The Last Christmas

“You’re always bah-humbuggy during the holidays, Curmudge. Why’s that?”

“Holidays are an awful lot of work, Julie. But they’ve always been more work for Mrs. Curmudgeon than for me. She worked harder than Santa Claus, but I was just a helpful elf.”

“How so, Rudolph? Did it have something to do with her profession as a church organist - choir director?”

“It had everything to do with it, Julie. Choir rehearsals began in October for the major Advent oratorio. But the efforts didn’t begin to get intense until December. Then we had to decorate the house for holiday entertaining. A tree inside and on the porch, figurines all over the place, and more greenery than a national forest. If all of the candles had been lighted, the house might have burned down.”

“Thank goodness it didn’t. So when did all the entertaining occur?”

“It began with a small dinner party for my long-ago professional colleagues and their spouses. We were a fairly subdued bunch, as you’d expect from chemists, but it took a while to straighten the house after they left.”

"I know the next event—the big oratorio with festival choir and orchestra. Remember last year’s awful snowstorm on Saturday? On Sunday there were more singers in the choir than people in the congregation.”

“Traditionally, we held the big choir Christmas party on the following Wednesday evening. That was the main reason for all the decorations in the house. The night before was spent making 80 or so ‘Aunt Lucy’s ham-and-cheese sandwiches’ to be served at the party. The usual beverage of choice was ‘Ethel’s punch’ that I concocted.”

“Of course, all of the parties included caroling around the grand piano. One year, even one of your friends with Alzheimer’s sang.”

"That’s right, Julie. With 40-50 people, the house was filled to overflowing. You can imagine the cleanup job after everyone left. At noon on the following day, Mrs. Curmudgeon’s colleagues from church came for lunch. Then a week later we did the full-house thing over again for another circle of friends.”

“Golly, Curmudge, with the parties and great music, I’ll bet that everyone had a wonderful time. It’s pretty evident that Mrs. Curmudgeon loved good friends as much as she loved good music. But I must admit that the whole effort sounds exhausting.”

“It certainly was. During one of our late-night cleanups, I commented to Mrs. Curmudgeon, ‘I hope we won’t be doing many more of these.’ It was not my intent to be prophetic. However, Mrs. Curmudgeon must have sensed more clearly than I that her interstitial lung disease was worsening and that these parties might be the last.”

“And finally Christmas arrived—along with pneumonia.”

"Mrs. Curmudgeon had to play three church services on Christmas Eve. It was quite a struggle for her to climb the 32 steps to the organ loft. Her breathing was labored…as if she were climbing to the top of Mount Everest. By the time the final service was over, it was Christmas Morning. She came down from the loft completely exhausted, and three weeks later, she died.”

“Curmudge, it sounds as if you helped everyone else to have a merry Christmas. Perhaps you and Mrs. Curmudgeon had a good time mostly because everyone else did.”

“Julie, she made great music and hosted holiday parties for about 40 years. In years past when people would ask when Mrs. Curmudgeon planned to retire, her answer was an emphatic, ‘Never.’ She would go on to explain that she hoped to flop dead on the organ console. She came close.”

Return to our Roots

“Listen up, Julie. We may be returning to our roots.”

“If you think that’s going to make you any younger, Curmudge, you’ll be disappointed.”

“I mean our blogs, Kaizen Curmudgeon and Curmudgeon’s Wastebasket. Remember how Kaizen Curmudgeon began in May 2007. Our intent was to document the progress of our Lean transformation at Affinity. Although we couldn’t always focus on Affinity, we were able to limit ourselves to Lean and its required leadership. We maintained that through the middle of October 2008. Then our anticipated local contributions failed to materialize. While waiting, we expanded our scope further into health care and leadership topics that might be of interest to our readers. We are still waiting and writing about topics from the literature that our readers might not otherwise encounter.”

“In those early days, Curmudge, draft postings that were rejected by our reviewers were, literally, dumped into your wastebasket. Then in January 2010 we formalized your trash can into a new blog, Curmudgeon’s Wastebasket. During the last half of 2010 and the first part of 2011, Wastebasket was populated by e-mails describing emergency medicine as practiced on the battlefields of Afghanistan. Since then, that blog has been relatively dormant.”

“Dormant no longer, Julie. It has been suggested that we return Kaizen Curmudgeon to its roots and limit it to discussions of Lean at Affinity. Most future discussions of other topics formerly posted in Kaizen Curmudgeon will be posted here in Curmudgeon’s Wastebasket.”

“Wow, Curmudge. Think of all the topics our Kaizen Curmudgeon readers would have missed if this limitation had been in place for the past three years: Patient Safety, Mistakes, Checklists, Amazing Devices, Evidence-Based Medicine, The Crystal Ball, The Laboratory, Sepsis, Primary Care Medicine, and more.”

“One might call missing those postings unintended consequences. So geht es im Leben.”

“You meant to say, ‘such is life,’ Curmudge. Postings on Kaizen Curmudgeon will quite likely become less frequent. Our new path forward will require more effort, but we’ll make the best of it.”

"As usual, Jaded Julie, you’ve got that right.”

Afghanistan ER--Mack Is Back

“Hey, Jaded Julie, Mack is back safe and sound.”

“Hooray! We’ve been waiting a whole year for that to happen. Does that mean that we won’t have any more postings with the Afghanistan ER title?”

“I don’t know. He was planning to accompany the troops on at least two more missions before the end of their deployment, and I haven’t heard anything about them. Perhaps he’ll have something to say when I see him in about a week.”

“Curmudge, I’m concerned about how the transition will be for one coming from the horrors of war back to the relatively peaceful U.S. No more patients with legs blown off and ghastly pelvic wounds. No more wearing a uniform soaked with (other people’s) blood. No more wondering if your next step will be your last.”

“It will certainly be a relief, but probably much more. We tend to think that to a physician it’s all in a day’s work, but they can’t avoid being affected by what they are seeing and doing day after day.”

“Do you suppose that it might be somewhat like grieving, where one’s sense of loss—and possibly in Mack’s case, outrage—will subside over time?”

“A big similarity will likely be that although images of persons and events will fade, a portion will be indelibly etched in some far corner of one’s mind. Apparently that has been the case with veterans of World War II. The rate-limiting step in healing is how long it takes for one’s mind to accept that what once was reality is no longer the case.”

“Interesting thoughts, Curmudge. They remind me of the Kaizen Curmudgeon blog where we often discuss topics about which you know little or nothing.”

Afghanistan ER--The Mountain

“Listen up, Jaded Julie. Mack copied me on a note that he sent to some of his Army friends.

‘Hi, everyone,

I just heard about Bin Laden's untimely death. Thanks for all the well-wishes and kind words. Sunday and Monday I was on an air assault mission. Yesterday, I was sleeping in the strong point and guys started talking about it. I guess the news was put on the tactical radio net. I was half asleep, thought I had just imagined it, but later when I woke up, I found out it was true. I think he was mainly a symbol, a coward who has just been hiding for the last ten years, so I don't know how this will change our fight over here.

Last two days were pretty tough; mission was up in the mountains. Saturday, some of one of the platoons was up on this mountain, a piece of rock about four-1/2 stories above the rest of the area. Anti-personnel mine blew the right leg off one of the guys, right at mid thigh. The temperature was about 98 degrees. I had to run (or as close to that as I could manage) about 500 meters through uncleared terrain with a guy in front of me with a Vallin (mine detector) and one of the squad leaders, climbing over walls and cutting through compounds. Then one of my medics and I had to claw our way to the top of this thing to take care of him. A proverbial nightmare!

The whole time the helo was saying over the radio that they were almost out of fuel and were going to have to turn back if we didn't get him down to the bottom in minutes. The Fast-One failed to fire its needle; never had that happen before. Eddie was conscious, but I could barely feel a radial pulse. So I decided to go for the second IV and try to get the other unit of Hextend on board and also do some IV morphine because he was in so much pain. Never had a lousy IV start give me so much anxiety! The first responders had done an excellent job on the tourniquet, as high on the thigh as this was; but there was so much oozing we kept adding combat gauze and more pressure dressings. All in this little spot on top of this damn dirty rock.

We had to lower the guy over the side and practically skate him down on a Fox litter. IVs both pulled out by the time we reached bottom, but got what we needed in. I thought we were going to lose him; but they told me last night he's alive, has had a surgery or two, and I think he's on his way to Landstuhl.

The exertion of the whole thing was horrible. I had a weapon, full aid bag, and also was carrying 7 liters of water because of the heat. I felt like the climb was going to do me in, especially with me being twice the age as everyone else. Anyway, I got back to the FOB last night, am lying low today. Have about 3-4 days until next mission. (I can't believe with less than a month until we actually fly home that we are still at this horrendous op tempo!)

Forgive me for unloading this war story. I'm not including my civilian friends that won't understand anything anyway. Take care and please stay in touch.—Mack’ “

“Curmudge, just hearing the story makes me feel exhausted.”

“When we lived in Washington State, Mack and I would speed-hike up mountains in the Columbia River Gorge. But then we were 20 years younger.”

“And no one’s life depended on how soon you got to the top.”

Afghanistan ER

“Hey Curmudge, I understand that Mack’s battalion is located in a new forward operating base.”

“It doesn’t sound much better than the old one, Jaded Julie. I just received this e-mail from him wishing a Happy Easter to friends and family:

‘Hi, everyone,

Happy Easter. I hope that everyone’s enjoying the day. I went on a raid today, actually flew out at about 0200 this morning. I think it was one of the most sinister places in this country I’ve been. A village with lots of little alleys and roads with walls on both sides. There were snipers taking shots at times during the day. One of the engineers got shot through both thighs; one of my medics and I took care of him. They may have hit the femoral vein, but I think he’ll be OK. Happened just as the sun was coming up. It was horrendously hard to carry him out of there to the helo, since the fields around the village were flooded in some places. Afghanistan is the #1 heroin-producing country in the world, and every square foot of ground in this part of the country is covered with poppy plants about to be harvested. We captured four guys who were making IEDs and explosives. Late in the afternoon, maybe an hour before we were getting ready to fly out of there, everyone was sitting up against a wall. Some of the guys were starting to clear the PZ for the flights out, when the enemy cut loose with five minutes of machine gun fire. Since we were behind the wall, no one got hit or anything. It was steaming hot all day, and everyone brought as much water as they could carry; but we were almost running out by the time we got out of there. Now I’m back in my hooch listening to “The Time Warp” from the Rocky Horror Picture Show and checking e-mail. About to get midnight chow. Please stay in touch because I’ve really enjoyed hearing from you while over here. Take care—Mack.’ “

“Curmudge, your grim countenance tells me that that wasn’t the kind of Easter you were expecting Mack to have.”

“You’ve got that right, Julie. I had Easter dinner with friends in a restaurant that was hosting a lot of noisy, seemingly carefree young people. I find the contrast between their Easter and Mack’s Easter disturbing.”

Debunking the Program-of-the-Month Myth

“This is what you and I were talking about four years ago—before the Kaizen Curmudgeon blog even existed: ‘Jaded Julie announces to everyone within earshot, “I’ve seen them all—Total Quality Management, Quality Circles, Baldrige, ISO 9000. We tried them, spent a lot of money, management lost interest, and they went away. They were all just the program of the month, like this new Lean stuff. It will go away too.” '

“To which I responded, ‘No, Jaded Julie, you’re wrong (mostly). Lean is not the program of the month, and it has worked too well to simply ‘go away.’ Here are the facts:

· All of the programs that you listed came from a common origin, W. Edwards Deming’s principles of driving out fear, employee empowerment, studying and improving processes, and reducing waste.

· The programs had many elements in common, such as people working together in teams.

· Over time, the programs evolved, became more sophisticated, and were given new names.

· Programs came and went because they were mismanaged. On this point you were correct, Julie: Management often lost interest before the programs could pay off.’ “

“You’re right, Curmudge. I was too quick to criticize; I’ve learned a lot in the past four years. Lean has been working well for us, and it has become widely used in health care organizations. But what are some of the other current programs? When I encounter them in my reading, I want to know what the author is talking about. However, it’s my guess that success doesn’t depend so much on the program itself but on how vigorously it is implemented.”

“Let’s start with an old name, Gemba Kaizen . Although this is the predecessor of Lean, the name is a trademark and is not used very much. Among the principles of Gemba Kaizen are management’s role in upholding standardization, focusing on the process, analyzing process data, establishing and implementing countermeasures, following PDCA cycles, revising standards, and policy deployment.”

“That sounds a lot like Lean. Because it is Lean’s predecessor, that should be no surprise. Lean has also strengthened the emphasis on housekeeping (5S), process analysis using value stream mapping, and A3 problem solving.”

“Most of what we have discussed can also be found in Six Sigma, where their project elements include Define-Measure-Analyze-Improve-Control. In addition, there is emphasis on process control, statistical design and analysis of experiments, and training of project leadership (black belt and green belt).”

“I assume, Curmudge, that you are going to mention the Institute for Healthcare Improvement’s (IHI) Model for Improvement.”

“IHI is sort of like a supermarket; if you need something, they are likely to have it. In this case, IHI can provide a lot of guidance as well as tools for improving a process. Principal elements in their Model for Improvement include: Forming the Team, Setting the Aim, Establishing Measures, Selecting Changes, Testing Changes using plan-do-study-act cycles, Implementing Changes, and Spreading Changes. A newer IHI tool is their Improvement Map .”

“Although the Improvement Map is free of charge, Curmudge, I understand that its use requires installation of Microsoft Silverlight software.”

“Here’s an improvement program—also fairly new—that comes from The Dartmouth Institute for Health Policy and Clinical Practice. It’s called Clinical Microsystems. To me, it looks like a highly structured, Lean-like approach to process improvement with preprinted documentation. The microsystem is ‘your unit,’ and it is defined as ‘the place where patients, families, and care teams meet.’ For people in the unit, job #1 is to provide care, and job #2 is to improve care. Steps on their Improvement Ramp include: Assessment of the unit, Theme (identified in the assessment), Global and Specific Aims (specific numeric goals), Ideas for Change, and then Plan-Do-Study-Act cycles. The organization provides so-called Greenbooks for applying these steps to specific units within a hospital (Inpatient Units, Emergency Department, etc.).”

“As you suggested, Curmudge, these programs—the old as well as the new—have a lot of features in common. So tell me, how does the newcomer decide which of these she will propose to her organization?”

“Jaded Julie, although we favor Lean and call it the Affinity Performance Excellence System, one does not need to be a purist. Pick and choose what might work best in your organization or unit. And feel free to supplement from the works of Quint Studer (Hardwiring Excellence) and James C. Hunter (Servant Leadership).”

“When we wrote much of this four years ago, we were contemplating changing my name to Enthusiastic Emily. Whatever came of that?”

“Jaded Julie, it will never happen. Your name has become a household word, or at least a hospital-wide word. You will no longer be jaded when I am no longer a curmudgeon.”

Afghanistan ER--Firefight

“Hey, Curmudge. We haven’t heard from Mack recently. Is the war in Afghanistan over?”

“Don’t I wish, Julie? Mack was in the States for a mid-deployment leave, but he’s back over there now. He copied me on this note to a friend:

‘Hi Rich,
It's been a decent week here. We had a ground assault mission three days ago; was nice because it was only one day. We left at 0400, got back at 19, in time for hot chow. The purpose was to hunt for bunkers and weapons/explosive caches. We found a lot of stuff and blew it all up. In the afternoon we got into a rather large firefight. The Taliban were actually hitting with more than their usual accuracy, meaning they were hitting the grape rows in front of us. We fired a ton of ammo, not really sure if we hit anyone, but certainly stopped their shooting. What the enemy usually does is fire on us for a short period of time, then simply break contact and disappear in the grape rows. They usually shoot from buildings like houses or grape huts but not for long. If they did we would get a bead on them and destroy them. They are usually not very accurate; their plan is to get us to pursue and lead us through fields where they have planted IEDs. We don't usually go for that anymore. The best part of this day was that no one stepped on an IED or got hurt. I'm all scuffed up from crawling over 5-foot high walls, etc. and destroyed a set of ACU pants. I'm certainly the oldest one out here, at age 49. Most everyone is in their 20s.
Mack’”

“It probably doesn’t make Mack feel any better to remember that he was an infantry platoon leader (prior to med school) before some of the younger soldiers were born.”

“Julie, if Mack slows up the troops any—and he probably doesn’t, I’ll bet they are still glad to have ‘The Doc’ come along with them.”

Afghanistan ER

“Hi, Curmudge. I see that Mack copied you on a note to one of his medical colleagues.”

“Right, Jaded Julie. When you read the note, it will be evident that it could only be fully understood by another Army emergency medicine doc who had served in combat. When I asked Mack about some of the terms, he dictated a rather cursory glossary (below). Here’s the note:

‘Hi Ian,
Had a terrible air assault day before yesterday, very dangerous area. One person killed by IED. Also Local National blown up accidentally by our APOB while we were trying to breach through really dangerous IED seeded area. Even though they did the whole procedure to warn the locals and clear everyone out. It was after dark when we crossed after the explosion, the people up front found a guy on the road, huge facial wounds but alive and struggling. I put in a tibial IO, (I carry the mini-drill in my Aid Bag). Hit him with IV Ketamine (in spite of the head wound. I heard that increased ICP with Ketamine was not really borne out by literature. Also only thing I had to adequately sedate him for any extended time). Also used some Versed. Did a cric, balloon failed so exchanged it for new tube over a stylet. Ran 2 Hextends IO for the crappy radial pulse. The guys used their Tac lights on their M-4s for light. Set up hasty LZ and evacd him. Guy made it back to the Role III alive; they did labs, CT scan, everything. He had a brainstem bleed and a depressed skull fracture, so they withdrew care and he died. My two medics and I were covered with blood. Several of us fell into a creek trying to get back to the exfil LZ so had to wait for 3 hours in the freezing cold while wet. We were in PZ posture in the dark; the Chinook almost landed on us. Whole planeload had to dive off 6-foot embankment to keep from being dismembered by the bird, then crawl up the sides of the ditch and run for the helicopter. Still scratched and sore from that.
Anyway, that's my world for the last 3 days. Take care—Mack’”

“Gosh, Curmudge, every note from Mack further strengthens my belief that war is Hell.”

“I believe most everyone can get that impression without the glossary, but here it is anyway:

IED—improvised explosive device
APOB—chain of explosives fired several hundred yards ahead of advancing troops to explode IEDs
IO—intraosseous. An ‘IV’ into a bone instead of a vein.
Ketamine and Versed—anesthetics
ICP—intracranial pressure
Cric—cricothyroidotomy; an incision in the front of the neck to establish an airway
Hextend—colloidal plasma volume expander
Tac lights—very bright, focused, visible light source mounted on weapon
Role III—advanced medical care. A battalion aid station is Role I.
Exfil LZ—helicopter landing zone to extract troops at end of mission
PZ posture—troops lined up in Pickup Zone in order of entry into helicopter”

“The glossary improves my understanding, Curmudge, but it doesn’t assuage my feelings one bit.”

“As always, Julie, you’ve got that right.”