Working through the steps.

by Dr. Joseph Adashek  President, CCMS

by Dr. Joseph Adashek

President, CCMS

For this month’s article I would like to focus on the state of healthcare for our inpatients and how difficult it is to practice medicine in the hospital.

In the past twenty years, providing care for our patients in the hospital has certainly become more difficult. It seems that many “safeguards” that are put in place do not provide more patient safety, but just add to the frustration of taking care of patients while in the hospital. When I ask hospital nursing staff why certain inane protocols are started, inevitably, the response is something such as: “patient safety”. Next to “I’m just being the patient advocate”, it is one of my favorite statements by nursing administrators.

As a high-risk obstetrician, the majority of my time is spent in labor and delivery.  The only surgery that I perform while in labor and delivery is a Cesarean Section (C/S), typically in the Cesarean Section operating room.

Now I know that many of you will find this surprising, however -- believe it or not -- we never performed the wrong surgery while in the Cesarean Section room in labor and delivery. Since we only perform Cesarean Sections in that room and the patient is awake, it would be difficult to perform the wrong surgery. Also, and this is an important point, I don’t know how to do anything else.  The patient does not need to worry that I’m going to perform a below-the-knee amputation while lying there pregnant with her baby. Now I get that there are people that have surgery and end up having the wrong procedure or wrong site operated on while the patient is asleep. However, in the C/S room, the patient is laying there pregnant and awake with their obstetrician standing over them. What procedure could we possibly perform other than a Cesarean Section? 

When we perform a scheduled Cesarean Section (CS), we perform it under a spinal anesthetic. What is different about this surgery is that a spinal anesthetic lowers the patient’s blood pressure, which in turn decreases blood flow to the baby. We only have a short period of time after a spinal is placed before the blood flow to the baby can be negatively affected. If the blood flow is diminished long enough, the baby can suffer hypoxia/anoxia and then the baby can become acidotic. Therefore, we need to start the surgery as soon as possible and deliver the baby as quickly as possible before hypoxia may set in.  

Now this is where “hospital safety” starts to become haywire.  Each hospital in the valley now has rules that seem to have been put in place by an attorney somewhere without any thought to the amount of time that is being wasted before we can begin the surgery. Some of the hospitals now require the nurses to obtain fetal heart tones before the patient can be prepped and draped for surgery. Even though the baby has typically been monitored for the past few hours and nothing has changed, the nurses need to try and find the baby and monitor it for heart tones. Sometimes, there are twins or triplets or the patient is rather fluffy and this may take a few minutes. I have never heard of a time where this changes the management at all. If the fetal heart tones are slow, we are going to perform the C/S. If they are normal, we are going to perform a C/S. Why do something when the information changes nothing about the procedure? Does someone think that the baby is going to die between the time it takes to bring the patient from her labor room to the C/S room?  All this does is delay the time before we can start prepping and draping the patient.

At this point, each hospital now has their own set of rules. One hospital states that you need to use two preps. When I inquired as to why this is, I was told that the sales representative told them to do that. What would have happened if the sales rep had told them they need 5 preps? The nurse in charge told me that they have no choice but to listen to the sales representative’s recommendations. I would like to be the sales representative in this case. There is one hospital in the city that has a rule that only a nurse can prep the patient. How is this possible? We are allowed to perform the surgery but now we are not allowed to clean the patient’s skin? We are responsible if an infection occurs, however, we cannot prep our own patient? Who makes us these rules? Meanwhile, the nurse that preps the patient now has to gown and glove to prep the patient twice. This is the same nurse that has to count instruments with the OR tech, place the Foley catheter, call the other staff and perform the “time out”. There are some hospitals that do not allow the doctor to count the instruments with the OR tech. So, even if the one and only nurse in the OR is busy, it has to be that nurse can cannot be the doctor. Apparently, it takes a nursing skill to count to ten. 

We now have to wait 3 minutes. Three minutes is a long time when you are wondering how the baby is doing.  

Now the Foley catheter has to be placed and we finally get to drape the patient.  We can finally get to call our all-important “time out”.  I understand the reason for the “time out”. We do not want to do the wrong procedure in the Cesarean Section room. One of the hospitals makes the patient say that she is having a Cesarean Section performed on her and the surgeon has to ask the patient. This is just in case the patient does not know. This is done AFTER the patient is prepped and draped for her C/S.

The time out is not even done yet and there is more to do. Even though we are in the C/S room, we need to discuss the fire risk. I do not even know what numbers mean what in terms of a fire risk, however, I pretty much can guarantee that the chance of a fire is small and the fire risk has never changed. When would there be an increased fire risk for a Cesarean Section? Are we using a blow torch in our future?

The nurse now has to continue yelling her time out. Next comes the indications for the Cesarean Section; “This patient is a patient of Dr. Adashek. She is having a Cesarean Section due to an active genital herpes outbreak. When she was 21 years old she had a wild night on Spring Break in Ft. Lauderdale. It was approximately after that when she found out she had genital herpes.” Just curious; who came up with the idea that we need to discuss the patient’s history in front of everyone in order to do the Cesarean Section? What difference does it make? Everyone there knows why we are doing the Cesarean Section. Again, this whole time, we still have no idea how this baby is doing.

No, we are not done yet. We need to discuss when the patient received antibiotics and which antibiotic she received. The patient now has to state her birth date out loud. Again, why is this? To make sure that we not performing the Cesarean Section on the wrong patient? She is awake and already told us her name and what she is having done.  

Finally, everyone who is in the Cesarean Section room has to tell everyone else who they are and what they are doing there. I guess we have to do this in case there are any CIA operatives in the room. I am the one with scalpel in my hand. Why do I need to introduce myself to the patient that I have been seeing for the past 9 months? “Dr. Adashek, I am the surgeon.” Sometimes, I need to operate on patients that are premature with known twins or triplets. In this case, there can be as many as 20 people in the room. Do you know how long it takes for that many people to introduce themselves and what they are doing there? I have had husbands say, “I’m the sperm donor. Can we start now?” After all of these steps, we can finally start our surgery. It is now time to HURRY and get the baby out since there has been so much time wasted doing the aforementioned items. I challenge you to find one obstetrician that did not deliver a baby by Cesarean Section that did not have a blue and depressed baby because this entire process took much too long.

All of the aforementioned steps have been added in the past ten years. This is the definition of good intentions gone awry. What is it going to be like in ten more years? Each hospital has continued to come up with something new to do after the spinal anesthetic and before we operate on these patients. We used to be able to walk into the Cesarean Section room, the patient had her spinal in place and she was prepped and draped by the OR tech. She was completely ready for her Cesarean Section. And, I know that you will find this hard to believe -- we never did the wrong surgery in the Cesarean Section room.

Next month, we will talk about the amount of mouse clicks the average physician has to click per day while working in the hospital.