Opportunities for Emergency Medical Services to Modernize

The article Rethinking EMS: Don't Knock Homeboy Transport addresses the value of advanced life support rescues.  The author uses scientific data as evidence that the present paradigm based on advanced cardiac life support and advanced trauma life support may be neither practical nor beneficial for patients overall.  The author also discusses the number of ambulance and helicopter accidents during various rescues, issues with pre-hospital dogma include that the "golden hour" of trauma only reflects a very small proportion of patients; and early cardiac drugs may or may not help survival.

The real issue at hand: Tremendous cost, falls in urban administrations under the umbrella of fire safety and there, one does not comfortably venture, if a politician, without be ready for a career-ending catastrophe.  However, there are ways to modernize and make fire-rescue more efficient, while saving huge quantities of capital and operating expenses.

The historical premise of fire-rescue resuscitation is that a cardiac arrest victims must receive CPR within 4 minutes to prevent brain anoxia-lack of oxygen.  However, new CPR studies show that chest compression without rescue breathing is sufficient to provide oxygenation prior to defibrillation for return of spontaneous circulation.

This means that with good CPR, you have more time to defibrillate.  Keep in mind, that at present time, a fire truck is sent to almost every call - arrives within the 4 minute time limit, followed by a rescue vehicle and supervisor on duty.  With proper triage through dispatch the necessity of multiple fire vehicles may be prevented.  Five vehicles do not a true resuscitation make.  If needed, additional help can be brought in.

A tiered approach toward dispatch and resource distribution can be created to save on manpower and machines.  It would be modern indeed, and might benefit from an approach like this:

• Incorporate the local citizenry through smartphone technology to be first responders.  Without the need for rescue breathing, the public should be more willing to provide CPR
• Have police carry defibrillators. 
• Use "Uber type" drivers with basic life support capabilities and defibrillators available.
• Allow paramedics medical legal liability protection to encourage self-transport.

The bottom-line- resource management is key.  Most rescue calls are not really life and death that can be handled cost effectively as remote triage platforms.  Yes, truly critical patients need rapid transport to the hospital for definitive care.  While our fire rescue personal do a great job, they can be utilized much less expensively and much more judiciously, as true first responders, without needed to be CHST thumpers.

“Mama Don’t Let Your Babies Grow Up To Be Doctors”

This is Waylon Jennings' and Willie Nelson's 1978 cover of "Mamas, don't let your babies grow up to be cowboys". The song, originally performed by Ed Bruce, was number 1 on the charts for four weeks in the spring of 1978 and was released on the classic duet album "Waylon & Willie".

In the famous song by Willie Nelson and Waylon Jennings, they opine about the hardships of the “cowboy life”.

This song was Waylon Jennings' and Willie Nelson's 1978 cover of "Mamas, don't let your babies grow up to be cowboys". The song, originally performed by Ed Bruce, was number 1 on the charts for four weeks in the spring of 1978 and was released on the classic duet album "Waylon & Willie".

When asked the question of whether you would want your children or relatives to become physicians in the modern era, the answer is always “YES… but….”

Motivations for becoming a physician are multiple with multiple answers. They are generational in scope and multi-factorial. These include

1. Saving the world

2. Helping mankind

3. A means to an end.

4. Avoiding the draft and the Vietnam War

5. Family tradition

6. Economically motivated

7. Opening doors

8. Raising your social statue

9. Good at “School”

10. etc.

The modern day physician is caught in the trap of the “fantasy” of the good old days and ever-changing landscape. The physician is no longer the perceived expert of their domain but a valued cog in the big picture.

Patients still love their personal physician but want input in all aspects of their care. The paternal system of “I’m The Doctor” no longer works.

The physician is also trapped in the electronic world of endless data capture that is rarely relevant to the individual patient in front of them. Click 18 more boxes and you might get paid. 17 boxes and you get a 50% reduction. Did the patient get better? Who knows?

The modern day physician has become a corporate employee with little autonomy unless you are a dinosaur from the past and cling to your “perceived” freedom. Once you accept Medicare and Medicaid payments, you are indirectly/directly an employee of the government.

Getting back to whether you would recommend it as a career. I would do it over again because of the positives definitely outweigh the negative. Every 10-15 years medicine has been shaken up for financial reasons and everyone survived. The burdens are different but with the proper understanding that early acceptors of change are always the winners.

Where Does Telemedicine Fit In??

The authors of Telehealth Poised to Revolutionize Health-care review the present and potential trends in telemedicine.  ” Three trends, all linked, are currently shaping telehealth. The first is the transformation of the application of telehealth from increasing access to health care to providing convenience and eventually reducing cost. The second is the expansion of telehealth from addressing acute conditions to also addressing episodic and chronic conditions. The third is the migration of telehealth from hospitals and satellite clinics to the home and mobile devices.”

​​SMThe article does an excellent job of delineating the present and potential benefit of telemedicine.

 

These include:
1.    Availability for underserved areas
2.    Reduction in costs
3.    24 hour service
4.    Providing specialty support in real-time
5.    Real-time ICU coverage
6.    Real-time diagnostic imaging
7.    Clinical consultation on time sensitive dilemmas like acute stroke and emergency treatment
8.    Etc.

These services will continue to expand but eventually spread to ongoing chronic care. A good example is Diabetes Treatment. It has become so complicated with multiple new medications that the average provider may not have the ability or time to coordinate the care.
Another service will be online support groups for various conditions where the endless questions and concerns of patients can be addressed and supported.

The modern generation will want easy access to health care without the delay and time spent directly visiting a Emergency Department, Urgent Care, and or Primary Care.

Some downsides include:
1.    Over-consumption of care.
2.    Most illnesses or problems are solved with tincture of time.
3.    Not knowing when it is important to go right to the Emergency Department because of the potential seriousness of the condition.
4.    Getting care from numerous sources without coordination
5.    Almost totally giving up on the regular Family Provider who “knows you”.

There are also legal issues (future malpractice issues), credentialing issues, lack of access to high-speed internet, and the reality that the computer cannot perfor  m life-saving measures or surgery.
Where telehealth fits in with the primary care provider, urgent care, Walmart/CVS, Dr. Google (being your own provider) and the ultimate safety net –The Emergency Department –will have to be figured out.  

Should Physicians Join the Union???

With the Brexit vote in the United Kingdom, endless global conflicts, and the 50-50 political dichotomy in the USA, it may be time for providers (physicians, Nurse Practitioners, and Physician Assistants to organize into an effective voting force.

 

In the interesting blog Physicians must unionize.  Here’s why, the author recommends that physicians create a union to protect their interests from governments, health systems, and the endless prevailing forces that the individual has no control over.

I would suggest reading the article as maybe the time has come for physicians to get organized and protect their substantial interests.

 

​​SLXThese interests include autonomy, financial security, work conditions, and protecting the greatest guild ever created. Physicians have reaped the benefits since the 1960’s thanks to a fee for service model and Medicare guaranteeing a financial floor to generate exceptional incomes for 30-40 year careers. Along with social status and respect, it is a great job.

However, practice and personal satisfaction has significantly decreased in the last decade. More government mandates (usually unfunded), hospitals employing physicians, and the destruction of the personal doctor-patient relationship has been steadily on the rise.

Physicians are generally organized if at all by specialty societies with varied interests. This diminishes the overall power and clout of all physicians. Critics would argue that doctors are overpaid compared to the world market and are chief offenders at driving up costs.

A similar argument can made against the National Football League Players Association (NFLPA). It has been called a joke because it represents rich football players. The football players do make great sums of money but their careers last 3-5 years with lifetime physical disabilities to follow.  Physicians can earn significant amounts of money over 30-35 years without similar threat to life or limb.

 

The union could  represent the physician body in the ongoing financial negotiations with CMS, insurance companies and hospitals, work rules, malpractice, contracts, Electronic Health Record implementations, ICD -10 implementation, and etc.

The individual has lost any clout to fight these forces or influence the decision making. A physicians’ union would put the “players” back in the discussion. And yet, there may be ethical and practical considerations that might keep some from wanting to join a union.  For example, would you cross a picket line to help the bleeding patient on the sidewalk?  Most would say yes, despite getting roughed up or jettisoned from the union.  And then, how many times have you seen a hundred or more physicians in a meeting (think union meeting) that agree on anything?  Younger physicians steer clear of medical entities, such as the AMA, which has a pre-union character to it.  Perhaps they realize that the results of joining could include an early retirement a la Jimmy Hoffa.  Lots to think about before unionizing.

Tai Chi for Health-care Practitioners

I recently started taking TAI CHI lessons to improve my balance, flexibility, and coordination.

It looks pretty easy on movies but does take a fair amount of training. People like myself, who cannot dance or suffer from right to left confusion will need to practice to gain muscle and brain memory.

​​SML

The article Tai Chi for Health-care Practitioners emphasizes the value for health care practitioners helping their patients. The programs includes  “applications for balance, geriatrics, stress and pain management, oncolcogy, PTSD,TBI, polytrauma, autoimmune diseases, women’s health. orthopedic, neurological, cardiovascular and respiratory rehabilitation".

           

Wikipedia states that “Tai Chi generally provides health benefits. In all the forms of Tai Chi there are movements that involve briefly standing on one leg, which may improve balance; circular movements of the shoulders and wrists which improve suppleness and circulation; learning the sequence of the set movements may improve cognitive function such as concentration; the social atmosphere can sometimes forge friendships and alleviate loneliness and anxiety; and the exercise itself can boost a person's mood and alleviate depression.[3][4]”

                       

My wife figured out at the first lesson that all the hand and feet movement should be considered preparations for striking and/or blocking an opponent. She’s right to have intuited the relationship between this originally Chinese practice, and the martial arts.  Many in the far east are skilled in both.  Not having 2 left feet will help with the movements. The individual motions are easy but the linkage and flow take practice, practice, and practice.

           

In general, TAI CHI is another worthwhile avenue to explore as we have a tendency to live longer and become quite immobile. You may learn how to dance. And if not, you may be able to defend yourself better.

Cost of the Click!

In the article The Hidden Cost of a Click, the author states, “A bad user interface can turn an EMR/EHR into a minefield of medical errors and inefficiency.”

At the present time, the number of clicks necessary to fill out a chart is endlessly time consuming and non-productive.  The cost per click is now being calculated and quantified.  The work flow is slowed down and there is a real-not imagined- price to pay.

One solution is to create an auto-flow sequence that is tunable by site or provider and that comfortably guides the clinician from one area of the chart to another in a logical-customary- sequence.  If an out of sequence entry is desired, this should be easily accomplished.  A system with automatic guidance will eliminate the need to figure out where one should go next, especially if one is interrupted.  When it is acknowledged that one area is complete, it then moves to the next area when documentation is continued or resumed.  Once the area is completed, the list shrinks.  Your favorite click might be auto-sequenced.

An example sequence could be...

• Vital signs
• Triage sheet
•  Past medical history
•  Nursing notes
• History and PE in logical order
• Medical decision making
• CPOE
• Lab and x-ray results
• Clinical course
• Final diagnosis
• Disposition
• e-Prescribing
• Patient education
• Follow-up
• Review nursing notes
• Sign the chart

Navigation would be significantly simplified.  The provider can always go to any area directly and in any order.  Nursing notes might be reviewed, if easily accessible.  Training would be simplified and hopefully stress-reduced.

Clicking Your Way to Burnout

The Mayo Clinic published the article Electronic medical practice environment can lead to physician burnout that “shows the use of electronic health records and computerized physician order entry leads to lower physician satisfaction and higher rates of professional burnout.”

It states that the negative effects of decreased efficiency, massive clerical burden, and provider burnout counterbalance the positive potential for quality medical care using an Electronic Health Record. These negative forces seem obvious to any practicing provider but are generally lost on administrators, insurance companies, vendors, and governmental agencies.

Logical reasoning would indicate, however, that when providers, including nurses, are “happy,” productivity, motivation, and commitment are increased, leading to higher quality and greater safety in health care.

The authors conclude that:  "Burnout has been shown to erode quality of care, increase risk of medical errors, and lead physicians to reduce clinical work hours, suggesting that the net effect of these electronic tools on quality of care for the U.S. health care system is less clear."

What is the solution? Some have been mentioned multiple times in previous blogs. But here is a list of EHR functionalities that have great potential to impact quality of care:

1.    User-friendly, site specific, specialty specific documentation

2.    Easy navigation with intuitive, user-friendly interfaces 99.9% consistent every day, every site.

3.    Changes, should be made gradually, to avoid having to relearn the program every outing

4.    Uniform CPOE (computerized physician order entry) that is the same in every system

5.    Institution of a national database to encourage real-time interoperability

6.    Voice activated technology built-in

7.    Bringing back the “Ward Clerk” – that is, let the doc do doctoring, the nurse nursing.

8.    Decreasing the work burden-eliminate unnecessary machine time, as well as homework

9.    “Alert” controls.  Too many alerts are ineffective, become “white-noise.”

10.  Ability to see what other people are documenting without making lots of clicks

11.   Every click should be counted to help design a better interface, with minimized clicks.

12.  Keep clinical interaction IT separate from bookkeeping and billing IT.

13.  Artificial intelligence that provides an “instant second opinion”

Hopefully, the future will brighter. Bean-counters should remember that clicks have financial and psychological costs. And the wrong click could cost thousands of beans.