Mind Snap


Donkey in BarnI’m getting just about fed up with the Medical Marijuana Advocates (AKA “JCAHO”, AKA “TJC”) and this whole bunch of HospitalCompare.gov bullhokey.

The chart police at our hospital audited a bunch of charts from the emergency department and I got letters about several “serious offenses.”

First, I got in trouble because I couldn’t be credited with giving antibiotics within the 4 hour … no … now make that 6 hour window for a patient with pneumonia. For the moment forget about the fact that this quality indicator may do more harm than good. Forget that most pneumonias are viral and that requiring doctors to give antibiotics for these viral infections, similar to using Raid to kill dandelions, increases bacterial resistance and helps to spread MRSA. But I digress.

It wasn’t that the patient didn’t get timely antibiotics. The patient got antibiotics not within just 4 hours, but within 2 hours. By the way, congratulations on your increased chances of acquiring MRSA due to our government agency’s blind directives, sir.
It wasn’t that the patient didn’t get appropriate antibiotics. The patient had allergies to several medications (that were from 50 years ago when he was an infant, so he didn’t know what the reactions were), and given his history, we used clindamycin.
My serious offense was that CMS supposedly couldn’t tell what medication was ordered. Instead of writing out “clindamycin 300 milligrams piggyback through the intravenous line over 30 minutes,” the order said “clinda 300mg IVPB.” The nurse gave clindamycin 300 milligrams piggyback through the intravenous line over 30 minutes. But it was still considered poor quality care not because the patient didn’t receive his medication … not because the medication wasn’t given in a timely fashion … but because micromanaging government clipboard patrols with apparently little medical background couldn’t figure out what medication was ordered.

Fortunately for everyone involved, the ClindaCyanide and the ClindaDrano were on backorder in the pharmacy. Otherwise, the patient could have received some other dangerous medication beginning with “clinda” via his IV. Oh yeah, I forgot, there are no other medications beginning with “clinda” aside from clindamycin.

Just another reason why the whole HospitalCompare.org web site should be viewed with a healthy dose of skepticism. The statistics don’t necessarily tell you what they purport to tell you.

But that’s not all …

I also got dinged because I didn’t do one of the Medical Marijuana Advocates’ “time out” forms before doing a lumbar puncture and before draining an abscess.

“Time outs” are required before surgery so that surgeons don’t cut off the wrong appendage or do surgery on the wrong site. There are multiple requirements for a “time out” including preparing proper documentation (because that contributes so much to patient care), reviewing relevant images (if any), readying any necessary equipment, making an unambiguous mark near the procedure site with ink that will still be visible after any skin preparation (doctor’s initials are suggested), and double-checking the site mark before the procedure.
I’m not actually sure that these are the requirements, because I tried to look them up on the Medical Marijuana Advocates’ web site, but they keep the requirements hidden. Isn’t it great how an organization that is supposedly advocating for patient safety keeps all of its initiatives hidden from public view? But I digress yet again.
In theory, I don’t have any problems with marking the site to be operated on if a patient is going to be put under anesthesia prior to surgery and won’t be able to say “Hey doc, why are you starting to cut on my left leg when the abscess is on the right leg?” I’ll even go as far to say that the “time out” concept is a good idea under those circumstances.

But apparently the Medical Marijuana Advocates are now applying this “good” idea to areas where it does not belong and are now citing hospitals for compliance issues if there is not a “time out” form on file for every invasive procedure – even those done at the bedside. Of course I can’t find this on the TJC web site either. If this policy is true, it is asinine.

How exactly is it that I’m going to do a wrong site lumbar puncture? It’s not like I’m ruling out meningitis in many jellyfish. I haven’t had to rule out a subarachnoid hemorrhage in a Siamese twin lately. I don’t suffer from short term memory loss, so it’s not like I won’t remember the patient who just signed the consent form for me to do the procedure. Explain to me how drawing a circle and writing my initials on the back of a patient getting a lumbar puncture is going to improve patient safety.

Leg abscesses are just as bad. Good thing JCAHO is saving us from maiming people with abscesses in the emergency department. “Yeah, sir, that 10 cm abscess on your leg disappeared in the three minutes that elapsed between the point when I examined you and the point that I returned to the room after going to get a scalpel. Oh well, as long as you’re here, I guess I’ll just fillet open your thigh to look for ingrown hairs. Ooops! The abscess was on your other leg! Sorr-rry!”

If we’re going to do these forms on every invasive procedure, the lab is going to have a lot more work drawing blood. A spinal tap can be considered “drawing spinal fluid”, so drawing blood must also be an invasive procedure. Now doctors are going to have to be involved with every blood draw.

I’m most worried about a couple of other invasive procedures, though.

Not sure how the female patients are going to explain to their significant others how my initials got on their crotches if I have to do a pelvic exam.

And I could be wrong, but I don’t think that too many guys are going to let me draw a circle around their anus and put my initials there before I get out the glove and lube to do a prostate check.

Well … I’m going to go have a time out, write my initials on my right wrist, get all the proper equipment together (including a bottle and a frosted mug) and have 12 oz of ClindaBudweiser p.o. before I stroke out.


  1. “Not sure how the female patients are going to explain to their significant others how my initials got on their crotches if I have to do a pelvic exam.”


    “Fortunately for everyone involved, the ClindaCyanide and the ClindaDrano were on backorder in the pharmacy. Otherwise, the patient could have received some other dangerous medication beginning with “clinda” via his IV. Oh yeah, I forgot, there are no other medications beginning with “clinda” aside from clindamycin.”

    Maybe they just finished reading “The Demon Under the Microscope” (good book BTW) and assumed that s/sulfa/clinda/ would yield the same confusion?

    You know, in case perhaps someone tried to squeeze some ClindaDerm through a heparin lock? 😉

  2. Apparently in the “ED” they drink cheap-ass ClindaBudweiser. In the “ER”, the cool kids drink ClindaGuinness.

    Let me know when you’re cool enough to come drink with us.

    PS: I saw what you did to my comment. You’re lucky I think you’re funny. 😉

  3. “You will never understand bureaucracies until you understand that for bureaucrats procedure is everything and outcomes are nothing.”

    Thomas Sowell

    Welcome to the procedure.

  4. To be fair, it takes me less than five seconds to do a time out before a conscious sedation on a Peds patient: “This is Jaydyn Smith who is getting Ketamine so we can suture his laceration. If everyone’s ready, let’s start with 1mg/kg of that sweet sweet Ketamine!” And that’s WITH my Texas drawl.

  5. We hospitalists are getting the same insanity. “The new rules say no antibiotics after joint surgery” SO even if the patient has raging sepsis and is in the ICU dying I get cited and have to explain why the patient is on antibiotics.

    The irony here is that if my collegues and I ignored the clinical data and let the patient suffer, I would be considered 100% compliant with rules and therefore giving excellent care.

    If I ever start treating protocols and not patients, shoot me. Being a doctor, practicing medicine is about treating patients.

    If we start treating protocols and charts, we are no longer doctors or nurses – we’re filler.

  6. I just received a second “violation” for not checking a box on the H&P regarding recent flu/pneumonia vaccinations. He was 80yo with end stage lung cancer.

    WTF? These “regulations” are irrelevant. Lesson: make sure you check the box, regardless of whether you actually did it or not.

  7. Do they have to make a circle at an IV site and intiial it?
    Make mine a clindamerlot!
    No, I’m not a cool ED doc, just a middle aged hospitalist. Oh why, oh why, didn’t I do an ED residency so I could have been cool???!!! Sigh.!)

  8. Ah gotta love the procedure verification forms. I always fill them out ahead of time so the radiologists I work with can just sign it when they come in the room. And I can say in the 3 years or so since we’ve had those stupid forms I haven’t once seen the doc actually do a timeout. But thanks to me none of them are dinged for not doing one because the paperwork is filled out and they signed it!

  9. As long as the paper trail is all good, then EVERYTHING must be good…..crunch the numbers/cook the books/it’s all in how ya word it !!!!! Unfortunately, the desk jockey clipboard toting QA minions have to justify their pricey position/job title created for them….who DOES think those up BTW ?……
    So, we just keep doing the best we can here in the Clinda-RealWorld……
    Be careful not to strain that left hand opening a can of Clinda RedBull !!!!!! or you won’t be able to mark anymore correct sites !!!!!

  10. I hate rules and paperwork as much as the next guy. But I’ve had a close call with wrong-site surgery and if I hadn’t spoken up, they would have cut into the wrong side of my jaw.

    An abscess seems pretty obvious. But things can get chaotic or the communication isn’t happening, and you end up doing the wrong procedure, or the right procedure on the wrong patient. (I’ve had a patient experience with mistaken identity too.)

    Go ahead and sneer at the time-out, and then try explaining yourself to the patient and the family and the hospital administrators and the lawyers when you screw up and make a mistake. Think how terrible you’re going to feel because you didn’t double-check. Think what it’s going to be like to see it in the headlines and read all the snarking and second-guessing and doctor-bashing in the online comments. Don’t assume you’re perfect and it’ll never happen to you; the doc who cut out the wrong kidney on a cancer patient probably never thought it would happen to him either.

    I’ll have a glass of ClindaChardonnay with you because y’all sound like fun people, but your attitudes about the time-out are, frankly, dangerous for your patients, not to mention your career.

    • Reading Comprehension on

      So just maybe you should read the part where he says real surgeries probably should have time outs. Then realize everything you said is therefore considered irrelevant.

  11. We did a time out on a central line placement the other day with the monitor alarming for BP 73/38. Even if it’s the wrong patient, please put a line in this one anyway!

  12. P.S. being from the home of what we now call the great belgian lager have a clindamiller …they’re changing the recipe on the the old Budweiser…say bye bye aged beechwood chips.

  13. I’m required to fill out the 5 page time out forms to do:

    1. a partial toenail removal for an ingrown nail

    2. LN2 treatment of a wart

    This ridiculous extension of a good SURGICAL rule is just plain moronic. Yeah, I am really at risk of removing a normal nail rather than the ingrown one, or removing a nail on patient that does NOT have an ingrown nail!

    2 years and I retire. Good-bye to this idiocy.

  14. It’s a shame that what seems a very good idea isn’t getting its due consideration because it feels like just another lame bit of busy work that takes you away from tasks with clear payoffs.

    I would point out that procedures are well known to be performed on the wrong patient — I’ve even read clever blog entries about how to deal with positive findings that have turned up on procedures done on the incorrect patient, and how to finesse the consultation done by the wrong subspecialist (Dr. John Smith in lieu of Dr. Jane Smythe or whatever)– the neurologist’s exam, EEG, and EMG study — painstakingly performed on the woman with the GI bleed.

    On my first visit to an orthopedic surgeon whose specialty was shoulder/elbow, I happened to be experiencing a bad day for the causalgia in my right leg. Unable to wear either sock or shoe, the big ugly purple foot was a vision of loveliness. I was there for a bad elbow fracture from the night before, that the ED doctor predicted would require prompt surgery. In other words, the sling and the cast should have been a give away! Instead, there gathered quite a crowd of fastbreaters in white coats, all staring at my leg… Some were even piling up supplies before beginning some shoulder/elbow procedure to ease the pain and save my… foot.

    Ridiculous examples, I know, and out of your context. You are, all of you, too intelligent, focused, and humble in the art of your science to fall prey to fatigue, panic, or the actual harm that inevitably results from hubris.

    It’s precisely the “Yeah, right, like *I* am going to err in deciding which labia has the Bartholin cyst or screw up the i.v. order for sedation and pain management (so that this annoying broad will shut up and let me drain the sucker). It all should have been handled at her PCP’s office during office hours, not on the 12th hour of my 7th consecutive day of 12-hour shifting. Damn this sinus infection. I can’t breathe. This really chaps my… OOPS! Well, these things can occur bilaterally, right?”

    You and most everyone practicing medicine are smart, talented, dedicated, and unlikely to make stupid errors that some idiotic checklist will prevent. But there is a small likelihood — and if forcing you to slow down and think small for a few moments helps diminish that likelihood? I am all for it.

    Why not put your furor into tweaking the instrument itself? Is there a more reasonable process for the ED that you could tolerate and perhaps even appreciate?

    Thanks for letting me vent in response to your vent!

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