Saturday, August 28, 2010

Genius Phones

F. N. Stein and IBS Computing announced today that they have completed design and construction of the next generation of smart phones. The new ultra portable phones are completely implantable, combining the latest in biocompatible materials with the most powerful nanotechnology ever developed.

“This new technology far exceeds the technology offered by the existing I- Phone or Android systems. The Q Phone, as it is called, comes in two parts which are implanted under the skin of the user, a receiver implanted in front of the ear and a transmitter implanted beneath the buccal mucosa within the mouth,” stated Dr. Stein, CEO of F.N. Stein.

He went on to add that the convenience and power of these phones will bring new meaning to the term “smart” phone.

“If the existing technology is called smart, these will have to be dubbed genius”, Dr. Stein gushed. “It will no longer be necessary to carry your phone in your pocket or on your belt and you can get rid of those ugly Bluetooth ear pieces once and for all.”

Dr. Stein went on to explain that the new phone automatically integrates with signals from your brain to dial a contact in a nanosecond. Conversations are completely private as the transmitter can send a clear signal even if it is only the faintest whisper. Incoming calls are audible only to the receiver and text messages are transmitted directly to the cerebral cortex. It will no longer be necessary to fumble with your phone or push buttons or “swipe” icons back and forth. The Q Phone is 100% intuitive and functions are executed with only a quick thought.

“The Q Phone goes far beyond “hands free”, Dr. Stein proclaimed. “It’s almost speech free. The controversial ‘driving while texting’ debate will become ancient history as these phones free the driver to concentrate on the road, even while sending out and receiving messages with just a thought.”

There are already hundreds of thousands of useful and unique “apps” for the Q Phone. Besides the obvious GPS or reading apps, the new technology expands the possibilities, making this phone truly worthy of the name “genius”.

Expected to be among the more popular applications is the new Date Buddy. This completely free app will be your coach during those trying moments when you are trying to make time with that hot babe at work. Instead of the usual fumbling for the right words, the Date Buddy will automatically monitor the conversation and transmit witty sayings to the subscriber, guaranteeing that the target will be swept away by the users dashing and debonair manner.

For the user expecting to appear on “Jeopardy” the Q Phone has instant access to the entire Internet, discreetly and secretly. The Wikipedia app can bring the entire online encyclopedia to the tip of your tongue instantly guaranteeing that even the dullest user will appear intelligent and sophisticated.

“We’re expecting to be able to release these implantable phones before the second quarter of 2011. We’re still working out a few bugs with the implant technology. Right now it requires a visit to the doctor to have the devices properly implanted. We’re hoping that a self implantation kit will be feasible before the final version is released”, Dr. Stein reported.

There was no immediate comment from representatives of Google, makers of the Android platform; however, Steve Jobs was quoted as saying “This implantable phone is pirated from technology developed by Apple. The IPhone 5 was slated to be such a device. We intend to file a patent infringement suit in Superior Court next week.”

Dr. Stein laughed off Mr. Job’s comments, saying that he had been working on this sort of device for decades.

More information is available at

We at “Heard in the OR” will keep you posted as this story develops.

Saturday, August 14, 2010

Don't Think

I read a missive from hospital administration recently, posted on the wall in the physicians work area at one of the hospitals. The message read something along these lines:

“Per JCAHO* regulations physicians should refrain from writing orders allowing for a range of medication to be administered. Specifically, pain medication orders should not say:

Dilaudid 1-2 mg IV Q3h prn pain

Instead such orders should be written:

Dilaudid 1 mg IV Q3h prn moderate pain
Dilaudid 2 mg IV q3h prn severe pain

Orders written in the former manner, allowing for a range of dosage allow the nurse administering the medication to make independent judgment decisions. Such decision making is not permitted under the nursing licensure.”

My reaction to this directive was that the lunatics are in charge of the asylum and everyone should run for cover. Nurses are to become robots, methodically passing out meds and dutifully charting when the patient last belched, while ignoring their patients overall wellbeing. I asked several of the nurses in various hospitals their opinion of this rule. I pointed out that, to me, there wasn’t any difference between the two orders. What they said was a bit disconcerting. The nurse is supposed to ask the patient about the severity of their pain and then medicate accordingly. So, if the patient responds that he is feeling severe pain he is given the higher dose, no questions asked.

Now, I’ve been in practice for over twenty years and I can tell you that pain; its intensity, quality, severity and every other aspect is the most subjective of clinical symptoms. I’ve had patients, who have undergone a very minor procedure, tell me the pain is the most excruciating they’ve ever felt, while others, who have just undergone a major abdominal surgery with a stem to stern incision, report only mild discomfort.
There are patients who appear nearly comatose after surgery, barely arousable, but will state that their pain is severe and will request their medication every three hours on the dot. In this situation, what is the nurse to do? Blindly administer the higher dose prescribed for severe pain or actually think that the patient’s pain may not be as severe as reported and give the lower dose, and/ or call the doctor to have the medication adjusted.

No matter what, a good nurse has to use her best judgment to care for her patient in the most compassionate, but also clinically appropriate, manner possible. Patients, who are human, have widely varying ideas of what the hospital experience should be, particularly when it comes to pain. For some, pain relief means completely numb from head to toe; for others it means just enough medication to have the edge taken off. Most are somewhere in the middle. The nurse serves as the doctor’s eyes, learns to make a proper judgment and provides a continuous image that complements the snapshot the doctor receives on daily rounds.

The idea that nurses not be allowed to think echoes the words of one of my medical school instructors, Dr. John Adams. In the early 1980’s I was at the University of Rochester Medical School in upstate New York. Dr. Adams was the classic curmudgeonly surgeon. Loud, intolerant of ignorance or incompetence by subordinates, he often chastised the residents on his service for writing orders with a dosage range in the way that is now prohibited. He must be working for the JCAHO, because his exact words were:

“Don’t write Demerol 50-75 mg IM q3h. That allows the nurse to think; we don’t want the nurses to think. Their job is to do what they are told to do.”

Who would have thought chauvinistic Dr. Adams was such a visionary?

Actually, I don’t think that he had such a low opinion of nurses, rather, I believe, he was trying to drive home a message to the residents and students: orders should be clear and specific. Such clarity allows the nurse to perform her task efficiently and provide the patient with the best care possible. Doctors and nurses are a team, working together to help an individual who is sick or injured recover and return to a normal life.

Years ago I read a study on factors affecting outcomes on critically ill patients. I don’t remember which journal it was in, but the study looked at ICU patients and a number of variables that could have an effect on the patient’s recovery. The only variable that made any difference was the quality of nursing care.

This makes perfect sense to me. The critically ill patient requires continuous monitoring. Most of the time it is the nurse that is at the bedside checking vital signs, urine output, oxygenation and every other parameter that may be indicative of the patients well-being. The best ICU nurses will pick up on subtle changes that could be harbingers of impending deterioration in the patient’s clinical condition. If such nurses are shackled by the “don’t think and don’t make judgment” rules, these critically ill patients will suffer.

Besides acting as physician’s eyes, nurses also provide a level of protection for the patient. If an order is written or a medication prescribed that seems to be in error the nurse is there to question it. Despite what some doctors may believe, we physicians are not perfect and sometimes errors are made. A vigilant nurse often picks up on this, questioning the order; calling the doctor for a “clarification” (correction). Sometimes it is an omission that needs to be brought to the doctor’s attention. In all situations the nurse is the patient’s advocate, doing his or her best to smooth the often bumpy road to recovery.

Doctor’s, by necessity, approach patient care from a very different angle than nurses. Medical School and residency teach us the underlying pathophysiology and the clinical manifestations of various diseases and medical conditions. We take this information and establish a diagnosis and institute a therapeutic plan. Our primary purpose is to see that the disease process is properly treated and see the patient to a complete recovery or at least keep chronic diseases under control.

Nurses share in this goal, but along the way they are often called upon to provide comfort, counseling and to allay fears. The nature of their profession allows nurses to do this in a way doctors cannot. The best nurses always seem to find the time to sit with their patients, provide reassurance and still manage to do all the ridiculous charting and filling out of seemingly endless forms that generate reams of paper that no one ever looks at.

In the middle of these essential activities the nurse often have their carefully planned schedule disturbed by a million other tasks, usually accommodating the interruption with a smile and a shrug of the shoulders. I know that when I have asked nurses to help with a bedside procedure they are only eager to help and always insist on finishing up all the cleaning and reordering of the patient room when I am finished. I sometimes wonder if it is eagerness to do all they can to help or if they really want to be sure that the patient’s room is properly returned to an orderly state.

Nurses are truly amazing in their ability to calm anxiety, inform ignorance, allay fear, provide comfort, stroke egos (especially OR nurses), see us all at our worst moments and invade our most intimate places and do it all with a smile and a wink that says “I know you don’t feel well now, but just give us a little time and you’ll back home with your loved ones before you know it.

I may be a bit biased towards nurses. After all, I married one; Laura, my wonderful, beautiful, intelligent wife of twenty five years, the cutest little nurse I had ever seen, always took the time to talk to her patients, share their feelings and make sure that all their treatment was delivered in the best, most professional manner. When we first met I think I used to exasperate her by my asking for patients’ vital signs and her appraisal of their condition. But, we shared our concern for the patients’ well being and have continued to share for twenty five years.

Nurses and doctors, along with surgical technicians, respiratory therapists, physical therapists, occupational therapists, speech pathologists, patient care aids and all the other allied health personnel, share a common goal; that is to treat the sick and injured and allow them to return to happy, healthy, productive lives. The doctor provides the diagnosis and overall therapeutic plan, institutes the plan’s delivery and makes alterations and interventions when necessary. The nurse provides the monitoring, the immediate delivery of therapy, nurturing, comforting and compassion on a continuous basis. If our nurses are not allowed to “think” our patients will end up suffering, with longer stays in the hospital and some, I am sure, will never leave the hospital.

It is something for all of us to think about.

*Joint Commission on accreditation of Healthcare Organizations

Sunday, August 8, 2010

Backyard Nature

The World Around Us

This evening I sat in my backyard next to our swimming pool and watched the myriad activity in the bushes and the trees that line the rear edge of our yard, separating our home from the neighbor behind us. From the near edge of the pool I watched as a Cardinal timidly foraged for food beneath the bushes. He would pick up a few seeds, stop and look around, then pick up a few more. This went on for about five minutes and then he made his escape, taking short hops through the bushes, presumably returning to Mrs. Cardinal.

A few feet away, a much bolder Blue Jay was in engaged in similar activity. Bolder than the bright red Cardinal, the Jay took few pains to hide himself and loudly announced his presence, once he had returned to the safety of some higher branches. The big black crows are even bolder, every Spring staking claim to the small park in front of my home. They can be seen on the ground and in the trees at the four corners of the park, a bit reminiscent of “The Birds”, although I don’t think anyone has ever been attacked.

I live in a suburban area, close to some wooded areas and several bayous. Surprisingly, this populated neighborhood is teeming with a variety of wildlife. Besides the aforementioned birds, there are finches, doves, squirrels, rats, field mice, frogs, lizards, a rare snake and at least one turtle. Sitting outside in the late afternoon seems to afford the best view. The heat of the day has diminished and nighttime predators are not on the prowl.

So, in the early evening it is possible to see numerous lizards scurrying about or catching the last few rays of the departing sun. If I watch closely I can usually see lizards racing along the top of the fence or sunning themselves on top of the stone Hippo statues that guard our pool.

In a few weeks I will be treated to the hummingbird spectacle. Every year for about two weeks, in late August and early September hummingbirds stop in Houston on their way south. We always set up a feeder and manage to attract some of these diminutive birds. Watching their social order is sort of a metaphor for humanity. Usually, one hummingbird will claim the feeder as his own. He will take a drink and then fly away to perch on the nearby tree, all the time keeping his watchful eyes on “his” feeder. If any other hummingbirds try to approach he will swoop in and chase them away. Of course, the other hummingbirds want their fill of the sweet, fake nectar, so they will team up. One pretends to go in for a drink and allows himself to be chased away and, during this pursuit the others will saunter in for a leisurely swig. Not unlike many people really.

The rats and mice that I see create something of a dilemma. I know that they are vermin and carry disease, but it just doesn’t seem right to kill them. For a while we had a bird feeder in the backyard. This feeder fed not only birds, but also squirrels, mice and rats. There were several nights when our dogs would be outside barking nonstop and, when I investigated, I found them looking up at one or more rats taunting them from a branch high above the ground.

My dogs, actually, are very efficient at keeping our home free of such vermin. Before we took down the birdfeeder I found five dead rats in a week’s time. One afternoon I inadvertently witnessed the spectacle. In the middle of the day the three dogs, two Basset Hounds and a West Highland White Terrier, were outside barking in the continuous manner that signaled that they had something cornered. When I checked it out I saw them standing around something that was on the ground. Before I could intervene, Genevieve, our fat Basset Hound made a surprisingly quick lunge and in an instant a big rat lay dead. Don’t let anyone tell you that Basset Hounds are slow and lazy; she made very quick work of that execution. Needless to say, I took the bird feeder down that day and didn’t find any more dead rats.

There have been other rodents that have invaded our home. There was the time I went to check on our dogs early in the morning. They had been doing there nonstop barking routine, but by the time I went to see what all the fuss was about the noise had stopped. When I checked on them I found a baby possum lying stiff on the floor by their doggy door. I looked at it, lying rigid on the floor and assumed it was dead, but then my wife and I began to wonder; there wasn’t a mark on the little beast. We picked it up in a towel and carried it outside, locking the dogs inside. We laid the little critter among the bushes behind the pool and, as we suspected, the baby possum picked its head up, looked around and scurried away. It seems that possums really do play possum.

More recently, I sat and watched a field mouse make its was around the side of our house. It saw me studying its movements, but pretended I wasn’t there as it walked between our garbage cans and then stopped at our back door, reared up on its hind legs and pushed against the doggy door. Luckily, for the mouse, it was too small to push the door open, because just inside the door, asleep on a cushion was our West Highland Terrier, Coconut. I am sure that Coconut would have made short work of that mouse. Unable to break into our house, the mouse went on his way, still unperturbed by my presence.

In my recently released novel, “Joshua and Aaron”, the hero, Joshua Smith is given a pair of “goggles” that allow him to see the teeming life that exists apart from humanity, in the city around him. He is told that “we see and hear what we’ve been trained to see and hear.” There is a wonderful world around us; full of life; a gift from God. All we have to do is take the time to sit and watch; it’s a spectacle better than anything television or the internet can provide.

Sunday, August 1, 2010

Dr. Write

CC: SOB and Abd pn.

65 y-o WM w/ hx of CHF, CAD, IDDM, Htn, &SLE was admitted @BMC c/o CP, SOB, LUE edema and UTI for 7 days. Pt. also c/o no BM for 1 wk. and + LGIB. Pt. also c/o abd. Pn and N&V for 2 wks. (-) flatus x 3 days.

As in HPI. + CHF, CAD, s/p CABG, LGB, BIH and ORIF LH.
MEDs: see list.

Cig: 2 ppd x 30 yrs. Etoh (-) ret.



Neck: NT, (-) Br.
Pul.: Cl. To A &P
CVS: RRR, nl S1S2 w/o m, S3 S4, (-) JVD
Abd: (+) BS, w/o HSM, B9
Rectal: WNL
Ext: w/o C, C, E, pulses 2+
Neuro: NLS

65 yo WM w/ MM Probs. Plan CT A/P, CXR, EKG, CC cath.
Consult GS, Card, GI, Pulm.

I will happily accept any one's translation of this perfectly plausible History and Physical.