Life In The Hospital

Necktie, Vector Tie

necktieIf you know me, then you know that I usually don’t wear a tie at work. For most businessmen, a tie is a necessary fashion accessory to the male work wardrobe. For me, it is a device to transfer bacteria from one to another patient.

Studies have shown that 50% of physician’s ties are contaminated by potentially pathogenic bacteria, like methicillin-resistant Staphylococcus aureus (MRSA). They dangle in all kinds of stuff when we lean forward to examine patients and we almost never clean them (come on guys, when was the last time you dropped off a couple of dozen ties at the dry cleaner?). In the United Kingdom in 2007, many hospitals took the issue of physician’s neckties to heart and prohibited them from being worn in the hospital. So why do we keep wearing them?

The men’s necktie has its origins during the 1600’s when Croatian mercenaries working for the French army during the Thirty Years’ War had a habit of knotting a handkerchief around their necks. The French picked up on it and called the knotted cloths “Croats” which got turned into “cravats”, King Louis XIV took it one step further and knotted a piece of lace around his neck and like wildfire, it became the rage all across Europe. The necktie as a fashion statement stuck and we’ve been wearing them ever since.

But neckties can do bad things to you. If they are too tight, they can make your glaucoma worse. If they get caught up in a piece of machinery, they can strangle you. And if someone wants to do you harm, grabbing you by the tie is a really easy way to do it (probably why then NFL dropped the necktie from the game-day uniform of running backs).

In our hospital, we require anyone going into and out of a patient room to sanitize their hands with alcohol hand sanitizer that we keep on the corridor walls every 10 feet or so. But so far, we haven’t invented necktie sanitizers to use after patient encounters.

Personally, I never got the whole necktie fashion thing. I always thought that they were kind of uncomfortable and were always getting in my way. So when I read the recent articles on bacterial colonization of physician ties, I rejoiced because I now finally have an excuse to not wear a tie to work.

October 23, 2016

Life In The Hospital

The Sports Page

reinikka_reading_the_newspaperLast week, we filmed one of Ohio State’s MedNet-21 webcasts, this one on Environmental Emergencies. One of the topics was hypothermia and one of the presenters, Dr. Nick Kman from OSU, made the comment that “a hypothermic patient is not dead until they are warm and dead”. That reminded me of when I was taught that a patient is not dead until you read the sports page.

I was a 4th year medical student and was doing a rotation in general internal medicine with Dr. Bob Murnane who was a very highly esteemed internist in private practice in Columbus. He had an old-school medical practice: he had a solo practice, his office was across the street from the hospital, and he took care of all of his admitted patients on his own service in the hospital.

One morning, I arrived at his outpatient office. His nurse said Dr. Murnane was over at the hospital after getting stat-paged about one of his patients who had just taken a critical turn. He had told the nurse that we should get over to the patient’s room right away. The other medical student and I ran across the street, ran up the stairs and burst into the patient’s room, both of us out of breath.

We were expecting resuscitation efforts to be underway but when we opened the door, there was Dr. Murnane sitting in a chair in the patient’s room, calmly reading a newspaper. On the other side of the room, laying in bed, was the patient, an elderly lady with advanced dementia who had been admitted with pneumonia. And she looked, well… dead.

Without putting down the paper or looking up, Dr. Murnane said, “sit down boys, it’ll be a few minutes yet”. So we sat down and for about 5 minutes, there was not a sound in the room, except for Dr. Murnane turning the pages of the sports section of the morning newspaper. Finally, he put the paper down, walked over to the patient’s bed, checked her pulse, and said “Yep, she’s dead”.

He went on to say that he never pronounces a patient dead until he reads the sports page.

It turns out that a couple of decades earlier, he pronounced a patient dead who didn’t appear to be breathing and didn’t seem to have a pulse but after the patient had been taken to the morgue, he sat up, very much alive wanting to know why he wasn’t in his hospital room. So ever since, whenever a patient seemed to be dead, Dr. Murnane would check for a pulse and check for spontaneous breathing. Then he’d sit down and read the sports page and when he got done, if the patient still didn’t have a pulse or respirations, then he’d pronounce him dead.

Well, I thought that was just another idiosyncratic Murnane-ism until 4 years later when I was a pulmonary fellow in the MICU. We had a patient with severe COPD who had respiratory failure and was on a ventilator. He got progressively more bradycardia and hypotensive and the family decided against CPR. I was tied up doing a bedside procedure on another patient and so the attending physician was managing this particular patient. Eventually, the patient became asystolic so the attending physician pronounced him dead and the nurses disconnected him from the cardiac monitor and extubated him so the family could spend some time in the room before he was sent down to the morgue.

About 5 minutes after the family went in, they started shrieking and yelling that it was a miracle and he had arisen from the dead. One of his children had a camera and snapped a picture of the guy just as he sat up in bed with a shocked wide-eyed, open-mouthed expression on his face. The next week, that picture was on the front page of the National Enquirer with the headline “Patient Comes Back From The Dead”. The article included the name of the ICU attending physician who subsequently had to change his home phone to a new, unlisted number because of all the people calling him wanting him to bring back their own relatives from the dead.

What had happened was that the patient had breath-stacking due to the severity of his COPD and eventually breath-stacked enough that the high pressure inside of his chest prevented any blood return to the right ventricle and he became asystolic. Once he was taken off of the ventilator, the blood started to return into the chest and his heart started beating again. Although not well-recognized at the time, we now know this to be an important reversible cause of asystole during cardiopulmonary resuscitation and will usually give a trial of stopping ambu-bag ventilation in patients with asystole during CPR.

In this case, the patient did go on to die in the ICU a few days after his “miraculous” recovery from death. But ever since, I always wait a few minutes and re-check the pulse and respirations in a patient that I am pronouncing dead, even if I don’t have a sports page to read.

October 16, 2016


Life In The Hospital

Lose Your Job By Using Email In 11 Easy Steps

If you are like many Americans, you probably wake up each morning thinking “I’d really like to screw up my life and lose my job today”. Well, some good news for you – I can help. I’m going to show you how you can destroy your career and lose you job simply by getting on your computer in the morning, before you even go into work. All you have to do is use email. After decades of observing physicians and hospital employees use email to mess up their lives and make people really dislike them, I now know the secrets and I’m going to pass them on to you today.

  1. When replying to an email, always use the “reply to all” button. This is such an easy way to infuriate people that I don’t understand why so few people use it. Sometimes, the use of “rely to all” is only just a minor annoyance, for example, when the department chairman sends out an email to all of the faculty announcing that a member of the faculty received a prestigious award or research grant – there is always a few people that will use “reply to all” to echo the congratulations. After the 15th or 20th time that your email alert goes off with these, you feel like you are in a pinball machine with the little metal ball bouncing endlessly back and forth between two mechanical flippers. But there are some people who have perfected the art of “reply to all” and use it to thank the administrative assistant who sends out the weekly grand rounds lecture announcement with the philosophy that no email is to small to reply to all. You can use this strategy to clog up dozens of people’s email accounts with your inane comments.
  2. If you can communicate something to someone with a 1-minute phone call or an email that takes you 20 minutes to type, always use email. Everyone will realize that you are wasting time inefficiently and it is a great way to make your boss pass you over for promotion or raises.
  3. Email while intoxicated. There is no law against it like there is with driving and it is a great way to sound like an idiot. This is particularly effective when coupled with off-color jokes since as that joke gets forwarded to more and more people, it is bound to eventually end up forwarded to someone in human resources. Not only is this a great way to get fired but it is also a great way to be sure that no other hospital in the area will hire you.
  4. Attach liberally. One of the best ways to become disliked using email is to send an email out with nothing but the message “see attached” and then attach a 20 or 30 page document, or better yet, several documents. Since there is nothing else in the body of your email message, the recipient will have to open the attachment and read it to figure out what you are trying to communicate. This is a guaranteed way to infuriate.
  5. When you are angry or if you get a particularly unpleasant email, always respond immediately. If you wait 10 minutes, you might have calmed down and actually responded in a rational and restrained way but if you respond right away, you’re far more likely to type in a message that you will later regret. It is much better to come across as an irrational hothead which is a far easier way to lose your job. Remember, a temper tantrum only lasts 5 minutes but an email lasts forever.
  6. If you have something critical to say about someone, always use email rather than a phone call or a face-to-face conversation. An email is a contagious thing and you should say anything by email that you would want taped to the front door of the hospital. So if you want to communicate that a manager made a really stupid purchasing decision, or a newly hired physician’s wife is really ugly, or one of the senior physicians is incompetent, be sure to put it in an email since there is a good chance that it will be forwarded repeatedly until it finds its way back to the manager/new physician/senior physician. This is a fantastic and highly effective way to screw up your life.
  7. Use unsecured email to communicate patient information. Unfortunately, the hospital’s email system is maintained on a secure server so you won’t get fired by sending another hospital employee patient-related information by email. Fortunately, any email address that ends in “”, “”, or “” is not secure and so a political candidate who is trying to dig up information about his adversary (who is your patient) can easily pose as your patient by email to get information about his recent hemorrhoid operation. Since this is also a violation of federal HIPAA laws, it is not only a sure-fire why to lose your job but as an extra bonus, you can also end up in federal court!
  8. Use sarcasm liberally. You can wear your emotions on your sleeve but your email has no emotion. With facial gestures and voice intonation, everyone will realize that you are making a sarcastic response or a joke. But in email, it can become threatening or just make you look stupid. Unfortunately, doing this once or twice is not enough to get you fired but if you make this a regular part of your day, then eventually you’ll irritate enough people to at least make everyone hate you.
  9. If you have an argument with someone, it is always better to do it by email. Email arguments are great – you always eventually say something that you later regret and the person you are arguing with is far more likely to forward your email to the person who will be in the best position to terminate your job.
  10. Whenever you are on vacation, always use the automatic reply function on your email account and be sure to indicate exactly how long you’ll be gone and where you are traveling to. That way, the guy who is sending you spam or a phishing email will know that it is open season on all of your belongings in your house. If you want to be even more sure of messing up your life, indicate in the automatic reply that you keep a spare key under your front doormat and include your house alarm code in the email.
  11. If you get an email from someone that you don’t know that asks you to open the attachment, always open it, particularly if it looks like the email comes from some place in Eastern Europe, Russia, or an island in the Pacific Ocean that you’ve never heard of. There is a great chance that this is a phishing attempt and a great way to get malware loaded into your computer. If you’ve been trying to get your monthly direct-deposit paycheck diverted to someone’s bank account in Costa Rica, this may be your best opportunity.

The internet has made our lives easier in so many ways and email has brought us lots of great opportunities to wreck our careers and lives. So, next time you wake up trying to decide what you can do today that will be really stupid and maybe even that you can regret for the rest of your life, you don’t need to go any further than your email account.

September 19, 2016

Inpatient Practice Life In The Hospital

The JCAHO Site Survey

We just went through our Joint Commission site survey and I have a few thoughts after doing this as a medical director. The Joint Commission for the Accreditation of Healthcare Organization (JCAHO or just “Joint Commission”) is the largest of several organizations that review and accredit hospitals in the United States. Hospitals pay the Joint Commission to do a top to bottom review of the hospital every 3 years and they look at everything from medical records, to equipment, to policies, and to the plumbing. The stakes are high: if you lose your accreditation, you can lose your ability to see Medicare and Medicaid patients. I’ve participated in about 2 dozen Joint Commission surveys between Ohio State and Select Specialty Hospitals in various medical director roles. This year’s survey was the first that I have gone through as a medical director for the whole hospital.

Each hospital will have an open “window” of time every 3 years that the Joint Commission can show up. The surveyors will show up unannounced at the hospital administration offices, typically on a Monday at 7:30 AM. The hospital then gives them access to all patient care areas, medical records, policies, etc. and the surveyors inspect… everything.

The number of surveyors can vary in number depending on the size of the hospital and other factors. This year, we had 8 surveyors: a social worker/counselor, a pediatric critical care nurse, a women’s health nurse practitioner, a former hospital chief nursing officer, an OR nurse, an infectious disease physician, a pediatric oncology nurse, and a former fire marshal. The social worker and the fire marshal were only here 1-2 days but the nurses and physician were here daily from Monday through Friday.

The survey consists of informal inspections and relatively formal sessions where one of the surveyors will sit down with a group of hospital leaders to discuss things like medication safety or credentialing. The real detailed part of the survey is when one of the surveyors goes to inspect a specific practice location. They may do this by deciding to go to the respiratory therapy department in the morning and the physical therapy department in the afternoon. They can also do this using a “tracer” method where they randomly pick a patient chart and then retrospectively follow that patient’s hospital course from when they first arrived in the emergency department to the operating room to the ICU to the nursing unit. They will inspect each location and interview staff at each location.

At our hospital, we have an accreditation specialist whose primary job is to ensure that we are always meeting accreditation standards for a variety of organizations that inspect us periodically. Each person who works in a hospital has a role to play during a Joint Commission site survey. As the hospital medical director, I found my role was a bit different than it was when I was a chief of internal medicine, MICU medical director, or PFT lab medical director. Here are some pointers:

  1. Read your bylaws and know what is in them.
  2. Know what is in your medical staff rules and regulations. I printed out a list of the titles and carried it with me.
  3. Know what your various hospital policies are. Again, I printed out a list of the titles to carried it with me.
  4. Have the policies and rules/regulations at hand. Ours are on our internal hospital internet site so I carried an iPad with me so I could pull them up if needed.
  5. Seek out the surveyors and introduce yourself. Accompany them when possible so you can answer questions.
  6. There is a penalty for guessing. You’ve spent your entire life taking multiple choice questions and knowing that if you don’t know the answer, you still have a 20% chance of getting the question right if you guess. With a Joint Commission survey, a wrong guess about something can be lethal. It is better to say that you don’t know and would have to check the files than it is to guess and be wrong.
  7. Get the medical staff involved. Too often, when they know that the JCAHO is in the hospital, the doctors will hide out in their offices or the doctor’s lounge. The surveyors really like to see the physicians engaged in the process so take time to introduce them.
  8. Walk through the hospital. The best way to keep your backyard tidy is to poop-scoop weekly all year round. But if you are hosting the annual office cook-out at your house, you still want to do a quick walk through the grass an hour before the party starts just to be sure. Same goes with a survey. Look for stuff stored in the hallways, unsecured medication drawers, dust on the sprinkler heads, and water stains on the ceiling tiles.
  9. Timing is everything. The surveyors are likely not going to be judging you on your choice of a statin in hyperlipidemia. It is just too subjective and hard to do in a short survey. What they can and will judge you on is whether you adhered to your policies. So, if your policy says you need an H&P on the chart less than 30 days before a surgery, that H&P better be dated < 30 days earlier. If your policy says that the anesthesia assessment needs to be done immediately before surgery, it better be timed before the start of the surgery.  If your policy says that a preliminary op note needs to be in the chart before the patient leaves the OR area, it better be timed before the time the patient is transported to the floor.
  10. It’s your policy, stick to it. Don’t make policies that the doctors can’t adhere to. A policy is what your doctors have to do every time, not what they should aspire to eventually do. If you put in your policy that your doctors need to assess the Mallampati class prior to doing procedural sedation, it has to be done and documented every single time.
  11. Everything expires. This is low-hanging fruit for a site surveyor, every bottle and package in your hospital has an expiration date whether it is a medication, a test strip, or a cleaning agent. Be sure that someone is checking them regularly. After our recent Joint Commission survey, I went through my refrigerator at home… there was salad dressing from 2011 in the back. Good thing they were inspecting the hospital and not my kitchen.

But the good news: we passed our survey. Next week, we have to start preparing for the next one.

September 9, 2016


Life In The Hospital

Screening Physicians For Drug Use

cannabis-sativa-plant-1404978607aklJune and July are busy months for our medical center’s credentialing department. Every year, we have more than a hundred new residents, fellows, and attending physicians who apply for privileges. Part of the application process is a mandatory urine drug screen. Positive drug tests for marijuana are becoming more and more common in physicians coming to Ohio from Colorado and other states where recreational marijuana is legal. We are now in a quandary about how we handle these physicians.

Most hospitals have adopted a zero tolerance policy for drug and alcohol abuse. Not only do we do urine drug screens for all new physicians but any physician can be required to undergo on-the-spot drug testing if anyone (colleague, patient, nurse, etc.) reports them as possibly being impaired at work. This is an incredibly powerful tool to prevent impaired physicians from harming patients but the testing does have the potential for abuse. For example, a couple of years ago, an inpatient who was seeking opioid medications threatened one of our hospitalists with reporting her as being under the influence of alcohol unless she prescribed oxycodone for him. She refused to prescribe it, he called the medical staff office reporting her, she underwent immediate testing for drugs and alcohol, and she passed her testing with flying colors.

Until recently, the drug policies were pretty straight forward, if your urine test was positive, you were determined to be abusing drugs or under the influence of alcohol at work. All that has changed with legalization of marijuana in some states. The issue is that cannabinoids (the main chemical in marijuana) are detectable in the urine for days and in some cases, as long as a month, after marijuana use. Let me give 2 examples of where this can be a problem for physicians.

  1. A medical student in Colorado might legally smoke marijuana for recreational purposes on an occasional basis. If that medical student then goes to another state to do his or her residency and undergoes mandatory drug testing, cannabinoids will be detectable days or even weeks later.
  2. A physician goes to Colorado for a ski trip and while on vacation, smokes marijuana. He or she then returns to their own state the following week and is accused of being under the influence of drugs at work. That physician provides a urine sample and it tests positive for cannabinoids.

In both situations, the physician legally used marijuana but because cannabinoids are so lipophilic, the urine drug test was positive long after the effects of the marijuana have worn off. However, as a medical director, I cannot tell from the urine test whether the physician smoked marijuana 4 days earlier in Colorado or 30 minutes earlier in a hospital bathroom. In order to protect patient safety, I am going to have to assume the worst, that the physician is illegally using marijuana in Ohio and may be practicing medicine under the influence. That means that the physician will likely need to be enrolled in a drug treatment program and undergo regular drug testing for the foreseeable future.

As a general rule, cannabinoids will remain in the urine for 2-5 days for the infrequent uses, 1-2 weeks for the frequent user, and up to 4 weeks for the habitual uses. However, because cannabinoids are so lipophilic, marijuana users who are obese will have positive urine tests for much longer than non-obese users and even relatively brief marijuana use in obese people can result in positive drug tests for up to a month.

It is also easy to see how the long detection period for cannabinoids could be used to intentionally cause harm to a physician. For example, if a vindictive former partner, a former spouse, or a patient who is suing a physician wanted to damage a physician’s career and knew that the physician had recently vacationed in a state where marijuana is legal, all they would have to do is to anonymously report them to their hospital as being under the influence.

So my advice for senior medical students at medical schools in Colorado, Oregon, and Washington: the marijuana smoke you inhaled in June might have been legal but your urine won’t be legal in July. And for the physician vacationing in Alaska, Colorado, Oregon, or Washington, stick with the local craft beer and pass on the marijuana.

July 12, 2016

Life In The Hospital

The Yin And Yang Of Yelling At Doctors

Yin_yang.svgAs a medical director (or any kind of leader or supervisor), it is your responsibility to call out physicians who are behaving badly. It is one of the things that medical directors like least about their jobs but if you don’t do it, then you become an enabler of bad behavior.

There are two ways to yell at a physician. First, it can be done at the spur of the moment when you see something, hear something, or someone tells you something that a physician did that breaks a policy, deviates from normal civil behavior, or violates international law. The advantage of this method is that you can invoke discipline as close to the time that the behavior was performed, kind of like yelling at your dog if you catch it peeing on the carpet. The disadvantage is that your temper is usually up pretty high and this can result in your emotional intelligence quotient falling by a couple of branches on the human evolutionary tree to about the level of Australopithecus. This method is highly reflexive and although it can get you the results you need, there can sometimes be significant collateral damage.

One of my former chairmen was a great guy but when he’d get angry, there were these two veins on his forehead just above his nose that would stick out. We all knew that if you were walking down the hall and you saw those two veins walking toward you that you should put your head down, look at your feet, and hurry past as fast as possible, hoping that you were not the subject of the excessive cutaneous venous engorgement.

The second way to yell at a physician is the planned ambush.  This requires forethought and careful rehearsal of what you are going to say. The advantage is that your temper has usually cooled and your emotional intelligence quotient is back in the usual Homo sapiens range. The disadvantage is that the longer you wait after the bad behavior, the less effective your yelling will be, a lot like yelling at your dog on Thursday for peeing on the carpet on the previous Monday.

Regardless of which method of yelling you do, yelling at a physician will suck the joy out of your day so it is important to have emotional balance. That is where the yin and yang comes in. Whenever you yell at a physician, you have to find someone else to pay a compliment of equal intensity to. If you are standing at a nursing station and hear a physician loudly complaining about the quality of the donuts in the physician lounge and have to tell him or her to knock it off, then you have to go find another physician to thank for coming into the hospital in the middle of the night to operate on the patient with a perforated bowel. There are a lot of ways to pay compliments and in order of effectiveness:

  1. A text to their phone
  2. An email
  3. A phone call
  4. Seeking them out and telling them in person
  5. A hand-written note
  6. A hand-written note with flowers
  7. A hand-written note with use of the medical director’s prime parking spot for a week

Disciplining a physician is almost always going to leave you feeling bad. So it is important to find something to make you feel good to maintain your personal psychic symmetry. Furthermore, if everyone knows you for your responses to physician badness, they will never know you for promoting physician goodness.

August 6, 2016