University of Illinois at Chicago
Wow, I can’t believe it’s my last blog post, it seems like just yesterday I was writing my first. The immense amount of knowledge and skills I have gained from this program has been incredible. I have really learned to look at processes and systems around me with a critical eye. I think what benefited me most from this program is the ability to think critically about all the problems around me, while empathizing with all parties involved while solving the problems that exist.
I realized that many problems I encountered were large scale problems with fixes that are not just as simple as designing a device to be more efficient or remodelling a hospital room. There are so many other factors that go into determining what improvements will be carried out such as funding, budgets, ethical barriers, politics. I have realized it is not possible to please everyone, but rather to acknowledge the different viewpoints of people and work towards solutions that are not so drastic. Humans are incredibly well adapted to adaptation even though they may not like it. I believe it is possible to change many problems for the better, not at a drastic rate, but step- by step.
Changes can be small. But 100 small changes can make a big change. I am very optimistic for the good changes that are coming to overall healthcare and I could not be more excited to partake in this revolution in my career. This Immersion program has felt like a giant leap into the ocean even though I now realize I have barely jumped into a pond. I hope to take everything I learned and work on making the ocean, and world a better place!
Special Thanks to my two partners, Rachel Joseph and Naz Hussain who were always there to help develop my ideas!
This week we visited the sleep clinic as they prepared for their nighttime sleep studies on patients. These clinics usually occur from 8pm to around 6pm. There were two techs working that night for a total of four patients. I was told that the volume of patients was more during the weekends. Patients check in and are given a parking sticker for the lot outside. Once they are settled, they are taken to the consult room that has a bed. They finish some paperwork for a few minutes while the technician gets ready. Once the technicians are ready. They prepare the body of the patient by cleaning the areas the leads will be attached with a gel. The leads that are used are gold plated although in other institutions, there are regular plastic leads that are used. The reason gold leads are used are because they have the best level of transmission which is needed since the facility is located right next to a MRI facility. The MRI machines have high levels of signal interference.
It takes about 30-40 minutes to hook the patient up to about 20 leads which are all plugged into a box that the patient may sling on their shoulder if they need to go to the bathroom in the middle of the night. This is the part that is the most complained about since many patients ask weather they can just wear a helmet and body suit. This is currently not possible since the leads need to have good contact with the skin in order to transmit signals well. Also, there are wireless leads that have been invented but this facility doesn’t use them.
One the patient is all hooked up, they are instructed to lay in the bed. The tech then goes into the holding room and performs some tests to make sure the equipment is working properly. There is an intercom system set up in the room where the patient can just speak if they need any assistance and the tech will hear them. The tech may also speak to the patient by pushing a button on the intercom. The preliminary tests provide a baseline for the rest of the night. There is a breathing monitor that senses when a patient is breathing and depending on if a patients breathing, they are put on a CPAP machine in order to see if it helps with their breathing. The prelim tests also monitor what a REM sleep cycle may look like by mimicking rapid eye movement done voluntarily by the patient (here also patient compliance is a key factor in providing an accurate test). Once these tests are completed the patient is told to sleep as they would normally.
Each of the rooms is equipped with a private bathroom as well as a television. There is also a camera that monitors the patient for the whole night for security as well as monitoring purposes.
I think these sleep test would be better utilized if they were performed in the patients natural sleeping environment such as the bed they sleep in every night. Some people may have different patterns when they are somewhere other than their own bed. Another factor that should be taken into consideration is if the patient sleeps with a partner in their bed or not because that may affect results.
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I also received an update from the procedure mentioned last week. Unfortunately the patient the bronchoscopy was performed on has small cell lung cancer. This was determined from the biopsies taken during the procedure and stained for cancer agents. I could see that the cells had little cytoplasm, enlarged nucleuses, and chromatin that wasn’t as condensed as it usually should be.
This week we observed the Sleep Clinic. Naz and I were not prepared for such a large change of scenery. Arriving at the clinic which is tucked away about a mile west of the hospital, we met the attending who explained the process of seeing patients to us. Expecting the regular routine of clinic visits, we were surprised to see how different the consult rooms looked like! They all had full beds all made up with pillows and their own bathroom. They pretty much looked like bedrooms with the exception of the chairs and desk that looked like ones in general consult rooms. Most of the patients we saw were coming in for problems with sleep apnea. Many sleep tests occur overnight at this clinic where patients are hooked up to electrodes.
We learned a little about the CPAP machines which help with sleep apnea. They all require some sort of face mask, and there are many available. Even though there are many different designs, in the end, there is still something on the face and it’s a human’s natural instinct to try and brush it away which in turn may make the machine less effective. The machines are able to monitor patient compliance on how much of the time they are being used. There are some insurance companies that require the machine to be used more than a certain percent of the time for insurance to cover the cost of the treatment. The attending mention a big problem of the machines and stated that it would be a lot easier if the machines were able to automatically upload the data to the system to view and analyze it instead of the patient bringing in the machine and physically downloading the data.
Overall sleep clinic was an interesting change and it would be nice if we are able to go back at around 8 pm to see how all the electrodes are attached to the overnight patients to see how the general process works.
While in the Intensive care unit, I noticed that many patients were hooked up to antibiotics on their IV’s. Recently, I had listened to a TED talk regarding antibiotics and some of the negative effects they may have. The gist of the talk is that as antibiotics are used more widespread, there are bacteria that are constantly evolving in order to stay alive, and thus antibiotic-resistant bacteria are born. As time goes on, the antibiotics need to be constantly evolving in order to keep up with the bacteria that are evolving on their own. For many drug companies, it is not lucrative to keep making new antibiotics and this humanity may be falling behind in treating bacterial infections. I brought this topic up with the pharmacist that was currently on rounds and he gave me an overview of how the hospital deals with antibiotics. There is a full time pharmacist whose sole job is to ensure that the correct antibiotics are used. The hospital generally tries to use narrow range antibiotics to solve specific problems. I deduced that patients can be treated with narrow range antibiotics only if their specific problem is known. This would have to be identified by tests or by a doctor’s discretion as they are admitted into the hospital. It seems that the faster the hospital is able to admit and perform the correct tests and diagnosis on the patient, the faster narrow-range antibiotics may be given instead of wide-range antibiotics that are given as precautionary measures. Patients are also instructed to finish their entire course of antibiotics in order for the infection to be wiped out completely even though they may feel better a few days after starting them. Here patient compliance plays a large role since patients may choose just to stop taking their pills just because they are feeling better.
While we were rounding, the rounds were interrupted by a doctor who informed us about the increase in cases of c.diff in the hospital which is an infection very easily transmitted through spores and causes bad diarrhea. She emphasized the importance of washing hands with antibacterial soap and warm water which is more effective than sanitizing hands. I noticed that in some of the older rooms (about half the ward has been renovated) that the sinks are in the back of the room. This is a problem since once the health practitioner has seen the patient, they must take off their gown and gloves at the door, but must venture all the way back into the room to wash their hands only to walk through the contaminated room to get outside.
I also asked the pharmacist about drug shortage since I noticed a sign on the drug dispenser that stated a shortage. He said that usually shortages occur when a certain manufacturing plant is either contaminated or short in supply. The manufacturing plant then sells the drug to a wholesaler which acts as the middleman to supply the UIC hospital. I was told that if there was a shortage, the drug wouldn’t be able to be bought from another wholesaler since UIC has a contract with its current wholesaler. In case of a shortage, usually the pharmacy has a stockpile of the drug so treatment will still be able to be delivered. If there is a dire shortage of a drug, all the pharmacists are notified to use certain drug in cases where the certain drug is the only option or in a life-saving situation. I think each shortage depends on what drug there is a shortage of, the number of patients in the hospital that may require it, and how much the shortage is. The pharmacists take all those factors, as well as probably a few more into consideration when dealing with drug shortages. This made me think about the overuse of drugs since the pharmacist implied that patients would get certain drugs only if they were absolutely necessary, but how would their care be negatively affected if they didn’t get a certain drug since it was in shortage?
It seems that patient compliance is a big theme in all aspects of pulmonary critical care whether it be in the pulmonary function testing, taking antibiotics, or taking different types of treatment such as asthma medication or using the CPAP machine.
Just as I’ve been doing for the last few weeks, I took the total amount of time required for bronchoscopy procedure. This case was an in-patient case so the first step was to obtain a signed consent form from the patient. The fellow that was going to be performing the procedure when up to the inpatient room about 30 minutes before the procedure was scheduled to start (10:30). He had already discussed the risks with the patient previously when he was consulting with her, so the signing only took a couple minutes, on a single sheet of paper. Then, things started going downhill. Everyone was ready yet the patient hadn’t been brought in yet. Finally the patient arrives and the procedure goes as follows.
11:15 –Nebulizer started with a 1% lidocaine solution. The lidocaine solution has been made from 1 part water and 1 part 2% lidocaine since the 1% was not available in the room.
11:26- Lidocaine gel is snorted by the patient to further numb her airway
11:33- Patient gets up to go to the bathroom (patient did go to the bathroom beforehand)
11:44- Q-tips with lidocaine jelly are inserted into the nostril to numb the area as well as to check whether the scope will fit. The nasal cavity is deemed in good condition for the scope. At this point the fellows realize that the scope plugged in, is a pediatric scope and it is switched out for a regular one. I am also told that all the steps thus far are completed by the pulmonary tech who is on vacation.
11:51- Sedation is begun to put the patient into a moderate sedation which is the general protocol.
11:55- The scope is inserted into the nasal cavity. After about 10 minutes of trying, which includes attempting to switch to a pediatric scope, the nasal cavity is deemed too small and thus the scope will have to be used orally. This process is extremely tense as the attending is raising his voice as he guides the fellow. At one point he seems so frustrated that he grabs the scope (without putting any gloves on) and attempts to put the scope in.
12:05- The scope is inserted orally, and finally the process of screening all lobes of the lungs is begun. First the left lobe is inspected which goes pretty smoothly. Each of the two lobes is examined quickly, efficiently, and to the satisfaction of the attending. He is very adamant about injecting a lidocaine flush through the biopsy channel at the entrance site of each lobe. The attending raises voice to emphasize the lidocaine but he has to do it about 4 times before the fellow injecting the flush does it without any prompting. Then the right lobes are viewed and many nodules are visible. It seems that the scope is irritating the area since as time goes on viewing anything becomes very difficult.
12:22- A biopsy is taken so the cause of the inflammation and nodules may be determined.
12:28- Another biopsy is taken from the surround regions in the right lobe. At this point visibility is becoming lower and lower which makes it harder to take the biopsy. Meanwhile, the attending is becoming more and more agitated, even yelling at the fellows multiple times. The overall environment in the procedure room is very tense. The attending even exclaims that the nurse is not watching the vitals monitor while she is grabbing a tool for the fellow. The fellow quickly jumps in and says he has been watching the vitals screen for the 20 seconds she has been away from the screen.
12:40- Another biopsy is taken and this one is done completely blind since there is so much blood and liquid that it is impossible to see anything.
12:45- Scope is removed.
Total time: 1 hour 15 minutes
The description for the procedure speaks for itself. As far as device design goes. The bronch scopes are designed very similarly to the endoscopy and colonoscopy scopes. The visibility issue here doesn’t seem to be a general problem during bronchoscopies, but the nature of this case caused for a lot of trouble. It seemed almost as if the scope was causing much of the problem. This was probably because the lung was irritated with this particular infection already which made it susceptible to damage from the scope easier.
I had the opportunity to take a closer look at the respirators in the intensive care unit. There is a fulltime technician that works with all the patients that need respirators. He is generally present every time there a patient needs to be intubated or extubated. The respirators are complex machines that need to work 100% of the time since any flaws could be fatal. I learned about the different modes the respirator has. On manual which delivers a breath to the patient at the given interval, and one spontaneous which allows the patient to breathe on their own, but delivers extra oxygen when a breath is taken and/or if the patient fails to breathe on their own. The respirator has a double filter system that essentially removes all pollution and bacteria from the air being delivered since some patients may have greatly suppressed immune systems.
If a patient has been intubated for more than 2 weeks, the chance of infection increases exponentially. The long term solution is to insert a tube into the trachea in which the air may be delivered instead of a tube in the mouth. This procedure is called a tracheostomy or simply trach. I had the experience of seeing this procedure done which utilizes a bronch scope. Generally bronch scopes go through the nasal cavity, but since the patient already was intubated, the scope was passed through the same tube. The rest of the procedure consists of making an incision, dilating to the proper size of the final airway tube, and suturing it into place. The procedure that I saw was performed in the Neuro MICU using the mobile bronch station. This mobile station consisted of the monitor and all the equipment to project the scope to the monitor which was brought to the patient’s room. This procedure also consisted of a PEG, or insertion of a feeding tube in the stomach. I had seen this before in my previous GI rotation and it is performed with an endoscopy scope. The difference between the endoscopy scope and a bronch scope is that the bronch scope is much smaller and has only a biopsy channel. Because of this, the mobile bronch cart has no need for a water holder since there is no flush being used. I saw that the tech had added a water bottle onto the cart so the endoscopy PEG procedure could still be carried out using the bronch cart.
I also saw some of the different politics of the MICU involving a procedure. A patient was slotted to receive a central line which was going to be carried out by the residents on the MICU rotation. A nurse however stopped by, said she really liked the patient, and said she had called the PICK team (a team that inserts a catheter through the arm instead of the neck) since it would cause the patient less pain. After she left I was informed that there really is no difference and the only reason she had asked for the PICK team is because if a central line was put in, she would have to stand and take vitals every five minutes which would be more work for her. It seems like the personal preferences of personal come into play in a patient’s medical care as well as the general workflow.
This week gave me a great introduction to all the different aspects of pulmonary critical care. Stay tuned for next week as I delve deeper into the inner workings of everything I’ve seen thus far!
Our day in the allergy clinic started with the nurse administering an allergy test where the patient is tested with different pollens. The patient is given positive and negative controls as well as all the possible substances that they have suspicions that they are allergic to. A device which has eight pointers is used and it penetrates the skin a small amount as to not raise blood but to allow the substance to cause a reaction if the patient is allergic to it. This patient seemed to have very sensitive skin as there was very little difference between the positive and negative control.
Then we were able to observe the nurse administer a spirometry test to another patient which measures lunch function. The test measures the volume you are able to inhale and exhale and how quickly you are able to do that. This test may give light to different lung ailments such as asthma.
We saw how rounds were carried out in the medical intensive care unit. The team of physicians assembles at 8 am in order to relay information about the previous night to the attending physician of the day. The resident that was present overnight relays the information to the attending, fellows, as well the other residents that will be taken over for the day. The general process is seeing the sickest patients first, then moving on to the newer ones, and finally finishing with the patients that have been established for a few days. The resident relays the information as well as a plan for the day and the attending reviews and approves the plan. Then the attending goes in the room and checks on the patient and relays any new information to the patient or family. A total of eleven patients were seen and the rounds took about 2 hours and 25 minutes. We also saw a patient that required a code one. When a patient codes they have no heartbeat and need to be resuscitated. There are about 15 part of the code team. The MICU is the department that announces all the codes. When a code one is announces, it is announced with the room number and wing of the hospital. The code team drops whatever they are doing and rushes to the room to take care of the patient. There were 15 people in the room along with one family member. The patient survived but yet the experience was still jarring.
We viewed the Fellows clinic where outpatients came in for consults. I was shown different CAT scans of patients torso’s and was told how radiologists and pulmonologists collaborate to identify different health risks. Speaking to one of the physicians, she informed me about the trouble patients have accessing medications. This happens because insurance companies frequently change the medications that they cover. When these changes are made, neither the physican’s office or patient is notified and when the patient goes to fill their prescription, they are charged the full amount, usually which medicare/medcaid patients aren’t able to afford. The pharmacist is very good about viewing the insurance company websites and keeping updated lists of medications, but sometime even the website aren’t updated.
I saw how compassionate Dr. Jacobson was in offering information to a patient with a possible patient diagnosis ensuring her, “We’re your team. We’re here to help you.” He made sure to tell her he would do whatever possible to help her gain information about her prognosis as well as understand and make informed decisions about her health care.
Pulmonary Function Testing Lab
I spent a morning in the testing lab, where the tech showed me the experience from the patient’s side. I was given the standard PTFs (pulmonary function tests) and was able to view my results. The equipment used was all very up to date and worked smoothly. The tech told me he had no complaints except for more space to move around in. The testing required a lot of cooperation from the patient which I was able to experience first-hand. The tests require a lot of voluntary breathing patterns that are different from normal breathing such as deep inhalation as well as exhalation. The tech was very good about urging me along throughout all the tests which I think was key to a good reading. I saw him use the same technique on a patient who was very compliant. I can foresee that if a patient is not very compliant these tests will be very hard to complete. I also was wondering what would happen if a patient spoke a different language since in a spirometry chamber, the patient hears the tech through a microphone and the translator service would not be able to translate quickly enough for the type of tests being done. The tech explained to me that he would resort to sign language and learn the words for inhale and exhale since there are not many words that need to be used. Next week I will talk more about the different quantities measured by these experiments as well as how they work as I am better acquainted with them.
THEY LET ME USE THE SCOPE!
I took a trip down memory lane back to the endoscopy suite where I had been the previous weeks for GI. The bronchoscopy procedures are done here as well although they use a smaller scope which passes through the nasal cavity to the trachea. This scope is different from the endoscopy and colonoscopy scopes as it is smaller and only includes a biopsy channel. The fellow and the pulmonary tech allowed me to practice using the scope on a rubber lung model which was absolutely exhilarating. I got the hang of it pretty soon and I was able to use the brush tool through the biopsy channel to brush out some material to study (it was just some rubber from the model).
This hand on experience allowed me to gain some real understanding about the mechanics scopes. Since this is a smaller scope the tip is only able to move up and down, in order to maneuver it left or right, one must twist the scope as well as their hand supporting the end of the scope in the direction they want to go. This wasn’t too much of a hindrance as I was able to get the hang of it in about 5 minutes and little instruction which led to the question whether or not I play too many video games. The one thing that was slightly hard about holding the scope was that it had to be elevated which can cause fatigue in the arm of the user during long procedures.
I was also shown along with a few other residents how to put in a central line for a dialysis catheter. The process was very methodical and I was able to show the fellow the process after one full run through. Although I was able to get the steps down, I know it would be very different when there is an actual patient and all the motions are going to involving real tissue and not just theory.
These first few days allowed me to gain an basic understanding of the workings of the pulmonary world and I am excited to delve deeper into the processes and devices used in the next few weeks!
We had the opportunity to attend a lecture given by Dr. Brian Boulay, an attending physician in the GI department. The topic covered was cholangitis and was attended by most of the fellows. This way the doctors are able to stay up to date on medical information which may better their scope of treatment. The lecture took place in a conference room around a table which encouraged the asking of questions while maintaining a casual air. We also learned about a choledochoduodenostomy, or rather attempted to say it!
Unfortunately our trust Dr. Sleesman had clinic duty but he sent us on an exciting field trip with Dr. Kankanala and his infectious laughter. Dr. Kankanala was off for morning duty at the Jesse Brown VA Hospital which takes care of all the medical needs of the veterans. It was a quick 7 minute walk after the lecture and we arrived to find that the computer systems were down. The VA uses a different EMR system called CPRS rather than Cerner which the UIC hospital uses. It is currently in a transition to new technology which didn’t seem to be going too smoothly.
The VA is a collaboration with physicians from UIC as well as Northwestern. Since the VA pays for half of the fellows’ salaries, the fellows split their time equally with UIC and the VA even though the demand is much more in the UIC Hospital.
After speaking to Dr. Stacy Prenner, an attending physician from Northwestern, my eyes were opened to many of the day to day problems she faced. Some of the inconveniences include patients that don’t show up on time, cancelations, prep orders that not completed when they should, and room turnover time. The accumulation of all these problems leads to an inefficient clinic which can waste valuable time of medical personal.
Once we returned to the general hospital, we were just in time to watch a capsule endoscopy. Dr. Sugir Velpari showed us the video feed from a previous capsule endoscopy. We then had the opportunity to view the process of a patient swallowing the capsule. A capsule endoscopy involves a camera contained within a pill that records pictures every 3 seconds and sends it to a monitor worn around the waist of the patient. Once the procedure is finished, the monitor is then plugged into the computer and the pictures are viewed at leisure. The battery life of the capsule ranges from 8 to 12 hours.
The patient is prepared for the procedure by a nurse explaining the whole process as well as how the device works which takes about 10 minutes. Dr. Boulay also uses a lead system to help track the capsule within the patient. There are 8 leads attached to the patient. Once that is completed, the capsule is swallowed and the amber light turns to a blinking blue. The patient will know once the battery stops working and when the test is over when the light turns back to amber in about 8 hours. The patient is instructed not to eat anything for 4 hours and not to drink anything for 2. The capsule seemed pretty easy to swallow and the whole procedure went pretty smoothly.
Something I also felt that was effective was mail tube system in place that allowed messages and samples such as blood and urine vials to different parts of the hospital! This saves manpower when samples need to be sent but, now messages may just be sent through emails.
We’d like to give a special shout-out to the entire GI Team! Thank you for being so welcoming, patient and answering all our questions! We gained a lot of valuable experience and knowledge from our time with you.
Beginning week 3 we moved to inpatient rounds guided by the wonderful Dr. Sleesman.
Most inpatients come to be admitted into the GI inpatient ward through the ER. They generally report to the ER and are assessed by the ER doctors, then transferred to the GI inpatient if their symptoms require treatment in the main hospital. Once admitted, they are assessed by GI residents. If immediate attention is required, the fellows and attending are contacted and the patient is examined by them and further action is taken if deemed necessary. If the resident does not see need for immediate attention, the GI fellow and attending physician examine the patient the following morning during their rounds.
Rounds take place at 7 am by the resident, fellow, and attending physician, some with a cup of coffee in their hand. Most inpatients are in on the 6th and 7th floor of the hospital which includes the Medical Intensive Care Unit as well as the GI Ward although we did observe a patient with a GI problem in the maternity ward.
As with the previous weeks I documented the general schedule of rounds. The general schematic for rounds includes a discussion outside the patient’s room where the resident debriefs the attending and fellow. The attending and fellow ask any questions they have to the resident and then discuss a plan of actions which encompasses ordering different tests, medications, and treatment plans. Then, all three enter the patient’s room and the attending speaks with the patient, asks any additional questions, and gives the recommendation and plan of action. If the patient has already been in the hospital for more than one day, the attending is essentially following up on the symptoms and test results. They then determine whether the patient is able to be discharged or kept for further observation or treatment.
7 AM- Rounds Start
7:13 AM- 7:17 AM- 1st patient – 5 Minutes
7:25 AM- 7:30 AM- 2nd patient- 5 Minutes
7:40 AM-7:47 AM- 3rd patient – 7 Minutes
7:55 AM- 4th patient not present in room- receiving ultra sound – 0 Minutes
7:58 AM- 8 AM- 5th patient- 2 minutes
8:14 AM- 8:21 AM- 6th patient – 7 minutes
Total time for Rounds: 1 hour 21 minutes
Average time with patient: 4.3 minutes
Some of the devices I noticed in the ward was a monitor that displayed the vitals of all the patients in the hallway. The monitor had a spot for 12 patients and at the time I viewed it, 5 were being used corresponding to the 5 inpatients in the hallway.
There were also portable computers in the hallway available for use if a physician, fellow, or resident needed to look up any information on the Cerner or Provation systems.
Although the time with each patient may seem low, the resident does spend more time with the patient getting the essential information. It is also important to note that some cases include multiple specialty doctors and thus they are examined by each specialty doctor team separately.
Finishing up the week in the lab, I came away with a better understanding of the processes in the hospital. Many of the doctors had their own insights on how their processes could be made easier and more efficient. One doctor told us that it would be beneficial to have a signal sent to indicate that the end of the colon had been reached during a colonoscopy. Another asked if it would be possible to create a scope that would be able to enter the bile duct in an endoscopy.
One of the most interesting parts of the week was that there were two patients that had swallowed objects, one a pencil, and one a metal cable tie. The process for removing them required an endoscopy which then used forceps to remove the objects. The metal cable tie procedure took about 15 minutes total. These patients who had swallowed the objects were incarcerated. I was told that these patients usually swallow objects to be allowed a trip to the hospital for a day out of prison. This seems like a vast waste of resources that could be otherwise prevented. If the prisoners were discouraged from engaging in such behaviour, they may be fewer cases that could have been completely prevented.
Something I noticed about colonoscopies is the fact that they are not always 100% accurate in detecting cancer for a variety of reasons. A major part in the colonoscopy is how well the patient takes the prep which encompasses drinking a large volume of liquid and laxatives. Many patients are not able to tolerate such a rigorous prep, and thus their colon may not be completely flushed out for the colonoscopy. Without a proper prep, the accuracy of polyp detection decreases. It may be beneficial to look for a way to make the prep for colonoscopies easier for patients.
Speaking of performing colonoscopies, there were cords all over the room that all medical personal had to be careful to step over which made their overall jobs harder.
Next week we will be doing inpatient rounds with the GI department!
After a week in the outpatient clinic, we ventured to the GI Lab in order to scope out some of the procedures that had been recommended to patients. The lab, located on the second floor was and easy to navigate rectangular shape which allowed for two different paths which helped with traffic in the lab. Just as in the previous week, I kept track of a timeline of events for a patient receiving a colonoscopy which can show the general schematic for procedures.
10:45 AM– Patient Appointment Time
10:15 AM– Patient Arrives
10:15 AM– Patient taken to lab, changes into hospital gown and has an IV inserted
10:45 AM– Patient is wheeled into procedure room and identity of patient is verified.
10:53 AM– Patient is given anaesthetic medication.
10:57 AM– Scope is inserted
11:34 AM– Scope is removed
11:40 AM– Patient is wheeled into holding area for recovery/rest for 30 minutes after last anaesthetic medication is administered which is about 10 minutes after the patient is wheeled into the holding area.
11:50– Patient is allowed to leave with family member/driver
Total Time Patient Spent: 1 hour 35 minutes
Total Time Attending Physician spends: 55 minutes
After the procedure, I was curious about the processes used to sterilize and clean the scopes. Once the scope is done being used the scope is placed into a drawstring bag and transported into the scope room which has an attached cleaning room. The scope is placed in a rack that has labels dirty and pre-cleaned.
The scope is then tested with air for any damage from the procedure such as needle punctures since submerging it in water will ruin the device if there is any damage.
Once the scope is deemed in good condition, it is submerged in hot water and a brush is used to clean out the different pathways that include a biopsy channel, a power flush, and suction. Larger scopes include a power flush since they are large enough to accommodate it.
Once the scope is pre cleaned, it is moved to the “BMW of washing machines,” which are very high-tech washing machines. Each machine uses a block that attaches to all the different channels of a scope. Different blocks are present for different sizes of scope as well as different brands of scopes such as Pentax and Olympus.
In order to be used, the technician must scan, his ID, then the blocks id, then the patient’s bar-code, then the bar code of the scope in order to begin the washing process.
Once all the correct bar codes scan, then the machine turns on and begins the process of washing which takes about 36 minutes.
The machine is made by Medivators and utilizes peraceitic acid to disinfect the scope.
The machine also performs the air pressure test that was performed manually and will automatically stop if there is any damage detected. If the scope fails the air pressure test, it is placed in a suitcase and sent to the company for repair.
The scope cleaning process seems very efficient although one small problem that occurred was that the scopes were not bar-coded properly. To remedy the problem, a scope of the same size was scanned instead of the one being washed to start the process. An easy solution to the problem would be to make sure each scope is bar-coded correctly.
This week opened my eyes to the large disparities within the hospital system. When asked what the biggest problem he faced, a physician replied with an ominous “its a systems problem.” My time here has led me to believe that many of the problems in the system come down to money. Just as the world revolves around money, healthcare revolves around money. The cost of healthcare is large on all ends of the spectrum from insurance, to patients, to doctors, to hospitals. Many of the problems I’m seeing already have solutions, yet the reason they are not implemented lies in the cost. There is a delicate balance of machinery vs. human capital, and any changes to the system could upset that. We must remember to look at problems holistically, and I have realized that even if there is a simple fix to a problem, the effects must also be taken into consideration. For example, if a device or process is made to be more efficient, it may decrease the amount of time a patient needs to spend in the hospital. However, this may decrease the profit the hospital makes, and thus the hospital administration might not encourage the change since they will loose money. Unfortunately money seems to take precedence in the grand scheme of things.
This doesn’t affect the beginning process of thinking of problem statements, but thinking about costs and the business will be important when designing and implementing solutions.
**Photos to come once the internet gremlins decide they will let me connect for more than 5 minutes!
Just when I thought my week couldn’t get any more exciting… it did. After getting into the general flow of things I was expecting another day of consults with more patients but Dr. Carroll had a surprise for us. He explained the basics of Total Parenteral Nutrition calculation, printed us a power point, pulled up a patients chart, and told us to figure out what the patient should be receiving in the IV. Christine and I were surprised at this unexpected turn of events and the fact that we were actually able to do math! Diving headfirst in, I pulled up one of the sources cited in the vague powerpoint Dr. Carroll printed for us while Christine pulled the information on which calculations needed to be used from the powerpoint. After looking up the patient’s diagnosis and height and weight using the Cerner powerchart, we were able to use the online instructions to complete the calculations. I was also able to pull up an online TPN calculation in order for us to check our numbers which did match up! After we finished we went of our work with Dr. Carroll who seemed pleased with our progress!
Dr. Carroll also told us that the price for the TPN for a year averages around a hundred thousand dollars. Christine and I were both taken aback by the cost of the healthcare and we inquired as to why it was so expensive. It turns out that the ingredients are not all that expensive but the process of making the TPN is since it needs to be done in a sterile environment. Also since there is only a select demand for patients that need TPN i.e. patients that are not able to feed themselves, corporations that make it such as Walgreens and CVS are able to control the price.
After an exciting Thursday morning, we observed some more G.I consults. We observed a few appointments with patients that were Spanish speaking. It seemed most if not all of the attending physicians were not Spanish speaking and thus the use of Ian was needed. Ian is an Ipad mounted on a potable stand that connects to an outside service over the phone which translates for both the doctor and the patient. I noticed that each appointment that Ian was used at required about double the time of a regular English speaking patient, yet on the doctors schedule there was no extra time scheduled. My mind immediately jumped to the conclusion that if a patient is Spanish speaking, they should be scheduled for extra time so that the physician is not running behind, increasing the wait time. The one thing I noticed all throughout the week was that the doctors were always running late resulting in waits upwards of two hours. It seemed that this was caused by the combination of schedules being overbooked with the notion that 30% on the patients would be no-shows and the fact that there weren’t enough rooms to put all the patients in at a given time.
My first week seemed to be a little different than everyone else’s but I feel I got to observe a lot of interaction with patients and medical personal! I can’t wait for next week in the Endoscopy Lab where we will have the opportunity to observe some procedures!
I began my first day, not quite knowing exactly what to expect although I did expect a somewhat calm day since I knew I was in the outpatient clinic of the GI/Liver specialty. Our first attending physician was not scheduled till 4 so in the meantime, my partner and I observed the waiting room as well as the attending conference room which is where all the medical practitioners congregate to debrief themselves on their patients, fill out necessary paperwork, and discuss different treatment plans with fellows that are working with them.
Once Dr. Carroll arrived we were taken on his first consult which included the use of a portable ultrasound to check the gallbladder of a patient which was exciting because we were able to see a device used as necessary. He demonstrated some of the features to us such as a the sonar capability of the instrument which shows the heartbeat. I was able to take the pulse of the patient to match it to the sonar displayed by the ultrasound machine!
The procedure for seeing patients seemed routine to him as he asked a wide array of questions then determined a course of action, most of which included getting different tests. Over the last three days, it has become apparent that most outpatient consults result in the patient explaining their symptoms and the doctor recommending different tests to be ordered such as colonoscopies and full ultrasounds. There seem to be no actual procedures carried out other than a physical exam on the exam bed present in all exam rooms and the ultrasound.
I also noticed that a patient that had their own chart on which they recorded their medicines as well as key information about them such as side affects and approximate times to take the medicine. This seemed to really benefit them and they said they had received a similar chart from the office. Here is the comparison of the two charts with the homemade one on the left.
I had the opportunity to follow a single patient through their entire process of when they walked in the door to when they left and was able to create a timeline as follows
2:00 PM– Patient Appointment Time
2:10 PM– Patient Arrives
2:50 PM– Patient taken to back room for vitals check
2:55 PM– Patient returned to waiting room to wait till doctor is ready since there aren’t enough exam rooms
3:05 PM– Patient called back to room and the Fellow is with patient till… (at this time the patient askes how much longer the appointment will take since her 2 month old is at home with the nanny, patient is given an estimation of 30-45 minutes)
3:18 PM– Fellow leaves room
3:25 PM– Fellow returns with attending physician and is with the patient till…
3:37 PM– The attending physician leaves while the fellow finishes with online orders until…
3:42 PM– The fellow leaves and the patient is told to wait for a Hep A/B injection
3:45 PM– Patient is sent back to waiting room while the insurance is being consulted to determine whether it is covered.
3:55 PM– Patient leaves reason unknown
Total Time Patient Spent: 1 hour 45 minutes
Thinking back to this experiment, I am able to see that from a patients perspective thatsome of the processes may take a long time of waiting. But also viewing it from behind the scenes in on the doctors side, there are a variety of factors that cause the longer wait time.