Practice in the real world. Redundancies: Say it again and again

Melinda Davis punched at the incision with her left hand and reversed the sponge to reveal its scarlet moisture.

"Drat", she said to no one in particular. "I must have given Millie too much atropine. I hope she isn't in heat when I get inside."

Krys Kelley looked on with some concern.

"Are you all right, Doc?"

"Yeah, we just need to watch this patient. We also need to make sure that we use something besides an NSAID for post-surgical pain."

"Duly noted," Krys said. "Speaking of pain, I need to take off tomorrow to go to the tooth dentist."

Dr. Davis laughed. "Hey girl, that's redundant!"

"What do you mean?

"I mean that the word 'tooth' is unnecessary. We know where you're goin' without using the word 'tooth' ".

Krys thought about that for a minute and responded. "Well, since grade school, we have all been told that people are animals. With that line of reasoning, is the term 'animal doctor' redundant, and should it refer to physicians or veterinarians?"

Melinda chuckled and then laughed.

She had never really thought about it in that way. She marveled at her assistant's insight. "Touché!"

Melinda went back to her work. The exertion of separating the dog from her uterus was starting to fog the glasses that were perched over her surgical mask. She stopped. In a few moments the haze started to clear. As it cleared, she immediately noticed that "Millie's" oximeter reading was getting too low.

"Krys, check Millie's gums, please."

"They look OK to me!"

"Pull out her tongue."

Krys noticed it then. "The tongue is turning blue, Doc."

"What is the flow rate?"

Krys became agitated.

"Krys what is going on here?" Melinda demanded.

"There isn't a flow rate," Krys screamed.

It immediately dawned on the both of them that the oxygen tank was no longer delivering the elixir of life. Both veterinarian and assistant went into emergency mode. Melinda was thinking a mile a minute and finally decided to stay scrubbed. The surgical ward suddenly was turned upside down with activity.

"Millie's" ovaries had been removed, but the uterus was yet to be extracted and the stump secured. Without the oxygen, there was no accompanying delivery of anesthetic. Millie would either die from lack of oxygen or would come up out of anesthesia with her insides erupting from the incision like a pulsing volcano. Decisions had to be made and had to be made right now.

After what seemed like an eternity, Melinda croaked out a horse and almost imperceptible question. "Do we have any E tanks that we can connect to the anesthetic machine?"

Alice Warren, who had been working in the ward, answered from across the other room before Krys could answer.

"No, Doc. On top of that, the tank connection has been broken for some time. We just use the H tank, but it just ran out!"

"Grab some valium and ketamine, and let me try to finish Millie up as best I can," came the strained reply from the frantic veterinarian.

Before Alice could arrive to get further instruction as to the dosage, Millie was starting to thrash about in spite of her hypoxia.

Under orders of Dr. Davis, Krys had long since disconnected the useless machine and had started blasting her human exhaust every eight seconds into the endotracheal tube. Millie added a few strokes of her own in irregular fashion. The jejunum was now pumping in and out of the incision like an unwelcome summer snake from under the porch.

The dosage of injectable anesthetic was blurted out, drawn and injected in record time. As the anesthetic kicked in, the unwelcome jejunum gradually could be made to retreat into the cleft in the midline of the animal.

Another eternity passed. Millie was still a little blue, and her respirations were excessive due to the added carbon dioxide offered by Krys. The pulse-oximeter machine had been disconnected and forgotten. Everyone was beyond adrenaline. Melinda looked around her at the various toys at her disposal — a new laser and ultrasound sat in the corner of the room. They would not help her now; it was veterinary medicine the old-fashioned way.

Finally as the ketamine began to tug at the struggling heart, the blood pressure returned for the first time since the beginning of the surgery. Melinda now battled bleeding of the uterus and finally the uterine stump. With muted determination, she finally completed the surgery. It was by any standard a Herculean effort. Melinda's glasses were now clouded with sweat and silent tears. The surgery room looked like a civil war infirmary. The underlying question was whether Millie would survive the day.

Melinda ripped off her gloves and yelled for an IV catheter and the fluid rack. Melinda swore under her breath and vowed to place an IV in all future spays. After placing the IV through her clouded spectacles, she finally took a much-needed deep breath.

Melinda had patients waiting in all three examination rooms. She didn't care. Millie was now the center of her life, and she would continue to work with Millie throughout the day and night. Millie gradually improved over the afternoon but was still unstable as evening approached. Melinda called her husband Bill and asked for the family cot her mother had given to her a few years ago. Melinda would stay with Millie.

Millie and Melinda struggled throughout the night, but by morning, the spay from perdition had returned to normal. Melinda had a full day of appointments waiting for her. Melinda closed her eyes for one last catnap.

Alice had been in the hospital for about 30 minutes before Dr. Davis opened her eyes from her last small stint of sleep.

As Melinda rolled off the cot, she needed a jolt of coffee in the worst way.

"Hey Alice, have you made coffee yet?" Melinda pleaded weakly.

Alice appeared with a sheepish look on her face.

"Sorry, Doc. Our one and only coffee pot broke yesterday."

Redundancies are good

No one at a veterinary hospital expects to run out of oxygen any more than a pilot expects to run out of gas thousands of feet in the air.

Yet, it happens. In a strange twist of terminology, the definition of redundancy originally was of something unnecessary or repetitious. In the computer age, the term has also taken on meaning more akin to a safety net. There are basic needs in any veterinary hospital. Some of these needs are so vital that backup systems must be planned and in place. In other words, redundancy is necessary. The problem encountered with Millie's spay was totally preventable.

These redundancies include:

• A backup anesthetic machine with backup oxygen on board.

• A backup oxygen cylinder for the original equipment.

• Normal service to the oxygen yokes on the original machine.

• Although controversial in some hospitals due to cost, an IV catheter in place before each procedure.

• An esophageal stethoscope.

• A crash plan in place for surgical emergencies.

More is less?

Lasers and ultrasound machines are an evolving necessity in veterinary medicine. However, basic equipment and backups are still very important to every well-managed facility. Having all the additional toys without basic backups really means that having "more is actually having less".

In other words, backup systems should be in place, serviced and in direct proportion to the critical roles they play in a functioning veterinary hospital. Although not always flashy, these hard-working pieces of equipment and systems are something we often take for granted. When missing, they simply stop the hospital.

A short list of things that without backup can cripple or stop your practice in its tracks include:

• Computer printers

• Computer hard drives

• Oxygen and anesthetic machinery

• Autoclaves

• Gas anesthetics

• Laboratory equipment

• Critical laboratory testing materials

• Answering machine

• Electricity (Do you have a generator?)

• Microscope and light

• X-ray film and processing fluids

• Euthanasia solution

• Dental machine.

This list goes on depending upon your personal preferences and critical needs.

What about drugs?

I subscribe to the "just-in-time" philosophy of drug ordering, and I sometimes get caught without a given medication. Usually this is not a big deal. Many drug items have their own redundancies (antibiotics) or can be scripted out if needed.

But there are some critical items. These include euthanasia solution and some of our anesthetics. Also keep in mind that the hassle and lead time for the ordering of controlled substances means that there is a real need to keep an adequate supply of these items in stock at all times.

The expense

There are items that will stop you cold but are inexpensive enough that backups seem to multiply right before our noses. These include such mundane items as surgical blades and stethoscopes. Drug companies keep us supplied with ink pens, calendars and calculators that work (on occasion). I don't think I have had to buy a calculator since 1985. Did I mention unlabeled floppy disks?

But what about an additional microscope or even a backup X-ray machine? If you have been caught, like I have, with a bunch of fecals to read and no microscope due to a broken stage or even a burned out light bulb, an emergency of sorts exists. Microscopes and their light sources need a backup.

The breakdown of a solitary autoclave can be brutal, too. On the other hand, the breakdown of an X-ray machine is not a showstopper. Just send your X-rays to your colleague for a few days. They only thing likely to suffer will be your ego. Considering the alternative, it might be a small loss.

From an economic viewpoint, not all backups need to be clones. For example, if you possess a Tonopen®, and it breaks down, a Schiotz tonometer will do in a pinch. (You do remember how to use it, don't you?)

Conduct a needs assessment

Look around your practice. You are surrounded by basic equipment that could go "belly-up," and deepen and enlarge that small constellation of ulcers in the antrum of your stomach. Make an equipment list, and make sure that this equipment is serviced and in good repair. In some cases, a piece of equipment or systems will be critical, and a backup is in order.

Remember that backup equipment need not just sit on the shelf waiting to step in when things break down. They can still be working for you. Backups can be used every day. Backups can also be used equipment — as long as it works.

Some examples of backups that can be used daily include autoclaves and microscopes.

Look at your list. Buy what you need.

Rule of thumb:

Before you go off the deep end buying cutting edge technology — make sure that you have a backup strategy for basic equipment that is currently critical to the life of your patient and to your practice.

For the lack of a nail a shoe was lost, for the lack of a shoe a horse was lost, for lack of a horse a rider was lost, for the lack of a rider a battle was lost, and for the lost battle a kingdom was lost. All for the lack of a horse-shoe nail.

~ ANON

Technology: an unending upgrade

Computers have a way of creating chaos where none existed 20 years ago. In my own practice, the one and only network printer "kicked the bucket" a few weeks ago — on a Saturday no less. I thought it would be a simple solution for a simple problem; buy a new printer. Wrong.

Printer death didn't stop our practice, but it created its own minor nightmare for the staff and clients for a while. But computer issues almost always start a domino effect. Although we had a "backup" printer in place, its network connection was lost when the computer it was connected to had to be replaced, and the network connection was inadvertently left out during the installation.

Therefore when the printer died last week, the practice went into paperless mode for a few days. You will find that printer models have a very short half-life — meaning that new software and connections are needed. So after several fruitless hours on my own, tech support was called in. They needed several hours to rig up one little old printer due to conflicts within the network and printer files. The explanation I received was that the operating systems weren't talking to each other because I had failed to download the latest updates. As you can imagine, the talk droned on and on.

The upshot, I was informed, was that I need more computers, and a newer version of the operating system on all computers and a much better (a.k.a. expensive) printer—one that likes to talk to other printers and possibly Neptune some day.

So to those veterinarians who seek simple answers to computer issues and backups: there are none. In the case of computers, not only do you need backups, you also need to invest in off-site, backup data storage. So, if you know what's good for you, you will frequently upgrade hardware, software, operating systems, networking software and devices and sometimes cabling and routers. Did I mention surge protectors and antiviral protection? What about interconnectivity to the Internet?

The long and the short of it? It is a good idea to know more than one computer guru and IT person. You may also need a good relationship with a banker (or two).

Happy computing.

Dr. Lane is a graduate of the University of Illinois. He owns and manages two practices in southern Illinois. Dr. Lane completed a master's degree in agricultural economics in 1996. He is a speaker and author of numerous practice management articles. Dr. Lane also offers a broad range of consulting services and can be reached at david.lane@mchsi.com