Sharia Law Comes to the Operating Room

Glacier Bay, Alaska - photo by JoAnn Sturman

Scott Sturman
fliesinyoureyes.com

Sharia is the moral foundation and religious law of Islam. Its two primary sources are the Qur'an and the Sunnah, a compendium of Mohammed stated and tacit rules of conduct, actions, and habits. In essence, since Mohammed was a perfect man and incapable of wrong doing, then it follows his every act and word mirrored this perfection. To attain the goal of ultimate piety, the individual must emulate and extol these idiosyncrasies to the most precise detail. A discussion of sharia is beyond the scope of this article, other than to say it is utterly comprehensive and delves into the minutest aspects of personal and community life.


One can only imagine what it must be like to work in an atmosphere where the rules of daily life are totally pervasive and enforced by a fanatical cadre of thought police. At some point the workings of society grind to a halt to abide with the mass of rules enforced by zealots whose livelihoods are based on their ardor and interpretation of obscure principles which defy logic and can be recalled only by rote memory. What would it be like to live under Mecca’s or Tehran’s stultifying Sharia laws? A visit to an American hospital operating room during a JCAHO or state inspection is the closest experience outside the Muslim world to a fundamentalist Islamic theocracy.

To understand the hospital inspectors’ mindset, several broad but accurate observations are in order:

Most inspectors have paltry leadership ability and seek positions of arbitrary power to assuage their fragile egos. They are uncomfortable with normal human discourse essential for problem solving and thrive in situations where their opinion is incontestable.


Rules are enforced non uniformly depending on the inspector and those being inspected. This caprice allows for infractions to be discovered in any institution. Finding fault, whether imagined or real, translates to job security for inspectors. All mandates are clustered under the euphemism of patient safety but with rare exception it is really about power and control.


Inspectors insist their findings and recommendations are based on science and research. This contention is utterly ridiculous, for the bulk of data is based on pseudo science or individual impressions.


Efficiency and cost consciousness have no influence on inspectors’ decisions. New rules mean more documentation, less time to spend with patients, and added expenses, but greater job security for the inspectors. In the last thirty years I have never heard an inspector offer this advice: “These suggestions may help reduce your costs, enhance time management, and spend more time with your patients.”


Hospital inspectors are illogical by nature and unable to temper their zeal with even a modicum of common sense. If told that 95% of all people killed in traffic accidents ate a meal in the 12 hours preceding the fatality, they would conclude the meal was responsible for the accident. The obvious solution is to ban eating at least 12 hours before driving an automobile.


Just as no non royal Saudi is immune from the religious police, no hospital, employee, or physician has recourse against a “finding” made by a JCAHO or state inspector. To defy or challenge an accusation is tantamount to apostasy and heresy. All that is lacking are the flowing robes and a Qur'an in hand.

After so many years of suffering through these inquisitions, one begins to feel it is impossible to hatch anymore surprises. Never under estimate the capacity of a bureaucrat to trammel on common sense. The latest onslaught brought new heights of absurdity as the tentacles of the bureaucracy extended into the finest details of operating room apparel, facial hair, and syringe labeling. The point has come where practice management guidelines have exceeded any semblance of usefulness and are a significant distraction from patient care. If shoe cover protocol, being allowed to wear an undershirt beneath operating room scrubs, and sideburn length were that important, I’d move to Saudi Arabia.

Clueless in D.C. - The National Drug Shortage

Thistle at Tinhorn Ranch, California - photo by JoAnn Sturman

Scott Sturman
fliesinyoureyes.com

We can’t throw the drugs away fast enough. It makes no difference if there is a national shortage or patients are deprived of them; we dispose of them anyway. The heart of the problem is the state hospital inspectors and the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) whose regulations force hospitals and doctors to waste millions of dollars worth of medications annually. The situation would be the stuff of high comedy if the implications were not so serious. Depending on the source of information, last year alone there were about 200 drugs in short supply - three times the rate as five years ago.

In the operating room it is no coincidence the number of drugs which are difficult to acquire parallels a similar increase in the level of governmental intervention in the daily practice of medicine. The intensity of control goes far beyond the purported goal of patient safely and insinuates into every aspect of care for the surgical patient. Just as the supply of ammunition can be used to restrict 2nd Amendment rights, control of the pharmacy is the key to undermining the independence of hospitals and physicians.

Most medications used in surgery contain preservatives. As long as the container is accessed in a sterile fashion, the expiration date of that particular drug is not exceeded, and a separate syringe is utilized for each dose then the drug can be safely administered to multiple patients. By adhering to this protocol, needless waste of valuable resources is avoided.

How much do we waste? In the operating room often as much medication is discarded in the trash as administered to patients in order to comply with state and JCAHO standards. When playing by the book and using a system which electronically dispenses all medications, it is not uncommon to use only 10-20% of a drug contained in a multi dose vial. This includes controlled substances like narcotics and others which have no abuse potential but are essential in surgery.

The Obama Administration ordered the FDA to address the problem by emphasizing increased production of drugs and cutting red tape to make them more available for patient use. A less expensive but more expeditious and effective tactic reins in regulators whose rules promote waste and scarcity. Ignoring the obvious solution will sustain current policy which insures the drug companies sell a lot more drugs than are actually needed and forces patients to compete with the garbage disposal for medications. In the meantime physicians must ask if bureaucratic regulations which force them to senselessly destroy medications are in conflict with the moral obligation to do what is best for their patients’ welfare.

The Medical Gestapo

In Haleakala Crater - photo by JoAnn Sturman

by Scott Sturman
fliesinyoureyes.com

It is when power is wedded to chronic fear that it becomes formidable.

Eric Hoffer, The Passionate State of Mind, 1954

“The inspectors are here, and they want to observe this operation!” The nursing director announced, as she stuck her head into the operating room. All of us knew the score. The inspection had little to do with surgery and anesthesia but everything to do with paper work and procedure. These situations border on farce. The operation room is not where most inspectors like to be. They invariably pull an ill fitting coverall over their street clothes, but despite their best efforts they look like a fish out of water. Hair hangs out from beneath their OR hats and clothing and well fed body parts cannot be hidden by temporary apparel.

The case proceeded uneventfully while the inspector and a nervous nursing director sat in the corner and poured over the chart, oblivious to any other activity in the room. Toward the end of the case the inspector approached me and stated she liked the way I labelled my syringes with dates, initials, and drug concentrations. Hardly a compliment since there were only two syringes in view, the drugs only come in one concentration, and I had prepared them 30 minutes ago at the beginning of the case. But in the inspector’s mind, this was real medicine. Having no idea of the patient’s condition, in her mind I had passed the test.

We in the medical profession are experiencing what the business community has for a long time. Every year a barrage of regulations comes our way which in most cases hampers efficiency and does little to correct problems they are intended to solve. Perhaps the most difficult aspect is the sense of helplessness when dealing with bureaucrats who enforce these rules, and short of knowing a politician who can intervene, there is no recourse - their word is law.

JCAHO is the tool the government uses to force hospitals to comply with policies and procedures. The organization was discussed in a previous posting, but essentially if JCAHO does not accredit a hospital, then the hospital receives no Medicare funds, and virtually no hospital can survive without Medicare. No hospital official will defy the most inane JCAHO ruling, since to do so undermines the hospital's solvency and the administrator's career.

Remember the days when a traffic policeman could use discretion when deciding whether a ticket or warning was issued? At least the violator felt he was dealing with a human being rather than a mindless robot. JCAHO is the cop who gives a ticket for every infraction and knows there is no traffic court to appeal the decision. To say that JCAHO's charter and ability to micro manage has expanded is an understatement. Good ideas or bad ideas are enforced in the same monotonous fashion – comply or else.

Professions function under different time constants. A lawyer's reaction time can be measured in months or years. A bureaucrat's in weeks or months, but for an anesthesiologist seconds matter. In some cases a patient’s well being depends on near instantaneous intervention. Traditional anesthesiology training programs preach this philosophy. All equipment is checked and emergency drugs are drawn up in syringes and made readily available to save time in case of an emergency. In most instances this level of response is not required, but just as in the case of US Airways Flight 1549, one never knows when a crisis will occur. It is with this in mind that every case is approached as if a catastrophe could occur at anytime.

Now this time honored approach is under fire. This level of preparation is considered to be a safety hazard. Rules and regulations demand all drugs, not just controlled substances, be locked away in the anesthesia cart or some other secure location at all times.

Regulators are masters of the what if ? game, where every conceivable scenario is considered irrespective of its likelihood. Their words are incontestable and when leaving the hospital well before cocktail hour, they must be consumed with a sense of self importance and power, knowing those on the front lines are subject to their every whim. Safely tucked in bed for a long night’s sleep, these regulators will never know if an avoidable injury was due to a drug that was not immediately available. That’s the patient’s and doctor’s problem.

JCAHO - Out of Control!

Cockatoo - Hamilton Island, Australia. Photo by JoAnn Sturman

Scott Sturman
fliesinyoureyes.com

“In any bureaucracy, paper work increases as you spend more and more time reporting on the less and less you are doing”

JCAHO web site: http://www.jointcommission.org/

Health care facilities are periodically inspected by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) which determines whether the center is authorized to deliver health services to patients. JCAHO's mission statement stands out like a banner on the home page of their web site, “Helping Health Care Organizations Help Patients.” The goal is commendable, but with rare exception a visit by JCAHO means more paperwork, added expenses, nervous administrators, and little benefit for patient care.


Most hospitals operate at a steady state level. Efficiencies and good patient outcomes are primarily the result of competent physicians, nurses and support staff, who attempt to do their jobs despite burdensome administrative requirements. When a JCAHO inspection is imminent, hospital administrators, whose jobs depend on the results of the inspection, prepare by demanding the medical staff and employees complete more forms. Even if the hospital has a history of providing exemplary care to its patients, a lack of documentation or failure to adhere to guidelines set by the government can expose the facility to fines and probation. Consequently, in the weeks leading up to a JCAHO visit every spare piece of equipment is hidden from view and administrators, who usually are cloistered in their offices, are in full view of their employees.

There is a standing joke that JCAHO and California State Inspectors work in these jobs, because clinical medicine is not their strong suit. Officials working for these organizations wield capricious power and find themselves in a position where their rulings are virtually incontestable. Knowledge of medicine becomes secondary to the ability to find minor problems in an organization and to exaggerate their importance. It is not uncommon to see a hospital administrator groveling before an inspector to try to achieve a more favorable rating.


Inspectors' ability to find fault in a hospital requires imagination and the ability to foresee potential problems that most mortals never grasp. Not long ago JCAHO paid a visit to our hospital, and evidently after the first day the hospital was performing too well. The followoing day an inspector visited the neonatal nursery and discovered the bottoms of the plastic bassinets where the newborns are kept did not have holes drilled in them. The potential problem, apparent to only the inspector, was in the event of a fire the automatic sprinklers located in the ceiling would deluge the nursery and fill the bassinets with water and drown all the babies. As ludicrous as this may sound, at the debriefing later that afternoon the chief inspector proclaimed the finding as “brilliant,” and new holes were drilled before the next morning.


If a reader looks in the history section of the JCAHO web site (go to “about us” then select “history”) and examines noteworthy occurrences over the last fifty years, it is impressive how responsibilities have mushroomed. The amount of oversight and the detail into which the organization can effect health care centers is stifling. Those of us working in clinical medicine are well aware of this phenomena. We are overwhelmed with paperwork that in appearance and detail is closer to a legal document than a medical record. Soon every sentence will begin with the word “whereas.” Nurses spend an inordinate amount of time functioning as data input clerks rather than caring for patients – all at a time when there are more patients and fewer people to take care of them.


There may have been a time when JCAHO and its sister organizations provided an unambiguous benefit to the public, but their scope has morphed into a monster satisfied only by more rules and regulations at the expense of common sense and efficiency. Legislation is needed to curtail their power and allow high functioning health care facilities the freedom to conduct operations in a more independent manner. It is time to tip the scale to the side of patient care and away from forms and impractical dictates. For this to transpire JCAHO's role must be redefined as advisory rather than adversarial. This means defanging the inspectors, so their far fetched accusations and preposterous interpretation of regulations can be challenged by hospitals. As it stands, they act with impunity and make paltry efforts to develop healthy, working relationships with hospital personnel.


JCAHO visits are lost opportunities, since inspectors are quick to criticize and slow to praise or offer helpful suggestions. In all the years our hospital has been subjected to these idiosyncrasies, I remember how few worthwhile ideas have been implemented as a result. The only certainty is more red tape and the hope of earning a passing grade, so we will not be bothered for a few more years.