A fantasy

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The day had gone very well. The vascular surgeon woke early excited for a morning in the OR and then an afternoon in the office. Driving to the hospital, he had planned out his day. A patient with a fempop at 7:30, an AV fistula at 10:30 am, a quick bite in the doctor’s lounge, and then to the office for two phlebectomies, a few new consults, as well as some returning patients.

Dr. Russell Samson

Fortunately, he had purchased an advanced electronic medical record so that reviewing old records and inputting new data went smoothly. He had been on call for the local hospital’s ER, but he received no calls, so his day was not impacted. After a dinner with his wife, also a surgeon, he helped put their youngest baby to sleep, played with his older children, took the dog out for a walk, read the latest JVS and went to sleep. Despite being on call, the phone never rang, and he had an uninterrupted sleep.

Now, what really happened!

The vascular surgeon woke early in preparation for a day in the OR and office. Traffic slowed him down, but he still arrived at the hospital just before his 7:30 start time. He expected his patient to be on the table prepped and ready for the procedure. But the OR supervisor informed him that new regulations required him to personally mark the site of surgery, update the H&P, and date and time the consent.

He was nonplussed. He had marked the patient last night and had signed the consent too. His PA had dictated a three-page H&P that was in the chart. However, the patient was still in the holding room. The surgeon rushed over, marked the leg again, and completed the required documentation.

“Well,” he thought, “I’ll run upstairs, discharge my carotid from yesterday, and by the time that’s done and I’ve changed into scrubs, my patient will be ready.” Impatiently he waited 5 minutes for the elevator, but it never arrived. So he elected to run up 10 floors and across to the other side of the hospital where the administrators had inconveniently placed the postop vascular patients. The patient was eager to leave. The vascular surgeon dictated the discharge note and signed into the hospital electronic medical record.

But the software insisted that he had to comply with numerous “safety” regulations before signing off. These required reviewing every medication and all discharge instructions. The patient was on 15 drugs, and the surgeon was unfamiliar with most. After 10 minutes of unsuccessfully trying to enter the relevant orders, he called a medical student over to help.

The patient was going to a skilled nursing facility. This required completing two more electronic forms. The software stubbornly refused to close the discharge section till he assigned the appropriate ICD-10 codes. After a few more frustrating minutes he finally clicked the proper boxes and completed the discharge.

It was 8:15 by the time he made the skin incision. The case went smoothly. He relaxed a little knowing that he probably would not run too late for the rest of his day. Finishing ahead of schedule, he dictated the note, spoke to the patient’s family, and went to preop his AV fistula scheduled for 10:30. Then back to the wards to complete rounds.

The first two patients were uncomplicated. The third had a fever requiring multiple orders in the EMR. Then heated conversations with the pharmacist and head of infection control, since the EMR would not allow him to prescribe the antibiotic of his choice. Back across the entire length of the hospital to see a patient with renal failure. But she was in dialysis at another distant location in the hospital.

At 10:30 he ran down to the OR ready to scrub. Again, this patient was still in the holding area. The patient’s potassium was 5.6, and the anesthesiologist wanted to run another blood test. Then the nurse had to go on break. Now there was confusion about whether a room would be available as another surgeon had a bump case.

Ultimately, he started at 11:30. During the procedure, his beeper went off constantly. There were already two consults in the ER. The fistula took a mere 30 minutes, but he had waited 90 minutes since finishing the fempop.

“Medicare should pay me for the time between cases, and I’ll do the procedure for free” he complained to a colleague as he passed her on the way to the ER to see the consults.

He sent the patient with the DVT home, but the patient with the infected foot would require later debridement. He admitted her and booked the OR for after office hours.

By the time he got to the doctors’ lounge all that was left was a half-eaten pack of Doritos and burned coffee.

He thought he would have a brief respite driving to the office. Then his surgeon wife called him in the car asking him to field a call from their son’s school since she was stuck in the OR.

He arrived late to the office. The waiting room was filled with hostile-looking patients one of whom made a point of holding up her watch as if to reinforce his tardiness. There were already three additions to his schedule. Further, his nurse told him that there was some issue with the internet connection to the server. Thus, despite his expensive EMR, no records were available. She had informed the patients that there would be a “little” delay.

While they were waiting she brought in reams of documents that had come in the prior day and needed his signatures. He also used the time “productively” to answer emails. When the EMR was back online, he returned to his patients who by now were seething.

A patient brought in a CD of a CTA. He loaded it up on a computer, but the disc kept spinning relentlessly. Cursing, he loaded it on a second computer. The instructions were indecipherable. He could get a picture up but could not scroll through the images. The program froze. By the time he had evaluated the disc, he had wasted over 20 minutes. He was running even further behind.

The next patient was a second opinion from a physician in another state. She brought in over 200 pages of medical records describing a multitude of prior procedures. Politely he explained he would need to read them first and rescheduled her.

The ER called again with a patient with a cold leg. He canceled the rest of the office and snuck out through a back door, afraid to witness the consternation in the waiting room.

At the hospital, he argued briefly with the anesthesiologist who was reluctant to anesthetize the patient who had eaten 5 hours before. So the harried surgeon read some vascular labs, and visited a few less stable patients. Then back to the OR to revascularize the ER patient’s leg and later to debride the earlier patient’s foot.

He got home at 8:30 pm. His wife had also been delayed by a long surgery. They put the baby to bed. There was no time to play with the other children. The surgical couple barely had the energy left to microwave leftovers for dinner. He was too tired to take the dog out for its nocturnal pee. He went to his study, picked up the JVS, and fell asleep in his chair. He woke up with a start as he felt the dog urinate on his leg.

Exhausted he climbed into bed. It had been a good day, he told himself. After all the ER had not been too disruptive. He drifted off into a deep sleep. And then the phone rang. Ruptured AAA in the ER.

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