28 May 2007

The War Prayer

Kevin Drum teaches me something I didn't know.

In 1904, disgusted by the aftermath of the Spanish-American War and the subsequent Philippine-American War, Mark Twain wrote a short anti-war prose poem called "The War Prayer." His family begged him not to publish it, his friends advised him to bury it, and his publisher rejected it, thinking it too inflammatory for the times. Twain agreed, but instructed that it be published after his death, saying famously, "None but the dead are permitted to tell the truth."

"The War Prayer" was eventually published after World War I, when its message was more in tune with the times.

The prayer:

O Lord our Father, our young patriots, idols of our hearts, go forth to battle -- be Thou near them! With them -- in spirit -- we also go forth from the sweet peace of our beloved firesides to smite the foe. O Lord our God, help us to tear their soldiers to bloody shreds with our shells; help us to cover their smiling fields with the pale forms of their patriot dead; help us to drown the thunder of the guns with the shrieks of their wounded, writhing in pain; help us to lay waste their humble homes with a hurricane of fire; help us to wring the hearts of their unoffending widows with unavailing grief; help us to turn them out roofless with little children to wander unfriended the wastes of their desolated land in rags and hunger and thirst, sports of the sun flames of summer and the icy winds of winter, broken in spirit, worn with travail, imploring Thee for the refuge of the grave and denied it -- for our sakes who adore Thee, Lord, blast their hopes, blight their lives, protract their bitter pilgrimage, make heavy their steps, water their way with their tears, stain the white snow with the blood of their wounded feet! We ask it, in the spirit of love, of Him Who is the Source of Love, and Who is the ever-faithful refuge and friend of all that are sore beset and seek His aid with humble and contrite hearts. Amen.
The editor of the Washington Monthly has made a video of The War Poem. Pretty Amazing.

Memorial Day

I Lost My Son to a War I Oppose. We Were Both Doing Our Duty

Memorial Day orators will say that a G.I.'s life is priceless. Don't believe it. I know what value the U.S. government assigns to a soldier's life: I've been handed the check. It's roughly what the Yankees will pay Roger Clemens per inning once he starts pitching next month.

Money maintains the Republican/Democratic duopoly of trivialized politics. It confines the debate over U.S. policy to well-hewn channels. It preserves intact the cliches of 1933-45 about isolationism, appeasement and the nation's call to "global leadership." It inhibits any serious accounting of exactly how much our misadventure in Iraq is costing. It ignores completely the question of who actually pays. It negates democracy, rendering free speech little more than a means of recording dissent.

This is not some great conspiracy. It's the way our system works.
An indictment of both the Bush administration's reckless and failed policies, and the Democrats who chose not to stand up to him.

25 May 2007

Friday light-hearted Political Commentary

This is amusing. Monica Goodling's testimony before the Judiciary Committee brings to mind another Washington scandal involving a famous Monica. The guys at Pollster.com must have gotten a little bored:
If I were to have a daughter, that is indeed one name I wouldn't consider! Being statisticians, they can't help themselves from doing an in-depth analysis of the timing & trend.

On a more contemporary note, this made me laugh:

Memory help for Republicans!

20 May 2007

The Triumph of the IPA

There is, I believe, universal agreement that the IPA is the king of beers, Anheuser-Busch's claims to the contrary notwithstanding. As I am a proud and unabashed hophead, I love and crave a good IPA. Tonight, my Beloved Wife sent me out to the grocery store for some diapers, as we were in dire need, and I thought I might avail myself of the opportunity to get a nice brew while at the local Food Emporium. I arrived at the beer aisle: lo and behold, what sight met me? Eight different IPAs to choose from! By state, there was:

Alaskan IPA (AK)
Sierra Nevada IPA (CA)
Full Sail IPA (OR)
BridgePort IPA (OR)
Deschutes Quail Springs IPA (OR)
Widmer Broken Halo IPA (OR)
Red Hook Longhammer IPA (WA)
Scuttlebutt Gale Force IPA (WA)

Glory and Hallelujah! But then the "Paralysis of too many options" set in. They are all great beers. My eye wandered down to the import section, and I ultimately settled on an English beer, St Peter's Old-Style Porter. (Not least because it came in an unusual bottle reminiscent of an old medicine bottle.) Described aptly as thus: "Dark brown colour with ruby notes, huge frothy off-white head. Malty, slightly metallic nose with notes of dark fruit. Malty, rather dry taste, roasted with coffee, dark bitter chocolate and a dry bitterness in the finish (and again, chocolate). Chocolate and hops, how could I resist?"

A good choice. I am pleased.

The Best Chief Complaint EVER

Fear not, readers, I have not gone off-line, like so many of our brethren. I have not been posting because my domestic tranquility has been shattered, which has left me with little time or energy to blog. Indeed I have barely even looked at my email, so if I have not replied to yours, I apologize.

You see, we are moving. My Beloved Wife went house-hunting with a new colleague, Patrick, who is moving up from California to join our group. She came home to me, and the following conversation ensued:

"Shadowfax," says she, "I've found us the perfect house!"
"But Beloved," I respond, perplexed and alarmed, "I thought it was Patrick who was shopping for a house"
"Yes, but I've found the perfect house for us!" (She is very excited.)
"We already have a house."
"Yes, but you are going to love this house."
"I love the house we are living in now."
"No, you're really going to love this house."
"Oh, I see."

I think she pulled some sort of jedi mind trick on me.

So we are moving to a nicer and needlessly luxurious house (how many sinks does one really need?) and we are currently in the throes of getting our current place ready for market -- new roof, refinish the hardwood floors, millwork, carpet, paint, countertops, etc. The place is a disaster zone, and leaving for work is a blessed respite from the chaos that is my home life. In fairness, the new place will be lovely, if I survive the moving process to get there. But in the meantime I toil from dawn to dusk either in the ED or the construction site that was our home. (And it should be noted that The Beloved Wife is working twice as hard as I am with the move and full-time wrangling of two rambunctious boys.)

So as partial compensation for my infrequent blogging, I offer you this, the BEST and MOST AWESOME chief complaint ever, seen in our ED quite recently:

Monkey Bite

I kid you not. I will leave the details to your imagination as in reality they are prosaic and quite detract from the sublime wonderfulness of the simple fact that someone came to our suburban, North American ER with a Chief Complaint of

Monkey Bite

I am a simple-minded man. This gives me great pleasure. Monkeys are comedy gold. For the rest of the shift I had a smile on my face. I love my job.

12 May 2007

The Way Dogs Think

Oh My God, I have been there. I so understand this. It also made me laugh more than anything else today. (h/t Orac)

Dog: I am starving.
Me: Actually, no. You aren't starving. You get two very good meals a day. And treats. And Best Beloved fed you extra food while I was gone.
Me: I saw you get fed not four hours ago! You are not starving.
Dog: Pity me, a sad and tragic creature, for I can barely walk, I am so starving. WOE.
Me: I am now ignoring you.
Dog: Did you hear me? I am starving.
Dog: Are you seriously ignoring me? Fine.

[There is a pause, during which the dog exits the room in a pointed manner.]

[From the kitchen, there comes a noise like someone is eating a baseball bat.]

Me, yelling: What the hell are you doing?
Me: *makes haste for the kitchen and finds dog there*
Dog: *picks up entire raw sweet potato, which is what was causing the baseball bat noise, and flees for the bedroom*
Me: *chases dog, retrieves most of sweet potato, less the portion which has disappeared into dog's gullet*
Me: ...That can't be good for you. It's a RAW SWEET POTATO.
Dog: I had to do it. I haven't been fed. Ever.
Full Text Here.

10 May 2007

OxyContin fallout

OxyContin Maker, Executives Plead Guilty to Misleading Public

This is news to me. I hadn't been aware of this developing case at all, and not knowing the details I really shouldn't comment on it -- but that's never stopped me before. Since there was a guilty plea, I can only presume that there must have been wrongdoing of some sort -- corporate types tend to have good counsel and rarely roll over unless they're nicked fair and square. But as a physician, it strikes me as kind of odd. I mean, oxycodone in any form is a highly potent narcotic and of course is has significant addictive potential, especially once you get in the higher dose range. Any doctor who claims not to have known that is lying or criminally incompetent. The use or misuse of these drugs (and they do have very beneficial uses) is entirely the responsibility of the physicians who prescribed them. So again, I guess the company must have done something wrong, but it really is hard to conceive of any behavior on their part which would materially have mitigated that responsibility on the part of the prescribers.


09 May 2007

Moving the Meat (Part Two)

OK, this is a little off the intended path of discussion, but ERNursey asked so nicely I can’t deny her . . . I was intending to focus on how the ER doctors can make themselves more effective at moving the meat, but as she and Anon point out, a huge part of this is the hospital side. If you board an admitted patient for, say, 12 hours, which is not uncommon, you are losing that bed from the pipeline through which you have to move the rest of your patients. Had the patient gone upstairs expeditiously, you could have pushed four more patients through that bed; they remain in the waiting room, increasingly pissed off and possibly sicker.

So what is it that effective hospitals have done to address the problem?

Caveat: none of these items is free. All generally involve resources, either administrative, staffing, or physical space. If your hospital it telling you that there are no resources available of any sort to address ER overcrowding, you are behind the eight-ball. Your best bet is to make the compelling argument that ER crowding is a hospital problem and try to get them on board with a system-wide improvement plan. Any plan that involves only the ED is going to fail.

I think of it this way: in order to admit a new patient, several events need to occur.

  1. The Bed: There needs to be an empty and ready bed upstairs.
  2. The System: The bed needs to be flagged as available and assigned to a new patient
  3. The Transfer: The patient, and care of the patient, transfer to the new unit

The Bed:
The bed needs to be empty ASAP. This means that the patient previously occupying the bed must be discharged, and the earlier the better. Engage the hospitalists and encourage them to do discharge rounds earlier in the day or more than once daily. Develop clinical paths to shorten hospitalizations. Employ discharge planners on the floors to identify patients who could be discharged but have not been, to find alternative facilities for patients who no longer need acute hospitalization (i.e. rehab or nursing homes), and to generally expedite the discharge process. Once the former inpatient is gone, turning that bed over needs to be a priority. Create rapid response teams in the Housekeeping corps to priority-clean open beds ready for patients. The hotel industry is the ideal model for this sort of program.

The System:
An empty bed does you no good if nobody knows it is available. There should ideally be a patient tracking board to make administrative staff aware the bed is ready; there are electronic products that do this already, or a clipboard/grease board still work. Sometimes the nurses on the floor delay notifying the supervisor that a bed is ready because they do not want to get another patient right away. There should be a single individual tasked solely with the mission to assign beds and shuffle patients to optimal utilization. We call the role the “Bed Czar.” This person should be roaming the hospital at all times keeping his/her finger on the pulse of bed availability. Traditionally this has been done by a nursing supervisor along with other administrative tasks; more recent thinking is that bed assignment at a medium-size or larger hospital is a big enough task to require a dedicated individual.

The Transfer:
Once a bed is ready and assigned to a patient the transfer still has to take place. Nursing leadership is essential in expediting this function. The ritual of “report” is almost sacred among nurses, but is itself one of the biggest barriers to the transfer. How many times is it that a transfer is delayed because the floor nurses are in report or about to take report? Or you can’t find an ER nurse to give report because they are engaged in patient care? There are many creative solutions and I do not presume to have an opinion on the relative strengths of each. The ED nurse can fill out a report form and fax it to the floor. Or you can have the nurse give a bedside report upon the patient’s arrival to the floor. Or there can be a designated “Admission Nurse” on the floor to accept all new admissions regardless of other activities on the floor. Also, staffing an “Admissions facilitator,” ideally a nurse, in the ED can provide many functions to expedite the transfer: calling report, bugging the doctor to write orders, communicating with the Bed Czar to orchestrate the bed assignment, etc. It’s hugely helpful in my experience. And last but not least, the patient does need to be physically moved upstairs, and if you do not have transportation techs, that too will slow you down. Make admits priority pages for transportation.

Ultimately none of these items will solve the problem if your hospital is just too small. But they will, especially if engaged as part of a large-scale efficiency program, allow you to get the maximum utilization of the resources that you do have. There are other creative solutions, like having an “Express Admissions Unit” which is a euphemism for a holding area for admitted patients. Or having a subunit for discharged patients awaiting their final release. Anon suggested just moving the patients upstairs and parking them in the hallways. Tempting as that sounds, it’s just passing the problem along. What I have outlined above will provide solutions (or partial solutions) to the problem. This is not really my area of expertise – it’s just what I have gathered listening to our hospital leadership team work on our system. Take it with a grain of salt, and remember that free advice is usually worth about what you paid for it.

Moving the Meat

In our ED, it’s all about throughput. We have a smaller ED than we might in an ideal world, and as a result, we need to eat, sleep, and bleed efficiency. We are not alone in that on a routine basis the demand for our services exceeds capacity. In fact, the Institute of Medicine released a groundbreaking report last year called “Emergency Care: at the Breaking Point.” In that report, a bleak picture was painted of the overall state of Emergency Departments nationwide. The trend is towards increased demand and reduced capacity – ED visits have increased by 20% over the past decade to 110 million visits annually, nationwide; there has been a net loss of hospitals and EDs with a net loss of about 10% of national capacity. The result is that in most EDs nationwide, the same scenario plays out on a daily basis: overcrowding, patients with extended stays in the waiting room, patients being treated in the hallways, etc. It is not just at academic and county hospitals any more – the problem has spread out even to relatively affluent community hospitals. This is not just a customer service issue; at every facility at which I have worked, there have been cases of patients dying while waiting to be seen. It is impossible to know certainly on an individual basis, but the inescapable conclusion from a systems management point of view is that these are preventable deaths, and we as a specialty need to take ownership of the issue and develop solutions.

In our ED, we are limited by external factors. We cannot increase the physical size of our ED, at least not in the short term. We cannot do anything about the nursing staffing levels, which are determined by larger market forces. All we can do to decompress the waiting room is to embrace the religion of throughput and strive to maximize the operational capacity of our department. The way to do that is by reducing length of stay.

It makes sense, if you look at it in a quantifiable way. Each ED bed is good, theoretically, for 60 patient-minutes per hour. In a hypothetical ED with 45 beds there is a theoretical capacity of 2700 patient-minutes per hour. If the average length of stay is 180 minutes, the expected throughput rate is 15 patients per hour. If the average length of stay can be reduced to 150 minutes, the effective throughput rate rises to 18 patients per hour, and the effective size of your department has been increased by 20%.

This has to be a team sport. Our efficiencies have been captured in large part in partnership with the hospital. Other service lines, like lab and housekeeping and central supply, have been engaged and have worked on improving the rapid turnover of ED services. The administration has worked to create “express admission units” and staffed admission facilitators in the ED to move admitted patients upstairs in a more expeditions fashion. These are essential elements of any efficiency program. But the ED physician remains the quarterback of this particular team, and without a motivated and effective leadership presence from the ED physicians, the initiative is unlikely to gain much traction.

Thus, over the next few days (weeks?) I will be running a series of posts on the topic of efficiency from the perspective of the ED physician. I started to write it as a single post, but it started getting too long, and longer yet as I started fleshing out ideas, tips, and tricks to generating rapid turnover in the ED. So I will break it down into a series of shorter posts. Stay tuned.

A Variation on the Theme...

Of the "Advice to Interns" series. I didn't write it and don't know who did (though I kind of wish I had written it). A snippet:

Advice from an ER doctor to drug seekers

OK, I am not going to lecture you about the dangers of narcotic pain medicines. We both know how addictive they are: you because you know how it feels when you don't have your vicodin, me because I've seen many many many people just like you. However, there are a few things I can tell you that would make us both much happier. By following a few simple rules our little clinical transaction can go more smoothly and we'll both be happier because you get out of the ER quicker.

The first rule is be nice to the nurses. They are underpaid, overworked, and have a lot more influence over your stay in the ER than you think. When you are tempted to treat them like shit because they are not the ones who write the rx, remember: I might write for you to get a shot of 2mg of dilaudid, but your behavior toward the nurses determines what percent of that dilaudid is squirted onto the floor before you get your shot.

The second rule is pick a simple, non-dangerous, (non-verifiable) painful condition which doesn't require me to do a four thousand dollar work-up in order to get you out of the ER. If you tell me that you headache started suddenly and is the 'worst headache of your life' you will either end up with a spinal tap or signing out against medical advice without an rx for pain medicine. The parts of the story that you think make you sound pitiful and worthy of extra narcotics make me worry that you have a bleeding aneurysm. And while I am 99% sure its not, I'm not willing to lay my license and my families future on the line for your ass. I also don't want to miss the poor bastard who really has a bleed, so everyone with that history gets a needle in the back. Just stick to a history of your 'typical pain that is totally the same as I usually get' and we will both be much happier.
Full text here. Obligatory disclaimer, in response to some of the more, um, passionate comments: I do not necessarily endorse the above in any respect. I just think it's hysterical.