Michael,
I think you are starting to add to the mental characteristics of your CV system.
tea
----- Original Message ----
From: Michael Firstenberg <msfirst at gmail.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Saturday, April 12, 2008 7:42:03 PM
Subject: Re: [HSF] Standard of care for lawyers {OT}
Ani,
What is going to happen to your system which is built around
housestaff/fellows who may either be of marginal quality or may not
even be available at all.
It sounds like a very reliable system is the smallest team possible -
a surgeon/PA/NP (anesthesiologist/pulm) group that works together day
in and day out for years rather than a different combination each day
- and every deals with their own problems?
-michael
On Apr 12, 2008, at 8:25 PM, Tea Acuff wrote:
> John wrote:
> "By moving to the university about 7 years ago, I traded a lot of
> advantages for
> the rather dubious distinction of being a professor. John Felge"
>
> Well at least you are a "bonafied" expert now, John. I think you
> made my point that for the attending to consult directly with the
> nurse and visa versa is a very efficient system, and with time a
> fairly trustworthy and transparent one. It is seemingly now a novel
> one and substandard one at that. To Michael's cry for help in a
> "broken" system (like Prasanna we all have choices to make,
> Michael) i can not tell that the layers and layers of protocol, and
> layers of caregivers, P4P, JACHO interventions or adoption of the
> latest best new intensive treatments have added much to better
> care. That they are primarily the work of third parties defending
> turf or "consultants" trying to justify their repetitive surprise
> inspections. This is a characteristic of medicine and doctors to
> NOT think through the problems that they create and instead come up
> with a universal "fix" (usually new inflexible rule or new
> expensive care intermediate) to solve the problem for them.
>
> As for PA's, Ani, I have worked with the same one for well over a
> decade. She is another pair of eyes and a very consistent OR
> assistant. She halves my out of OR work day and likely shortens my
> OR day. However, she is not my night and weekend on call
> surrogate, nor is she a source of net income to my practice. I did
> not critisize your system except to say that I have fair skepticism
> for your blanket dismissal of one that may be the most common in
> the US certainly out of academia. How can the most common solution
> be substandard? I can understand if you merely think it inferior.
> Don't kid yourself or me, Ani. Everyone here and certainly any
> lawyer will qualify you as expert. Point out possible disadvantages
> all you like (I like hearing them), but be both clear and careful
> if you wish to establish standards for others.
>
> tea
>
>
> ----- Original Message ----
> From: "Jbflegejr at aol.com" <Jbflegejr at aol.com>
> To: OpenHeart-L at lists.hsforum.com
> Sent: Saturday, April 12, 2008 2:00:58 PM
> Subject: Re: [HSF] Standard of care for lawyers {OT}
>
> Hal, I am now in an academic setting. I relied virtually
> exclusively on
> nurses in a previous life and that for 25 years. They did not open
> the chest for
> tamponading patients and that didn't happen often anyway. I lived
> four miles
> from the hospital and if I was at home, I could get here in less
> than 10
> minutes during the night when no ordinary folks were on the
> streets. I doubt if
> intensivists would be much use there. The nurses did put in
> central lines and
> arterial lines with none of the complications that I see daily in
> my present
> setting and could have put in Swans but for some bureaucratic
> obstacles. The
> cardiologists charge for S-G, called right heart cath, and could
> not allow it
> to become a non-billable nursing procedure. I almost never saw
> pneumothorax
> during the first two postop days after I started routinely opening the
> mediastinal pleura a little bit so the mediastinal tubes would
> handle any lung
> leaks that might happen. We had a policy of not leaving any central
> lines in
> place for more than 48 hours and the nurses changed them. We did
> not have
> anesthesiologists or CRNA in the hospital at night those early
> years. Routinely I
> kept the patients asleep and on ventilator until the next morning
> after
> operation which eliminated the need for early reintubation which I
> would have had to
> do. With the patient ventilated and pacing wires in place the
> nurses could
> manage with telephone guidance anything but bleeding. Sometimes
> when there was
> a need for take back for bleeding I did it without an anesthetist
> and just
> gave a big dose of morphine and some curare. Often the anesthetist
> did not get
> there from home until the case was finished. We did not have in house
> anesthesia coverage until it was mandated to maintain the
> obstetrical service. By
> moving to the university about 7 years ago, I traded a lot of
> advantages for
> the rather dubious distinction of being a professor. John Felge
>
>
>
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