एक सामान्य अस्पताल में पर्दे के पीछे

Editor’s Note: Dr. Eric Logan and First Presbyterian Hospital are pseudonyms, used at the request of the doctor interviewed for this article. The photos accompanying this article are stock photos.

March 7, 2012 -- Dr. Eric Logan is unhappy with President Barack Obama.

Back in July of 2009, President Obama suggested that surgeons were doing many unnecessary surgeries. “Right now, doctors a lot of times are forced to make decisions based on the fee payment schedule that’s out there,” President Obama said. “The doctor may look at the reimbursement system and say to himself, ‘You know what? I make a lot more money if I take this kid’s tonsils out.’”

“I’d love to have him come to the operating room when I’m doing emergency surgery,” Dr. Logan grumbles. “He could see exactly how unnecessary these surgeries are.”

Dr. Logan, an orthopedic surgeon, works six nights a month on call at First Presbyterian Hospital. As we sit in his office, the conversation shifts to the hospital’s inefficiency. A woman in the emergency room (ER) has an abscess in her shin that is causing her a great deal of pain and is not responding to antibiotics. It needs to be removed before the infection spreads. She arrived at the ER at 10am. It is now about 7:45pm.

“It takes about two hours to do the tests and so forth to determine if a patient needs surgery,” Dr. Logan says. “I got the call around 2pm that I would be doing surgery. But it wasn’t until 5pm that I was told to come in to the hospital.”

He picks up the phone and calls one of the nurses he’ll be working with this evening. He asks if it is time yet to do the operation. The nurse informs him that the anesthesiologist cannot be found.

“It happens all the time,” he says wearily. “The problem is that no one is accountable in the operating room. One part of the hospital is in charge of the surgeons, another is in charge of the nurses, and another is in charge of the anesthesiologists. If you have a problem with someone, you have to go all the way up the chain of command. This lets people get away with not showing up in a timely fashion.”

Shortly after 8 pm the anesthesiologist is found. By 8:30 pm the surgery is ready to begin.

A few feet from the operating table sit the tools of an orthopedic surgeon’s trade. Two four-by-four tables are filled with drills, screws and pins, making it seem a bit more like auto-shop than an operating room.

The anesthesiologist gives the patient an anesthetic that renders her unconscious. Since it is only a small portion of the patient’s shin that is being operated on, why not give a local anesthetic? The anesthesiologist explains that the area around an infection usually becomes “acidotic.” This means that the bodily fluid around the infected area has an increase in acidity that keeps local anesthesia from working very well.

In the operating room one of the nurses scrubs the patients’ shin with an orange liquid known as “Chloraprep,” a combination of soap and alcohol.

Dr. Logan pushes on the area around infection and swabs some of the liquid that comes out. He then draws a small oval of the part of the skin to be removed. He makes an incision in line with the oval and removes the infected portion of skin.

After the skin is removed, Dr. Logan and the resident (a medical student learning to be an orthopedic surgeon) put a tube into the open part of the skin and pump in a disinfectant. Another tube is inserted that sucks the disinfectant out.

“The problem is that no one is accountable in the operating room.”

–Dr. Eric Logan “We put a lot of disinfectant in,” says Dr. Logan. “We have a saying, ‘dilution is the solution to pollution.’” Once that is finished, the resident closes the wound with sutures.

The surgery is finished shortly before 9pm. The patient has waited nearly eleven hours to have a piece of skin the size of a dime removed from her shin.

“Waiting like this—it isn’t good for the patients,” Dr. Logan worries. “The longer we wait, the more that swelling can increase, and that can make it harder to operate. It can mean more pain for the patient, increases the risk of infection, and can slow recovery time. Slower recovery time can mean the patient misses more work.”

He goes to the waiting room to visit with the patient’s family. He lets them know that the operation went well and that she should recover nicely. They seem relieved.

He then walks through a number of corridors. But his walking is almost labored, like something is weighing him down. What it is becomes apparent shortly after he arrives at the doctor’s lounge.

“See that nice 55-inch plasma TV?” he smirks. “That was the administration’s response to surgeons complaining about the amount of down time between surgeries.”

There is a lot of down time in between surgeries at a major hospital. This time it may impact Dr. Logan’s family life. His 11-year-old son is playing his first football game at 9am the next morning. Dr. Logan figures that he might make it by half-time.

Soon he is called in for the next surgery, a man with a hip fracture.

Dr. Logan heads toward the operating room with his labored gait. Then, as he nears the operating room, his pace quickens some and his eyes widen a bit.

The patient has waited nearly eleven hours to have a piece of skin the size of a dime removed from her shin. Waiting increases the risk of infection.

He scrubs up and a nurse helps him into a lead vest. X–rays will be used continuously during this operation. All personnel in the operating room must wear a lead vest to prevent the damage from long-term X-ray exposure. The patient doesn’t wear one because his exposure will be no longer than the operation.

Dr. Logan puts on two pairs of latex gloves. When doing surgery on bones and joints, a variety of small, sharp objects, such as bone fragments, can tear a glove.

The X-ray machine looks like a big letter C sitting on top of an industrial vacuum cleaner. The X-ray technician is able to rotate it around the patient if necessary. Two cords go from the X-ray machine to a big box. On top of that sit two screens; one is a top view of the area being operated on, the other is a side view.

Dr. Logan calls out “picture” every time he wants the X-ray to be updated on the screen. He does this frequently as he drills three pins into the patient’s hip. The operation is finished shortly before 10pm. This patient was luckier than the previous one. He was admitted to the ER around 2pm.

Dr. Logan heads to the ER to check on his coming workload. A new patient has been admitted from another hospital. He was in a motorcycle accident that snapped his right femur in half. Dr. Logan asks one of the nurses where the patient’s X-rays are. She doesn’t know. It later turns out that the other hospital sent the patient without his X-rays.

He must do what he calls a “triage,” a process whereby he determines the priority of treating patients based on the severity of the patients’ conditions.

“I have a patient waiting with a broken ankle,” he says. “Surgery would be best for her, but she will heal just fine if with a cast. I’m not going to be able to get through the more serious surgeries I’ve got if I operate on her.”

He meets the patient and her husband and explains to her that they’ll be putting a cast on her ankle. She seems relieved.

The difference between a cast and surgery?

“About the same,” says Dr. Logan, after he has left the patient. “Although she’ll have about two weeks more recovery time with the cast.”

The next patient has fallen off a step ladder. He broke his right ankle and the bone punctured the skin on the inside of the leg.

“Falling off a step ladder is actually a pretty common injury,” Dr. Logan says.

After the anesthesiologist puts the patient under, a black foam-rubber block is put under is right leg to elevate it.

The resident begins to make an incision. One can see the bone sticking through the punctured skin. The foot almost dangles off to the right.

The resident makes a second incision on the outside of the ankle. Screws are inserted into the ankle to hold it together.

The resident sutures the incisions in the patient’s ankles after the screws are inserted. The patient was admitted to the ER shortly before 9pm. It is now just after 1am.

Dr. Logan again finds the patient’s family in the waiting room. He lets them know that the operation went well.

He now seems more upbeat. “This night is going a bit quicker than usual. If we don’t get hit with a sudden rush of emergency patients in the next few hours, I’ll get out of here on time.” His son’s football game beckons.

After spending some more time in the physicians’ lounge, Dr. Logan is called back to the operating room for the patient with the broken right femur. The patient was admitted around 9:30pm. The surgery begins at 2:45am.

“Our incentives are not aligned.”

—Dr. LoganIn decades past the patient would have spent months in a body cast to heal this sort of injury. Now, a long pin will be drilled into the top of his femur all the way down through the bottom part, fusing the two halves together. Then screws are inserted on each end to secure the pin in place.

An additional orthopedic surgeon, “Dr. Scott,” is required for this surgery. The camera X-ray machine is placed over the patient’s right thigh. Dr. Logan and the resident begin the operation by drilling the pin into the top of the femur, while Dr. Scott grabs the patients’ right ankle and yanks and twists the leg so that the two halves of the femur will line up. It is difficult as the patient is large—at least 250 pounds—which makes the leg less cooperative. Dr. Logan calls out “picture” countless times so that he can see in the x-ray screen if of the pin is being drilled in properly. It’s not. As it reaches the bottom of the top half of the femur, it slides off to the side, making it impossible to drill into the lower half. Dr. Scott continues to pull and twist the patient’s leg while Dr. Logan and the resident drill the pin into the femur and then retract it numerous times.

After about half an hour of futility, Dr. Logan decides it would be better to have two physicians pulling and twisting the leg while one physician drills. He and the resident switch places with Dr. Scott, and the tug-of-war continues. It is excruciating to watch. One can’t help but send up a thankful prayer for modern anesthetic.

Finally, the two halves line up and the pin is drilled down to the bottom of the femur and then the screws are inserted to keep it in place. It is now 3:50am.

Was this Dr. Logan’s most difficult surgery ever?

“No, not at all,” he says.

Was it at least in the top ten?

“Yeah, I think so.”

Dr. Logan finds the patient’s family sleeping in the waiting room. He wakes them and tells them that the surgery went well and that the man should recover nicely.

As he heads back to the physicians’ lounge, he reveals one more hospital inefficiency.  It’s called the Post-Anesthesia Care Unit (PACU). It’s where patients go after they have had surgery. Nurses there monitor the patients until they are either ready to go home if they’ve had minor surgery or ready to be moved to a permanent room in the hospital if they’ve had major surgery.

Making changes to this system is a lot like kicking an 800-ton marshmallow.

“The hospital limits the ratio in the PACU to one nurse per two patients. If there are 20 patients in the PACU and ten nurses, then the PACU will refuse to take any more patients until one of the patients in the PACU is moved,” says Dr. Logan. “If a patient is in the operating room when the PACU fills up, he must wait until one of the patients in the PACU is moved. So we keep him in the operating room. That means patients waiting for surgery will wait longer.” It also costs the hospital more. The operating room costs about $300 an hour to run, the PACU only $50.

Why doesn’t the hospital call in more nurses when the PACU fills up?

He shrugs.

Dr. Logan also works regularly at a local physician-owned orthopedic specialty hospital. (He is not one of the owners). “I can get more done there in twelve hours than I can here in 24,” he says.

To be fair, even the most efficient system of emergency surgery would not be as efficient as the scheduled surgeries at a physician-owned specialty hospital. When the surgeries are scheduled days or even weeks in advance, the staff knows exactly what type of operation they will be doing. That makes it much easier to prepare the necessary equipment.

In emergency or urgent surgery, the staff never knows what type of case is going to come through the door next. If there are three sets of tools to treat a particular injury, but five of those cases come through the emergency room doors, that will result in down time between surgeries. The tools will need to be sterilized between surgeries, a process that can take up to three hours. Further, it may be a type of surgery that the hospital doesn’t perform very often, in which case the equipment may have to be brought in from elsewhere.

Dr. Logan also explained it as the difference between “a pop quiz and an exam that you have a few days to study for. You’re going to be a lot more organized if you’ve had time to prepare the material.”

But surely the staff at McBride Orthopedic Hospital face similar difficulties when patients come through their emergency room. Yet it’s possible for a patient to go from the emergency room to the operating room at McBride in about two hours. What’s the difference?

“Our incentives are not aligned at First Presbyterian,” says Dr. Logan. Logan gets paid on a patient by patient basis. He’s responsible for the patients that come in during his shift. He has an incentive to keep the process moving along, so that there is less down time between operations. But the staff who clean the room are paid by the hour. They work an eight to twelve hour shift, and they get paid the same if they do two cases or ten. They have less incentive to work quickly. The anesthesiologists work on a hybrid model: they get paid on a patent by patient basis but another anesthesiologist takes over at the end of a shift.

“If everyone got paid on a patient by patient basis it would be much more efficient,” says Dr. Logan. “And what’s frustrating for me is that I go to the emergency room and see the patient in pain and anxiety while he is waiting. And he waits an extra 30 or 45 minutes and does that mean another hundred-thousand bacteria gets into his wound? It’s not good for the patient.”

Making changes to this system is a lot like kicking an 800-ton marshmallow. The hospital has many different departments, making it hard to target the people in charge.

“Where I work, the patient goes through the emergency room, the pre-op, the operating room, the post-op, and then to the floor,” says Dr. Logan. “Those five areas—each one has its own nurse administrator, each has its different budget. Getting everyone together to make any changes…good luck.”

At McBride, if an employee has a problem, he simply goes to the CEO, Mark Galliart.

Clearly, Dr. Logan finds this frustrating, so why doesn’t he quit this and work at the specialty hospital full time?

He stops and thinks about it for a few moments. “Well, pride is one reason. I’m one of the few doctors in this town who does what I do. Second, by doing emergency surgery, I’m on the ‘frontline’ of medicine. That gives me a rush. And, well, what really makes it worth it is I’ll see one of my patients come back a few months later and he or she can go to work, take care of their family, and so on. That’s very rewarding.”

डेविड होगबर्ग इन्वेस्टर्स बिजनेस डेली के लिए वाशिंगटन स्थित संवाददाता हैं और मेडिकेयर पर एक आगामी पुस्तक के लेखक हैं। वह पूर्व में नेशनल सेंटर फॉर पब्लिक पॉलिसी रिसर्च में एक वरिष्ठ साथी थे, और रियो ग्रांडे इंस्टीट्यूट में एक साथी थे। आप ट्विटर पर डेविड का अनुसरण कर सकते हैं: @DavidHogberg

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