25- Where’s Buttercup?

This post is about our current political situation and the greatest movie of all time “The Princess Bride”. If you haven’t seen it, stop reading and go find it. It is probably playing on tv somewhere. And then come back when you have an inkling of what I am referring to.

You know when Wesley is panicked after being dosed with Miracle Max’s pill and he is demanding answers to, among other things who are you, are we enemies, why am I am on this wall, where’s Buttercup, why won’t my arms move? And Inigo Montoya calmly responds “Let me explain…” and pauses and continues “No, there is too much. Let me sum up.”

That is the mood today.

There has been an entire stream of shit decision and shittier actions from this administration. A firehose stream. The intention is to drown us. Or to give us so much information and things to react to that we cease to react.

The hits keep coming.

There are hits to education that are the 50% reduction in force to “return the education to the states”. Well and good, but there are states that are struggling with what the government gives them. West Virginia, are you paying attention? West Virginia is frequently 50/50 states, and not in a good way, in education.

There are hits to the healthcare industry. Medicaid is on life support at the moment. Reminder, there are over 72 million Americans on Medicaid. This pays for elder care, nursing homes, the children that are under treatment for all sorts of things. You know, like the children that survive being born at 23 weeks that are heralded as miracles. Miracles that will most likely need care for their entire lives. Medicaid also provides healthcare for at least 37 million children. These are vaccinations and well child visits. To lose Medicaid would put a double whammy on the hospital systems that are already struggling.

There are hits to the National Parks system. Not only did 1000 workers lose their jobs, but some parks had to adjust hours and are no longer allowing overnight visits. There are 63 named National Parks but that does not come close to explaining the breadth of what they do.

There is an unelected person who bought the election running around with a group of under aged 25 boys pulling the pieces of the government apart. A la the neighborhood bullies torturing the neighborhood pets.

There is the megalomaniac despot wanna be running a smear and revenge campaign against anyone he thinks has ever wronged him. Someone needs to remind him that it is speak softly and carry a big stick, not scream and shout and use the stick against anyone he deems as lesser. Psst, that is everyone who has less than $1 billion dollars.

That is where we are now. At the mercy of the man child.

I love that for us.

We need a Dread Pirate Roberts. Or, at the very least, an Inigo Montoya. Or a Brute Squad Fezzik.

I’m not picky.

But we need a Miracle Max, not a Prince Humperdinck flailing about.

Sunday Post-it 3/16/25-LOL

The post-it reads “Alpha numeric spelling is just coding.”

This post-it got me thinking about coding in a couple of different ways. What is meant by coding? It is a communication style that seeks to with hold information that might be damaging or incomprehensible to the non speakers. For example the anesthesiologist can say that they need an ABG, CBC, BMP, PT/PTT, T&C and a lollipop, and I know that something bad is happening or has the potential to happen at the head of the table.

I was kidding about the lollipop.

This spate of orders makes me wonder if there is unanticipated bleeding and the patient is not doing well. In response, I would look at the suction canister to see if I can see what they are seeing, and I would offer to get the tube colors that they need as a way to confirm the colors that they need. I would also glance at the back table/mayo and offer the scrub tech additional lap sponges if I see they are down to one or two. I would nudge the red lined kick bucket to be more accessible for the scrub tech.

I would also ask if the patient needs a higher level of care. By that, I mean does the patient require ICU or a transfer to a tertiary hospital. This is code

My next step is to call the supervisor to request an additional set of hands or the ICU bed or to get the ball rolling on the EMTALA paperwork. Which is the Emergency Medical Treatment Act and Labor that allows the emergency treatment of patients.

All of that from the sudden request for lab tests. But, to be more specific, those lab tests. The 17 letters tell a story.

Yes, but… Talking in medical code, AKA the acronyms that you know are near and dear to the heart of all medical personnel, is also done to protect patients. After all, little pitchers have big ears. This means that there is always someone who is listening. And being human they often will take the worst inference of what was just said. AKA the patients will jump to conclusions that aren’t true. And panic.

Parents do this too. Parents can spell out a word that they know the child will react to. Such as B*A*T*H or I*C*E*C*R*E*A*M.

Pet owners do this as well. Such as spelling out the word R*I*D*E or V*E*T.

Both times it works until the kid or the pet can work out is being spelled.

Are we coding in these instances so that the kid or the pet doesn’t become too excited?

I am writing this post because I caught myself coding a social media post the other day. I didn’t care how other people perceived the post but I wanted to share the information for those who are also frustrated by the current atmosphere.

And there I go again! AARRGH!

I think I need a N*A*P.

Best Kept Secrets of the OR #22- FAQ of friends

FAQ means frequently asked questions.

Today I got a phone call from a spouse of a friend I hadn’t heard from in years. Damned degrees and the time and attention sink they are!

During the call, they asked me not where I’ve been as I kind of dropped off the radar because of school and the gym closing. Instead, they asked me one of the FAQs all healthcare workers get, who would I see for X problem?

This is one of the most frequent questions that we get. Presumably, us healthcare workers know the best doctors/surgeons and our friends and family want to know.

It is the highest mark of respect that we can give these doctors and surgeons to refer a friend or family member.

This friend called me because I had referred them to the surgeon who replaced their knee a bunch of years ago. Now they wanted information on a sports surgeon. Of course I gave them a couple of names. I ranked them as well, telling them that Dr. X was my favorite.

And then I asked them not to tell Dr. X that they were my favorite.

They laughed and we chatted for a few more minutes but they said were going to call the surgeons as soon as they got off the phone with me.

I rang off, after telling them to give their spouse my best and vowing that I would reach out to them.

Even as we give recommendations as healthcare workers, we have to keep in mind the different personalities and expertise of the different surgeons. After all, the total knee surgeon might not be the best fit when the request is a sports surgeon. Not that the total knee surgeon couldn’t do the sports surgery, but that they might not be the correct fit for the request.

No, I am not talking about the look at your rash/bump/do I think the bone is broken FAQs.

Because ew.

That might not be the kind of relationship we have.

Best Kept Secrets of the OR #20- HIPAA still applies to immigrants

I cannot believe I have to write this.

The Health Insurance Portability and Accountability Act remains active for the immigrant population. You know the one that guides all of our interactions with patients? The one that if we breach it will lead to punitive action by your employer?

Yeah, that one.

Well, suppose the Immigration and Customs Enforcement comes to your hospital, and this has started. However, hospitals and churches were not overrun by ICE because there are reports of them coming to hospitals and asking about employees that may be illegal. In that case, HIPAA laws are still in effect.

What if they ask about patients?

HIPAA laws are still in effect.

Supposing the employee they are asking about is a patient of a doctor of the system, HIPAA laws are still in effect. And you can’t tell ICE anything without breaking the HIPAA law and policies.

This is a very scary time in this country. That should be acknowledged.

What should also be acknowledged is that this is a problem of their own making. Remember in 2024 there was a bipartisan law that passed one of the chambers and then was torpedoed by the other part of Congress? Because someone came out against it so he could run on immigration and border control? Remember that?

You might not. But look it up.

Misinformation is rampant and often used to their advantage. Don’t buy into their lies.

Make sure you take care of yourself.

And your patients.

Because that is why hospitals exist. To care for patients, no matter if they are from down the street or the next state or from somewhere else.

Hospitals and churches should be safe places. Schools, too, but we know what they think of that.

FFS Friday 1/3/24- Un-Fancy

Life in the hospital continues to be a struggle with the increase of covid patients and the increase of flu patients and the increase of RSV patients and, unsurprisingly, the increase of whooping cough patients.

The holidays, the gift that keeps on giving to the hospital.

Also a gift/burden to the hospitals? The anti-vaccination movement. That someone made up because it made them feel powerful and popular and the political right seized upon the idea and started preaching anti-vaccination propaganda to their followers. The man who would be president in 17 days said it best in 2016, “I love the poorly educated.” And that was before the 2016 election.

If you are going to be on the side of anti-vaccination that does increase the supply of sick patients in the hospitals. If they can afford it. Otherwise, they are out there spewing germs and viruses everywhere. Because no one can afford to call off sick.

It can go back further all the way to Christopher Marlow and his 1604 work Doctor Faustus. This is where the man sells his soul for pleasure and knowledge. Being excessively educated leads to his eternal damnation. So the war on education started back when books were horribly expensive because the printing press had only been invented less than 150 years before. And printing presses were banned by the sultan of the Ottoman Empire upon pain of death.

Wow.

This post took a marked turn. From the trials of the hospital during the holidays to anti-vaxxers, to the war on education, to keeping people stupid is the point. This post was a wild ride.

I write this so often, this was not the post I wanted to write. But I do free write a lot.

I wanted to write about how un-fancy the hospital culture is during the holidays when it feels like it is every healthcare worker for themselves. We are surrounded by glitz and glamour of the holidays, and hospital-based providers are holding the burlap sack, begging for some more.

To bring it back to the Friday theme of FFS, this has definitely been an un-fancy post.

I just don’t have the energy to make it fancy.

Tuesday Top of Mind 12/10/24- Sympathy for the devil?

This is a follow-up from last Wednesday’s post when there were 2 separate healthcare related breaking news items. The United Healthcare CEO who was shot and the Anthem Blue Cross Blue Shield only paying for X amount of anesthesia for any given case. And the insurance company solves for X.

The entire US was on edge and reacting to both these news items ALL WEEK LONG.

On Friday, December 6th, Anthem came out and rescinded the suddenly toxic policy. You know what dispells gloom in a fairy tale? Or what gets rid of mold in the house? Light. If you shine light on an issue the rats will run. Yes, I am aware that I am mixing my metaphors. The sentiment is true. If we pay enough attention to the shitty things that corporations do, we might be able to stop some of their worst impulses as they chase profit.

I have additional thoughts.

The reaction to the shooting and subsequent death has been fascinating. It has been the man is dead, yes, his wife widowed, yes, and his children half-orphaned yes. But people are flipping the script and talking about how many people have died because of the policies that enriched the insurance companies. Some people are even sharing what happened to them or a loved one. The stories of denial of care are heartbreaking.

Can we have compassion for his family? Yes. Can we hate what he worked and stood for? Another yes. Does the American public who has had their care nickeled and dimed for years have sympathy? Not many, and more would sooner have sympathy for the devil.

No American, not even a rich, conservative Ivy graduate like the accused, hasn’t been harmed or denied by the privatized healthcare in this country.

Note- he has only been charged, there has been no trial, and he is fighting extradition back to New York.

The First Rule of Acquisition is once you have their money, you never give it back. Sounds a lot like healthcare in the US does it not?

I am referring, of course, to the 285 Rules of Acquisition that were set out and explored on Star Trek: Deep Space Nine.

If they can deny and delay and deny and delay and outlast you, the insurance companies don’t have to pay and they get to keep the money. For whatever it is you want them to pay for, all they have to do is make up arcane rules that the consumer unknowingly violates. Oh, they don’t tell you what the rules are. That would be cheating.

Kind of reminds me of “ignorance of the law is no excuse”; which is a legal principle.

The question remains- which one is the devil?

Post-it Sunday 12/8/24- Circuses every where

The gown card reads “Sometimes I feel like running away to join the circus but, really, how much different would that be?”

Dat-dat-dadadaditda
dat da dah
dat-dat-dadadaditda.

You tried it in your head and recognized it immediately, right?

So starts the screamer theme song for many circuses. Because that is what they are called- screamers. These are the marches that the circus is most well-known for. That’s something I learned today.

But this post is about another kind of circus.

The shift circus or the unit circus. It’s all the same.

This person is new and says it was better at their old place and this new place should change so that they are not uncomfortable learning new things anymore.

That person wants to go home early. Again.

That person wants to ride the clock but does not want to actually do work.

This person is riding the clock, waiting to complain that they are being sent home early.

This person has too much education and will not be going home early but will also not do any additional work. Even when asked by the charge nurse.

That person disappears after being sent home and the charge nurse thinks they have left. Only for them to pop up after several hours to inform the charge nurse that it is time for them to go home.

This surgeon is three hours late and wonders why they got bumped. Doesn’t the OR know they are very important? The charge nurse points to the policy that states the next case can begin if a surgeon is more than 1 hour late.

This surgeon wants to add on a surgery, what do you mean there are several cases ahead of me, don’t you know who I am? And they have a tee time/flight/dinner with the family to get to. And they simply cannot be late.

This policy has been changed because the laws in your state are stripping the bodily autonomy away from women. But don’t worry, it isn’t as bad as those other states.

This patient is crashing because no one did a complete history and physical on them. They are crashing because there was no lab work. If a simple CBC or H&H was done, the low blood count would have been picked up on, or the extremely high white count indicating infection somewhere would have been caught and a new total joint would NOT have been put in.

Boy, do I have bad news for myself.

Every hospital/operating room is a circus.

Sometimes in running away from one circus you go from the frying pan into the fire with the next hospital circus.

Breaking news 12/4/24

It is rare that I get to write about kind of breaking news.

Today there were two separate reports about insurance companies.

12/4/24- United Healthcare CEO Andrew Witty was fatally shot by an unknown assailant outside of a hotel in New York City, and the killing was captured on hotel surveillance. The victim was due to host an investor day in a Hilton hotel. The suspect has not been located. United Healthcare is the largest private health insurer in the U.S.

I don’t have a lot to add except that United Health Care had the largest denial of care rate of all the major insurers.

11/14/24- (not sure why this is just gaining traction today)- Anthem Blue Cross Blue Shield announced that it would not be paying anesthesia costs for the entire duration of a surgery in 3 states. The states are Connecticut, New York, and Missouri. Instead, it would only pay for a certain amount of hours of surgery. Presumably, the patients or the hospital, or the anesthesiologist would have to eat the remaining cost of the anesthesia.

Wow.

No idea where this idea came from. Greed, probably. The insurance parent company reported a 24% year-over-year profit increase in June 2024.

No idea how the decisions were made for how long each surgery will be covered. Presumably not by surgeons.

Because a surgeon would know and understand that there are unforeseen things that can happen during surgery that would make it longer. Does the insurance brain trust that came up with this think that surgeons are just making surgeries longer for the hell of it?

To me, 2 1/2 years into a research degree, this smacks of pilot study.

To be expanded to other states when they can.

You know, for the money. Certainly not for the patients.

Post-it Sunday 12/1/24- A Cultured Kind of Surgery

The post-it reads “Hey doc, are you expecting a different result from a mm away?”

A culture is a lab test that tests for infection in a location where the culture is taken from.

This location can be anywhere in the body. I’ve done cultures on abscesses from the top of a patient’s head all the way down to their toes. Different patients, mind you.

The reason behind doing a culture is twofold. It lets the lab and the surgeon identify the particular pathogen that is causing the infection. It also allows the surgeon to order the correct antibiotics targeting the pathogen. A third possibility is that there is no infection that is causing the symptoms. However, even that is an answer. A negative result and lack of a pathogen is still an answer.

However, this post is about a surgeon who is culture happy. They culture everything. And I mean, everything. Oftentimes there are multiple cultures, within the same geographical area on the body.

My question to that surgeon is why run these expensive tests when the area that is cultured is essentially the same place. I do understand pre and post-lavage cultures. This is when the body part is cultured before irrigation and after to see if there are any lingering bits after being sprayed with the equivalent of a garden hose.

What I don’t understand is the multiple cultures after the incision and before the irrigation. Please help me understand why this is routine for the culture happy surgeon.

Is the pathogen just under incision different than the pathogen 1 mm in? I guess it could be. Especially when there is a verifiable pocket of pus that looks different. And I understand culturing separate body parts, such as the heel of the foot and the knee. But how often does that happen?

And at what a cost to the patient?

Best Kept Secrets of the OR #15- What you ignore or suggest is treated as normal

This isn’t a positive best-kept secret. In fact, it makes me mad and is probably making some of your charge nurses mad too. But not the one who is trying to be your friend and suggested that you call in sick, in front of another charge nurse, because you couldn’t get that day off.

However, this is directed at the other charge nurses who permit this behavior.

Apparently, in today’s working operating room, all you have to do to get the day off that was denied is call in sick. No thought was given to the rest of the OR team that now has to work short. No thought is given to the patients who are going to be worked on that day when the rest of the OR is working short. No thought was given to the person who makes the schedule that you just took a giant dump on.

This is because you didn’t get your way and you are making it everyone else’s problem.

Number one- there are rules for a reason. Only one person per staffing level (scrub tech, registered nurse, orderly) can be off at the same time, on the same day. Writing as a previous staff scheduler whose OR was run a lot leaner than the one you enjoy, there are reasons for that rule. You are damning someone else to work extra. The rules are different in each unit. In this unit, one person per staffing level is allowed off for a specific day.

Number two- this is for the charge nurse who suggested that a team member call in sick to accommodate their desire to have a certain day off. To that charge nurse I say don’t do this. Don’t make the rest of your team work extra so that you can be buddy-buddy with another team member. It reflects badly on you.

Number three- what you permit becomes the new standard. And will most likely come around to bite you in the ass.

Just no.

Don’t do this.

You are UNDERMINING your authority.

Consider that.

Or you might want to be friends with all of your subordinates and wonder why they don’t respect you.

You choose.