One word: autopsy

Feeling the lull of work this past week? Same here... joking. But i did partake in a fascinating process at work. As an AMC, autopsies aren't a common procedure; they only conduct ~35-40 per year. That said, the director of pathology invited us to not only explore the process but also observe an actual autopsy. Firstly, a disclaimer before divulging the details-- death is deeply saddening time for a patient's friends/family, and though I didn't know this person, much sympathy for his family.

Random side notes:

• pathology residents must conduct min. 50 autopsies for program completion
• tissue/organ donation helps ~80 people
• patient's spouse/family must agree to research use of samples/tissues (not opt-out)
• If you're an organ donor, those are removed immediately after death (as in prior to arriving at the autopsy station)

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So I get an email saying 'yo we're starting like... now' or something similar. I get down there, fix myself with the "keep me sanitary and disease-free" garb, and then start asking the director questions about the process. He said there's not a specific step-by-step process for an autopsy, though the process has generally the same order of steps, working outside inward so as to preserve all body parts. As I approached the body, I took gradual glances at the body and eeeeeeeased into view. Being my first autopsy observation (obvi), i wasn't sure how my nerves and stomach would handle it.

Go! So they start and surprisingly enough don't do a full recap of the patient case or anything (as in 'this guy has _______, with ________... and he was _________). Communication fail. This patient had Spina Bifida, which turned into a urinary tract infection; however, the doctors weren't sure what the actual cause of death was. After measuring the scars, pupil size, and limbs, the residents began making incisions (taking turns) and pulling back the skin. To preserve the appearance for the viewing/funeral, the incisions are made in a minimally invasive manner. Then the blood/fluid was soaked up and the bones were cut apart. To keep myself together, I made sure to only view one part of the body at a time, say the arm, chest, or pelvic area. Something about the head that was a little tougher to view, so I limited looking there... perhaps the eye factor.

So the residents proceed with the cutting and resection of various tissue samples and organ removal. Each component is put in a separate bag or bucket for analyses. The toughest parts to remove were all of the organs TOGETHER-- (ridic!) as well as the testicles. Once the organs were removed, though, the process went rather quickly, because they were divided among the residents (and attending) for analyses. The only part that I had to turn away for was at the very end when one resident removed the brain (that's a G-rated adjective). He then casually put it in a bucket of formaldehyde like it was no big... right near the end of the procedure, the attending handed the heart my way and instructed me to hold it and i declined. Figured i needed to take this one step at a time. And let's be honest-- today I had skipped steps 2-76.

The most incredible takeaways from my autopsy observation:

• the residents have mastered the process like a car assembly line
• there is no timeout concurrent with the analyses and minimal information exchange as they investigate
• i find the whole process extremely intriguing, notably in how similar the process apparently is regardless of the case complexity/condition (gunshot wound or shortness of breath)
• how much "background info" there is from simply analyzing someone's organs
• how beneficial organ donation is to other people (you should seriously consider being a donor

I didn't leave a "changed man" nor did I faint. So that was good. But i do have a whole new appreciation for a process typically seen as less glamorous and more about a horror film. But I really see this as a HUGE opportunity for medical breakthroughs, notably in that death is a default period of mourning, followed by burial and memory reflection. We need to be better about educating people on the benefits of not only organ donation (don't do you any good 6 feet under) but also of post-mortem research and education. The human body is like hidden world in itself (heck, the brain alone is..). I left this day wondering how to better leverage findings from autopsies for medical advancements and future case improvements, even be it palliative care. And given that this guy is exactly my age, I'm first to say that I am extremely fortunate to live the life i do.

Keep calm, carry on..

2 weeks ago i shadowed an MD in the emergency dept. (formerly called the "ER") while he was working the night shift. I was always eager to do so, given that i've never experienced the ED outside of my 2-3 personal unfortunate encounters, of which i'm of course oblivious to observing how the place operates (least of your worries, right?!).

Expected observations-- the ED staff sees a LOT of random crap. And of that, a large chunk of ED-fed cases are not "ED-worthy". Over the course of the night, we confirmed one pregnancy and investigated another woman's pregnancy issues (abnormal discharge). We also saw 2 patients who are quote "regulars", coming in weekly for the same condition, which is nothing at all (more of a mental health issue). Then comes the good schtuff. One dude comes in on a stretcher sitting up at 90 degrees after crushing a vertebra in a bad car accident. The kicker? He absolutely refused to lay down on a straight board and strapped in, so the EMTs kept him upright, strapped against ~8-10 pillows between his back/head and the stretcher. What a knucklehead! In doing so, they explained that he did risk being paralyzed... and he was okay with that. This is when you empathize for the shcrap that clinicians have to put up with. Another guy thought he had a heart attack and turns out he just drank enough for 3 people and was still feeling the lingering effects. One lady had CHF and was unable to breathe, so we had to put her on a bi-pap. And another pt had what the Dr thought to be a classic seizure, as per the description by his wife. This was a great example of the importance of communication and the risk of misinterpretation, as one person's language often means something totally different to another. The Dr had to decipher the wife's story amidst her excitement and put the pieces together. Turned out to be a textbook seizure. Another textbook case was a cold, which expectedly is a frequent case that arrives to the ED that shouldn't. This is a prime example of when a triage nurse is necessary to sift out the non-critical cases.

Unexpected observations-- So that was the pretty textbook side of the observations. But with that came a lot of surprises. First and foremost, where's all the chaos that comes with "emergencies" just like on the TV shows?! There was not a single person running or stretcher flying through that joint! Nah, probably a good sign.. or at least best practices. In fact, the MD i observed was calmer than a golf tourney announcer. He calmly rounded, at random, to see how patients were doing. Something that I was very surprised by, and also concerned with, is how arbitrary the case review process is conducted. In fact, there is (at least at this ED on this night) no "best practice" protocol for how patients are triaged, notably the order, acuity, room placement, MD/nurse assigned, or treatment status tracking. They pretty much just arbitrarily circled the halls and checked on various cases.

Per the MD i shadowed, the case/EMR updates were usually made at the end of the shift; he said he has no problem remembering the facts and never confuses patient cases (so he says..). When we had downtime he would make updates accordingly, though. The ED also has an e-whiteboard tracking case status, including incoming cases. However, i think it's used incorrectly... so much info not referenced or even collected that the board is capable of and could be a huge time-saver (and CYAer). It was also very interesting to see the MD never request or confirm a patient's insurance status or ability to pay. He treated every patient equally, which is above the minimum requirement of EMTALA. I also found the MD's "BS report" to be really interesting. Because patients often come to the ED complaining of symptoms that are either unrealistic, not true, or severely exaggerated, he would commonly barrage a patient with questions and intertwine/follow up with specific condition questions. If the patient had inconsistent responses, he typically concluded that their condition was either not true or low priority. He said that patient pain level and/or description of condition is frequently exaggerated or even invalid, in hopes of seeing a MD faster.

This was probably the kicker of the night... a gradual observation. With the recent rise in patient safety and cleanliness, i really expected everyone to be extra careful with hand hygiene. FALSE. In fact, the MD i shadowed didn't wash his hands even once over 4.5 hours!!! After each patient observation, he flicked the hand sanitizer lever barely making contact and surely not getting any sanitizer on his hands. And while he had the whole "be consistent" part down pat, he consistently failed to actually clean his hands. This is quite scary and makes me want to squirt my physician's hands with cleaner at my next dr appt. I mean, if you mess around with someone else's open wounds, genitals, and bodily fluids, i would like a clean slate. Just sayin'. Joking aside, this is a HUGE risk, liability-wise and something that probably needs to be further evaluated. Note to self..

By 3:30am the flow had slowed and it was time for me to bounce. I'll be back for more, i just know it..

You can do it... we can help.

Have it your way... no, really.

A few weeks ago, I had the pleasure of connecting with an outpatient nurse, named Holly, for a day. It's hard to beat a richer experience than working alongside a nurse for the day. They remind me of Mr. Fix-it, the jack-of-all-trades pretty much. Knowing that my passion is in informatics, she geared the whole day in that regard. As we walked through Holly's daily routines, I reiterated to state the process as is, be 100% honest, and highlight all aspects of IT and informatics within these processes. And boy, did she ever! Before long i had 5 pages of process notes, many of which were highlights of areas for improvement. Many of her process, as I learned, were doing the trick, but it was extremely inefficient. This is because different teams were tasked with creating various widgets/tools, and they weren't interoperable in the end. The result? 378 IT systems across the university. Interface much? Sheesh. By the end of the day, I had a huge tally of process improvement projects to forward on to the hospital strategy and innovation council for consideration. As I've found in the past, some of the best ideas come from a newbie with a neutral mindset... who isn't afraid to speak his/her mind.

Anything you can do i can do betteeeeer.

Working at a massive AMC, I never thought I'd experience stiff internal competition. I gotta tell ya--- things are pretty fierce around this joint. And while it sometimes can work to your advantage in creating innovation and constructive conflict, this definitely isn't the case. So i'm helping to manage a project on anticipatory patient care, and naturally, I took a scan of fellow projects across the health system. While none were identical to what I was partaking in, at least 5-6 were, in some way, shape, or form,  related to or in parallel with our project. It's taken the last 3 months to convince the leadership to have these projects dotted-lined to one another! The result? Saving many months of duplicative work with potentially very similar outcomes. I've started a spreadsheet of both duplicative initiatives/projects and related/parallel projects, with plans to soon share with leadership in hopes of merging efforts. And we wonder why so many projects fail-- lack of communication.

Does that come in platinum?

Being a big bro has been eye-opening these last few months. I think above all else it's made me realize that many kids of Gen-Z have a defining sense of entitlement. An extremely generous donor gave us 2 tickets to the Titans game a few weeks ago-- on the 2nd row back!! We could practically touch the players. So as we left, I asked Andre if he enjoyed the game. He explained how it was okay, but in his thank-you to the donor (which i have him write to every donor/supporter) he was going to request that he get us box seats for next year because these weren't good enough. Wha?! The flipside of this experience has taken a while for me to build but i'm seeing it like so-- people of all types walk this green Earth. Regardless of upbringing, people have different desires in life. My goal is to teach Andre that nothing is free and he must work for it. I want him to see not only the value of a dollar for all people but also the importance of appreciation. A few weeks ago, he told me at the end of a trail hike that I 'am the best big brother ever'. That definitely makes it all worth it... over one hill and on to the next. I guess this is what 'making a difference' is all about...

Multiplicity

Ever been working on something only to later find out someone else was doing the same thing? D'oh! Working in a large decentralized organization definitely presents its challenges. Over the last few months i've been previewing many different parts of the health system and have been exposed to some really cool things. Given that i'm seeing so much in such a short time, and covering so much ground at that, I've started mapping out exactly what i'm experiencing, in the form of observations and themes. It reminds me a lot of scribing your dietary intake or monthly spending habits. You don't realize what's actually happening until you put pen and paper to it. So i started writing down every instance of a project or idea and tagging a person/dept to it. Ever since, i've started putting teams/people in touch when they had similar ideas and/or had already started on a project to address the same issue/challenge. It's amazing how much better outcomes turn out when a more diverse group of heads come together. A nurse brings up different points than a physician, a med tech, a statistician, researcher, analyst, intern, environmental services, and so on. So often only HiPPOS (highest-paid person's opinion) are leveraged for scaling and/or approving major changes at an org. But i often wonder-- why aren't the people on the front line who are most knowledgeable in specific scenarios leveraged more? Why is it so often up to the C-suite to implement change that effects an entire org or dept, when they have no idea of what is actually going on at the front line or the downstream impact(s)?

Some of the most memorable Nashvegas experiences to date? On the city bus. In so many ways, it's opened my eyes to many aspects of life. Intellect, appreciation, open-mindedness, mental health, socioeconomics, respect, patience, time management,  conflict mgmt. What i love most about public transportation, just like subways, is it's classless arrangement... a physician standing next to a disabled military vet, sitting next to a single mother with 3 kids, and 2 broke undergraduate students riding to Broadway. A melting pot, that's for sure!

Playing with silly putty

There's a med for that

Medications, whether over the counter or prescribed, often remind me of cars. It seems that we're forever trying to frame the next big breakthrough in pharmaceutical research without trying to utilize what's already in front of us by way of other products/industries. Have you ever wondered what current products and medications could actually treat and/or supplement treatment for an ailment or condition in which it was not initially intended for? It's no different than aloe vera on a burn or coke on your car battery. It's a practice called repurposing, something that is growing immensely at our hospital research labs. Investigators are targeting previously unknown benefits and uses for existing products. To give you a random example, the mapping process for repurposing could be as unexpected as prescribing prilosec (traditionally for GERD patients) to athletes to minimize exercise-induced asthma. The benefit (and goal) is to ultimately minimize R&D spending by pharmas, the single-greatest expense for medication costs themselves. This is clearly a major avenue for opportunity... stay tuned.

I think you said...

There may soon be an end to the nightmare of filling out 15 pages of the same shcrap when seeing a new doctor (referral or otherwise). Our team is piloting a new platform, whereby previously defined orders (things that doctors submit with "authorization", such as prescription, physical therapy, etc) are saved as templates for future entries. It remains to be seen whether this will be more beneficial for the provider (as a template) or for the patient (in preventing both adverse treatment and carpel tunnel syndrome from the duplicative forms).

Teach 'em early

My new goal for my Little (mentee) is to teach him the value of a healthy, balanced diet. He currently eats fast food numerous times a week, which is never a good sign for someone so young to fall into this track. The previous myth (and really still holding true in majority of America, sadly) was that every person must always clean their plate... seen sort of like the 'American way'. In the 3 weeks we've known each other, we've talked about eating 6-8 small meals per day, preferably using only small plates as a default limiter. I'm a big believer in education as a form of soft power as opposed to merely telling a kid what they can't do, because even if you tell them what they CANNOT do, how will they ever know what they should do? Andre has never been taught this nor the rationale/benefit of doing so, so this is a short-term goal of mine. Soon enough, we'll be talking it up about what he consumes. Baby steps...

Gimme 6 weeks... weeks?!

After getting my bearings for the first several weeks, I've since started working on a project related to recruitment waste. And while this is somewhat unrelated to my interest(s) in IT/informatics, it's a fantastic opportunity for me to make an immediate impact. Last week I led a quasi-kaizen event for nursing stakeholders. The purpose was to streamline the recruiting process for the dept. Why? It currently takes over 6 weeks just to post a position... post! Talk about quick reflexes... there is much work yet to do but the prelim findings are interesting. It's amazing what happens when you get people together to talk things out.

I've started mentoring a boy in the community as part of the Big Brothers Big Sisters program-- we'll call him Andre. It's something I've always wanted to do, so I decided to make it happen. I've only met with him twice yet i've learned so much about myself already. Most notably, appreciation for what I have and the opportunities I've encountered. He's experienced more as a 6th grader than I did as a high schooler; pretty amazing what your surroundings do to you (both of his parents are incarcerated). The highlight of this wknd was his fascination with hybrid cars. He couldn't quite grasp being able to turn on a car with a button OR having a car turn off automatically... blew him away! His curiosity is overflowing, though, that's for sure. I'm looking at how best to channel it for his benefit. Stay tuned...

Boost! Check it out-- a video to continue inspiring you to do good. Talk about passion...

http://www.ted.com/talks/giles_duley_when_a_reporter_becomes_the_story.html

Welcome to the Music City

I never thought music and nature could co-exist outside of Austin but apparently Nashville is from the same breed. Funny enough, the most dangerous thing of it all is that Chuy's is down the street! I've found my "secret" park for what i'd usually say people-watching... except it's sans people. Which is why it's "secret". Well, it's more so because it's downtown and most people live in the burbs. So i have this plush park/gardens all to myself 5 days a week. It's ridiculously nice and includes the state's history with some frilly gardens and a rolling water globe. The view is pretty alright... it's only a straight-on view of the capitol bldg and surrounding lawn. Maybe i'll continue reading there...

Learning the ropes of a new health system always takes time. It's always very interesting to compare different cultures and systems of organizations. I find this to be quite advantageous as i've transitioned across numerous organizations and regions, adapting rather easily to the changing climates. With marathons, music festivals, and various other events year-round, I definitely don't have to look far for things to do.

My brain is on overload with ideas for possible improvements and/or concentrations. I'm continually digesting the opps (stoked!) and will note more on what keeps me roaring in future posts.