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Tag Archives: Policy

Google Glass in the Emergency Department

Google Glass is trying to make inroads into the medical field and there have been several stories about how it is being used in the emergency department. One story begins with how Boston’s Beth Israel Deaconess Medical Center is the first hospital in the world to use the glasses for direct patient care. The benefits are reportedly legion: “Information like the patient’s name, their past medical history, even X-rays can all come up with Google Glass and could be life-saving, especially if a patient can’t communicate or doesn’t know their allergies and medications.” Yawwwwn … er, um … WHOA! The physician who is spearheading the Google Glass program at Beth Israel says that “I can say, ‘Page nurse,’ and say, ‘Nurse, can you get me some more sedation, thanks!’ And it will page them automatically all through voice commands and voice dictation.” That’s great. But there are other products out there that do the same thing. Think Vocera. And in Dr. Horng’s example, the nurse would then page the doctor back and say” “Doctor, I’ll get you some more sedation as soon as you put the order in the computer. Administration doesn’t let us take verbal orders, remember?” Then the doctor would have to walk out of the patient’s room, with Google Glass flashing e-mails and cat videos into his peripheral vision, so that he could enter the sedation order into the computer, then re-page the nurse and tell her that the order has been entered, which she’ll probably already know about and will only serve to piss her off because of the needless interruptions from the doctor playing with his new toy. Either that, or the doctor will sit in front of the patient having the following argument with an inanimate object … OK Glass … OK GLASS! Open patient John Smith chart. No, not that one. Close patient John Smith chart. Open patient John … what’s your middle name, sir? … Open patient John Francis Smith chart. Close patient Francis Smith chart. Open patient JOHN Francis Smith chart. Open orders. No, I don’t want hors d’oeuvres. O-PEN OR-DERS. By now, the patient is either annoyed or laughing. In either case, Google Glass probably cost more time than it saved. No sooner did the pixels dim on the first story than another story pops up about how not only did Google Glass just *work* at Beth Israel Deaconess Medical Center, but how Google Glass SAVED A LIFE! It turns out that the same Dr. Horng was treating a patient with a “severe brain bleed” and that the priority in brain bleed patients is to lower the blood pressure. However … dun dun dun duuuuuhhhhhh … the patient was *allergic* to some unknown blood pressure medication and … dun dun dun duuuuuhhhhhh … the patient was also taking an unknown blood thinner. Dr. Horng was able to find the answers “almost instantly” using Google Glass and “was able to administer the right medications to slow the bleeding and save the man’s life.” I call bullshit. Let’s walk through a typical patient experiencing a “severe brain bleed.” First, the patient doesn’t walk up to the registration window saying “Pardon me, ma’am, but I happen to be having a severe brain bleed – left hemisphere, temporal region.” The patient walks up to the registration window (or is brought in by ambulance) saying “I have a headache.” Perhaps the patient has “weakness.” Or maybe the patient is brought in by ambulance unconscious. But a “severe brain bleed” is a diagnosis made after workup, not a presenting symptom. So even with the help of Google Glass, a ...

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Proving a Negative

A young lady comes to the emergency department and wants to be evaluated for a … somewhat nonurgent … problem. Chief complaint: “I’ve lost 50 lbs in the past month.” She felt a little weak as well, but she had just lost too much weight. No other symptoms. The patient weighed 132 pounds. Her skin wasn’t sagging. Her jeans didn’t appear to be new and they seemed to fit pretty well. Nothing about her seemed abnormal on exam. But she insisted that she weighed 180 pounds just a month earlier. No old records in the computer. I asked her if she could show me a recent picture of herself on her iPhone. She briefly stopped texting to check, but she couldn’t find any. I asked her to show me her drivers license. Nope. Didn’t have that, either. I was quickly developing an opinion that this was a snipe hunt. Snipe hunts like this are an example of another conundrum that many physicians face. We are often expected to prove a negative. Clinically, I can say that the patient did not appear to have lost 50 lbs in the past month. I can even say that it is unlikely [although not impossible – don’t comment with all your weight loss feats] that any patient could lose 50 pounds in a month. But what if …? What if the patient had cancer that caused some type of weight loss and I didn’t evaluate her for it? What if the patient had a bad outcome from a metabolic problem that I didn’t screen for? What if, as a result of weight loss, the patient had developed an severe electrolyte abnormality or other blood abnormalities? Retrospectively, if the patient suffered a bad outcome, it would be easy to allege that weight loss is an obvious symptom of [insert bad outcome here] and that Dr. WhiteCoat was careless because he didn’t evaluate the patient for this problem. I suppose that the same issue holds true for a febrile child. If a three year old with a runny nose had a fever of 102 at home, but looks fine and is afebrile in the emergency department, he’ll probably get a pass on the workup. But if an afebrile 27 day old infant reportedly had a fever of 102 at home, get the lumbar puncture tray ready. A physician must have a certain degree of risk tolerance in choosing whether or not to do testing to evaluate an odd complaint, but where should we draw the line between “necessary” and “unnecessary” workups? And in case you were wondering, yes, I did labs and a chest x-ray on the incredible shrinking woman. She was anemic. Her hemoglobin was 10.5. Not enough to hospitalize her, but enough to recommend that she follow up with the on-call physician for a more thorough weight loss/anemia evaluation. I’m going to be eating my words if she comes back next month weighing 80 pounds.

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Increased Workload = Increased Medical Errors?

They throw around that lame 98,000 preventable deaths per year statistic, but the survey is still quite telling. More than one third of 890 hospitalists surveyed stated that their workload exceeded safe levels on at least a weekly basis. As a result of this increased workload, 22% of doctors stated that they had delayed admissions or discharges, 10% stated that they had failed to promptly note/follow up/act on a critical lab value or radiology report, and 7% stated that they had made a treatment or medication error. In addition, 22% of doctors believed that they had ordered potentially unnecessary testing, 12% believed that the quality of care they provided had worsened, and 5% said that it was possible/likely/or definite that a patient died due to the increased workload. As more and more doctors become employees of hospitals, I wonder how long it will take before hospital CEOs and administrators start being named in malpractice lawsuits (no malpractice caps on non-physicians, folks) for inadequately staffing the hospitals.

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Healthcare insurance but no healthcare access

California doesn’t have enough doctors to provide healthcare to newly “insured” patients under the UnAffordable Care Act. California state senator Ed Hernandez asks “”What good is it if they [state citizens] are going to have a health insurance card but no access to doctors?” Wait. Health care insurance doesn’t mean that patients will have access to health care? Where have I heard that being said for more than 3 years? The government is going to give patients their medical “insurance,” but access to physicians is limited by government policies, payment cuts, and administrative red tape — which are driving many doctors from the primary care business and are, in effect, rationing care to patients. California’s grand plan is to allow physician assistants, nurse practitioners, optometrists, and pharmacists to provide primary care services. I liked one of the commenters who said that he went to see the doctor, but was referred to the janitor who gave him a bag of medications for $5. These other health professionals and their organizations seem to naively think that the patients they will treat only require management of simple medical problems. In reality, most patients have multiple interrelated chronic medical problems that must be managed together. Take diabetes, for example. Will it really be cost effective to have an optometrist manage a patient’s diabetes and perhaps monitor the patient’s diabetic retinopathy while the patient still has to be assessed and monitored for diabetic nephropathy, diabetic wounds and wound care, diabetic neuropathy, the increased risk of heart disease, oh and the impotence that often accompanies diabetes? Should the optometrist prescribe Viagra for a diabetic patient with heart disease or not? If the optometrist refers the patient to a bunch of physicians to make those decisions, then the government has just created an additional layer of bureaucracy which will cost more money. If the optometrist just blissfully monitors the patient’s glucose levels, prescribes insulin and doesn’t regularly evaluate the patient for diabetic complications, then the patients are receiving government-sanctioned poor medical care. That should make the trial lawyers happy … if the optometrists have insurance for the millions of dollars in damages when bad outcomes occur. These health care providers are begging to get in over their heads and we need to let them do so. The medical establishment should really stop fighting this idea. Allowing governments to implement a system that reduces access to doctors, increases complexity in medical care, and that will likely increase bad outcomes will eventually create patient outrage with government officials who adopt the idea. We all should be part of a team, but not everyone is able to play quarterback. I predict that these types of policies, if implemented, will ultimately increase the demand for physicians. Unfortunately, the underlying problem is that most of us will be expected to pay more in “taxes”, insurance premiums, and other fees … for less medical care. But remember that everyone will be insured, so things will be OK. In anticipation of hate mail from nurse practitioners, physician assistants, optometrists, pharmacists, and possibly even Lucy VanPelt expressing outrage at my unprofessional stance because there aren’t any studies showing worse outcomes in medical care provided by those with less medical training, I’ll quote a comment that I posted on KevinMD’s site a couple of months ago in response to a nurse practitioner who asserted that he had “the same ability to provide patient care [as physicians] based on the evidence.” You’re right about all the studies, I’m sure. In fact, I bet there aren’t any studies showing that treatment rendered by grade schoolers is any worse than ...

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Social Media Fair Play

JustADoc commented about a Yahoo News story concerning an obstetrician who posted a mini-rant on Facebook about one of her patients always being late. The obstetrician’s post said “I have a patient who has chosen to either no-show or be late (sometimes hours) for all of her prenatal visits, ultrasounds, and NSTs. She is now 3 hours late for her induction. May I show up late to her delivery?” After the post became widely distributed, some people called for the doctor to be fired. Others defended her as a good physician. The hospital assured all their concerned patients that the hospital would “reinforce their high employee standards.” The Yahoo news story created a fake retort from the obstetrician’s hospital (I looked up the hospital’s Facebook page to make sure it was a fake retort) saying When I look back at my post last week about State Medical Board investigations for what are deemed to be inappropriate online posts, I started thinking. If people agree that doctors’ livelihoods and the money and time they spent on their medical educations should be threatened because of a potentially offensive statement, shouldn’t that be the standard for everyone else as well? An offensive statement is made by a hospital, investigate the administrative staff. Maybe fire them and blackball them from further jobs in hospital administration. Politicians make an offensive statement, investigate them, too. Maybe they get fired and prevented from working as a politician. Same for CEOs, federal workers, journalists, editors, public employees, judges, lawyers … everybody. Anyone receiving government assistance gets the same treatment. Make any offensive statements and you get investigated. If the statements are offensive enough, you’re on your own. You are no longer eligible for government assistance. Sound outrageous? I agree … in all cases.

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Art Kellermann Rand Rant

One of the posts in my Twitter feed was a re-tweet of something asserted by Dr. Art Kellermann (@ArtKellermannMD). Dr. Kellermann is a distinguished physician. He is the Director and VP of Rand Health. At one point he was a professor at Emory University, but apparently does not practice emergency medicine any more. Dr. Kellermann’s tweet said the following: Dr. Kellermann’s tweet references an editorial article that he wrote in the Annals of Emergency Medicine titled “Waiting Room Medicine: Has It Really Come to This? The article was from 2010, so I’m not sure what prompted him to tweet about it in 2013, but nevertheless, the article at least seemed pertinent … until I read it. The assertion in Dr. Kellermann’s tweet was a quote from his article and was reportedly supported by a 2001 brochure created by the UK Department of Health (.pdf file). The context of Dr. Kellermann’s assertion in the article he wrote is as follows: The ED is more than a clinical setting; it is a “room with a view” of the best and worst of modern health care. In the United Kingdom, a crowded ED is considered a telltale sign of a poorly managed hospital. If that perspective ever takes hold on this side of the Atlantic, things will change. Until then, it is up to us. Things will change if our perspective changes. Until then, change is up to us. What a feel-good nonsensical assertion of nothingness.

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