AskTog: The Pump

The Pump

This month, I’m offering exclusive inside information on one of the more esoteric interfaces in existence. It’s a device I hope you will never have to use. I know I wish I hadn’t.

As you know, DNA is usually coded in a double-helical sequence made up of four distinct molecules. My DNA, however, is coded in JavaScript. And not that bug-free version. As a result, I was given the opportunity to explore deep into the healthcare system this month, a lot deeper than I might have liked.

I’ve returned from the experience minus a deranged kidney with a newfound respect for just how bizarre an interface designed for more than one master can become.

The Pump (again)

It used to be that when the swirling mists of anesthesia wore off, you would wake up in the recovery room with absolutely no pain medications at all. Then, they would start throwing you violently around from one gurney to the next until you finally arrived at your bed, still with no pain relief. (I think the thought was that people fresh from surgery, like infant boys and lobsters, can feel no pain. This is apparently based on the theory that if it is helpless, it is OK to strap it down and torture it because, see? It isn’t hitting you back.)

Nowadays, that has all changed, sort of. Doctors, following, as usual, the lead of dentists, have discovered “pain management,” a complex web of techniques designed to keep the patients from getting on the doctor’s nerves by groaning so much. At the heart of pain management lies The Pump.

Hospitals revolve around three characters: The Doctor, or MDiety, the nurses, and the patients. Supporting these primary players are a variety of stage hands, but they don’t really count.

In the pre-Pump days, nurses were charged with administering pain medications. The system worked like this:

Doctor prescribes 75 mg of Demerol every four hours. Nurse actually injects it every 4.7 hours, when she has time. Patient spends 15 minutes in blissful euphoria, followed by 4.45 hours of intense pain.

If the patient complains about the pain, this becomes prima facia evidence that the patient is a drug addict. For the patient’s own good, the nurse cuts back the dosage (also, in the process, resulting in a little more Demerol for her Saturday Night “light up.”

Enter The Pump (one more time)

The pump has changed all that—sort of. The nurse is now out of the picture and spending Saturday nights with nothing more exciting than a fifth of Jack Daniels and maybe a few Darvocets. Instead, Doctor and Patient take stage center.

The doctor is the client, the guy you sell software to, that IT manager who has never touched a keyboard—or undergone surgery—in his life. He will never use the product, but he will hand over the cash for it and he will want—nay, demand—full control over it.

The patient is, of course, the user, that helpless schlimazel who will use our product regardless of its virtues or lack thereof.

The pump epitomizes commercial software. It offers the end user the illusion of control while actually placing the real control in the hands of the client. The interface, while at first glance appearing simple, is anything but, with a complex twist that is truly diabolical

How it Works

The Pump consists of a large syringe controlled by a computer. The computer meters the contents of the syringe, typically morphine, directly into the patient’s bloodstream via a tie-in to the patients IV line.

The patient calls for a bolus of morphine by pressing a button, similar to the nurse’s call button, typically safety-pinned to the bed near the patient’s hand. The pump is the patient’s friend.

The Advantages

The nurses are out of the loop, cutting back on hospital expenses and limiting those people who would control the patient’s pain and suffering to just doctor and patient.

Patients are no longer forced into euphoria. This might seem like a real minus, but addiction to pain medication is strongly correlated to this euphoria. If the pain medication never enters that zone, patients tend to be weaned off the meds without problems.

Patients need no longer suffer long periods in agony, since, if the pain medication is insufficient, they can give themselves another boost.

The system is inherently safe; should the patient become too “trigger-happy,” he or she will simply fall asleep. It’s pretty hard to press that button when you are asleep.

The Disadvantage (to the user)

The patient is only indirectly connected to the pump, via the computer. It is the doctor who is really in charge. The doctor orders both the frequency and dosage of the pain medication. If the doctor has underprescribed the pain medication necessary—and doctors do so routinely—the patient can press away on that pump until the cows come home and ain’t nothin’ comin’ out.

The Twist

The patient receives no feedback as to whether the pump delivered the goods. Let’s say the doctor has had the nurse program frequency to a minimum of every 15 minutes. If the user—patient—presses that button after 14:59 seconds absolutely nothing will happen. No drug, no beep, nothing. Since the drug is administered gradually, it can become impossible to tell whether or not anything was received.

Since the post-surgical patient is usually way too out of it to do time calculations, even if they had been trusted to retain their watch, they are left in a quandary. When can I press? The obvious answer is early and often; the more often you press, the better the odds of pressing shortly after the next “window” opens.

But here’s the catch. The stupid computer records how often you press, then rats you out to the doctor. The designers of The Pump apparently felt that such feedback was important to the doctor—who is the only person really in control of the pain meds. With this information, the kindly docto could respond by increasing the meds until the patient didn’t see such a need for constant pressing.

As soon as you adopt this press-early-and-often strategy, however, the nurses quickly caution you against it. It seems in “real life,” doctors, just as they did 20 years ago, see your reaching out for medication to be a sign of drug addiction, and they cut back the dose.

The user is then left in this quandary, with a dose of medication perhaps available, but a fear that actually using it may cause them to be placed into more pain and suffering. Not so different from how we treat our own users, no?

In my own case, I adopted the “around every five minutes” strategy, figuring that I would at least hit shortly after the 15 minute time-out without going too far over. I also had the distinct advantage of having along for company my wife, The Doctor, who not only is responsible for saving my life by diagnosing the cancer early enough (we hope), but who crawled down the throat of the one anesthesiologist who tried to cut down my meds upon my complaint, rather than increasing them.

While you might not be so advantaged, there is hope. For all its failings, the pump is a tremendous improvement over the crappy drugs every four hours they were giving 20 years ago. And the anesthesiologists are wresting away control of pain management from the surgeons. (God help you if a male surgeon who has never had surgery himself is in charge of “pain managment.” You’re lucky to get a couple of extra-strength Tylenol.)

The legal landscape is changing, too: A doctor in Oregon was recently successfully sued for the pain and suffering his patient underwent when being undermedicated.

Still and all, the silence of the pump should be replace with a soft voice saying "just a couple more minutes."

As for me, I am probably cured—time will tell—and am on the mend. However, I’m not so well I can churn out a full issue of AskTog, so, until next month, this will be all. Peace be with you and stay the hell away from hospitals.

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