How pneumatic tubes symbolizes our health system

About once or twice a day, everyone on our hospital’s computer network gets an emergency message that scrolls across the bottom of our screens, highlighted in the colors of danger and warning.

They include things like a notification that a particular data system is down and that a backup on paper will have to be used for documentation, or the hospital is approaching critical occupancy capacity and will be on standby until the patients already in the emergency room get beds upstairs.

Just the other day, one of my favorites — an oldie but a goodie — popped up on the screen.

“The pneumatic tube system is down, we are working on it, and backup systems are in place. Please use these until further notice.”

An old but useful system

First off, we don’t use the pneumatic tubes system in our practice, since we are across the street from the main hospital. It would be cool, however, if rather than a live person picking up specimens several times a day, we could just pop them into a hole in the wall and have them disappear over to the lab immediately. Presto, change-o!

But we all get the same alerts, whether they apply to us or not, which makes sense in case it impacts your life in some tangential way.

What strikes me as odd however, is that we are still using pneumatic tubes to deliver specimens to and from the labs, and for various other tasks around the hospital. While I’ve never had to design a system for rapid delivery across a large institution, pneumatic tubes seem somehow just arcane and quirky enough to make them quaint and interesting, but probably more than likely to break down.

Whenever I see this message, I think of old movies where the newspaper reporter rolls up his freshly-typed breaking story, puts it in a carrier tube, and sticks it into a copper tube coming out of the ceiling, where it is sent off with a whooshing thumping sound to a typesetter down in the basement. Breaking news!

It also reminds me of carrier pigeons and the elaborate system of bells in place at old English manors meant to alert the downstairs staff that the upstairs folks were hungry, or needed the tea service removed. Think “Upstairs, Downstairs,” “Downtown Abbey,” and countless other PBS series imported from England.

Time for a change?

The residents who work in the hospital tell us that they really do rely on the system to quickly get specimens down to the lab. Nothing is better than the tubes for moving a STAT specimen, such as cerebrospinal fluid from a lumbar puncture, or a repeat specimen for a critical lab value that will be needed to drive medical decision-making when the answers are need urgently. And it is clear that the system is hardwired into our hospital, with tubes buried within the walls, interconnecting all the floors, labs, and operating rooms.

When I hear that the system is down, I think of the people tasked with finding the clogs and removing them, opening up panels in the walls, probing the intersection nodes, peering down the tubes with flashlights and plumber’s snakes to locate the jammed or broken tube. I think of cracked glass phlebotomy tubes leaking blood behind the walls somewhere. I think of ruptured plaque and thrombus blocking someone’s coronary artery in an acute MI.

But if we were building a successful system for moving specimens today, would we use an air-driven tube buried within the walls, which surely seems like it’s destined to get clogged and break down, and has proved itself capable of doing just that? The frequency with which we see this alert suggests that it’s time to rethink our specimen transport systems, just as we need to rethink all of the systems that we use in health care just because we’ve always used them.

I’ve written before about the new robots that roll around the hospital, delivering food trays from the kitchen up to the patient floors — how this seems like a pretty good idea on paper, but its implementation — although quirky, fun, and interesting — has been less than ideal. I’ve often seen them stuck and whirring, unable to navigate an unusual obstruction in their path they are not programmed to overcome.

As a medical resident long ago, and a medical student before that, I remember when those of us on the bottom rungs of the hierarchy of the hospital team, we were the runners, we were the transport system. When the senior resident did a blood gas on a critically ill patient in the ICU, the intern or medical student would be standing by with a bucket of ice, and the capped specimen would be hustled down the hallways, down a few flights of steps, and hand-delivered to the lab. I remember waiting there, sweating, while the technician ran the specimen through the machine, and the tiny printer spat out the results. These were torn off, handed to me, and I would sprint back up to where the team was waiting to adjust the ventilator or change a medication.

Rethink, simplify, streamline

I’m not suggesting that we go back to the days of the pony express, or the ancient Roman messengers who were handed off messages in a relay from one person to the next in what became the inspiration for the Olympic races. But perhaps it’s time we use the pneumatic tube, and how we approach this problem, as a way to rethink the delivery of health care, much as we no longer use carrier pigeons to deliver the news to the generals at the front.

Every health care interaction is composed of multiple parts, all centered around our patients, which we then investigate with our history, physical examination, lab testing, imaging, consultations, and procedures. We’ve allowed incredibly cumbersome and clunky systems to build up around everything we do to try to take care of our patients, such that every part of the process seems to only bog us down instead of moving us forward and delivering results.

From the electronic medical record that requires every member of the team to spend the vast majority of their time staring at a computer instead of taking care of their patients or learning about the disease that they are trying to treat, to the pneumatic tubes that take specimens to the lab and robots that deliver food from the kitchen, we need to rethink, simplify, and streamline the way we take care of our patients.

If we fail to do this, the tubes will only remain clogged, with nothing good coming out at the other end.

Fred N. Pelzman is an internal medicine physician who blogs at MedPage Today’s Building the Patient-Centered Medical Home.

Image credit: Shutterstock.com

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