September 17th, 2009 by Paul Auerbach, M.D. in Better Health Network, Opinion
No Comments »
This past December (2008), there was a report in Healthcare IT (Information Technology) News that got me thinking, of all things, about medical situations in outdoor wilderness environments. The substance of the report was that researchers at Vanderbilt University (I worked there in the late ’80s as Chief of the Division of Emergency Medicine) “found that physicians who receive training in a technology-rich environment, but go on to work in a less modern facility feel they can’t provide safe, efficient care.”
The study related to information technology, but is probably applicable to many other modes of technology. As it was reported, the Vanderbilt study included more than 300 medical training graduates. Of those who “were working in an environment with less IT,” some 80 percent reported “feeling less able…to work efficiently, to share and communicate information, and to work effectively within the local system.” The lead investigator Kevin Johnson, MD explained that “going from being a medical student where somebody is always watching after you to a role where you could potentially make a mistake that could actually harm a patient is already hard enough.” But “when you get there and realize that the systems they have are less functional and less pervasive…there is an entirely new set of challenges.”
To all medical students, residency graduates, or anyone else who moves from a highly supervised environment to one where you are on your own, welcome to the club. The whole point of learning how to be self-sufficient is to be able to go it alone when the need arises. What is most striking about wilderness medicine is the notion that one moves to a setting that is austere and resources (people, technology, supplies, communication, etc.) are frequently limited. This can be very unsettling for experienced practitioners, and is even more so for neophytes.
We live in an age of technological imperative. Doctors train in hospitals with large, complex intensive care units. The emergency department is equipped with all the latest gadgets, and specialists are on call 24 by 7 to help out when a difficult or puzzling situation arises. That is not the case in the wilderness, on the battlefield, or out at sea. Expectations change from perfection to doing enough to get the patient to a higher level of care, or just to make it through the hour, let alone the next day.
Think about it. Take your favorite medical instrument(s) and think about how you would practice if you didn’t have access to it. Could you diagnose heart failure without a stethoscope and pulse oximeter? High altitude cerebral edema without a CT scan? Septic shock without a blood pressure monitor, central venous catheter, arterial blood gas measurements, and a battery of laboratory tests? I think the answer is “yes” if you were properly trained.
Technology is good. In fact, it is great. Patients are better off for the ability of health care professionals to apply all manner of diagnostic and interventional devices and techniques. However, I believe that at the same time we are all taught how to do things in the city, we should learn how we must sometimes do them in the country.
image courtesy of cdneverest2008.com
This post, Physicians Should Learn How To Practice Medicine With And Without Technology, was originally published on
Healthine.com by Paul Auerbach, M.D..
September 14th, 2009 by Emergiblog in Better Health Network, Opinion
No Comments »
Emergency has something in common with Labor & Delivery.
Neither department has control over their census.
Medical/surgical, telemetry units and ICUs have a finite number of beds. When they are full, they are full; they cannot physically expand to more beds.
ED patients and laboring women are never turned away no matter how full the department may be. Oh, the ED may triage and L&D may send a patient in early labor home, but in both cases, eventually, all will be seen.
Labor and delivery has one advantage over the ED.
They can have someone on call.
I’ve never worked in an ED that has had an “on-call” nurse.
****
I will never understand the logic behind staffing an ED based on the previous 24 hour census.
If the ED does not meet a pre-determined number of patients on one day, the break nurse for the next day is canceled and there is much wailing and gnashing of teeth as the department goes over budget.
Never mind that the acuity level of the patients who were seen was through the roof. Or that 50% of them were admitted. Or that the next day, acuity again sky high, the nurses go without meals/breaks and the department is required to give penalty pay. Again, there is much wailing and gnashing of teeth for having to pay this penalty, a penalty that would never have been required had the break nurse not been canceled.
****
Now if the ED is slow, staff can always go home early. But not too early, because you never know what is coming in through the doors. So maybe an hour, 90 minutes early, knowing that the remaining staff can handle whatever they need to handle until the next shift comes in.
But what happens when the patients overwhelm the staff, both in acuity and numbers? Ambulance diversion doesn’t stop the walk-in critical patients. The MIs and the possible CVAs. The GI bleeders. The potentially septic. Trying to get patients out of the department and up to the floor doesn’t work when the floor won’t take the patient for four hours because it would put them “out of ratio”.
This is a huge issue on the night shift. When there is only one unit clerk/registrar, two nurses and an ED tech after 0300.
Of course, at night it is feast or famine.
Either the feces hits the proverbial fan or…it doesn’t.
Which is exactly why we need a nurse on-call.
The ED needs flexible staffing that accounts for those times when the acuity level/census is overwhelming. Not canceling the extra break nurse is one way of doing that on days and evenings; using the on-call system is another way that could be utilized at night. If it can be done in L&D, why can’t it be done in the ED? Surely the money saved in penalty pay for missed breaks and meals would make it budget neutral.
All I know is that trying to drop staff in an ED based on what happened the previous 24 hours makes zero sense.
(And don’t even get me started on why nurse-patient ratios are treated like unbreakable rules on the floors, but it’s okay for the ED to be waaaaay out of ratio and nobody blinks….that’s another whole post!)
*This blog post was originally published at Emergiblog*
September 4th, 2009 by Paul Auerbach, M.D. in Uncategorized
No Comments »
Michael Kilbourne and colleagues recently published an article entitled “Hemostatic Efficacy of Modified Amylopectin Powder in a Lethal Porcine Model of Extremity Arterial Injury”( Annals of Emergency Medicine 2009;53:804-810). The purpose of the study described in this article was to investigate the blood-stopping ability of a modified amylopectin powder in an animal (pig) model of severe limb bleeding created by an injury to the femoral artery.
Following creation of the injury, animals were treated either with regular gauze with manual compression or with specially modified amylopectin powder and manual compression. Some of the endpoints measured in the study were total blood loss, survival, and time to bleeding cessation.
Post-treatment blood loss in the amylopectin powder-treated group was much less (approximately 0.275 liter) than in the gauze group (approximately 1.3 liters). Bleeding was stopped in approximately 9 minutes in the amylopectin group, and never stopped in the gauze group. 100% of the amylopectin animals survived, and none of the gauze animals survived.
While this study was directed to improve care for victims of major trauma (including wartime situations), the applicability to situations in the outdoors is direct. Many blood-stopping bandages have come to the civilian market, and they are quite useful. I carry them with me whenever I’m going into the wilderness, and often when I cover athletic events as the team doctor. They’re useful for nosebleeds and cuts, not just for severe injuries. Some of the product names include HemCon Bandage, QuickClot, BleedArrest, QR, Celox, and BloodStop. There will undoubtedly be improvements in these products, in particular the delivery systems, be they bandages or powders.
image courtesy of www.instructables.com
This post, Amylopectin Powder’s Amazing Ability Top Stop Hemorrhaging Fast, was originally published on
Healthine.com by Paul Auerbach, M.D..
September 4th, 2009 by admin in Better Health Network, True Stories
No Comments »
By
Edwin Leap, M.D.
An emergency physician, like me, may be the worst possible person to discuss relationships with patients. I mean, one of the reasons I chose this specialty was that I didn’t want long-term relationships with my patients. I see, now, that God has a great sense of humor.
See, the county I landed in after residency is small enough that I do know many of my patients, and I do see them more often than you might imagine. After all, our hospital is ‘the only game in town.’
There are some patients I know quite well, and thus I know with reasonable accuracy who is sick and who isn’t, based on how they looked or behaved before. It doesn’t always work, but frequently it does.
Which brings me to trends in primary care. I don’t know if I’m really a primary care provider or not. Some years we are, some years we’re considered specialists. Whatever. It doesn’t really change the work. It might change the pay, as administrations place different emphasis from time to time. But I do see a lot of primary care. I watch internists and pediatricians, family physicians and ob/gyns do their work. And what I see, from the standpoint of the emergency room, is a drift away from relationship.
The thing that brings it up most poignantly is the trend towards hospitalists. For those of you not acquainted, the hospitalist is a physician whose practice is focused on admitting patients to the hospital, caring for them, and discharging them back to their regular physicians (if they have one) when the acute situation is over.
Now, I know some great hospitalists. And I understand the need for them. As hospital care becomes more complex, as offices suffer when their docs are at the hospital, as the goal becomes ‘discharge as soon as possible,’ wherein utilization review committees are prime-movers, the idea of the hospitalists makes great sense, and probably bears much fruit.
However, a relationship is severed. We have many community physicians who do not do hospital work. And more now that the hospitalist option exists. So let’s say I have patient X in the evening or on the weekend. His physician doesn’t admit. I call the hospitalist. ‘Patient X is having chest pain. His cardiac labs and EKG look alright, but it just seems concerning to me. Can we admit him?’ Hospitalist: ‘well, he doesn’t have risk factors and everything looks OK, what are we going to do? Do a second set of labs and let him see his doc tomorrow.’
Now, that was a technically correct encounter. But if his own doc had been on call, as in the past, he might have said ‘I’ve known him for years. He doesn’t complain. That isn’t like him. Let’s keep him overnight.’ Scientific? Maybe not. Possibly useful? Absolutely.
See, the hospitalist is driven by admissions and discharges. And he or she has no abiding relationship with these patients. In the same way, the family physician who won’t admit has severed his relationship. ‘So, I see you were admitted last week!’ He’ll get a report. But the next serious illness that comes around will still be a situation in which the patient is admitted to a stranger with a lack of personal interest (I don’t mean that they don’t care, just that they aren’t personally connected over a long period of time).
I see both sides. The hospitalist has a focused mission and a busy service. The family doc has a focused mission and a struggling office to run. But somewhere in between is the patient, who has been left afloat between two continents. I guess the ER is the ‘desert island’ in between.
I don’t know the answer. But I know that when they come to my emergency department, I have
Doctor and boy looking at thermometer, Norman Rockwell
to put together the pieces and do the right thing. I don’t have all of the information. But before you scream ‘EMR,’ remember that medicine is more than data points. Even if I have the data, I don’t have the sense of the patient. The knowledge his or her physician has from personal, repeated interaction.
So I have to put the data together, decide if it heralds something perilous, and then I have to be a salesman…just to get someone else to look at the patient. I am, in a sense, a voice-activated robotic surrogate for everyone; from family physician to hospitalist, obstetrician to urologist, ENT to general surgeon. But then, that’s another post altogether.
What I mean to say is, when we lose relationship, we lose some of the most important bits of information in all of medicine. Humans are complex, and in order for us to care for them, at least in the setting of being hospitalized or discharged, it’s remarkably useful to know them.
What do we do to fix it? I have no idea. I don’t believe it’s a thing that can be repaired with compensation schemes. Perhaps only philosophically, as we teach young physicians the value of relating to their patients more than scientifically. Or if it works better, to explain to them that science is more than labs, stress-tests, x-rays and biopsies. Science is the pursuit of knowledge.
And patients are best known by…knowing them.
How’s that for a koan?
Edwin
August 25th, 2009 by Paul Auerbach, M.D. in Better Health Network, Health Tips
No Comments »
We are still in fire season in the U.S., and with persistent hot, dry and windy conditions, may see quite a few more conflagrations this summer and into the autumn. The fires that can be attributed to human behavior occur for the same reasons year in and year out, whether they are accidental or intentional. So, we will face them, and knowing what to do before they happen can be a prerequisite for survival.
Of course, fires occur worldwide, and there is much to learn from the experience of others. Some months back, there was an interesting commentary in the news during fire season in Australia that pondered the question, “Why did so many die in Australian bushfires?” Here is a paraphrasing of the response:
“Yes this is awful – devastating to the psyche. For Australia, this is bigger than the twin towers and we cannot blame an external agency. Much of it we did ourselves. All over central Victoria, it was the worst fire weather by far that has ever been experienced. Temperatures were above 40 degrees centigrade (105 degrees fahrenheit) for days, there was no significant rain for months, and there were strong to gale force winds straight out of the central desert for days.
It seems that most people who died actually did so trying to flee at the last moment. They died on the open or in cars, especially in crashes along the roads or running into fallen trees. Even before the fires hit, it was so hot that eucalyptus trees were dropping large branches everywhere.
Many who survived in the fire storm did so in prepared or ad hoc refuges and bunkers or inside their houses, leaving their homes only when the houses were burning but the main fire had passed.
The problem was that in some areas the winds were so strong that houses were torn apart by the wind, leaving no option but to be in the open. As usual, many of the injured did not have suitable clothing. For some, the attire of shorts and thongs may have been fatal. The fires were so hot that they melted alloy wheels on cars. Many, if not most, people living in the area at least evacuated their children, and the elderly and sick. Most houses were relatively well prepared for ‘normal’ fires. This is a semi-rural area, so people had water, pumps, mobile and fixed sprays, and plans. The problem was that they had no chance to use them, because everything happened so fast and was so intense.
The area was beautiful-the sort of dangerous beauty that comes from houses situated amongst trees. The area is a mountain ash forest. Many of the trees around the houses are stringy barks and cyprus pines, all of which become explosive in fires. There was ember spotting as many as five miles ahead of the main fire front. The actual fire winds were over 100 kilometers per hour. At times, the main fire front moved at 30 to 40 kilometers per hour.
Some persons commented that one of the most bewildering aspects of ‘Black Saturday’ was the disconnect between the general and, ultimately, prophetic warnings issued by authorities beforehand and the absence of specific information when the fires overwhelmed communities. But really! There is not some celestial fire watcher able to communicate with everyone and tell them what to do! Phones were out, the emergency call (000) was overwhelmed (1800% over normal call volume) and the operators were actually listening to people die without being able to help.
There have been so many extraordinary stories of bravery and good luck, but it is really difficult to put it all into perspective. People everywhere seem to be really quiet and depressed. There is a constant barrage of awful vision on the TV that keeps on reinforcing the horror. Really well known people are dead. So many kids and complete families.”
Key points for those who will one day face the prospect of encountering a wildland fire:
1. The thermal intensity of a wildland fire is beyond imagination. It is far better to be away from the heat than to try to shelter within it and try to survive. Escape routes should not be left to serendipity or improvisation. Anyone who lives in an area that is vulnerable to wildfire should have a plan for when and how to escape.
2. One needs to understand fire behavior, and how to avoid panic. Last minute attempts at self rescue are often marked by tragedy.
3. The wildland-urban interface is growing. The minority of homeowners subject to wildland fire risk have properly cleared their property of remediable fire hazards, and likely are not completely prepared to protect their lives and dwellings.
4. Warning systems are not infallible, and resources are easily overwhelmed. Everyone needs to take personal responsibility for being on the lookout for wildfire, and for his or her response to an encroaching blaze.
5. The aftermath of most natural catastrophes can be as devastating as the event. Entire communities and populations are affected, so we share the responsibility to prevent fires, report them promptly, protect our family and friends, and assist response teams in doing their jobs to suppress fires.
This post, How To Survive A Wildfire: Lessons From Australia, was originally published on
Healthine.com by Paul Auerbach, M.D..
This past December (2008), there was a report in Healthcare IT (Information Technology) News that got me thinking, of all things, about medical situations in outdoor wilderness environments. The substance of the report was that researchers at Vanderbilt University (I worked there in the late ’80s as Chief of the Division of Emergency Medicine) “found that physicians who receive training in a technology-rich environment, but go on to work in a less modern facility feel they can’t provide safe, efficient care.”
