Tuesday, December 02, 2008

The Art of the Bump

Ask any surgeon, of any stripe, what bugs him or her the most about working in a hospital OR and you will almost always hear some variation the them of "wasted time." You see, for us, time spent waiting is valuable time irretrievably lost, which could be better spent in the OR, seeing patients, or getting home earlier. The root cause of most of our irritation is "turnover" time, i.e., the time that it takes to get the last patient out of the OR and the next patient in and off to sleep. Turnover time is routinely significantly longer in the hospital than in an outpatient setting, for a variety of reasons (staffing, motivation, sicker patients, "it's the way we've always done it," etc.).

But there is one physician-initiated problem that wreaks havoc in the OR schedule --- the bump.

What is "the bump?" It means that a surgeon has decided that his or her patient needs to get to the operating room NOW, with no ifs, ands, buts or excuses, and that the next room that is available needs to have its schedule "bumped" to provide this accommodation. The larger the OR, the more likely that there will be a room finishing up in time to get the urgent patient squared away in a timely fashion. Of course, the larger the OR, the larger the hospital, and thus the more likely that there will be such a circumstance on any given day.

So, imagine a full day in a busy OR. You may have a room full of total joint replacements, which were scheduled months in advance; a couple of CABGs that are these days almost always semi-urgent; a room full of cataract surgeries; a general surgery room with colon resections, cholecystectomies, and the like, added to the schedule within the past week or so; a room with a couple of robotic prostatectomies, likely scheduled within the last few weeks; and so on. At 8:30 AM, a patient with a ruptured AAA hits the ER, and the scramble is on ---- who gets bumped? Which room has the most give in the schedule? Which room will finish first? Which surgeon will scream the loudest if he does get bumped?

Unfortunately, though the last question should not have any bearing on how the schedule gets massaged to accommodate an urgent or emergent case. But, as with many other situations, human nature is to take the path of least resistance, and the staff running the OR desk will often avoid the hornet's nest in Room 1 and bump the nice guy in Room 2. However, in true emergencies, most surgeons are more than willing to allow their room to get bumped......and then they go to work on the front desk to try to get the remainder of their cases shifted to another room. After all, it is very inconvenient for the patient who has gone through the rigmarole of preop evaluation, prep, labs, and paperwork to reschedule an elective or semi-elective operation.

There are two other ways to "do the bump," however, that don't fall strictly in the category of dire emergencies. The first is what I would call the "semi-urgent" bump --- this is the case of a patient with a bowel obstruction with possible bowel ischemia, perforated appendicitis, perforated diverticulitis, etc. These are patients who need to get to the OR sooner rather than later, and if they are forced to get in line and wait until the end of the day they would potentially have a worse outcome. This is where the surgeon needs to develop "the art of the bump," namely the ability to go hat in hand to another surgeon and plainly state "I'm sorry, but this guy really needs surgery, and I need to bump your room." What is helpful is to have enlisted the assistance of the front desk and have already arranged a way to minimize the disruption to that surgeon's OR day. Once again, almost always the "bumpee" acquiesces to the "bumper" with a minimal amount of grousing. This is common courtesy on the part of both surgeons, and serves the interests of the patients involved. Like the disco ball, it is a bit less than elegant, but serviceable nonetheless.

The last type of bump is what I would term the "bump of convenience." This is the case when a semi-urgent case needs to get to the OR, but the timing is rather suspect. This occurs when a surgeon demands to start a case, and bump whoever needs to be bumped, only as soon as his office is done. Or when the room needs to be bumped to do a case that could easily wait until the schedule could accommodate the patient because he has other plans --- a meeting, a dinner, theater tickets, etc. As long as I have been in practice, I have never seen this type of bump accomplished with a friendly request to the "bumpee." In these situations, the bumpee generally discovers the truth of the issue only later on; speaking from personal experience, this sets me to a slow burn, and it is hard to maintain a level of professionalism when dealing with the bumper.

Every OR has 2 or 3 of these types of surgeons, and they cause headaches for the rest of us. They are practicing a bait and switch type of con game, but rarely come out ahead in the long run --- most OR front desk managers are adept at figuring out who is honest, and who is just a hustler.

So, when a surgeon must bump the schedule, a little bit of finesse is required. If you will pardon my '70s background and disco references, expertise in the "art of the bump" involves a bit of a dance, with the give and take of a lead dancer and a follower, and the grace necessary to both ask for and allow someone to "step in" when needed.

Monday, December 01, 2008

Giving more than my share of thanks

Pancreatitis. Oh-my-God pancreatitis. Pancreatic cancer. Esophageal cancer. Colon cancer. Rectal cancer. Undifferentiated cancer with metastatic disease in the abdomen. Melanoma. Really, really bad melanoma. Cholecystitis. Choledocholithiasis. Cholangitis. Gastric cancer. Bleeding gastric ulcer. Bleeding duodenal ulcer. Perforated duodenal ulcer. Appendicitis. Perforated appendicitis. Diverticulitis. Diverticulitis with abscess. Perforated diverticulitis. Perforated diverticulitis with septic mesenteric venous thrombosis. Post-CABG ischemic bowel. Incarcerated inguinal hernia. Stab wound to the abdomen. Cecal volvulus. Mid-gut volvulus. Small bowel obstruction. Small bowel obstruction with gangrenous bowel. Alcohol withdrawal with DTs. Boerhaave's syndrome. ITP. Hypersplenism. Ruptured spleen. Ruptured diaphragm. Incarcerated paraesophageal hernia. Achalasia. Traumatic brain injury. Massive trauma with hemorrhagic shock. Massive trauma with hemorrhagic shock and DIC. Carcinomatosis with bowel obstruction. Postoperative wound dehiscence. Postoperative bleeding. Postoperative pulmonary embolism. Spontaneous adrenal hemorrhage. Breast abscess. Breast cancer. Abnormal mammogram. Colonoscopic perforation of the bowel. Traumatic pneumothorax. Iatrogenic pneumothorax. Multiple rib fractures with hemopneumothorax. Flail chest. Respiratory failure. Ulcerative colitis. Ulcerative colitis with dysplasia. Ulcerative colitis with invasive colon cancer. Crohn's disease. Crohn's disease with enterocutaneous fistula. Alcohol or drug dependence complicating surgical care.

Yup. I have seen them all in the past 12 months, and more. And even though it's a little past the official "date," I am certainly more than happy to give thanks that neither my family nor I have had to suffer from any severe health problems in the past year. That is, until my brother the Googlemeister decided to break the cardinal rule of Christmas decorating --- never, I mean never, get the stuff out of the attic until after December 1st! So, in addition to the above, I can now officially state that today I am thankful that I am not my brother:

For the uninitiated, there is a fracture extending up from the elbow (which is dislocated) linearly in the humerus, basically splaying it out like a tripod. Fortunately, he's way smarter than me, and doesn't have to make a living with his hands (he'll have to switch from a keyboard to a Blackberry for a while, though). And as bad as this fracture is, what he doesn't know is that it could have been worse. Most folks tend to think of fractures only in terms of the broken bones:
Those that play tennis know that there are a host of muscles and tendons in the area. However, there is a little bit of expensive real estate here as well, mainly the artery and nerve trunks heading towards the lower arm and hand:

One of those shards of bone could have easily lacerated an artery or nerve. So, all in all, I have to say I need to "give thanks" yet again, on his behalf.

So, my dorky little (over 40 still doesn't count) brother, best wishes for a speedy recovery!