imitate the character of “Columbo” in the old TV series. Hand to the forehead, self deprecating, “Maybe this is a silly question, but I was wondrin’ … ”

Columbo’s style goes against our doctor programming to be “seldom wrong and never in doubt” and I encourage you to let that go. Columbo was never called disruptive and was always very effective.

• Try asking questions instead of telling people what to do (giving orders)
• Try channeling Columbo when you speak
• You have no idea how massively effective this is with administrators (and everywhere else in your life)

Find solutions and build consensus

In your pre-meeting discussions, if you find your concern is shared by your colleagues, build consensus (before the meeting) on several solutions or ideas to address your concerns. You will have consensus on the concern and the possible solutions in your back pocket before the meeting begins.

Appeal to the highest value possible at all times

Always keep the team focused on the highest possible corporate value – one that everyone can agree to. Usually this will be quality of care or patient satisfaction. This is your trump card. When you are bringing up any clinical concern about an administration proposal, relate it to one of these  higher values whenever you can. It can sound like this.

“I know we all agree that none of us wants the quality of care to suffer as a result of this initiative.”

This phrase used early and often keeps everyone focused on the big picture, and not your objection. It states something no one can disagree with and keeps them from immediately disagreeing with you.

What not to do

• Don’t communicate like a doctor
• Do not raise your concern the way you would normally do on automatic pilot, as a declarative statement of fact. Example: “I think this is a bad idea and here’s why.“
• Always ask a question. Remember to channel Columbo. Be either curious or confused.
  • “I am confused here.” (Columbo)
  • This patient flow initiative is supposed to make it easier to see 35 patients a day, but a number of us here are concerned it will only increase the EMR documentation backlog and that will affect the quality of care. I am curious what your thoughts are about our concerns here Mr. CEO?” (open ended question)
• Do not show any emotion that could be perceived as negative
• Do not:
  • Stand up
  • Raise your voice
  • Furrow your brow
  • Slam your fist on the table, point fingers, slam doors, swear, throw things
  • Or send any body language signals of anger, frustration or hostility.
• Focus on your breathing and ask question
• If you do feel any of these emotions, name them out loud
• Let people know what you are feeling with a civil tongue. Just make sure you have done the work before the meeting so that everyone is aware of your concerns and feelings.
  • “I must admit when I hear your answer, what comes up for me is frustration.  I am curious (Columbo) what we can come up with for a proposal here that could address both of our concerns. “ (open ended question)
• Do not leave a paper trail or voice mail trail
  • It is completely appropriate to be seriously paranoid about documentation of any of your concerns in a format that could be shared. Do not send emails, text messages, messages through your EMR or leave voice mails especially if you are upset and venting to someone you feel is a trusted colleague. If you must vent in an email, write it and then delete it. Do not create a paper or voice mail trail.
  • If you do leave recorded or written evidence of your concerns, you are running an almost 100% risk of those documents or voice mails falling into the hands of someone who will label you as the next disruptive physician on staff. Here’s why.
  • It is impossible for them NOT to take your concerns and tone out of context.
  • Make sure you raise your concerns only in conversations, where the other person can understand your energy, tone, body language and caring for everyone involved – especially the patients. There is no way any of that can be understood through a text, email or voice message, especially by an administrator who does not agree with or understand your position.

Ultimately, if you work in an organization with a pattern of hostility towards the physicians and clinical staff and a habit of bullying with the disruptive label, you will decide whether that is something you will tolerate  or not. You always have the option to vote with your feet.

If you do decide to leave, it is my intention that this disruptive physician toolkit ensures the following:

• Your concerns have been heard
• You gave it your best shot at ensuring the program made clinical sense
• You don’t have the disruptive physician label hanging round your neck to get in the way of you finding a better position

Have you ever been labeled as disruptive?

If you are in a leadership position, what communication tools do you use to avoid the disruptive physician label?

If you have tried channeling Columbo, how did that go for you?

Dike Drummond is a family physician and provides burnout prevention and treatment services for healthcare professionals at his site, The Happy MD.