14 January 2011

Why I hate medical journalism

In this heartbreaking CNN report, they tell the story of a child who, after a five-hour wait in an ER waiting room, developed Strep sepsis and nearly died. It's a terrible story, and a terrifying case both as a parent and as an ER doctor. To their credit, the authors treat the subject seriously, without too much sensationalism, and they provide a serious look at the status of the nation's ER overcrowding crisis and they shed some light on its causes. They obtain one of the greatest explanatory metaphors I have ever read on ER overcrowding: 

Dr. Sandra Schneider, president of American College of Emergency Physicians, says the backups occur as emergency departments struggle to find beds for admitted patients."Think of the emergency room like a restaurant where people come in and go out," she says. "Now imagine a restaurant where the customers come in, but never leave. They come in for breakfast, they stay for lunch and they're there for dinner." When a patient is admitted to the hospital and needs to remain for additional procedures, they take up available inpatient beds leading to a domino effect, Schneider says.

Lovely metaphor, and immediately accessible to laypersons trying to understand the complex dynamics of ER patient flow.

So why do I hate this article?

First of all, in this case, it sounds like the "human interest" example they used was wrong, or at least illustrates a different point than the authors wanted to. The real cause of this child's outcome is not just the overcrowding of the ER, but the error of the triage nurse. A febrile child with petechia or purpura is a medical emergency, and this is clearly one of those cases where the triage nurse missed it. This child should have been rushed back, regardless of what else was going on. While the overcrowded ER was a contributing factor, the proximate factor here was a medical error. A secondary (and unknowable) issue, medically, is that if the child was sick enough to have purpura on presentation, she was already in DIC and probably would have gone on to have the same outcome of the amputations, etc, regardless of the wait time. Obviously, the delay was not helpful to her, so that's more of a quibble that will probably be left for the malpractice attorneys to debate.

But that brings me to the larger point. It's not just that they got the "human interest" case wrong -- it's that they had to have one at all to make the story "work" according to the journalistic conventions. Why does there have to be a dead child for readers to care about ER overcrowding? Is it not enough to walk through an ER waiting room and see dozens of people waiting in pain for hours on end?  The guy with a broken fibula, appropriately triaged, who has to wait for three hours for an x-ray and pain relief? The dehydrated child who can't stop vomiting? The kidney stone? Is it OK that these non-emergent cases cannot be treated in a timely manner? Or walk through the halls of the ER and see the patients languishing on gurneys for hours and days. Is that not enough to communicate to a general audience that there is a crisis in the ER, and in the nation's hospitals? 

This aggravates me because the incredibly touching and tragic human interest element of this story completely overshadows and distracts from the real problem. People will read this and come away sad for the patient and family, or maybe angry at the medical providers. But the systemic problem, the one which affects so many ERs across America, is demoted to the twenty-first paragraph, when it should be the headline. It should be in 100-point bold font across the front page of CNN every day. But a little girl suffered a terrible disease, and readers will be given that to chew over and dwell on, and the crisis that contributes to these outcomes gets short shrift.

That's why I hate medical journalism.


Wise Bass said...

I noticed this when I was reading BBC News online, followed by the New York Times. BBC doesn't seem to do that - they'll just baldly state what the problem is, and then support it with commentary and the like. The NYT, on the other hand, almost always starts off with some personal anecdote.

Marc said...

If you read most of the American press problems in ER take place in other countries, notably the 'socialist' NHS in the UK.

So - have we got stats on waits in US ER, especially for those in considerable need, adverse outcomes, time spent on gurneys etc.

And is your ER as you describe?

Marya Zilberberg said...

Good post! The American Hospital Association conducts an annual survey of hospital executives -- I know, not the best source, yet... -- and puts out a Chartpack on their web site, which I like to cite a lot: about 40% of all ERs report being on diversion at some point, and the most common reason is lack of staffed ICU beds. The pack is full of interesting numbers. Found here:

Nurse K said...

If the rash doesn't blanch, the child's gonna crash...

One random problem that I'm seeing is that newer ERs don't seem to be built with hallway spaces, at least around here. I've worked in 3 or 4 ERs built in the last 2 years that had nowhere for a patient pulled out of a room to make space for another one to go unless you drive them literally into the middle of the nurses' station or park them in the middle of the hallway and obstruct traffic flow through the department. Or, of course, you can take a patient out and stick them in the lobby on a cart, I guess. People just tend not to do this though. You face fire marshal problems, HIPAA problems, etc.

Not sure why new ERs are being built like this. No flexibility.

Alison Cummins said...

I don't see much of a difference between identifying the issue as a triage problem or a wait time problem.

The triage nurse missed it, but if there were no wait time she'd have been seen right away and it wouldn't have been an issue.

PGY1 said...

"A febrile child with petechiae or purpura is a medical emergency, and this is clearly one of those cases where the triage nurse missed it."

At the risk of drawing some hate, why are nurses responsible for determining what constitutes a medical emergency? The clinical acumen of triage nurses depends on a combination of intelligence and clinical experience, both of which vary widely among ED nurses.

Same goes for doctors, you say? Compared to medical education & residency training, nursing school is brief. Nurses don't do residencies and are taught by other nurses. How can we expect even an excellent nurse to have clinical judgment on par with a that of a physician who has trained for years prior to entering practice?

pdx rn said...

yep, story here is bad triage nurse, not crowded ER. Totally missed the point.

There is also no mention of the overcrowding in CA ERs caused by the law that limits the number of patients that nurses on the floor can care for but in no way limits the number of patients nurses in the ER can care for.

PGY1, don't you think nurses get training too? Petechial rash is one of the first warning signs you learn in pediatric nursing.

PGY1 said...

@pdx rn: I don't dispute that nurses get on-the-job training after nursing school, but it doesn't compare to the breadth and depth of medical residency. I'm more familiar with nursing curriculum than most physicians and I have no reason to disparage it, but it is no replacement for medical training.

Anonymous said...

Why, in this day and age, is there not a master computer program put together by industry that doctors and nurses follow in diagnosing. I know the response will be "because it's an art..." but that's kind of like software engineering back in 1990. At some point, the profession grows up and realizes "Ok, it's not an art. Much is routine and agreed upon already", and given a list of top-level non complaints the computer program says "push on the rash and release. Did it turn white? Click yes/no or I'm not sure"

And if someone follows all these rules, then nobody gets in trouble.

The diagnoses matrix for 95% of what we encounter in humans is much smaller than our tax code, and that has been bubbled up to user interface (Turbo Tax) that just about anybody can handle.

Anonymous said...

Is your alternative physician triage?
As an emergency physician, I can tell you that is not a viable solution. I am in the back taking care of multiple (often sick) patients and cannot readily evaluate (even briefly) EVERY person that presents to triage.

PGY1 said...

You're right that I don't suggest a viable alternative. I just think it's short-sighted to blame the "bad triage nurse" for missing something when s/he is not really trained to fully evaluate a patient. The error is likely at least partially attributable to an imperfect system. Btw, was this a peds ED? If not, then the triage nurse would have had even less experience triaging children.

Cartoon Characters said...

my job is specifically triage and pediatric petechiae and purpura is a medical emergency in our assessment list. Pretty basic actually.
And I am not a "specific" pediatric RN....and in fact have never worked peds.............

pdx rn said...

PGY1, what is your training? Nurses are trained in triage, its part of our job. There are some doctors that are lousy at diagnosing too and miss things.

Petechial rash as an emergency is very basic, not something esoteric that can be missed.

A computer program to triage, yep great idea. Type in rash and see what that gets you. The main question for triaging kids is "does the kid look sick?"

Perfect example, the well looking child that has been vomiting but has a petechial rash around his mouth from the vomiting. He gets to go back first just in case. Not rushed back but first without a wait, bumped to front of line.

When I triage the last thing I tell every patient before I send them out to wait is "let us know immediately if there are any changes or if you need anything."

The comments section for that article are awful. Its all the parents fault the kid got sick for getting her ears pierced.

shadowfax said...

To PGY1:

With regard to nursing and triage: it's a skill, and a critically important one. Only the experienced nurses who are felt to have excellent judgement are allowed to triage in our facility. There is so much that a nurse has to know, and so much dependent on their ability to rapidly (and accurately) assess a patient that you cannot have a weak link at triage.

ER nurses get educated in the same emergencies that we MDs do: they know to look out for the AAAs, the SAHs, the occult MIs, and yes, the septic kids. How many times do I see a triage note where the RN wrote, "worst headache of life"? I groan when I see it, because I know I now have to rule out SAH, but the point is that the triage nurses are aware of these life threat and they are actively looking for them -- as they should be. This case sounds like it was just a clean miss.

The difference between an MD and an RN, at least one of them, is that while we are both aware of the life threatening diagnoses, and both are able to screen for them, the knowledge base of the MD should go deeper in both the intricacies of diagnosis and treatment options. But to say that nurses can't or shouldn't be able to recognize badness is kinda ignorant.

And if you really are a PGY-1, let me give you two really important pieces of career advice:

1. Listen to your nurses. They will save your ass, but only if you respect them enough to value their assessments.

2. Be nice to your nurses. Many employers, including this one, check nursing references when hiring.

pdx rn said...

PGY1, you obviously know nothing about triage if you think "fully evaluating a patient" is what you do at triage.

If I'm not mistaken the joint commission standards for experience for triage are 2 years as an ER nurse and 6 months at your present institution.

Nurse K said...

After the 30,000-50,000 (who knows) ER patients that I've seen, maybe I should go to medical school so I can figgur out what's wrong with 'em and if they's sick or something. I just kinda blankly stare in their directions now. One time I noticed one was coughing. That was pretty cool.

I think it would be humorous to watch a PGY1 resident try to figure out sick/not sick on a never-ending parade of people in a 5-minute timeframe per person to include no or 30 seconds-or-less chart review, a set of vitals, a discussion (dementia or otherwise) of whatever you want to talk about to drill down to severity of illness, inspection of visible body parts if necessary, no physical exam except MAYBE lungs if it's borderline, and a set of vitals. Oddly enough, I seem to never really let anyone die, but I'm sure I will sometime just by odds alone.

Couple this with a full ER and you choose which person gets the next bed and then talk the charge nurse into sending ambulances to the lobby to accommodate your one person of the 7 you've triaged in the last 30 minutes who is ill. Have fun, PGY-1.

Anonymous said...

From personal experience, it isn't even a nurse doing triage at some ER's.

Around here, it's sometimes an EMT. And I'm not really in the boondocks either.

And I've seen them send bad asthma to a waiting room, with not so good consequences. And then when asked to recheck, the response was "We're really busy, there's nothing I can do about it".

Another guy came in at the same time clutching his chest, saying "Triple bypass". I kid you not, he sat there too - although he was near the desk. No oxygen though.

ummm... ABC?

Yes, I know that sounds like I made it up - but I didn't. It really was that bad.

Asthma patient was with me, I eventually made enough of a stink, an RN took one look and paged respiratory stat - but he did suffer some long-term harm. Heart guy - nothing I could do, I hope he was ok. We did talk to the ED director the next day, and she was appalled. I suggested she may want to check on the heart guy too, hope he wasn't downstairs.

Overly full ED is bad, incompetant traige is worse. Together, they can be deadly.

The thing with waiting with a broken arm, in pain vs. that poor little girl - the guy with the broken arm suffered, but didn't have long-term consequences. The little girl has lost so much. Would she have anyway? We'll never know. Nor will she, or her parents.

PGY1 said...

@NurseK: "I think it would be humorous to watch a PGY1 resident try to figure out sick/not sick on a never-ending parade of people..."

I should have known my comment would lead to insults. I never implied that I am trained to do triage nor that my own skills are anywhere near that of an experienced nurse. I freely admit I'm very early in my own training. But if it makes you feel good to remind me that I don't know everything (as if I need a reminder!) then go right ahead. In fact, you can remind me of that for the rest of my career b/c it'll always be true.

@shadowfax If your triage nurses are well-trained then I stand corrected with respect to your facility and likely many others. While I have not interacted much with triage nurses at my current facility, I have seen significant variation at other well-known facilities in my admittedly brief experience.

Btw, nothing in my initial comment implies that I don't like nurses or that I'm not nice to them! The floor nurses at my facility are nearly all simply excellent. We respect each other and work well as a team to provide effective care. I consistently get 5/5 ratings on my nursing evals and I really like working with them.

ASP said...

This is a non sequitur a day later, but I wonder what you think of the Times story today about the incredible trauma surgery performed on the victims of the Arizona shooting. To a layman (me, anyway), it was astounding and dramatic. http://nyti.ms/eOVR7H

Nurse K said...


No insults, just chuckles. Non-ER residents and med students doing their little rotation can barely get out of a patient room in 45 minutes and usually don't have a clue what's going on after doing a complete history, physical, and whatever else. It's cute, really. Usually that 45 min adventure doesn't include talking to the nurse who can tell you what's wrong in 5 seconds, but I digress.

Come on down to the ER and hang in triage for an hour on a busy day with 20 in the waiting room or more (in a 25 bed ER). You'll see what we do. Ask your attending when you go to the ER.

You'll be like, "Wow, a nurse figured out that patient had ruptured diverticulitis in 3 minutes just by talking to the guy and brought him back first rather than letting him wait like a "regular" diverticulitis patient? How'd she know that without labs, a CT, and a full exam?"

You might learn something too about how to drill down fast when people are sick.

Anonymous said...

Yes, it is humorous to hear a resident tell us nurses can't triage when one reason ER's are backed up is from residents sitting in rooms yapping at patients for 45 minutes trying to figure out what the triage nurse figured out after talking to the patient for 2 minutes.

Nurse K said...

One problem with triage is that it assumes the nurse has time to re-eval patients who are waiting. If the patient comes in with vague symptoms that get less vague as time wears on and you can't re-eval them, people could die that way too.

Lots of times you have to choose between seeing new patients and delaying finding their badness or re-checking patients already there who might be getting worse. A lot of times, I'd just run around the lobby and ask everyone, "Anything different since we last talked? Better? Worse? Same?" Half the time, I don't really care what they say, I just have an excuse to get another glance at them for pale/sweaty/distressness/eating chips.

In really bad situations, I've yelled into the lobby stuff like, "If anyone feels worse or different than when they came in, raise your hand or come up and talk to me!" If people don't speak English, well...

It sucks. They don't train you to scream things at people in a lobby, but you do what you gotta do.

Anonymous said...

Nice save.


PGY1 said...

@NurseK: I'll take you up on your offer to spend an hour in triage on a busy day! But no, really -- I'll be sure to do that on my EM rotation later this year.

Oh, and I talk to the ED or floor nurse as part of every patient work up and morning pre-rounds. Skipping that would be downright idiotic. I'll hunt the nurse down if necessary.

JimII said...

For what it is worth, journalists are also bad at reporting on the law and nuclear power. In fact, I am pretty sure all professionals are unhappy with the way journalists cover their profession.

I suppose the question is whether the lay person would be as disserved by the story as the insiders think. I mean, most people would read the story and come away with the idea that overcrowding in the ER is still a big deal and probably not much more.

Anonymous said...

Journalism nowadays is basically he said/she said, without bothering to investigate to see what the actual facts are. Its as if they can't discern between facts and opinions.

One handicap when reporting on medical cases is the hospital is prevented from commenting due to privacy concerns whereas a patient can make whatever crazy claim they want.

We are only hearing the patient's side of this story. Sadly, I have a feeling it is correct.

A local paper did an article where a patient made a claim that they were not given any pain medications for an injury when treated in an ER. I know for a fact that this was a falsehood. But of course the hospital cannot comment on the patient's treatment because of HIPPA.

Alice Robertson said...

I wrote a post up in response to this, but I am unsure why MedPageToday censored it. I wish I still had it. It seems it is not medical journalism you dislike...you, obviously, practice a form of it yourself? I like reading both sides and hope if the story in question is on a blog you will use the gift of writing to illuminate other aspects of the story in an effort to give the reader enough information to form an honest opinion.

Your problem seems to from the vantage point of the writer. Some write from the aspect of a patient and from that view surviving the ER experience is not as important as who is ten beds away or in the hall. Your vision from your seat in the arena gives you more depth and details the average patient would not experience...hence why medical series like Grey's Anatomy are so popular. Reporting about a mistake that almost costs a life is of more interest to the average reader than casting a broken bone would be.

To the poster who wondered about a checklist...read up on Dr. Atul Gawande's Checklist Manifesto.

Coin Magic Tricks said...

Sometimes media doesn't give exact information or they use to lessen the information. The problem here is all about the writer. I think people will decide if they will believe it or not. But sometimes people immediately decide to believe the writers without knowing the real facts. I think these article must be emphasize to people that they shouldn't judge the situation without knowing the real facts.

Darlene, RN said...

The ED is indeed a very busy place. Triage nurses have to possess a "clinical eye" in order to identify and anticipate a patient's needs. There are a lot of other aggravating factors that make patients stay longer in the ED than expected. So I see no point blaming it all on the nurse. What's the average time a does a patient stay in the ED anyway?

Freelance MD

aedes said...

Nurse K:

I'm not sure where you work, but around these parts, if a third year medical student is taking longer than 20 min to do a complete assessment on a patient (including ordering labs, etc.), something is seriously wrong. This is in a tertiary care centre with a catchment area of about 2 million. It sounds like you need to work somewhere where medical students get better clinical training; we're hiring locally ;). (We run hospital wards on our own in our third year here - you need to learn fast :p)

Nurse K said...

Aedes: I wouldn't want to work anywhere where 3rd year medical students were "running" anything, sorry.

Christian Sinclair, MD said...

Does anyone know of a good site that looks for good and bad examples off medical journalism? Just wondering. I think it is the role of health care professionals to call them on it via blogs and other means.