Monday, October 20, 2014

When Life Imitates Art

There is a television show called “The Strain” a television series that premiered on FX on July 13, 2014.  It was created by Guillermo del Toro and Chuck Hogan, based on their novel trilogy of the same name. The show depicts a vampire-type apocalypse that when superimposed on the “Ebola Crisis” have very similar characteristics.
In the show the “infection” which leads to a form of vampirism has the following characteristics:
  1. The illness arrived by plane.
  2. The illness is spread by direct contact.
  3. The illness is contained in a “wormlike parasite” which looks very similar the electron microscope pictures of the Ebola virus.
  4. The victim proceeds to transmit the illness directly to their immediate contacts (the people they love).
  5. The Centers for Disease Control are both the heroes and villains.
  6. Decisions about protecting the community are a complex interaction between fact, fiction, political issues, financial issues, and last medical issues.

It is interesting the parallels and if one get rid of the vampire stuff, pretty close to reality. These are complex problems which hopefully will get sorted over time.
The recent admission of an Ebola victim to a Texas hospital has created a furor in the media but how could the Emergency Department send someone home with “fever and feeling bad.”  The blame game started with triage nurse, the Emergency Department, the hospital system, TSA and Homeland security, and now the Electronic Health Record for not identifying this problem the first time.
Before everybody gets upset, the reality of Emergency Medicine is that it is traditionally a reactive specialty that once it identifies the specific threat it is nimble and organized to create policies to avoid missing the next case.

The Texas hospital had the misfortune of being the first place known to have had an Ebola exposed patient leave the department without initially identifying that individual and setting the “government” machinery on them.
The individuals involved unless prescient are victims of a system error where the safeguards were not already in place. The institution having no experience of what to look for probably were not geared up. The Electronic Health Record and clinical decision support (artificial intelligence) is probably not geared up to give the providers adequate warnings.
Blaming individuals will not solve the problem, but a plan to be ready for the next case is the proper pathway. These are “system issues” that require an organized response. Vampire shows are not for everyone, but sometimes they are well-made and interesting.

Tuesday, October 14, 2014

Is There a 'Black Box' In Your Future?

The article Does a surgical 'black box' open the floodgates for malpractice suits? reports that a Canadian team of surgeons is creating a black box for surgery similar to aircraft. 

In ancient times surgeries were viewed in a theatre where one could watch and learn.  However, most surgeries today are isolated to the direct participants.  The black box would give a real-time analysis of surgical performance, errors, and endless feedback.

The problem is not the data itself, but potential downside use of the data for malpractice litigation.  Most surgeons of course, would avoid adding suit-risk to their practice, if indeed litigation is the use that is given the most press.  Yet it is sad to ignore the potential of such devices that have potential clinical application in many other settings, such as in the emergency department and heart catheterization lab.

The use of the term black box is a bit Orwellian.  We are not in 1984 and most physicians, even may surgeons, recognize the value in real-time feedback.  Being human, mistakes happen, and any device that enables more comprehensive observation of the care process, giving guidance when needed, will be well appreciated.  BUT, that appreciation will disappear, if the name black box is used or the look over your shoulder aspect is the one that is emphasized.  Even may p-to-date cars warn drivers of impending accidents.  Why not offer the same technology in the surgical suite?  As with most innovation, the devil is in the details and marketing of such products is key.  These provide feedback in a manner no different from any other clinical decision support (CDS) device.  Advice from a CDS system can be either accepted or rejected, and the ultimate responsibility remains that of the physician in charge.

Similarly, the advent of Google Glass, with its ability to record every viewpoint, is in the same vein, ad may make the concept of the black box already obsolete.

What will surgeons do?
  1. Resist, if able
  2. Perform only life-threatening surgery in these arenas
  3. Try to perform most surgeries in a Surgery Center
These are doubtful.  Most likely they will initially explore, then comply with whatever mandate requires use of real-time feedback technology.  Indeed, providers may be forced to behave as if always on camera (and that may be a good thing).

Monday, October 6, 2014

Real-time Emergency Medicine with Google Glass Technology

Google Glass is a definite leap toward the inevitable future of direct mind-CPU integration.  One does not have to be a crystal-balling futurist to see that surgical chip implantation in the brain is not too far behind.

The article Google Glass May Help Emergency Physicians Improve Patient Care identified potential uses of the device in tracking, decision support, and diagnostic aid (the first tricorder).  Of course, fans of the science fiction series Star Trek, know that a tricorder is a hand-held multi-function device that Doctor McCoy depended on for sensor scanning, data analysis, recording data, and more importantly diagnosis.  During the years the original show ran, most Trekies could not even imagine the wireless world that we have now become so accustomed.  Nevertheless, it does not take much further imagination to conceive of a medical world in which past records, CT results, lab data, immediately visualization, and decision analysis all wirelessly get synthesized and collated through a common central device, such as Google Glass.  Hence, what was once science fiction is now considerably closer to science reality.

An especially intriguing potential use for Google Glass is real-time supervision and consultation.  As the number of Nurse Practitioners and Physician Assistants increases, the need for careful monitoring increases.  Thus when supervision is enabled in real-time, the system will experience delivery of coordinated care that is inherently more safe.  For academic organizations, think of an attending being able to effectively supervise more residents than could be possibly be achieved by walking from bed to bed.  And then, even in our own practices, a cardiologist might review an EKG as it is actually taken, through the device at the same time as you, naturally speeding up disposition.  The list of conceivable benefits goes on and on.

With the ability of the Google Glass to take photos and record evaluations, the encounter itself, as well as its related data can easily be transmitted to a person who may be in charge.  At the same tie, the accuracy and quality of care can be monitored and expertise and assistance, when needed, can be given immediately.  Of course, there will be some naturally expected barriers to full adoption, not the least of which will be the necessity of acquiring experience, along with the need to promote an atmosphere of cooperation among practitioners, where guidance is seen as providing real-time feedback and advice, and not as demanding or disparaging.

Additional benefit will arise if this technology enables the staffing of facilities with fewer high level and therefore more expensive individuals.  One might ask: how many physician will be needed to staff a 60,000 visit emergency department in the world of the near future?  Currently, general wisdom says one would need 12-16 physicians and 8 supporting PA and/or NPs on a full-time rotation of shifts.  One can anticipate that the balance within this ratio might well change in a Google Glass supported ED, requiring less physicians and facilitation the use of more support-level practitioners.  The Glass might enable the eyes of one ED doc to roam much further than before.  such a far-reaching vision would also be a great benefit to rural hospitals and locations that find it difficult to attract physicians, since observational immediacy could be obtained without physical immediacy.

Glass data could be sent right to the consultant to help clarify, expedite, and provide hopefully better care- how Trekies is that!  It promises to have an equally strong real-time presence in the documenting and decision-making process.  The Google Glass linked EHR of the future can well be envisioned as documented by a reviewable folder of commentaries, snapshots, an videos of what occurred.

Of course, the tricorder will not put health-care providers out of work because you will need someone like McCoy to say to the captain: "Dammit Jim; I'm a doctor not a ...!!!"