29 February 2008

Pharma Shenanigans

Some of you may remember that a few months ago I was interested in trying out Provigil, a medication that's FDA Approved[tm] for shift work sleep disorder (whatever that is). I was surprised to learn how expensive it was -- about $10 a pill, and my insurance did not cover it.

Funny story. Turns out that its maker, Cephalon, was playing some funny games to prop up the price, quite possibly illegally. Details over at my blog on MedPage Today.

Oh, and the Provigil? It worked great. I was mentally sharp at 0300, no headache or hangover, no jitteriness. Something akin to a wonder drug, I thought.

But it gave me hives. So much for that.

28 February 2008

Jon Arbuckle, Post-Modernist

Garfield, without Garfield, becomes, in the author's words, "a comic about schizophrenia, bipolar disorder, and the empty desperation of modern life ... a journey deep into the tortured mind of an isolated young everyman as he fights a losing battle against loneliness and methamphetamine addiction in a quiet American suburb."

It must be seen to be believed.

I am not this cool

But I wish I were.

These great tats are sported by a remarkable young man who started as an ER tech in our ER, went on to become a PA, and subsequently went on to work for (what else?) a cardiology group.

Bonus points if you can identify the abnormalities in each tat. Dr Wes, you are disqualified from the contest.

I can't say it better than this

The difference between FDR's America and GWB's America.

From Andrew Sullivan.

26 February 2008

Speaking of Aviation

This is a great way to lose your job:

Story here
. Backstory and comments here.

Moral of the story: don't scare the crap out of the Chairman of the Board.

Much better video here; damn -- they stayed at 50 feet the whole 8000 foot length of the runway! Some nice pics here. Note in the background you can see a couple of Dreamlifter large cargo freighters parked -- they're chop-job 747s, grotesquely enlarged, used to ferry parts for the 787 around the world. Possibly the ugliest things flying.

Transplant surgeon charged in patient's death

Ouch. This is going to be chilling for the transplant community. To be sure, it sounds like there were protocol violations, and that the surgeon needs a refresher on the importance of meticulous ethics in organ harvesting. But a felony? You've got to be kidding me.

The Sequel

As follow-up to my post on error management in medicine, I dissect my own error for your education and edification and gratification...

Read it over at MedPage Today.

Death from Above

It's been a bad week to be in the air.

Scalpel and his commenters pretty thoroughly covered the case of the woman who died en route from Port-au-Prince to New York, and I don't have much to add to their comments, except to agree that oxygen probably would not have made the critical difference between surviving and not. While all health professionals tend to grit our teeth whenever we read lay media reports of medical care, it's particularly cringe-worthy that numerous media reports describe the AED as "malfunctioning" or broken. If it didn't fire, it's because the heart rhythm was not VT or VF. That is not a failure of the device -- it's working as designed.

I'm presuming the pads were properly attached. I once saw someone try to put them on over the patient's clothing. Not gonna work.

Erik pointed out a link to a really cool gadget which allows remote telemetry and diagnostics. I could see wearing it in the ER if all that data was displayed on the wristband. It's like a tricorder, almost. But looking at the pics, I suspect that the data would be available only to the remote consultant, which is a bummer. (Hey, that might be a neat moonlighting opportunity.)

I recall when I had to perform rounds on sequential trans-atlantic flights, it was maddening because Olympic Air didn't even have an AED; Delta did have one, but there is no display, so I couldn't even see a rhythm (a key limitation, since the patient's pulse was about 160).

In an unrelated but oddly coincidental story, a co-pilot of a British Airbus A320 died in flight on a trip from Manchester to Cyprus, forcing an emergency diversion to Istanbul.

It's a little surprising and different from the first story, since the passenger was known to have heart problems, whereas the pilot was young and healthy. I don't know as much about England's CAA medical standards, but the FAA is relatively stringent with regard to a First-Class Medical required to pilot large jets -- any history of Coronary Artery Disease or Diabetes will get you grounded. There are provisions for getting your ticket back, but it requires excellent control and rigorous documentation. The net result is that as a group, professional pilots tend to be much healthier than most. Which makes an episode of sudden death that much more surprising. Maybe he flew so much he developed a DVT and died when the blood clot went to his lung. We'll never know; lotsa things can kill you quick. Sad for his family.

Curiously, it was almost exactly a year ago that the same thing happened, only it was in the US, and the captain, not the first officer. I wonder how often that sort of thing happens?

25 February 2008

Don't let the lawyers win!

Sorry for the extended silence. I had family in town and was working and my three-year-old had a birthday party, so I've had not a second to sit down and think, much less blog. Life is getting back to normal now, so hopefully I can get back to a regular publishing routine.

I hate to return with some bad news but here it is:

Though I have hit my goal in St Baldrick's donations (yay!), Jim II, self-righteous frequent commenter, and notorious shyster lawyer is closing in on me!

Apparently, this shameless parasite has reached out to his well-heeled friends in the -- grr -- legal community -- and is using their ill-gotten monies to try to topple me off my throne as highest fund-raiser for Nathan's Network. Now, this isn't about ego, and it isn't about me. It's about the honor and integrity of those of us in the health care professions. We simply cannot allow the lawyers to outdo us!

So, I beseech you, please, take a moment, dig deep, and click on the link below to make a donation to Nathan's Network, and send a message to the Trial Lawyer's Association: we doctors, nurses, and allied health care professionals are morally superior to you.

Oh, yeah, and erm, support the kids. Them too.


19 February 2008


Ooops. I almost forgot. My latest musings can be found over at MedPage Today:

I made a mistake recently, a fairly serious one. We don't much like to talk about our mistakes in medicine; when they're not so obvious that the lawyers get involved, or if they aren't so egregious that they get sent to the medical staff quality committee, then they tend to get swept quietly under the rug.

More after the link

Diurnal variation

I'm always fascinated by the changes that occur in the course of the daily rhythm. It comes, I suppose, from working in an industry that is staffed 24/7. The daily life of an ER is predictable and cyclical, illustrated above in an old graph (2004) of daily registrations at one of our ERs. 7AM: the place is pretty quiet; clean up a bit and roust out the drunks. 10AM: the ambulances start rolling in. 2PM: getting overwhelmed. 8PM: fully overwhelmed Midnight: starting to dig out. 4AM: dead.

One thing I had never thought to look at is the likelihood of surviving cardiac arrest, by time of day. Apparently, according to a study released today in JAMA, patients who have an arrest are more likely to die if it occurs on the night shift or weekend. That makes sense, I suppose. Since there are fewer scheduled admissions during those hours, the staffing levels are lower; the experience levels of the nursing staff tends to be lower, since more senior nurses tend to grab the day shifts; and the normal human functional nadir occurs around 0300. So the likelihood of noticing a patient going into arrest is slightly lower, the delay in calling the code is longer, and the time required to assemble a full team is longer. I haven't read the full study, but on quick review it seems very reasonable to me.

But that's only true for inpatients. Apparently, in the ER, your survival rate is the same regardless of time of day. That probably has to do with the ER's ability to rapidly respond to, well, emergencies. The entire team is there, including the doctor, there may be some advance warning from EMS, and while we too are not at our best at 0300, the workload is lower and we are able to quickly jump on emerging situations.

Interesting study. I'll have to read it later, but for now I'm off to my own night shift.

17 February 2008

Sponsor my scalp!

Just in case anyone has forgotten, I'll be shaving my head on St Patrick's weekend as part of a fund-raiser for pediatric cancer research.

I'm really close to my goal of $10,000 -- at about $8200 as of this writing. I can use every little bit towards my goal; no amount is too small or too large to help. So if you are reading this, I ask you to consider clicking on the link and contributing a small amount towards a cure for all variety of cancers that strike down kids.

I am doing this in memory of my friend Nathan Gentry, who lost his battle with neuroblastoma this past summer, and also in honor of Henry, who is as you read this an inpatient at Johns Hopkins getting a bone marrow transplant for medulloblastoma.

Whatever you can give is appreciated -- even just $10, $25, or $50. Some readers of this blog, people I have never met in person, have donated as much as $500! I'm overwhelmed by that sort of generosity. But I don't need big donations to hit my goal. I'm so close that even just a dozen modest gifts will put us over the top. Will you be the one to step up to the plate? I hope so.

Here's how it works: you click the image below. It takes you to my page on St Baldrick's website, and you can make your secure, tax-deductible donation by clicking the "Donate Online" link. Then you feel the warm tingly goodness of karma suffuse your body, and in a few weeks, I send you an email with an image of my pristine, gleaming scalp, and you get to chuckle at how goofy I look.


I'm already over $9,000! You guys rock!

If for any reason you have trouble with, or are uncomfortable with donating online, you can call the Baldrick's phone number and donate over the phone. The number is (888) 899-BALD. Happy donating!

Ice Hotel

This is amazing -- stunningly beautiful. A hotel in Sweden built entirely out of ice. I wish I could visit, though it's as cold as a witch's teat, it is.

More photos here.

15 February 2008

Get ready for that 10% cut

This doesn't sound good.

Commentary: Senator Baucus is annoyed at the AMA, so he banned them from the hearings which will determine whether the 10% cut in Medicare professional reimbursements will be delayed/canceled. You may recall that, once more, Congress reached an eleventh-hour deal to postpone the cut in December, but only for six months, instead of the more typical one-year reprieve. So the issue needs to be re-visited this spring. My reflex is to get all indignant that our voice won't be heard at the table, but it's really not a big deal. The AMA is a terribly ineffective advocate for physicians on Capitol Hill, there are plenty of other advocacy and specialty groups to speak for us, like the AARP, and the position and needs of physicians are well enough known that the AMA, while not exactly superfluous, is expendable in this case. If it appeases Baucus to make the AMA the sacrifical lamb this year, it's worth it.

More concerning: "House Ways and Means Health Subcommittee Chair Pete Stark (D-Calif.) on Thursday said that he doubts Congress would be able to find the money for a patch and that the cut would go into effect." Ruh-roh! I don't know too much about Pete Stark, except that his name is on a piece major legislation that greatly complicates and restricts the financial relationships between physicians and hospitals. He does not seem open to the needs of physicians; though, FWIW, he is quoted as saying that they want to take a comprehensive look at creating a whole new payment system. It sounds kind of scary to me, but if he's looking at fixing the SGR, we need to make nice to him and keep him on our side.

If the 10% cut goes through, it will be an unmitigated disaster. There will be a lot of Medicare patients who do not have doctors. If there are any readers of this blog who live in CA-13, the Oakland area, I'd make it a point to give a call to Rep Stark's office or send him an email.

For that matter if you live in any of the districts represented by the W&M Health members, give their office a call. Be polite and make sure they know how concerned you are that access to care for Medicare beneficiaries will be severely impacted by the 10% cut.

Baucus, for what it's worth, does seem more attuned to the need to stop the cuts in the short term.

Performance Improvement, part three

I've written about the operational crisis our ER built up to over a series of several years, and the general themes of the turnaround plan we developed. Today I'd like to break it down into a little more granular level of detail, and address the "process analysis" and improvements we developed. It has been said that in the average ER seeing 20-30,000 patients annually, you can just let things happen and, provided adequate staffing, the patient flow will remain adequate. But patient flow is analagous to fluid dynamics, wherein the resistance to flow increases exponentially with flow rates: as an ER scales up, the friction increases disproportionately to the point that process break down and stop, unless they have been carefully engineered.

Our ED was using the same old ad hoc processes we'd had for a decade or more. We had a white board to keep track of the patients and order status, paper charts, paper orders, and a free-floating staffing model. Stone age.

The first thing you do when re-engineering the core processes is to flowchart it: in its simplest form, this exercise consists of putting each essential step on a post-it note and laying them out in the sequence they occur. You identify the rate-limiting steps, and try to identify inefficiencies, such as tasks done in serial which could be done in parallel, or a low-value but time-consuming step being performed before a high-value step.

One example is registration. It's crucial and necessary, of course, but adds nothing to the visit from the standpoint of patient care. Yet for some reason registration was traditionally performed before the physician's assessment, sometimes even before triage! For most patients, there is a lot of "down time" while the assessment is underway when the registration can be performed. So one new process was to do a "quick reg" consisting of name & DOB on patient arrival, just to get them in the computer, and later, the registrar would come back to the room with a portable computer to complete the data acquisition. There was a lot of cultural resistance to this, but it removed a key choke point.

For us, the limiting factor over-all was and is the size of our ER. We have 50 beds, but that may not be the best way to define the size of a facility. I think of it more in the sense of an ER's "Virtual size." Given that there are, for each bed, 60*24 = 1440 bed-minutes per day, the functional capacity of our ER was 50*1440 = 72,000 bed-minutes. At an average Length of Stay (LOS) of 260 minutes, the operational capacity of the unit was 276 patients/day. Our annual census of 100,000 results in average volume of 273 patients/day! We were operating exactly at our full capacity, in fact over, since patients present in surges depending on time of day and day of the week. We "created" extra beds by sticking patients in the hallways, and leaving patients in the waiting room until the daily surge tapered off after midnight.

Given that new beds were not in the budget, the challenge became this: how can we reduce LOS and by doing so free up some operational capacity and increase the "virtual size" of the ER?

Throughput. It's all about throughput efficiency. This has been the major challenge of my administrative career, and is why this blog is titled "Movin' meat," since the topic is always on my mind.

So: attack the bottle necks and wasted time.

Triage. A good triage takes maybe ten minutes, including documentation of the irrelevant information the Joint Commission requires us to collect. During peak hours, 10-15 patients present through the front doors. One triage nurse cannot handle that sort of volume. So we added staff in triage, flexing up and down, to triage 2-3 patients simultaneously.

Waiting room time. When patients are in the waiting room for an extended time, it makes sense to initiate the work-up from triage. This can be done effectively through the use of standing orders. At a higher cost, more complete work-ups can be initiated by staffing a midlevel provider such as a PA or even a physician at triage. Some fraction of patients can even be discharged directly from triage. It greatly increases patient satisfaction. However, the payroll cost of this measure is generally not offset by any increase in patient fees, and care can become somewhat fragmented when different providers begin and conclude the work-up.

Initiating a standard order set, including labs and x-rays, while patients are in the waiting room can speed things up very effectively, since by the time the patient is placed in a bed there may well be results on the chart, expediting the disposition. This requires additional resources (phlebotomy, e.g.) at triage, further reducing resources in the main ED. The most time-consuming tests, like CT scans, are generally not included in triage protocols, for good reason, which places an upper limit on how much utility can be extracted from waiting room time. There is also often provider resistance to standard order sets; each doc likes to do things his or her own way and in some cases can sabotage the protocols by complaining and decreasing nursing compliance.

All of these interventions lose value dramatically if and when the patients stop spending significant time in the waiting room. Ultimately, the ability to utilize the waiting room time is limited by the absence of a attending provider to personalize and direct the care. When there are unavoidable waits it makes sense to use the time as best you can, but for maximum efficiency it is best to find a way to eliminate the wait and bed patients immediately.

Bed-to-physician. Wasted time; worse than "waiting room time" because the patient is wasting valuable bed-minutes. I'll discuss closing this time gap later.

Order entry. Tends to be idiosyncratic to each institution. In an ideal world, one-click physician order entry would be ideal. Technical challenges preclude that for us, and we remain with a kludge-y paper-based workaround. But the time between the entry of the order and its implementation can be significant if not well-designed.

Lab and X-ray. Creation of dedicated lab tech positions in the ER to enter the orders, draw the blood, and act as gatekeeper of results resulted in quicker turn-around time (TAT) for lab results. The use of point-of-care testing such as iStat, iStat troponin, urinalysis, and blood gasses in the ER can greatly decrease the TAT until you get the most critical lab data resulted. However, this requires buy-in from the pathologists, often skeptical of these devices, and dedicated space in the ER. It's a thing of beauty to see a patient with chest pain, have an ECG and Troponin in hand, and be ready for dispostion in ten minutes. For us, x-ray was not a significant delay. Digital radiology with 24/7 wet-reads by a large local group, communicated by fax/phone prn, left little room for improvement on this front. Your mileage may vary.

Disposition to departure. This falls into two main subgroups depending on the patient's destination: home or an inpatient bed. Patients going home are typically not too much of a challenge, though some patients with social challenges (i.e. need a ride, still drunk, etc) can have an extended epilogue to their ED work-up. Making this a focus and having pro-active nurses to prompt the doc to discharge the patient can help, but it's not usually a make-or-break point. We have experimented with having discharge planners in the ED. It can help, but honestly, they tend to spend most of their productive energy upstairs on the wards.

Admitted patients, however, are a huge problem. Admit-to-bed times can be 120 minutes or more, and in an ER with 30+ admissions daily, you can see how that cannibalizes the availability of ER beds for new patients.

I'll leave aside for the moment any discussion of "patient boarding," which is a much bigger and more intractable issue. When there are no inpatient beds, or no ICU beds, patients will just reside in ERs nationwide, sometimes for days. The solution to that is more beds, more staff, more hospitals. Not forthcoming any time soon. I'll limit this discussion to the "normal" hospital which has inpatient beds but it typically slow in finding them.

Institutional Commitment
The most important and difficult step to solving this is getting buy-in from the rest of the hospital. Modern American healthcare institutions tend to devolve into a bunch of petty feudal fiefdoms with very limited interests beyond the end of the hallway. The inpatient wards tended to view ER overcrowding as an ER problem. They didn't see their units as having a role in the cause or the solution to ER congestion. That is a mindset which is difficult to change and requires hospital leadership to take charge and make ER congestion a hospital-wide issue.

There must be centralized authority in one person for bed assignment and turn-over. Historically this resided in some sort of "head nurse" or "Nurse Supervisor" who bear a host of administrative responsibilities. But in a large facility, this is a big enough job to dedicate one person to. We euphemistically call this person the "Bed czar," and he or she has power to determine bed placement, shuffle patients around, overflow into other units, and act as a gadfly to inpatient nurses and ancillary services to be ready for incoming patients. Medical staff need to be prompted to make "discharge rounds" the first daily priority, and housekeeping needs to be organized into rapid response teams to turn over vacated rooms immediately. Major hotels do this better than anybody, and the medical industry can learn from their processes.

Other barriers to overcome include the tradition of "calling report," which takes forever. The accepting nurse is busy, or on break, or "can you call back in 40 minutes because it's change of shift and we're giving report?" But it can be replaced with a faxed report, or bedside report, or designating an inpatient nurse as the "admitting nurse" for all ED admits. And maybe the bed is ready but there are no physician orders on the chart. Or the admitting doc wants to keep the patient in the ER so they can come ans see them there. On and on and on. In our ED we have a RN dedicated to being the "admissions facilitator" whose entire job is to keep tabs on all the patients designated for admission and knock down the obstacles to getting them upstairs.

Most controversial is a process of boarding hallway patients in inpatient hallways. This is a new concept, endorsed by the Joint Commission as a strategy to ease ED overcrowding.
It's likely to incite civil war wherever implemented, but the theory is sound -- an admitted patient is less vulnerable in an inpatient hall bed than in a chaotic ED hall bed, and nothing motivates the inpatient team to "find" a bed than the threat of a hallway patient. We've not had to implement this plan, but it exists, and in any crisis remains our ace in the hole to decompress the ED.

I'll leave off there for the moment, though so much more could be said on these few topics. Already I grow long-winded. Tomorrow I will write about the new management philosophy that the ED team developed, and when I say "tomorrow" I probably mean "in a week or so" since it turns out that these posts are time-intensive to write, and I may, just may, choose to spend some time with my kids this weekend instead.

Indulge me on this....

14 February 2008

Massachut... er, Massatchus, um, MA Health Care Plan

I've heard Kevin's criticisms that a universal health plan like the Massachusetts plan will do little to increase access to care so long as the number of primary care providers remains static (and probably inadequate even before universal health), and I agree with him. This is a consequence of the slow auto-amputation of primary care in this country, itself a consequence of the systematic underfunding of primary care. I couldn't agree more that it's a tenacious problem.

But it's not a problem due to universal coverage. Universal health is a partial solution, not a panacea.

One element of the MA plan that appear to be working as designed is that it has apparently reduced the burden on the regions emergency departments. The report indicates that the number of unfunded ER visits is down nearly a third. It implies that patients are not seeking care for non-emergent complaints, but does not back up the claim, and I rather suspect that the formerly indigent patients continue to use the ER for routine care as there are not enough PCPs for them. But, as an ER doc, I can take some satisfaction that "we" are at least now getting paid for those services, which will reduce the need to cost-shift the expense onto better-funded patients.

Ezra blogs over here
about the fiscal controversy surrounding the plan, perhaps best summarized as "it's a victim of its own success."

11 February 2008

I'm so happy I don't work in Buffalo

Nothing against the city, mind you. I've visited. A lovely town, with scenic Niagara Falls right there, some lovely casino resorts across the river in Canada (a whole 'nother country! Who knew?), and no shortage of snow.

But the other night, when they brought in an NHL player with a severed carotid artery suffered in a bizarre on-ice accident, well, I rather suspect the ER doc who was on duty wound up needing a new set of shorts.

Did I mention that it was his Carotid Artery? You know, the one in the neck? (We call it "Big Red.") And it was severed.

Technically, it was only lacerated. The vascular surgeon, Dr Sonya Noor commented that if it was severed, it would have retracted and been technically much more difficult to repair. They had his common carotid cross-clamped for fifteen minutes or so (thank god for a patent circle of willis in a young non-atherosclerotic patient!). Either way, it bled a damn lot.

I've seen my share of vascular injuries. They can be pretty scary. Multiply the stress level by a factor of ten when it's in the neck, and another factor of ten when it's a pro athlete, a celebrity of sorts. If I don't misread the AP report, did he get a trach? I would hope not, but with neck injuries you never know. He's a lucky guy.

The surgeon commented that the artery was "a normal, beautiful artery," which might mean that, unlike most of the vessels she sees, it wasn't crusted with cholesterol and calcium, but also brings to mind the last couple of sharp, penetrating vascular injuries I have seen -- both of them femoral. In both cases the surgeon commented, marveling, that the kitchen knife (or whatever) used to cut the vessel created a cleaner, nicer edge than he was ever able to get using a scalpel in surgery. I guess the soft tissues around the artery bolster it enough to produce that nice crisp cut. Funny.

Man, not the sort of injury you associate with pro sports (even hockey!). Nice job by the ER and surgical team.

And I'm still glad it wasn't me!

A Nasty Little Game

Pretty simple concept. You're a virus, and you can mutate, acquiring and shedding characteristics of transmissibility, lethality, and visibility. You need to spread to get a toehold on every continent before the world community closes the borders. Choose your attributes carefully -- become too lethal, too quickly, and you'll fall victim to a quarantine! You win by eradicating mankind.

Not terribly realistic, of course, but realistic enough to be a little scary. I think in fact the game's logic underestimates how rapidly a highly infectious disease would spread worldwide (SARS, anyone?) and overestimates how effective "closing borders" would be. Fortunately, the lethality component also is overstated, but then, what fun is it being a virus if you don't get to depopulate the globe?

Via Richard S Matthews.

Parody (Politics)

You've seen the original Obama tribute by will.i.am, now here's the inevitable McCain parody...

A Tough Call

I was explaining to the mother of a child with a runny nose and fever, that antibiotics were not likely to help her child's viral upper respiratory infection, when the nurse pushed her way into the room. "Sorry to interrupt, Dr SF," she said, "but I've got medic 6 on the line with a cardiac arrest and they need you right now."

Read the rest over at MedPage Today.

09 February 2008


Looks like Obama swept all three states today, as did Huckabee. My experience in the WA caucus was pretty amazing. In 2004, the caucus was large and busy; this year there were about four times as many people there. We were in a local union hall, and the turnout could have filled the room several times over. There was no parking within a mile or so. They wound up moving several precincts off-site somewhere; I'm not sure where. Rumor is there were over 200,000 participants. The Obama fervor was remarkable; in our precinct we could barely find anyone to deliver a pro-Hillary speech, and in the end, our precinct went for Obama 6-1; several friends of mine came back from their caucuses with similar experiences, and similar margins of victory for Obama. One friend, in Seattle proper, had a closer ratio, only 3-2 for Obama. The SLOG, NW Progressives and Horse's Ass report similar experiences. Looks like the final will still be pretty resounding with a 2-1 ratio for Obama. Not just a win, but a blow-out, which is nice; Obama was expected to win, but to win by such a decisive amount can build some serious momentum.

As for myself, I got elected as a county delegate, and one resolution I hope to advance will be to drop that idiotic frigging caucus system and go to a primary. I may be pleased because my guy won today, but my wife was at a birthday party with the kids and didn't get to vote; several of my partners were similarly disenfranchised, as they had to work. It's a profoundly undemocratic way to pick a nominee.

On the other side of the fence, with Huckster beating Walnuts in all three states, though only one in a blowout. Maybe conservatives are signaling that they are not on board with the McCain coronation? I doubt it can be detailed at this point, but "A" for effort, guys!

05 February 2008

Malpractice and John Ritter

Kevin and Dr Wes linked today to a news piece about John Ritter's case going to trial. To summarize, he experienced chest pain, dizziness and nausea on the set of his sitcom, was taken to a hospital, and subsequently died from a ruptured Thoracic Aortic Dissection (TAD).

It's always hazardous to try to read between the tea leaves and decrypt the media reports. But it's a lot of fun; there appears to be plenty of data out there at this time, so let's see what we can sort out from the available sources.

The first thing that jumps out at me is that Ritter was apparently diagnosed with a heart attack and taken emergently to the cardiac cath lab. One report states that "Around 7:15 p.m., a test showed abnormalities ... consistent with a heart attack. [The cardiologist] was at Ritter's bedside at 7:25 p.m." My interpretation of this is that most likely the ECG showed a ST-Elevation Myocardial Infarction (STEMI). That's the thing that gets you a cardiologist in 10 minutes. It's possible he just had an normal/nondiagnostic ECG with an elevated Troponin, indicative of a non-ST Elevation MI. This is generally less urgent with regard to treatment, but I suppose a movie star would get the VIP treatment with a cardiologist at the bedside in 10 minutes.

A point of contention was whether a Chest X-Ray (CXR) should have been done before Ritter went to the cath lab. The answer is debatable. If it was a STEMI, there is clear and compelling evidence that the door-to-balloon time is essential to outcomes, and many institutions dispense with the CXR in these cases, if it would delay cath. The diagnosis of STEMI is made on ECG. CXR adds little to the work-up. The plaintiffs allege that a timely CXR would have made the alternative diagnosis of a ruptured TAD. However, a CXR cannot be diagnostic of TAD; it can suggest it, but the vast majority of TAD cases show an non-specifically abnormal CXR. Even a CXR highly suggestive of TAD would require further tests to confirm, before treatment could proceed. The follow-on tests of choice would be a CT scan -- or a cardiac cath, which Ritter got.

On that basis, I think the plaintiff's allegation that failure to accomplish the CXR as ordered was responsible for his death is not substantiated. It was definitely not negligent, and probably would not have altered the outcome.

Another allegation was that the cardiologist's decision to anticoagulate Ritter with heparin, a blood thinner, was negligent and contributed to his death. Certainly, if he was bleeding already, a blood thinner would make it much harder to save him. The talking point their attorney uses is that he got "the exact opposite" of what he should have. In retrospect, that's true enough. But was it negligent? The American College of Cardiology's management guidelines for MI state, "Antithrombin therapy and antiplatelet therapy should be administered to all patients with an acute coronary syndrome regardless of the presence or absence of ST-segment elevation." The treatment Ritter got was standard for an MI; the question of negligence hinges on whether it was negligent to treat on the presumption that Ritter was having an MI.

MI's are very common. There are over 600,000 diagnosed annually, or 2 per 1000 Americans. Ritter was high-risk for an MI; he was 54, had high cholesterol, and was male. He may have had other risk factors; we don't know. MI is the number one killer for men Ritter's age, and there was evidence to suggest this was an accurate diagnosis. TAD, conversely, is terribly rare. A ruptured TAD occurs at a rate of about 5-10 per million Americans annually, with 2000 cases annually in the US. So it's several orders of magnitude less common than an MI. About 2% of these cases present with a myocardial infarction at the same time. So a back-of-the-envelope estimate would be that there are maybe 20-100 cases like Ritter's annually in the US. Contrast that with the 600,000 "standard" MIs. It's very, very, very rare, and notoriously difficult to diagnose. Patients with TAD can present with many different varieties of chest pain, or no pain at all.

The textbook answer is that doctors have to maintain a "high index of suspicion" for TAD. True, but how high? It's irrational and impossible for every patient with an MI to get a CT scan before cath. The dye alone would kill their kidneys, and the delay in revascularization would contribute to measureless death and disability.

Given that Ritter had a very rare disease, which presented mimicking another emergent diagnosis, it's very hard as a doctor to view the cardiologist as negligent. Most ER docs hear this story and say, "Thank God that wasn't me, because I would have done the exact same thing." Which is really the opposite of negligence, isn't it?

Finally, when it comes to causation, the critical question of "did the doctors' treatments cause or fail to prevent" Ritter's death, one thing should be taken into account. A ruptured TAD has mortality of 80%, and even with treatment, in the best cases, the operative mortality remains at 20% (which includes elective repair of non-ruptured aortas). He presented contemporaneously with the rupture; it would have been difficult under the best circumstances to save him. Ritter was unlucky enough to have a very rare and very deadly disease. His untimely death was sad. But the limited evidence at hand does not suggest that medical negligence contributed to his death.

Which begs the question -- if there was not negligence, then why have nine other entities settled for a total cumulative settlement of $14 million?

Because juries are not qualified to make the determination as to whether there was negligence. They are laypersons with limited knowledge of medicine, diagnosis, or statistics. They are swayed by the pathos: the suffering of the widow and small children, the sadness of the loss of a beloved star, and the righteous anger of the family who believe the doctors killed their loved one:

"You can't treat my kid's dad for something and kill him in the process," [Ritter's wife] said. "I think the money will show how angry the jury will be about what happened to John and what could happen to them."

They will listen to grey-bearded professors contradict one another, flip a coin as to who was more credible, and issue a verdict. And the plaintiffs are swinging a big stick -- a $67 million one. If you lose, you lose very big. Safer to settle for policy limits and walk away, rather than take that downside risk.

And the lay population wonders why doctors are cynical and mistrusting of the medical malpractice system.

04 February 2008

A Surge that I approve of

From Pollster.com

Obama and Patriots fan Ted Kennedy were at Giants home stadium The Meadowlands today. Said Barack, "This campaign is about bringing people together, and for me to be able to bring a Patriots fan to the Meadowlands the day after the Super Bowl is like bringing the lion and the lamb together. We can bridge all gaps and all divisions in this country."

Obama then congratulated Giants fans, and said he had been commiserating with Kennedy. "My Bears didn't even make the playoffs," Obama said. "Although I think we should take heart, Ted, by the fact that sometimes the underdog pulls it out."

The Lessons of 1994

Some good news on the prospects for reform from the TNR blog:

Today the Service Employees International Union (SEIU) announced it would be launching a $75 million election-year campaign on behalf of universal coverage. ... the effort will feature paid advertising to "draw sharp distinctions between the Republican and Democratic presidential nominees' approach to health care, and what those differences will mean to working families." But it's not just a bunch of television and magazine spots the union has in mind. They're also planning to finance what sounds like a pretty substantial ground effort, including a rolling publicity tour to stage events across the country and an outreach effort designed to collect stories of hardship -- which, surely, will help spread the word about reforms, as well.
What's more important than the dollar amount, though, is the show of commitment -- and, in particular, the timing of it. As veterans of the 1993-94 Clinton health care fight know, that effort failed was the fact that the political pressure came overwhemlingly from one side. When the drugmakers, small insurers, and others opposed to the Clinton bill started running their advertisements ... the administration was largely left to fight back on their own. Expected support from unions and other sympathetic groups didn't materialize until it was too late.
Nice to see it coalescing early...

The problem with mandates

Democrat Hillary Rodham Clinton said Sunday she might be willing to garnish the wages of workers who refuse to buy health insurance to achieve coverage for all Americans.

Hillary should be smarter than this. I mean, what a dumb, stupid thing to say, handing opponents of reform a tailor-made talking point to use against the idea.

However, this does illustrate the problem with the whole framing device of a health insurance "mandate." It's a negative frame, describing an obligation and begging the questions, "what if I don't want it?" and "what if I refuse?" The answer to that is that a mandate is not optional, that there needs to be some enforcement, usually punitive or otherwise coercive, and the whole thing winds up looking oppressive and unwelcome.

What proponents of health care reform ought to be advocating is not some idea of compulsory mandates, but "Universal" health care, with "automatic enrollment." People view these as positive features of a health care plan, and while the net effect is similar, the perception is vastly different. I would hold up Sen Wyden's Healthy Americans Act, once again, as an example of how this ought to be designed and marketed. There are no taxes (which people hate) or garnishing wages (ick), but simply "premiums," a funding method most people fundamentally view as fair and reasonable. Enrollment is taken care of when you file your 1040, which effectively captures the vast majority of Americans, and the premiums are withheld from earnings much as they are for the majority of Americans today.

Maybe Obama was wise to avoid the idea of mandates altogether. But he also loses the universality totem as well. Krugman bashes him yet again today, arguing that universality would be more cost-efficient than his half-measures plan. My actuarial chops aren't up to analyzing the argument, but it seems t pass the sniff test. I don't entirely agree with Krugman's anti-Obama rhetoric, neither on the facts nor strategically, but he does summarize it well:
while it’s easy to see how the Clinton plan could end up being eviscerated, it’s hard to see how the hole in the Obama plan can be repaired.

Ezra Klein piles on as well:

There is no doubt in my mind that [Hillary] will do everything in her power to move us towards universal health care, and she will do so having thought long and hard about what went wrong in 1994. By contrast, it is not clear to me that Obama will gamble on health care, and given how he's spoken about it throughout the campaign, it's even less clear to me that he's thought hard about how to enact it.

Though I like Obama and want him to be the nominee, I do agree that his approach to national health reform is probably his weakest point as a candidate.

Ordinary Monday

Comes between Super Bowl Sunday and Super-duper Tuesday.

Obama up by three points, 49-46, in the most recent CNN Poll. It's the first and only poll showing Obama ahead of Clinton nationally, so it is pretty significant. It might be an outlier, but it's consistent with the recent trends.

Yes we can!


Nick over at Cogitamus tries to bring my expectations back to earth, pointing out that up to half of CA voters may have already voted by mail, and Hillary had a ten-point+ lead when those votes were being cast. His spread: best case, Obama wins the day by 50 delegates, worst case, Hillary walks away with a 150-delegate lead. Either way, there's a lot of campaigning left to do.

Scary Trend

Given how the economics of medical reimbursement are slanted towards procedures and against office-based practitioners, it's hardly surprising. I have to agree with Kevin and Dr Brayer that health care reform will be of limited benefit, if not a total failure, unless the underlying perverse incentives are addressed.

03 February 2008

Performance Improvement, part 2

I wrote yesterthread about the operational crisis that we experienced in our ER in the early part of this decade. I'd like to pick up the threads of that story and continue on by writing about some of the changes we made.

Of course, I can't provide a comprehensive list of the elements of the turn-around. There were too many people involved, doing too many things. So I'll briefly summarize the major themes and deal with them in more detail individually. By the way, I'm not an MBA and have never taken a management course, so if there are any professionals out there, please don't cringe if I misuse a buzzword, mis-categorize an intervention, or just generally treat the most obvious facts as stunning insights. I'm probably a pretty typical doctor in that the most basic concepts from management 101 are earth-shattering revelations to me. But then, that's part of the problem, isn't it? We have all these physicians out there playing amateur manager without a clue, re-inventing the wheel as we go along. So here we go:

Process Analysis
When nothing is working, it's hard to look at the process without feeling overwhelmed. Where to even begin? We looked at the choke points and the patient flow to see what worked, what didn't work, and where we could find efficiencies. For us, the initial problem seemed to be the waiting room -- it was always full! This was in fact caused by various bottlenecks at triage, bed placement, MD assignment, disposition decision, and admission to the hospital. Eliminating (or at least reducing) the bottlenecks was undertaken in sequence, during which we had to deal with cascading consequences -- for example, getting patients in beds faster resulted in physicians being overwhelmed by the influx, which slowed discharges, etc.

Institutional Support
The biggest conceptual change was that the ER's gridlock was not an ER problem, but a hospital problem. Nurses and doctors on the floor could not shrug it off as "somebody elses's problem" but were obligated to take ownership and contribute solutions. Other service lines were also involved.

Management Practices
While the fundamental problem was identified -- dissatisfied patients -- there was no clear understanding of exactly which factors determine patient satisfaction. Furthermore, the ED was a data-poor environment, with limited ability to track patient flow. The physicians historically had been managed via a policy of "benign neglect," and there was substantial variation in the docs' operational capacities.

New Resources
It is hard to bootstrap yourself up without increased resources. Every ER Director has a wish list a mile long of the things they would like. In an environment of limited resources, we had to choose the few areas in which we could get the most 'bang for the buck.'

Culture Change
It sounds like fluff, but this is incredibly important. Working in a county-ER type setting, with a lot of uninsured/welfare patients, there's a temptation to view patients as parasites, or burdens, or anything other than customers. To rebuild the concept of customer service as the core mission of the ER, to instill it into the staff within the ER, and to communicate that it was not "show" but a real and sustained focus of the organization was a very difficult endeavor. To do this while at the same time empowering the nursing staff and improving morale was exceedingly difficult. Leadership is an interesting phenomenon, and the investment from the top leadership in the hospital as well as the ER nursing leadership was the key to driving much of the culture change.

This sort of change did not come overnight. In fact, since the seminal events that instigated our performance improvement plan, the time elapsed has been several years (longer than the existence of this blog). Staying power, continued focus, an emphasis on long-term trends instead of short-term oscillations in data, and the patience required to effect the change and see it sustained over time were required. Notions of an overnight turnaround or abrupt changes would have been unrealistic and probably would have poisoned the relationship between management and the ER staff.

Starting tomorrow, I will break down each of these categories into more detail. Stay tuned!

Link-y goodness

I have no idea what the heck this is all about, since I don't speak Netherlandish, but I'm still really glad to have seen it.

If you were looking for an explanation for the unmistakable reference to the Death of Cicero in yesterday's Marmaduke, you can read it at the Comic Curmudgeon. I am in awe.

Every seen the pictures of faces on Mars? Here's the newest and best one so far!
Though a commenter over at the Bad Astronomer makes the insightful point that this is probably just viral marketing for the upcoming Watchmen movie:Quis custodiet ipsos custodes? Indeed.

I'm off to a SuperBowl party. See you all later.

Sunday Moring Obama-rama

I don't see McCain's supporters coming out with anything as cool as this.

Obama up by 2 points in California today, according to one poll. Of course, it's Zogby, and their polls are so reliably wrong that it may not actually be good news for O. But still, after a couple weeks' surge, he's drawn very close, and this is the first poll to show him with a lead. So we can hope.

Among the blizzard of endorsements this week, almost lost was the fact that Hillary has drawn
the most unexpected - and possibly unwanted - endorsement of the whole race so far. If word of it gets out, it may just propel Obama to the nomination.

I don't get the whole McCain-hating thing. I don't like him and don't want him to be president, but he seems like a perfectly reasonable choice for the GOP; possibly the most electable. I'd make a joke about Republicans eating their young, but I suppose it's far too late to refer to Grampa John as "young."

02 February 2008

Some Good News

Henry has some good news from his pediatric oncologist.

I'm really glad for them.

01 February 2008

Farewell to CARS

A sad day. The Crazy Apple Rumors Site, known generally as CARS, has gone on hiatus, after apparently losing their funding. Damn, I'm gonna miss "them." They always had the best sources for rumors about upcoming Apple products, and insightful analysis of the technical specs of newly released Macs. Nowhere else could you get the insider's view of Apple executives, including recluse and alleged Canadian Phil Schiller. Their liveblogging of the MacExpo keynotes was legendary. And don't forget that it was CARS who put sexbots at the top of Apple fans' wish list. (Editor in chief John Moltz remains the first and only man in human history to utter the word "sexbots" on NPR.) I'll even miss their somewhat perplexing and off-topic fascination with the intersection of Apple computers and certain foodstuffs such as pudding, waffles, and, um, more pudding.

Technology! Whisky! Sexy!

Damn. Guess I'll go on over to As the Apple Turns and vote in their poll for the 300th time.

Watch me!

Apparently I am one of the "Ten Health Blogs to Watch in 2008," according to "Dr Manny," managing editor of Fox News Health. I will never again claim that Fox is biased against liberals! Well, not their health division, anyways. Still, quite an honor, and thanks to Dr Manny and his team for selecting me.

So there you go, America. You have your marching orders: Watch me!

Pay for Performance

Think it's going away any time soon? Think again:

Senators Call On CMS To Expand PQRI
Senate Finance Committee Chair Max Baucus and Minority Member Charles Grassley sent a letter to the director of CMS on January 23 urging the agency to expand on its efforts to link physician payments to quality of care. The influential Senators told CMS they plan to introduce legislation that will extend the Physician Quality Reporting Initiative (PQRI) into 2009 and beyond.
Building on the recommendations enacted in the Medicare Extension Act of 2007, Baucus and Grassley suggested pooling quality data from multiple payers, and allowing providers to report performance data in the aggregate. The letter noted that "we believe that greater focus should be placed on measures that assess higher levels of performance rather than adherence to minimum standards of competence."
The lawmakers also said they plan to pursue statutory authority for CMS to post on its website the names of providers that satisfactorily participate in PQRI.

See the updated Emergency Medicine measures over at MedPage Today.