Emergency Physicians Monthly is the independent voice for emergency medicine, bringing together commentary from the top opinion leaders, clinical reviews from leading educators and quick-hit departments covering everything from ultrasound to toxicology.
This week: Facility coding and virtual monopoly blamed for extreme ED bills; Should docs trust tattooed medical instructions?; Popping zit with woodworking blade = bad idea. Join in as our editors discuss the week’s headlines.
In an analysis of over 70 million ED bills, the Health Care Cost Institute (HCCI) and Vox have determined that facility fees rose 89 percent between 2009 and 2015, which is twice as fast as the price of outpatient health care and four times as fast as overall health care spending
Nicholas Genes, MD, PhD: ED use of higher-acuity billing codes increased substantially from 2009-2015, just as electronic health records were adopted in large numbers. Probably not a coincidence. I’ve long argued that EMR finally lets us document the care we were always giving – maybe now fewer charts are downcoded because our documentation is better (and so, we should have been collecting more prior to 2009). Or maybe the charts are full of garbage macros and unnecessary, cookbook orders and the charts should be downcoded. Maybe both are true, and it varies case-by-case, or ED by ED.
I just know that, in most shops, when a EP codes a chart as 99283 and the billing company later says it could have been a 99284, if only the documentation was better, the doctor will get dinged. Get enough dings in a month, or year, and the doctor starts to suffer professional consequences. It’s just what’s happening. Meanwhile there is essentially zero pressure from the billing companies (or administration) about charting less. If an EP takes extra time (or uses a macro) with an ankle sprain and codes it up to a 99285, no one says “hey, you’re being inefficient, and possibly fraudulent, so spend less time on charting for cases like this.” Maybe the billing company will downcode it; maybe they won’t. The doctor rarely even sees what ends up getting billed in his or her name. I’m not saying that doctors aren’t responsible for their notes, but we practice in a system where everything is geared toward charting more.
Ryan McKennon, DO: I agree with Nick, EMR had a lot to do with this and maybe it is just ERs getting paid what they were supposed to and catching up to the changes in CPT. The argument that “ER care” as a whole is monopoly a little ridiculous. Hospitals compete with each other all the time, and prices for a given CPT code are generally set by CMS or the insurer following suit, not the individual hospital. The exception is for those without insurance. ERs are also not “the only care setting open during off-hours.” Urgent care are usually available and many offices have late hours on certain days. Finally, there is no incentive to decrease resources which would result in lower CPT codes. Could that abdominal CT or head CT be done as an outpatient? Probably, but patients wants to know now. They have to pay their co-pay or deductible anyways, not much financial incentive not to. Docs don’t want to liability, especially if the patient doesn’t or can’t follow up in a timely manner. Not doing may also result in lower RVUs. All of this results in a level 4 or 5 visit which may otherwise be a 2 or 3.
The case of a 70-year-old Miami man without ID admitted to Jackson Memorial Hospital unconscious and high BAC with a “Do NOT Resuscitate” tattoo raised questions for doctors
The doctors later discovered he had a history of lung disease, heart problems, and diabetes. They consulted an ethics expert and honored the man’s wishes, but the case is underscoring the need for EOLC standards and people to take their life in their own hands via advance directives. Original Article by The New York Times.
E. Paul DeKoning, MD, MS: Probably fits into the category of measure twice, cut once. I’d probably talk to my risk management folks, too. How many times do we encounter families who disagree with a family members advance directive or a patient who doesn’t even recall ever completing a DNR? You would think that if he went through the effort to get the tattoo and this his seeing this in the mirror every day would mean he actually agreed with its message. Then again, it wasn’t tattooed as a mirror image so he could actually read it.
Nicholas Genes, MD, PhD: It’s great that an ethicist was available in this case, and he makes a good point: “You don’t go through that trouble, look at it every day in the mirror and actually not mean it.” But I could easily see an ethicist (or a lawyer) arguing the converse: end-of-life wishes can change faster than tattoos can be removed – would you bet this guy’s life that he hasn’t updated his goals of care? In the future, perhaps, we’ll have tattoos of the URL to our secure cloud storage, accessible by ED physicians, where we’ve uploaded a MOLST form that’s kept up-to-date with our wishes.
Ryan McKennon, DO: The article states the tattoo “produced more confusion than clarity.” Seems pretty clear to me. He had already filled out the requisite paperwork (though did not have it on him). If that tattoo had not been there, I have no doubt CPR would have occurred. More confusion? Maybe, but that confusion worked in his favor preventing procedures being performed against him that he explicitly did not want.
Advice: Don’t pop zits using a woodworking blade
Popping zits have been decried as bad practice for decades, but doing so with a woodworking blade could do more than spread bacteria and cause more zits—it could lead to a nasty fungus. Original Article by Gizmodo.
E. Paul DeKoning, MD, MS: Huh. Who knew?
Nicholas Genes, MD, PhD: There are more things in heaven and earth, Horatio, than are dreamt of in your philosophy.
Ryan McKennon, DO: Well, there goes my idea for patenting a new dual use cutting device.
This week: Toyota tune ups ER discharge process, making it 40% quicker; ERs may stop ushering loved ones into “the other room”; There’s several reasons why ERs get a 5-15% increase around the holidays. Join in as our editors discuss the week’s headlines.
Toyota likes to help make nonprofits more efficient, so when the company came to Plano, Texas, Parkland Memorial Hospital CEO Fred Cerise got first-rate consulting that would have cost hundreds of thousands.
The consulting enabled its exceedingly busy ER to reduce average discharge time from 52 minutes to 31. Toyota’s team worked with nurse and other front-line staffers to analyze the process and come up with three big changes that took the lead out. Original Article by Dallas News.
William Sullivan, DO, JD: This is rather remarkable. Not because of the improvements in the process, but because the improvements didn’t come from a highly-paid consulting company. Good on CEO Fred Cerise for being more innovative than a typical CEO, but Dr. Cerise still has a lot to learn. I’d venture a guess that if the CEO just asked the ED director (or went to the ED and asked the staff) how to improve workflow, he would have gotten similar – and probably better – insights. It doesn’t take a foreign car company to pick out the processes that hold up ED throughput. And the thing is … Toyota *understands* that. One of the quotes in the article states “It’s all about empowering front-line workers … they’re the experts.” The real question that needs answering is why hospital management needs an outside consultant to appreciate the wealth of knowledge a hospital’s employees possess. I’m sure that there won’t be a follow up article, but I wonder whether these changes will adversely affect other aspects of ED throughput. In other words, by focusing more on the discharge process, will Parkland’s ED focus less on other aspects of patient care? BTW, Toyota agreeing to help Parkland only on the condition that the project not be used as part of a layoff plan – that’s a lot of karma points for Toyota in my book.
E. Paul DeKoning, MD, MS: Don’t totally disagree with Bill, but I don’t think this is a complete bust. Potentially a way for leaders in industry to share some of their expertise when it comes to systems and efficiency all while involving medical professionals in the process. But we need to be at the head of the table.
Ryan McKennon, DO: Sometimes it just helps to have someone from the outside to say the same thing. I think there are several reasons for this. One is that it can be difficult to point out areas that need improvement as it seems to “blame” other people you work with. It is much easier for an outside entity to say the time between discharge orders and the patient leaving the department is too long, if this comes from the director it can sometimes be interpreted as “the nurses are the problem.” Big corporations also seem much more facile at pulling relevant data from whatever EMR you are using. These large companies have spend billions in process improvement over the years, why not try and use some of that knowledge to improve our process, when applicable, and with cooperation and input from the department? Yes, yes, I know this is a utopia idea; call me an optimist.
On TV dramas, loved ones are usually whisked away when docs work frantically on patients. But increasingly, ERs and ICUs are allowing parents to stay with their child instead of ushering them into another room.
A nationwide survey recently found that 90 percent of Americans believe that by their side is the right place for them to be during a life-threatening injury or illness. While there are many upsides such as calming the patient or advocating for them and informing doctors of vital information, there are still issues that can arise. Nonetheless, some see the trend eventually carrying over to adults. Original Article by Healthline.
William Sullivan, DO, JD: I agree that having families present should be an option. However, there also must be a policy that if the family is disruptive in any way, they get escorted out. Families have pushed me out of the way, pointed fingers in my face, and (alleged) family members have given me incorrect information about a child’s medical history. Just last week I had a family member threaten me because I asked him to back up and stop recording me while I was trying to fix his son’s scalp laceration. He was literally putting the phone between my line of sight and the patient’s head. Then he repeatedly told his son “Daaaamn. Your head’s f***ed UP!” His son obviously became more upset, and repairing his laceration became even more time consuming and difficult. Parents can definitely be a calming influence on their children during an emergency, but we can’t assume that having family members in the room is always the best policy.
E. Paul DeKoning, MD, MS: “If your child were injured, would you want to stay with them while they received treatment?” Absolutely, no question, not negotiable. We actually do this pretty well here, including in activated traumas. The only time we may ask family to step out is certain sterile procedures or those involving radiation, like use of the c-arm for reductions, or if they’re disruptive and not-redirectable. And if mom or dad (usually dad) is likely to pass out in the process.
While CDC estimates indicate there aren’t actually more injured people during the holiday season, there are spikes in some common injuries and issues.
William Sullivan, DO, JD: Any time I read headlines touting the “inside scoop” on something that happens in the emergency department, I roll my eyes a little. Then I see that this article is trending on the Business Insider. Now I’m getting agida. A 10-12% increase in patients due to injuries playing touch football during Thanksgiving? Most years it’s too cold to play football outside by Thanksgiving. Injuries hanging lights? I see a couple of those a year. But do those types of injuries outnumber the sports or other outdoor injuries (bicycling/rollerskating/skateboarding) during the summer months? Doubtful. Intoxication is a year-round activity. Although alcohol-related ED visits are on the rise in the US (2.4 million in 2002 to 3.8 million in 2011 according to this study), I wasn’t able to find any data showing a spike during holidays. The uptick in ED visits during the winter holidays is probably due to three things: 1. There aren’t any doctor’s offices open during holidays. 2. Families visiting from out of town haven’t seen mom or dad for the past year and think that a gradual process since last holiday season is instead an acute issue needing immediate attention. 3. Influenza. Then again, telling people to plan ahead, visit their ailing family members more often and get influenza vaccinations probably would make for much of a trending article in Business Insider, would it?
E. Paul DeKoning, MD, MS: My ED is typically NOT tons busier on the holiday. Day after, yes. Day of, no. If scheduled to work a holiday and given the option, I’d definitely take the early shift over the later shift. Mainly because nothing else is open and social issues are harder to navigate. And don’t forget domestic assault as the day wears on. A bit off topic, but a great quote: “And if you do have to go to the ER, it’s best to bring someone along to help.” That’s just good advice any day of the year. Unless, you’re a doctor and a family member needs to go to the ED. In that case, stay home. Taking care of family members of physicians can be super painful–it’s so hard for us to not be the doctor. However, taking care of physicians is a totally different story. It’s true that doctor make terrible patients. In my experience, they’ll let you do whatever it takes to make them better.
This week: GOP lawmaker Diane Black wants EMTALA changed to allow ERs to turn people away to cut costs; People avoided hospitals until ERs revolutionized them; New survey says 59 percent of docs have quietly suffered offensive remarks about their physical characteristics. Join in as our editors discuss the week’s headlines.
Rep. Diane Black (R-Tenn.), an emergency room nurse, told MSNBC host Chuck Todd she’d like to see ERs be able turn away patients according to their discretion to help keep health care costs down.
She takes issue with Emergency Medical Treatment and Active Labor Act (EMTALA), a congressional response to stories of “patient dumping” (denying treatment to patients or send them elsewhere usually because the individuals didn’t have insurance) signed into law by President Reagan in 1986. Various organizations, including the Institute of Medicine, have long called for amending the law to ease emergency room overcrowding, though outright appeal is unlikely—and talk about it is not common in health care debates. Original Article by Huffington Post.
Ryan McKennon, DO: Half of the problem with EMTALA is that most people don’t understand EMTALA. The congresswomen states, “I would get rid of a law that says that you ― you are not allowed, as a health care professional, to make that decision about whether someone can be appropriately treated the next day, or at a walk-in clinic, or at their doctor.” That is not precisely what EMTALA says. A physician can absolutely tell someone they can be appropriately treated the next day or at a walk-in clinic, after a medical screening exam (MSE) has been performed and there is no emergent condition. EMTALA has no problem with this. Some hospitals, I have heard, are doing this. A MSE is performed and if you want to be treated for a non-emergent condition, co-pay or cash is due up-front. Most do not because by the time a MSE is performed and documented, and required tests and treatment are performed to rule out or treat an emergent condition, all the work is pretty much done. If a congresswoman, who is also an ER nurse, doesn’t understand this, I’d be willing to bed the rest of the House and Senate doesn’t either. My two big issues with EMTALA are that is it an unfunded mandate and vague on its implementation. The federal government mandated all this care without subsidizing it which should change. CMS has also been very vague and fluid with what is considers an emergent condition. Although the courts have generally given great deference to the physician’s determination of whether an emergent condition existed, CMS is not so forgiving, especially recently regarding psychiatric conditions.
E. Paul DeKoning, MD, MS: Ryan nailed it. Unfortunately, she doesn’t know what she is talking about. The lay press won’t either and likely won’t seek to figure it out but rather capitalize on the story to further some agenda.
Seth Trueger, MD, MPH: The big thing that get missed with EMTALA: for the real low acuity stuff, the MSE is the whole visit.
William Sullivan, DO, JD: Most people don’t understand EMTALA, but at the same time that lack of understanding may allow Representative Diane Black, a former emergency room nurse, to make inaccurate arguments with a wider appeal to the public. For example, it creates a lot stronger argument to modify EMTALA by incorrectly stating “we’re required to treat everyone – even the person who has had a sore throat for a week” rather than saying “we’re required to screen everyone and treat those people having emergencies.” The first argument allows her to continue the argument that unfunded government mandates prevent emergency departments from saying “No, an emergency room is not the proper place” for minor complaints. That creates a public furor and gives her more political power. The second more accurate argument does not. I’m not so sure whether Rep. Black is ignorant or whether she’s a well-rehearsed politician. Or maybe both. I suppose the two aren’t mutually exclusive. And Seth is right – often the MSE is the whole visit. But if we want to battle the inertia and begin to change the mindset of people who use the emergency departments to get prescriptions for ibuprofen, who repeatedly demand doctor’s notes after missing work, or who are on their seventeenth visit for the same toothache and have allergies to everything except hydrocodone, something has to change.
It’s hard to imagine, but hospitals did not always equal health. Prior to the 1870s hospitals were avoided by the vast majority, but sterilization followed by major innovations like antibiotics, diagnostic imaging, dialysis, and corticosteroids ushered in emergency wards with staff employing techniques learned from WWII.
Soon hospitals became “the first line of defense instead of the last resort,” a phrase repeated by many journalists, and demand for for hospitals was met with the 1946 Hill-Burton Act, which funded the construction of over 6,800 facilities nationwide. Original Article by History.
Ryan McKennon, DO: Interesting article. The growth of ER really comes down to the fact that we are so good at what we do. We can take care of any illness and any time of the day or night, and with unprecedented speed.
E. Paul DeKoning, MD, MS: While I’m somewhat partial, I agree with Ryan that we are good at what we do. Both by choice and out of necessity. As I was talking with one of my residents the other day about how we didn’t choose to be cardiologists, we in fact did choose to become cardiologists. And traumatologists, gynecologists, infectious disease experts, and toxicology whiz kids. Dermatologists, pediatricians, gastroenterologists. Social worker, therapist, confidant, and sometimes even friend and chaplain. What an amazing career we are blessed to do each and every day!
William Sullivan, DO, JD: We’re great at what we do, but in a way, we’re becoming victims of our own success. See above. Reminds me of that old Yogi Berra quote – “No one goes there nowadays – it’s too crowded.”
A joint WebMD/Medscape/STAT survey of more than 800 U.S. physicians showed that 59% have heard offensive comments in the last five years about their physical characteristics—namely youthfulness, gender, race, or ethnicity.
As a result, 47% have had accordingly had requests for other personnel. While African- and Asian- Americans received the most attacks, patients found plenty of other populations to demean. Quoting docs who say the situation isn’t generally talked about, STAT shares numerous personal stories in addition to reporting on the study. Original Article by STAT.
Ryan McKennon, DO: It’s nice to see Penn State Health taking a stand and changing its patients’ rights and responsibilities to cover discriminatory behavior. As policy, they will not honor a request for a new physician based on patient’s prejudices. The comments after the article, however, are severely disheartening; I am surprised how many people are totally fine with physicians being the targets of verbal abuse.
E. Paul DeKoning, MD, MS: Go Penn State (and that’s from an MSU Spartan).
William Sullivan, DO, JD: Difficult topic. On one hand, I think that prejudice against health care workers is under-reported and we do need to talk more about it. We’re just seeing the tip of the iceberg. On the other hand, we also need to be careful not to let our concern for this topic spin out of control. There is a gray area in which patients may make inappropriate remarks with no ill intent. For example, not long ago an elderly patient was having back pain and asked me to stand up by the bedside so she could show me on my back where she was having pain in her back. When doing so, she said “Oh, you have a cute little butt.” I suppose I could have been offended, but laughed it off – along with the rest of her family who was in the room – because I knew she was trying to be funny in what I realized was a stressful time for her. Then I diagnosed her with metastatic disease to her lumbar spine and sacrum. I’ve had patients insult me about my hair loss and the scar on my nose from skin cancer. Do I get offended? Maybe a little. Then I walk out of the room, maybe give them half a peace sign, move on to the next patient, and have a good story to tell during the next dinner party. Some people are just jerks and bringing their jerkdom to their attention probably won’t change them. Another point to consider: We all have biases. We’re human. Is it in the best interests of patients or physicians for Penn State to enforce a policy requiring patients to accept care from physicians against whom they may have a bias? Will patients listen to advice as well? Will patients look for some bad outcome so that they can confirm their unfavorable bias about the physician? Should it matter? Don’t know the right answer, but definitely is a topic that deserves more discussion. And if you want to see how some members of the public are already perceiving this as a bunch of whining by highly paid professionals, read the comments to the article.
This week: ACEP says “Prudent Laypersons” at risk with Anthem Inc ED policy, study finds lack of follow-up after ED visits; California nurse’s house burns as she evacuates patients in Intensive Care. Join in as our editors discuss the week’s headlines.
ACEP has stepped up its opposition to Anthem Inc’s policy of rejecting ED claims it feels may not have been necessary after a visit, which ACEP says Anthem inhibits the “prudent layperson” from seeking care for issues that may be urgent or deadly.
Nearly 70% of respondents polled by ACEP say they oppose company’s policy for emergency care when the final diagnosis turns out to be non-urgent, saying it asks patients to self-diagnose dangerously similar symptoms. The CDCP reports only 4.3% of ED visits are non-urgent. Original Article by Medscape.
William Sullivan, DO, JD: Retrospective denials of coverage. Think about this concept for a moment. If a patient comes to an emergency department with a complaint, often physicians have to do testing in order to rule in or rule out an emergency medical condition. In fact, EMTALA requires that patients presenting to the emergency department get a medical screening exam that is reasonably likely to determine whether an emergency medical condition exists. Anthem is now telling its insureds that the insureds have to be smarter than the doctors they are going to visit. Patients must now have the clinical acumen to determine whether or not their complaints represent an emergency medical condition – without the benefit of testing that emergency physicians would normally need to perform. Got that folks? Patients have to be smarter than their doctors! And if patients don’t demonstrate that level of clinical decisionmaking, they get penalized with a large medical bill for daring to seek care for what is retrospectively determined to be a “non-emergency.” What a joke. Arbitrary and capricious policies like this are probably a good indicator why Anthem is #29 on the Forbes 500, has revenues of $84 billion, and has a market cap of $43 billion.
Nicholas Genes, MD, PhD: I am glad ACEP is pushing back on this, and at the same time, we need a better strategy. Bill, in the linked Medscape report, the Anthem insurance rep specifically says – “If a patient presents with chest pain that later turns out to be gastroesophageal reflux, Anthem will pay that claim” and “I am absolutely certain we are not violating the prudent layperson standard.” Their policy may hurt their some of their customers, sometimes, but something tells me this insurance juggernaut knows what it’s doing – and their arguments are getting savvier. Our specialty is backing itself into a corner. We can’t keep pretending that nobody over-uses the ED, and no visits are avoidable. It’s a small problem – not a big number of patients, and not a big fraction of expenditures. But when we say it’s a non-issue, we’ll be seen as making the problem worse, rather than helping craft a solution. In a nation where people with really serious medical problems are struggling or going bankrupt, there will not be much sympathy for ED super-users and serial mis-users… and there will not be much tolerance for those who defend the status quo.
A Yale University study published in the Annals of Emergency Medicine found the rate of obtaining a follow-up appointment after an ED were lower than previous studies.
It used secret shoppers to pose as patients with various types of insurance needing care after being to the ED for back pain or hypertension. Only a third could get primary care appointments within a week, and those with Medicaid faired the worst. Original Article by Fierce Healthcare.
William Sullivan, DO, JD: This isn’t a big surprise. There’s a primary care physician shortage and it is getting worse. Fewer doctors means fewer available appointments which means a longer wait for appointments. The study notes that Medicaid patients have the toughest time getting follow up appointments. Many physicians don’t take Medicaid because the insurance often pays less than the cost of providing care – in addition to all of the paperwork involved. Since Medicaid ranks are increasing with the ACA and fewer doctors accept Medicaid, the problem is compounded. Note that in the study data, 57% of the follow up physicians denied an appointment because they didn’t accept Medicaid “insurance.” Contrary to what the study authors suggest, coordinating care between emergency departments and primary care practices isn’t going to help this problem. If the appointments aren’t available or if the primary care provider doesn’t take the patient’s insurance (which is one reason why the ACA’s goal of “insuring” all patients is such a farce) then the patients aren’t going to get timely follow up care.
Nicholas Genes, MD, PhD: Bill, you just raked Anthem over the coals! And you’re right to do that – they really are a ginormous corporation, scheming to screw over patients to further enrich shareholders. But then you switch gears and ravage Medicaid as being insufficient insurance to entice physicians. It sounds like your problem with the ACA was that it didn’t go far enough – Obamacare shouldn’t have just expanded Medicaid, but offered a competitive public option for insurance, too. If that’s what you’re saying, I’m glad we finally agree! And it’s just in time, too – because this physician shortage can only end in one of two ways. Either we make it worth the doctors’ time to see patients on public insurance – or we consign these folks can be managed by PAs and NPs.
Having moved to California from Indiana, Julayne Smith had just bought a house in California weeks prior to working an overnight shift in the ICU at Kaiser Permanente hospital in Santa Rosa during the fires
William Sullivan, DO, JD: What a scary story. Good wishes to all of the hospital staff going through this to help their patients. Couldn’t imagine being in that situation. I wish everyone who complained about “uncaring” hospital staff could be forced to read this article.
This week: NPR on a Houston ER during Harvey; Hospitals preparing for Irma; Health records among Harvey losses; Supervised drug injection in Canada. Join in as our editors discuss the week’s headlines.
Downtown Houston’s only hospital is just blocks from a convention center where thousands of Harvey evacuees are staying.
As NPR reports, 600 patients were seen in the first five days, and many staff who have been working 15-16 hour shifts, haven’t been home since Harvey hit—and some may be underwater. Nurse Araron Pardon says he’s never seen such emotion in staff. “People that you work with you think that wouldn’t crack just put their head in their hands and take a second to cry to themselves, or not to themselves, and wipe away the tears and get back to work,” he says.” Original Article by NPR.
E. Paul DeKoning, MD, MS: Totally get it. Today more than ever. Not wanting to draw attention away from the needs of Harvey or Irma victims, we had our own scare here last week: active shooter + hospital = truly scary situation…and a week like no other. Didn’t actually reply to last week’s series because I was holed up in a helicopter hanger while our hospital was on lockdown. For more info, look here. Regardless, there is no “business as usual” during and for a long time after events like these. As I told my residents in the aftermath of our own crisis, while none of us signed up for this, we actually kinda did. We chose to commit our careers–and by extension a good portion of our lives–to the care of people in what is perhaps the worst moment of their lives. That includes natural disasters like Harvey and Irma, terrorist events, active shooters, all the way down to STEMIs, CVAs, and for some, even the common cold. At times, we’re actually living that pretty crappy day right along with our patients–like those providers in Texas and Florida. We can’t forget to “put our own oxygen masks on first.” The second victim thing is real and we need to take care of each other–and actually let others care for us. Oh, and hug your family perhaps a little tighter or longer than usual. And give thanks.
Nicholas Genes, MD, PhD: Wow, Paul, I’m so sorry you and your colleagues and patients had to go through this.
Given good planning and decision-making, hospitals can continue to provide medical services
despite disastrous conditions.
Hospitals should start with quality information—not hype—from sources such as National Oceanic and Atmospheric Administration, then focus on communications, running drills, making checklists, testing reliability of resources, and creating a post-storm plan. Original Article by Healthcare IT News.
E. Paul DeKoning, MD, MS: As far as “what our hospital did”, I’ll let you know using my example above. We’ll be rehashing this for months. This sort of thing just doesn’t happen up in my neck of the woods…or does it? As an institution, we are looking at all aspects of what happened, what [thankfully]didn’t happen, and what can be better. I think there can be a tendency to over-look what didn’t go well and, fortunately, that isn’t happening here. I am appreciative of the leadership of our new President and CEO less than 2 months into her tenure here. My hope is that we respond to the event instead of react to it. I know there will be changes in our ED security–most of these events start or end there–but we aren’t alone. We all need to think differently. Every day. Like, I will never be without my phone, my keys, or my wallet/ID.
For patients and medical professionals, the information void that comes from a natural disaster can be almost as devastating as the disaster itself, Wired explains.
Just over a decade ago when Katrina, only about 25% of docs reported using electronic records. Today, the numbers are reversed, with 75% keeping electronic records, but access is still the issue. But there is hope on the horizon. This summer, Federal health officials finished the first big test of new technology, PULSE (Patient Unified Lookup System for Emergencies) that allows disaster workers to find and view all important documents—prescriptions, recent test results—for anyone that walks into ER, shelter, etc. Original Article by Wired.
E. Paul DeKoning, MD, MS: While I certainly do relish being able to find and utilize medical records of ED patients, at the same time we specialize in the care of patients with a paucity of time and information. Our training is precisely geared to provide acute care even if we don’t know what is going on. The bigger challenge in my mind is the ongoing management of more chronic issues.
Ryan McKennon, DO: I have a hard time getting information on a patients medical history from the hospital across town on a regular weekday, I can’t imagine in gets better during a natural disaster. Luckily, as Paul mentioned, we do much of our job with a deficit of information already. I really feel bad for PCPs and specialists (and patients) who are trying to piece this stuff together after the fact. Maybe someday we will have a universal EMR transmittable between systems without all the unnecessary faxing and forms, but as long as we have different proprietary software and some of the over-restrictive clauses in HIPAA, it will be a long time coming.
Nicholas Genes, MD, PhD: I’ve been following Pulse with interest and hope it works. It’s a little like the “waiving of HIPAA” that was discussed in the aftermath of the Orlando mass shooting. Best case scenario: Pulse works great in an natural disaster, letting EMTs and EPs and primary care doctors exchange records and share data. Then people start asking, why do we need a natural disaster to use this technology – wouldn’t a patient’s personal emergency suffice? And if popular pressure mounts, we back into a robust national Health Information Exchange with reasonable break-the-glass capabilities.
Every Day, hundreds visit Insite, North America’s first supervised drug injection center, located in Vancouver.
Opened in 2003, more than 75,000 people have injected more than 3.6 million times in total. Can it still be a good thing? Original Article by HUB.
E. Paul DeKoning, MD, MS: I frankly have a hard time stomaching this one. I understand what might be a unique opportunity (article calls it a Touch Point) to perhaps help these individuals transition to recovery, but I would suspect that’s a pretty rare occurrence and doesn’t actually happen near as much as the author or the Insite staff would have us believe. I wouldn’t be surprised if there was some policy actually forbidding staff from initiating such a conversation in order to not violate the “safe space”. I liken it to telling my kids that they can play with a loaded weapon, but they really should do it in my presence so that if something “bad” happens, I’ll be there to help them. That’s probably a gross overstatement, but it illustrates what I think is a conflicted message such facilities give: we provide a safe environment for you to participate in a behavior that is inherently dangerous on all levels. Ostracizing such individuals on the other hand, tends to push them further toward the periphery of society and into the shadows where we may never reach them. We all know it’s a real problem that involves real people who never set out to be addicts. Just not sure “normalizing” the behavior is the right approach.
Ryan McKennon, DO: Why not take this money and spend it on inpatient rehab? It’s all well and good that Insite staff can help individuals transition into recovery, but that assumes that these resources actually exists. There is a substantial lack of both inpatient and outpatient resources for those who are seeking help with recovery, seems like that would be a more effective use of the money.
Nicholas Genes, MD, PhD: As a society, I think we’ve come a long way toward viewing addiction as a disease and not a moral failing… but not nearly far enough to let “supervised injection sites” proliferate in the US. This issue just seems too vulnerable to simplistic but powerful slippery-slope arguments (are we going to hand out drinks in the drunk tank? are we going to let the smokers come back inside?) Also It’s not far-fetched to think the current Attorney General would encircle the first such American safe drug-use cafe with DEA agents, and arrest anyone who walked in or out (patients, surely, but maybe staff too – as accomplices to a crime). As far as analogies go, Paul’s is good, but I keep returning to HIV pre-exposure prophylaxis. The equivalent here would be not just prescribing meds that facilitate risky behavior, but also supplying a venue for the risky behavior to unfold. That may happen in some enlightened future, when so many other issues of US healthcare access and cost are solved, but that’s not today.
This week: Digital records need redesign to avoid physician burnout; Asian American ER doc refused by white nationalists in Oregon; Two-way video calling tablets already saving lives in England. Join in as our editors discuss the week’s headlines.
While Electronic Media Records (EMRs) should make health care better, they are a major cause of frustration cited by doctors and overhauling them is at the top of the list of ways to transform healthcare in a December 2016 STAT survey
They take too much time and focus attention on billing codes instead of the patient, notes Stanford School of Medicine Dean Lloyd Minor. Original Article by Quartz.
Nicholas Genes, MD, PhD: The Dean of Stanford thinks EMRs are a big part of the reason physicians are burning out. There’s no question that I enjoy shifts more when I have a scribe – I get to spend more time with my patients, and I don’t have a hundred onerous clicks waiting for me when I have to break away. But I can’t blame EMRs too much, either. There really isn’t any question that EMR has made tracking patients and reviewing records easier, and has made ordering meds and prescriptions safer. And the staff doesn’t seem to look forward to EMR downtimes, when we have to break out the marker boards, paper charts and order slips. No, the problems in EMR are due to the problems in healthcare – documentation burden is an outgrowth of what CMS and insurers insist on, for reimbursement, and what various regulatory agencies are looking for, to monitor performance. I don’t know if it seemed like a good idea, in 1997, to say an E&M Level 5 physical exam documentation would require two items in each of 9 separate systems, but that’s what we agreed to, and the EMR is there to make it happen (and if we miss an item, the billing company is happy to alert the administration to our deficiencies and lost revenue opportunities). The EMR is also where we’re documenting sepsis performance, as we wade through pop-up alerts part of a half-dozen Corrective Action Plans from the last few years. But every year, we see more and more patients, often sicker, without a commensurate increase in staffing or space or resources – so what might’ve seemed like a reasonable amount of charting in 1997 now seems stifling. Is it the EMR’s fault, or all the conflicting administrative goals that have been shoe-horned into it?
William Sullivan, DO, JD: The pull quote from this article is “EMRs aren’t working on the whole. They’re time consuming, prioritize billing codes over patient care, and too often force physicians to focus on digital record keeping rather than the patient in front of them.” Amen. Funny that I have seen some docs take into consideration what EMR a hospital uses before they sign employment contracts. The article calls for a “revamp of EMR design.” We’ve been calling for that for 15 years. The EMR companies don’t care. They make changes that suit their needs, not that improve operability or information sharing. I’ve worked with half a dozen EMR systems and I’ve yet to find one that doesn’t frustrate me on a daily basis. In fact, EPIC just rolled out an “upgrade” that significantly increased the amount of time it takes for me to chart and to discharge patients. Nick is onto something, though. EMRs were built to address an issue created by payers for healthcare. In order to minimize reimbursements, the payers keep changing the documentation rules, which results in changes to EMRs, which results in patient charts being overloaded with increasing amounts of irrelevant (and potentially harmful) information and metadata. I laughed when a colleague once told me that comparing EMRs was like comparing excrement, feces, and poo. Of course, you’ll also have to note what color that poo is, whether it is intractable or not, and whether it is an initial visit or a subsequent visit for the same. Don’t worry – there’s an EMR for that.
Ryan McKennon, DO: There are two problems with burnout caused by EMRs as Nick mentioned. The first is the EMR itself, designed with the end user as an afterthought. The second is that we have to document most of this stuff at all. Who does all this documentation really help? Certainly not the patient. Does the diagnosis of URI or pneumonia become more or less likely because I documented a lung exam? Does my documentation of the review of systems really help the next doctor in caring for the patient? Do they even look? These exams and questions need to be done but does the documentation of them help the patient? I know, I know, if you don’t document it, it didn’t happen. If I don’t document a time of death is the patient still alive?
Dr. Esther Choo says a few ER patients refuse her care each year based on her race
She says patient prejudice is so common, many physicians “consider it a routine part of their jobs.” Original Article by CNN.
Nicholas Genes, MD, PhD: Kudos to Dr. Esther Choo, for seizing the moment and raising awareness about so much of the ridiculous crap so many ED physicians have to put up with. One of my favorite tweets during the dark period around Charlottesville was this one, also shared widely on Twitter.
William Sullivan, DO, JD: Good for Esther. Awesome to see her discussing the issues on CNN. Hopefully others can do as good a job as Esther does to shine a similar light on many of the other issues that affect the practice of emergency medicine.
Though the University of Virginia has been experimenting with ambulance telemedicine, seven British ambulances equipped with the technology are the first in operation worldwide, linking neurologists to EMTs treating patients who may be losing two million neurons a minute due to stroke
Nicholas Genes, MD, PhD: So this article is in Video Conferencing Daily, but it could have easily been Venture Capital Daily, as I often hear a lot of pitches about bringing more ED expertise to EMS staff, via technology. (We do have an innovative community paramedicine program at Mount Sinai, and I enjoy beaming into patients’ homes via iPad to help interpret the data EMS is collecting, and guide management, via our online medical control program. We’ve definitely cut down on avoidable ED visits and I think the patients appreciate the technology.) But when it comes to guiding care after a decision to transport has already been made, well, in NYC that’s just not such a huge concern. Our paramedics are well-trained, and transport times are pretty fast.
William Sullivan, DO, JD: Neat in theory, but color me skeptical. I’d want to see more data before jumping too far into this. Maybe there’s a place for video calling technology along side telephone triage, but we still need to see how it will be implemented, who will pay for it, and whether it has any effect on outcomes. Does it offer any advantages over simple telephone calls? Take a stroke patient, for example. It isn’t like EMS is ever going to be administering prehospital tPA. Even with a confirmed stroke in the field by newfangled video calling, the patient still needs a CT scan at the hospital prior to thrombolytics. Will EMTs waste more time transporting the patient because they are establishing and dealing with the video link than they would just “scooping and running” a potential stroke patient to the hospital? Remember how Google Glass was supposed to be the next revolution in medicine … until it wasn’t? Let’s see how prehospital videos affect care. Oh, and I’m putting paramedics on notice right now: the first time I get some medical video call that is oriented vertically instead of horizontally, I’ll lose my everloving mind. Not sure how many clicks it will take in an EMR to get the correct ICD-10 code for THAT diagnosis.
Ryan McKennon, DO: I cannot see much use with EMS for transport times less than about 30 minutes. Physical exam is almost never the bottleneck for giving tPA, its the CT and lab work. If EMS reports they have a stroke, clear the scanner and do the exam after the patient returns while they are drawing blood. I do like the idea of having someone on video at the other end of a 911 call (medic?) who can help the caller or other people first to an accident to administer BLS while EMS is en route. With the prevalence of smart phones and video messaging, the technology exists in the community already.
This week: Trump may declare opioid epidemic an official emergency; Survey says more nurses appreciate knowledgeable patients than doctors; The common impulse to “move on” after deaths in the ED. Join in as our editors discuss the week’s headlines. Join in as our editors discuss the week’s headlines.
With 63% of 2015’s 52,000 American overdose deaths due to opioids, urgent federal intervention has been recommended by President Trump’s commission on the epidemic, and Trump has indicated he plans to make it official soon
Doing so may allow funds and other aid to reach hard hit areas more easily, just like aid for natural disasters. Six states have already declared opioid emergencies. Original Article by The New York Times.
Jaime Hope, MD: The opioid epidemic is clearly a problem. In Michigan where I live, in 2014, more people died from overdoses than motor vehicle collisions. Bringing attention and funding to the problem is helpful, but there needs to be strategic use of the dollars. Throwing money blindly at a problem isn’t the answer. I hope this leads to meaningful dialogue to reach efficacious and evidence-based solutions to the problem. We need to change the conversation about addiction from a judgmental/punitive approach to understanding and treating the underlying problems that lead to addiction in the first place. www.artistsforaddicts.com and www.geniusrecovery.com are sites with a mission to help be a force for good in the fight against addiction.
E. Paul DeKoning, MD, MS: Even up here in New Hampshire, we have a real epidemic. Totally agree with Jaime that just throwing money at the problem, while perhaps helpful in the short term, by itself won’t fix it just like it hasn’t fixed public education. Addiction is more than simply a drug problem. Why is it that some patients break a leg, take opiates, and never develop addiction while others get hooked on the first and even appropriate use? I personally believe it is a reflection of deeper issues, whether they be a history of abuse, mental illness, familial propensity to substance use/abuse, trauma, or deep emotional pain. Not everyone for sure, but quite a few. Simply removing the substance won’t work–it has to be replaced with something else, something edifying. We have a lot of work to do. See also below on Patient Death.
A survey of a thousand attendees at a MedScape event in San Diego in July shows distinctly different feelings between doctors and nurses regarding “patient empowerment,” with 82% of nurses considering it favorable compared to 54% of doctors
Jaime Hope, MD: Empowerment sounds like a great idea. However, “I’ve done my research” can elicit eye rolls from many EC staff. Some patients fall into the “Lay persons rarely use their research to create a differential diagnosis but rather to support their preconceived ideas.” camp and some are genuinely interested in their health. The thing is, the internet isn’t going to go away. And people want to learn and have a sense of control; illness is scary and makes people feel disempowered. Because patients aren’t going to stop researching, we need to adjust OUR expectations. It is a golden opportunity to educate people about credible resources. If you have a good patient-physician relationship and listen respectfully, you can engage in an excellent dialogue and help make a difference in a patient’s health. Empowerment is here, embrace it!
E. Paul DeKoning, MD, MS: Uhhh. Agree with this quote form the article, “Lay persons rarely use their research to create a differential diagnosis but rather to support their preconceived ideas.” At the end of the day, “empowerment” (if that’s even the right word) is a two-edged sword: it’s helpful when I can reassure the patient that they don’t have what they think they have (and they believe me). Not so much when the come seeking my advice but don’t want to hear what I have to say. But, as Jaime pointed out, the internet isn’t going away.
One doctor reflects on the common impulse to “move on” after deaths in the ED
While embedded in ED culture, he argues it’s time to come together as medical personnel and pause—or better still, full stop—any death. Original Article by STAT.
Jaime Hope, MD: I agree!! Even though it is part of our job, witnessing a terrible death is still sad and affects us. We should have support to stop, debrief, and have ongoing dialogue in particularly upsetting cases. We are human beings and we have feelings. This is ok! We need to talk to each other, support each other, and acknowledge that our job can be hard.
E. Paul DeKoning, MD, MS: We’ve talked about this in a prior Crash Cart and I ended up writing about it here. Just my $0.02 but Jaime’s comments and the above article on the opioid emergency are related: EMPs and other physicians aren’t immune to such addictions–we experience and preside over pain every day. It really is what we do. While it is an honor, if comes with a price. Like my own recent trauma code that made me weep on my way home from work. If we aren’t personally grounded, healthy, and whole, and have a system in place to fill us back up after we have experienced such horror, we run the risk of falling into addictive patterns ourselves. Especially if we’re Type As that hate asking for help or admitting weakness. How often do we hear about physicians getting busted for diverting substances from the OR? I’ll answer for you: far too often.
This week: NomadHealth aims to reduce staffing shortages; One company behind many out-of-network charges; Why human trafficking needs an ICD code. Join in as our editors discuss the week’s headlines.
The Association of American Medical Colleges (AAMC) projects a shortage of 40,800-104,900 physicians relative to need by the year 2030
An offshoot of telemedicine, Nomad Health, describes itself as the “Airbnb” system of medical staffing, matching doctors—and soon to be nurses—with hospitals looking for freelancers. Original Article by Fortune.
E. Paul DeKoning, MD, MS: Sounds awful, even worse then locums. Don’t sign me up. Systems stuff is much of what we do on any shift and short-term assignments seem to be potential for systems-type medical errors. Doesn’t sound good to me.
Ryan McKennon, DO: I think this just increases the thought that we are all dispensable cogs that can be replaced by any warm body. Programs like this may help some areas staffing problems, but hurts others. The number of RNs (and physicians) is finite, programs like this do not increase the number of docs or nurses, just shift them around. It also is likely to increase errors. How do you acclimate to new systems with short periods of employment, this seems to be even shorter stints than locums work. Most importantly, what about the teamwork that develops when a group of people work together for a period of time. Systems like this encourage changing hospitals frequently and while this may be fun, new, and challenging, I don’t think in the long run it’s necessarily good for patient care.
In America, more than 1 in 5 visits to an in-network ER result in an out-of-network doctor bill, and nearly a quarter of all ED docs work for a national staffing firm
But new research shows the issue isn’t scattered at hospitals across the country; it comes from select doctors at certain hospitals run by a company called EmCare. California and a few other states have tried to cap how much out-of-network docs can charge and limit such “surprise bills,” but some doctors have fiercely lobbied against such actions, which may weaken their bargaining power. Original Article by The New York Times.
Ryan McKennon, DO: I don’t work for and have no affiliation with EmCare, but I think this piece was a bit unfair. The insurance company (who lists the hospital as in-network) refuses to negotiate with a staffing company who then bills patients directly and somehow no one is angry at the insurance company. Out-of-network bills will always be higher than in-network bills, this is not exclusive to EmCare. They compare with the previous ER group who was able to negotiate with the insurance company which is an unfair comparison. The level 5 charts increased from 6% to 28% when EmCare took over. This is likely because staffing companies like EmCare have a heavy focus on charting and billing appropriately so as not to lose revenue. Some of the older, smaller groups may not have that same focus (for good or bad). The implication here is that EmCare is billing inappropriate CPT codes. If they are, its fraud. And if the authors believe that is the case, they should say so in the article.
Is it time for human trafficking to be recognized as a medical diagnosis?
What do “struck by a duck,” “Sucked into a plane’s engine,” and “walking corpse syndrome,” have in common? They’re all codes in the International Classification of Disease (ICD) created by the World Health Organization (WHO). As the WHO approaches its 11th edition, two doctors that that research and treat human trafficking are advocating for its inclusion in the code, noting that an estimated 21 million individuals are victims of it. With reports of human trafficking in the U.S. on the rise, physicians can help identify victims by thinking about trafficking as part of their differentials. Original Article by STAT.
E. Paul DeKoning, MD, MS: The topic of Human Trafficking is an important one–I guarantee I/we are seeing these patients and missing opportunities to truly save lives. However, I’m not sure if this is the answer. I can also guarantee that I have never used the codes for “adult and child abuse,” “problems related to release from prison,” “disruption of family by separation or divorce”, or “victims of crime and terrorism.” I was taught to never state unequivocally that a patient was assaulted, but rather that there was “alleged assault”. This may be that. We simply don’t have all of the information at our disposal to make these types of definitive diagnoses and potentially give our patients a label that is just wrong, at least from the ED. It can be difficult to get wrong diagnoses or even erroneous allergies removed from a patient’s chart: “problem list drift” tends to end up carrying on thru a chart. Given the potential stigma associated with such a diagnosis, I would avoid ever using it—and I’m a proponent of giving voice to this hidden epidemic. A better option is to continue to give voice to the problem and get patients the care and protection they need; don’t worry about the ICD code.
Ryan McKennon, DO: I agree with the author that it is important for physicians to think about human trafficking, “Screening for trafficking, much like screening for intimate partner violence, involves recognizing a pattern of medical presentations from exposure to physical and emotional traumas as well as signs of being in an abusive relationship.” That being said, I’m not sure how an ICD-10 (or 11) code helps to do this at all.
This week: Physicians openly discuss mistakes; Why the term “dry drowning” needs to go under; NaloxBox’s solution for ODs may be worth a shot. Join in as our editors discuss the week’s headlines.
A surgical resident at University of North Carolina says physicians need to talk more openly about their mistakes, advocating for debriefings in addition to the standard M&M conferences
She says trainees often fail to realize errors aren’t usually the failure of a single person but the failing of a system of safeguards and points to the 2013 National Healthcare Quality Report, which says most health care workers believe that mistakes will be held against them. Original Article by STAT.
Jaime Hope, MD: Mistakes are a huge part of medicine as they are a huge part of being human. Medical mistakes are now the 3rd leading cause of death in US hospitals. They continue to add checks and balances in the system and into our EMRs. We get so many pop-ups, it is easy to get warning fatigue. And even those pop-ups can fail. I had a loved one who was accidentally prescribed both Eliquis and Xarelto at the same time. And the pharmacy filled and dispensed them at the same time. The warnings failed to pick the duplicated anticoagulants. Only because I was filling her pill boxes did it get noticed. She was a good compliant patient and was just “following orders”. All the checks and balances in the world aren’t enough though. We need a culture change. We are so afraid of getting berated, fired, and sued that mistakes are not openly discussed in many forums outside the M&M, which can often be punitive anyway. How can we change the culture so we can talk in an environment free of fear?
William Sullivan, DO, JD: Sure, full disclosure would be nice. The problem is with the implementation. How do we define an “error”? The possibilities are endless. Is it an “error” to delay treatment of an MI for 30 minutes? What if you’re in a single coverage ED and running a code on another patient? In this article, was the intern’s failure to diagnose compartment syndrome an error on the intern’s part? Or was it an error on the attending for not teaching the intern sufficiently about extremity burns? Or was it an error on the system for putting the intern in that position and not having an attending evaluate every patient on arrival to the hospital? “Error” is a nebulous term. Two knowledgeable observers could view the same event quite differently. Consider dueling experts in pretty much every medical malpractice lawsuit. The problem is that as soon as an event is labeled a “mistake,” someone has to be blamed for that “mistake” – even if the medical care was reasonable. Then comes the cascade of finger pointing … by senior physicians, by hospital committees, by hospital administrators, by state agencies, by federal agencies, by patients or families, by plaintiff attorneys, and by insurance companies. Is it any wonder that medical providers “fear the bad outcome”? Good on the author for debriefing the intern and turning a “near miss” into a teaching moment, but we’ll never stop the blame game in this country, and errors – when they do exist – will always be minimized.
Though the media airs stories of it during the summer, medically speaking, there’s no such thing as “dry drowning.”
E. Paul DeKoning, MD, MS: While we’re at it, a few additional terms to eliminate: double (and yes, even triple) pneumonia; walking pneumonia; chronic congenital Lyme; oh, and do you actually have to die when you get electrocuted? And bloating. What is it exactly?
Jaime Hope, MD: People clearly don’t understand the process but this term sure makes for some scary and sensational headlines. It reminds me of when Natasha Richardson died of an epidural hemorrhage after a ski accident and everyone with a minor head injury thought it would happen to them. She had a severe injury and was unconscious for a period of time prior to her lucid interval. People who die after a significant water aspiration are likewise symptomatic. One cough in the pool won’t kill you a few days later. And Paul, while we are eliminating terms, I also submit calling gastroenteritis “the flu”. And if you have a (gasp!) “double ear infection”, it’s probably a virus. We love the drama of the double, though, right?
William Sullivan, DO, JD: Nice article and nice description of the events that occur with drowning. The bottom line is that whether it is wet drowning, semi-moist drowning, or dry drowning, it is treated the same way. I think that the only people who care about nomenclature are the idiots who came up with ICD-10. Because we really have to differentiate between “bathing cramps”, asphyxia due to submersion, lung edema from an external agent, anoxia due to drowning, and asphyxia due to drowning (that’s ICD code T75.1 for all you future coding buffs). Oh and don’t forget to note whether it is an initial encounter or a subsequent visit or you’ll be in big trouble. I’ll have to take a poll, but unlike the definition provided in the article, my definition (and Webster’s Dictionary definition) of drowning is death from suffocation due to liquid in the lungs. Otherwise it’s “near-drowning.” Slightly different treatment depending on the diagnosis. And Paul – add “low grade fevers” to your list. It’s a fever or it’s not a fever, dammit. It’s like calling someone “low grade pregnant” or saying a light is “low grade on.” There isn’t some magical middle ground and even if there were, it doesn’t change anything. Enough already.
E. Paul DeKoning, MD, MS: One more phrase to debunk: high tolerance for pain. Often co-presents with a fever of 98.6.
Nicholas Genes, MD, PhD: This is a good place for Dr. Amy Levine’s article on Summer’s Water Woes including “dry drowning.”
When professionals are unavailable, Good Samaritans can save the day
That’s the thinking behind NaloxBox, an emergency medicine kit providing life-saving naloxone to bystanders in the growing number of American communities where overdosing is common. The two professors behind say the kit has “the same goal as a fire extinguisher or an automated external defibrillator—to enable anyone in the wrong place at the right time to save lives.” Original Article by Futurity.
E. Paul DeKoning, MD, MS: Sounds reasonable for certain locations “where overdoses are likely to occur.” Where is that exactly? I’ve got some ideas. “It can happen to anybody in any walk of life,” Capraro says. “Our distribution should reflect that distribution of the epidemic.” Ok, so should we place it right next to the AED at the mall?
Jaime Hope, MD: I’m on board, seems like a great idea. The question is where to place them so that they are the most impactful. There has to be some kind of data about most common locations of overdoses. Although it can happen in all walks of life, I’m guessing even the wealthy users aren’t shooting up at Tiffany’s. Let’s get this into the hands of those who can help the most.
William Sullivan, DO, JD: OK, so the sentiment is good, but until the price of Naloxone comes down, I see this as something that will come up missing quite often. The price of Evzio is $4,500 per prescription. These NaloxBoxes contain four doses of naloxone. That’s $18,000 per box at the highest markup. Supposedly the company offers bulk deals to some groups for a mere $37.50 per dose – which is still $150 worth of medicine sitting in a small easily accessible and easily removable box. How about just ditching all of the regulations and making Narcan available over the counter so anyone can purchase it at any time?
This week: Older patients sometimes have good reason to leave; Ordinary and unusual Fourth of July tales; New tech gives own point-of-view. Join in as our editors discuss the week’s headlines.
ED physicians working the Fourth of July expect run-of-the-mill summertime incidents and some firework injuries.
But sometimes the bombs don’t burst in air (lodging unexploded in a patient) and the “blue” is in a baby diaper. Original Article by ABC.
William Sullivan, DO, JD: Amusing anecdotes. It never ceases to amaze me how ridiculous some people can be with explosives. YouTube is full of videos of people shooting (or attempting to shoot) rockets from their rear ends and blowing up pretty much any combustible substance. The stories in this article and other “Hold my beer while I …” stories just serve as a further reminder that emergency physicians have pretty much unlimited job security.
E. Paul DeKoning, MD, MS: My son and I love to watch crazy things with fireworks on YouTube. You should check out 300 rockets. Amazing what one can do with 300 rockets, a solenoid, a pickup truck, and a drone. We avoid the ones where limbs get blown off–that’s just gross. Also, same son may or may not have had blue poop from too much frosting. So relieved it’s nothing serious!
When older patients disregards medical advice and decides to leave, they may be making the right call.
A large national sample from 2013 found that 50,650 hospitalizations of patients over age 65 ended with A.M.A. discharges—and the numbers are rising, though still not 1% of of senior hospitalizations. Original Article by The New York Times.
William Sullivan, DO, JD: This article irks me. First, the 20/20 hindsight that Dr. Callahan exhibits when describing the treatment of her father with a near-syncopal event is depressing. “He should have been discharged right from the E.R.,” she said. “This was cookbook medicine, done without thinking. It was very adversarial.” If she was so sure that her father should have been discharged from the ER, then why did she allow him to be admitted? She could have taken him home immediately. There’s no doubt in my mind that if her father (“with a long history of cardiac problems”) went home, had an arrhythmia and died, she would have been the first one pointing fingers at the emergency physicians for discharging him without proper evaluation. Then some NYU bioethicist states that physicians are essentially using AMA forms as “coercive” weapons and that physicians are being “paternalistic” for requiring patients to sign AMA forms and accept responsibility for their actions. He needs to look up the terms “coercive” and “paternalistic” in a dictionary before doing any more media interviews. If competent patients want to make bad decisions, it is entirely their right to do so. An AMA form simply documents that patients are aware of the risks and benefits of the decisions they are making. Somehow twisting this process to suggest that the AMA process is “coercive” and suggesting that medical providers should just take responsibility for a patient’s poor decisions is nothing more than a cheap shot by the article’s author, Paula Span. Shameful.
E. Paul DeKoning, MD, MS: I’m not buying it. I just find this whole article hard to swallow. It’s not against the law to make bad decisions and, while I don’t always agree with my patients’ decisions, i find it hard to believe that the setting the author describes is common place. If even real. I actually seldom have patients sign the AMA form–I find it to be adversarial and accomplishes little. Instead, I sit down and we have a conversation. A real one about all the bad things that could happen (but frankly probably won’t). And then I document the aforementioned conversation. Everyone leaves happy (at least happier) and I don’t lose sleep about being sued. Patients sue doctors they’re mad at.I tend to be a strong believer that the above approach avoids the pissed off patient who’s ready to sue. I can’t imagine any physician I know acting the way the author describes, holding patients against their will. Last time I checked, if they have capacity, that’s illegal.
Ryan McKennon, DO: Like Paul, I rarely have people sign the “AMA” form and simply document a discussion we had about the risks and benefits. That being said, what’s the big deal? If you disagree with your doctor and want to leave, why is so much offense taken at signing a form that states exactly that? The forms are typically very short and written in plain language explaining the conversation that has already taken place. People have no problem signing a credit card application that is 20 pages, small print, written in legal jargon but lose their mind if they have to sign the AMA form which has been explained to them. It certainly does not rise to the level of coercion “use of force or intimidation to obtain compliance” – dictionary.com.
Nicholas Genes, MD, PhD: I don’t understand how this article about ED patients wanting to leave only gives lip-service to the concept of medical decision-making capacity. Preventing an actively suicidal patient from leaving isn’t controversial (right?). Preventing a delirious older adult from walking out alone in the middle of the night isn’t controversial (right?). I agree with the earlier comments about shared-decision making with family, in lieu of an AMA form. I know and work with Dr. Callahan and am surprised this conversation (and its documentation) didn’t happen in this NJ ED. Maybe there was an attempt at it but the ED doctor really was being unreasonable. Usually when a patient wants to go, in the custody of their physician family member, that’s a good thing, and I just document that we spoke and they understand the risks of leaving before the workup is complete.
New POV technology should provide insight into physician decision making, according to a July AEM study.
The study is the first time the own-point-of-view perspective has been used in the study of medical decision-making, particularly clinical decision-making in emergency medicine. Original Article by ScienceDaily.
William Sullivan, DO, JD: The study alleges that recalling reasoning during a patient visit is better with Google Glass-like “point of view” setups than with using a camera recording from the corner of a room because fixed cameras aren’t suited to fast-moving environments, can’t capture facial expressions, may catch other information, and may increase a physician’s self-awareness. Not sure that facial expressions or perceived self-awareness are going to make much of a difference in me recalling my reasoning for ordering a cardiac workup in an elderly patient with chest pain, and there aren’t any studies comparing the two modalities of recall, so I remain skeptical of the application. I hope this isn’t just a way to justify implementing some future iteration of Google Glass into the medical workflow.
E. Paul DeKoning, MD, MS: Invention is the mother of necessity–sounds like technology looking for an application. I thought this went away when Google Glass took a face plant. The Joint Commission could implement a similar technique in helping me remember what I was thinking when I chose to eat that sandwich at my workstation that one time. Wait, no I didn’t. That was somebody else and I’ve got POV footage to prove it.
Ryan McKennon, DO: For some reason the article has me envisioning an Orwellian future where will all end up wearing body cameras like police officers do. Just needed to get around all the HIPAA problems first.