The Ebola “Shake”

As the Ebola epidemic shows no signs of dissipating, it is probably time to change some common greeting customs. The standard greetings depending on location, culture, and state of intoxication include handshakes, hugs, kissing both cheeks, chest “bumps”, high five, low five, and multiple variations on above.

 

               With skin-to-skin contact, spread of the virus is possible but unlikely, as the infected contact is thought to require high illness severity accompanied by a high viral load.  To avoid transmission, but continue the formalities of social greeting, the suggestion has been made to switch to the lightly closed fist “hand-bump.”

               There are two variations of this:

1.      The covered hand (where you pull your clothing over your fist and then make contact.)

2.      The uncovered hand where you feign actual contact, gesture, miss, and retain the psycho/social effect.

The Japanese culture with traditional bowing has already solved this dilemma. Not sure that this will translate to a more macho western culture.

               There has been much controversy in the news media about the proper way of avoiding the spread of Ebola worldwide. The options of travel bans, closing air traffic, quarantine, and testing stimulate expert opinion. These expert opinions are extremely varied and seem to be based on political orientation to avoid panic and medical need according to the CDC based on medical evidence according to epidemiological techniques. At the present, there are shifting recommendations on a daily basis.  The 24-hour news cycle, political correctness, and true lack of knowledge makes it look like there is no black or white answers.

               In large part, these shifts reflect an imperfect science regarding the transmission of this virus.  The ease with which it spreads in some situations (e.g. to healthcare workers) is offset by a variable period of contagion (thought—but not guaranteed-to maximize at 21 days), an ill-defined onset of viral shedding (headache? myalgias? rhinorrhea? low-grade fever?), a degree of permeability to protective gear that is almost uncanny, as well as an unknown capacity to mutate and circumvent measures being established.

               Moreover, effective treatment is now generally agreed to depend on one dimension:  supportive care with adequate hydration and electrolytes.  It is almost cholera-like, and electrolyte depletion is now thought to be the final common pathway to death.  Quite likely, when the analytics are complete, they will show that most of the deaths in W. Africa could have been prevented with simple IV hydration.  Not to mention that much of the transmission there could have been averted by common-sense burial practices*, along with mitigation of unnecessary fear.  Yet, in those countries, at the height of the disease, those infected (including many healthcare workers) were sent to the back (rooms, tents, fields) and left alone, where they, of course, died.  Treatments such as convalescent serum, plasma, ZMapp were, in all successful cases, given along with good supportive care, and full hydration. Hence, it was, to any cogent medical mind, the hydration and support that made the difference.  Since cases are now being shown to recover just with fluids, the other “treatments” were clearly superfluous.

               The probable truth is that there are no straightforward solutions to the problem of stopping transmission.  They become, and are becoming more and more, epidemiologic and political decisions.  The common sense approach of attacking and isolating the problem at the source through quarantine and support sounds the best but may not be the whole answer.

               The Ebola epidemic will ultimately probably be controlled or burn-out itself and life will go on. In a prior blog (Life Imitates Art) it was stated that is really hard to get things right without the necessary experience. The fact that multiple communities and countries are trying different things will allow the analysts to come up with a “game plan” in the future for the next uncontrolled world-wide pandemic.  We should consider the present infection as a “test” of our preparedness and make the appropriate adjustments.

*In one well-known case, when it was thought the outbreak was just about under control, the body of a woman who died from Ebola was taken from the hospital under gunpoint by relatives.  Her remains were taken to their home, and the practice of full contact mourning caused a resurgent outbreak in the area.

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.

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).

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 ...!!!"

Doctor Errors Kill 500,000 Americans a Year

The article published last week the author claims that Doctor Errors Kill 500,000 Americans a Year. 
The Institute of Medicine in 1999-2000 released a report that 44,000-98,000 patients a year die as a result of medical errors.  The main categories of error at the beginning of the 21st century were diagnostic, treatment, prevention and system errors.

 

In this article, only about 15% of a decade later, raises that number to 500,000.  Is 500,000 accurate?  Well, that depends on how the counting is being done, as it is an inherently complicated analysis to determine whether "a specific action or inaction directly lead to a death".

 

 

Causality: is the relation between an event aka the cause and a second event aka the effect, where the second event is understood to be a consequence of the first.

 

A chief aspect of the complexity is the blur that naturally occurs between events that are simply associated in time, and events that are causally linked.  When events are merely associated with one another, they may appear to be causally linked because one comes before, and the other occurs after, but causation is nevertheless absent.  When events are actually linked by causality; however the earlier produces or directly contributes to the later.

 

Sorting this out may seem achievable, but often is not.  moreover, for the purposes of health-care analysis or litigation, it is quite easy for one side or the other to make before-after appear like before caused after.  When cause and effect are obvious then the attribution of causality is clear.  Usually this only happens in simple cause-effect circumstances.  Say a person weighs 500lbs and is known to have eaten three gallons ice cream nightly for the past 15 years.  In this care, the cause-eating ice cream- is certain without any doubt.

 

But in medicine, things are rarely ( or never) so simple.  For example, suppose a man presents to the ED having been brought in by rescue after a car accident.  He begins to have some chest pain, and an EKG is done, which shows an Acute MI aka heart attack.  Now what was causal regarding the MI?  Was it the physiological stress of the car accident, the psychological and physical stress of the rescue transport, or perhaps his wife yelling at him before he left home?  Could the MI have occurred before the accident, and the physiological stress of the infarction have precipitated the accident?  Or, could he have bee exposed to some drug or the substance decreased his coronary flow, and been a definitive causal factor?  In this example, no one knows, and claims of such knowing are highly suspect to be thoroughly biased, and likely influenced by funds on the table.  There are simply a panoply of associated factors present, any one of which, or any combination of which, might have been causal.  The same is true with respect to medical errors, except in this field of inquiry, causal factors within the system itself are the most dominant associated factors for which individuals in the system are frequently blamed.

 

Indeed those who study medical errors fully are the first to acknowledge that prevention of such errors are for the most part systemic issues.  That is, humans are simply not error free; systems on the other hand, can come much closer by putting into place checks and balances to catch errors whenever possible.

 

In heath-care litigation, the claim made does not take into account the complexity of determining what really caused a bad outcome.  The number claimed by the Institute of Medicine was considered outrageous at the time, and for good reason; indeed this number seems high and sensationalistic.  They clearly equated bad outcome with caused by an error in care.

 

The numbers are less relevant than recognizing the presence of an underlying system problem that needs fixing.  Recently, system analysis experts have working toward a plan where the individual practitioner is not the recipient of the total blame, but a pathway to fixing the problems for all involved.

8 Malpractice Dangers in Your EHR

In the 8 Malpractice Dangers in Your EHR article, the author analyzes the legal risks implicit in the use of an electronic health record.  These include:

• The healthcare provider is legally responsible for the medical record not the vendor and/or consultant even if there is the claim of a faulty product..
• Copy and pasting text.
• Lack of password control.  Sharing your password may allow certain entries and/or additions to look like provider direct input.
• Ignoring clinical decision support without careful documentation of why.
• Customizing your electronic health record without realizing you may be affecting the main data base.  Critical pieces of data must be acknowledged not just placed in the body of the note.
• Using the meaningful use criteria for payments may lead to a change in the standard of care.
• Entering incorrect information due to time pressures.
• Altering the patient-provider interaction by focusing on the computer screen, not the patient.

It is advisable any provider should read the entire article.  Most of the time, worry about these points is unnecessary.  However, the majority of lawsuits and complaints cannot be predicted in advance.  The best solution is to fully understand that every feature an electronic health record offers has some potential downside.  If aware, the provider can compensate with some explanation placed directly in the record.

The legal field is getting more sophisticated about its analysis of the electronic health record and using it to their client's advantage.  One of the huge issues is the creation of complex meandering timeline of events.  The computer documents the exact time the data was input, but does not realize when the actual events occurred.  Spending a little time on the clinical course can put large amounts of data in a logical order.

Getting the Dread On!

My long-time Emergency department colleagues collectively called the anxiety and anticipation about having to perform perfectly on the next shift "Getting the Dread On".  This implied that the worry about the stresses of the next stint could begin any time from when the last shift ended.  The definition of dread is great fear or apprehension.  Common synonyms include fear, apprehension, trepidation, anxiety, worry concern unease, angst- you get the picture. 

After reading these descriptions, one would wonder why anybody would work at this job.  We'll save that for a another blog.

Some shift work health consequences include:

• Sleep disorders
• Diabetes Mellitus
• Headaches
• Ischemic heart disease
• Fatigue
• Stress
• Poor appetite control
• Substance abuse
• Problems with medications
• Problems with interpersonal relationships

The biggest fear is making mistakes leading to poor patient outcomes.  This coupled with volume and performance pressures, patient satisfaction scores, the ever-looming threat of malpractice suits, and chronic self-doubt can immobilize an individual.

It is probably time to retire or find a less stressful career than Emergency Medicine if getting the dread on is a recurring theme in your life.  Fortunately, most people learn to deal with the stresses and overwhelmingly positive side to the job, and they soldier on!