CDC: Smoking deaths cost $92 billion

From CNN.com

Early deaths caused by smoking cost the nation about $92 billion in lost productivity between 1997 and 2001, the Centers for Disease Control and Prevention reported Thursday.

Smoking reduces life expectancy an average of about 14 years by way of lung cancer, heart disease other illnesses, according to the CDC.

In the study, "lost productivity" meant lost wages. The CDC gave no overall estimate of the smoking-related health-care costs over the same five-year period, but estimated them at $75.5 billion in 1998 alone.

Altered Standards of Care in Mass Casualty Events

From the Agency for Healthcare Research and Quality (AHRQ), excerpted below. The webpage has a link to the reoprt and recommendations.

Mong the recommendations:
-Develop general and event-specific guidelines for allocating scarce health and medical resources
-Implement a process to address nonmedical (i.e., finance, communication) issues related to the delivery of health and medical care
-Develop a comprehensive strategy for risk communication with the public
-Develop practical tools such as searchable databases for verifying credentials of medical personnel on-site during a mass casualty event
-Develop a "Community-Based Planning Guide for Mass Casualty Care" to assist preparedness planners

The excerpt:

A mass casualty event could compromise the ability of health systems to deliver services meeting established standards of care. It is critical to plan for adjusting current heath and medical care standards to ensure that the care provided in a mass casualty event result in saving as many lives as possible.

To address the issue, an expert panel was convened by the Agency for Healthcare Research and Quality (AHRQ) and the Office of the Assistant Secretary for Public Health Emergency Preparedness, U.S. Department of Health and Human Services (HHS).

Move EMS from DOT to DHS?

Another article from JEMS, excerpted below:

A Homeland Security Policy Institute (HSPI) task force announced today that EMS would be more appropriately delegated to the U.S. Department of Homeland Security (DHS) than under its current administration by the U.S. Department of Transportation (DOT). The task force makes the assertion that “the time is ripe for EMS to move to a more suitable federal agency” because the modern responsibilities of EMS have outgrown its home with the DOT, a home that made sense when early EMS still focused on transporting MVC patients, according to the press release.

Gunshot-Wound Patient Slain in EMS Presence

From JEMS magazine, excerpted below:

Seventeen-year-old Billie Rutledge lay on a stretcher, bleeding from handgun wounds and yelling for help, while Detroit paramedics rushed to remove his clothing on Saturday, June 7, according to Free Press. However, before the paramedics could finish assessing him, the masked assailant returned to the scene, now armed with a shotgun, and fatally shot Rutledge in the head.

Rutledge, who had reportedly just finished serving a sentence for a misdemeanor conviction the day before his death, was on a walk with a friend when he was shot several times.

According to police reports, EMS arrived at approximately 3:30 a.m. and found Rutledge lying in a driveway, bleeding from small-caliber bullet wounds and screaming for help. Paramedics James Peyton and Toby Hanna put the patient on a stretcher and snipped off his clothing to locate the wounds.

As they carried the stretcher to an ambulance, the paramedics heard the sound of a shotgun racking and turned to find the assailant on scene again. Peyton and Hanna fled several yards before they heard two shots, the police report states. They were not injured and were on optional stress leave the following Monday.

ER Stats

From the National Center for Health Statistics "FASTATS" Emergency Department Visits page, (Data are for U.S. for 2003)

Number of visits: 113.9 million

Number of injury-related visits: 40.2 million

Number of illness-related visits: 74 million

Number of visits per 100 persons: 38.9

Most commonly diagnosed condition: acute respiratory infection

Percent of visits with patient seen in less than 15 minutes: 22.3

Average time spent in emergency department: 3.2 hours

Percent of visits resulting in hospital admission: 14

Percent of visits resulting in intensive care unit or coronary care unit admission: 1.3

Air Transport of Brain Injured Patients

Some good news for fans of air medical transport (we've been under fire lately), from an article on WNEP, based on research published in the Annals of Emergency Medicine:

A study finds patients with traumatic brain injuries who are transported by medical helicopters have higher chances of survival and better recoveries than ground-transported patients, according to a study published as an early online release by Annals of Emergency Medicine this week (The Impact of Aeromedical Response to Patients with Moderate-to-Severe Traumatic Brain Injury).

Helicopters are used in many systems to respond to major trauma victims because of their ability to transport patients rapidly and without delays that may hinder ground transportation. They also often have crews with advanced training and greater experience managing critically injured patients.

“Until now, there has been very little evidence to support whether frequently used air transport provides any more benefit to injured patients than ground transport,” said lead author Daniel P. Davis, MD, University of California San Diego Department of Emergency Medicine, and Mercy Air Medical Services in San Diego.

Unknown Illness Forces SLU Emergency Room To Divert Patients

From KSDK Newschannel 5's website, excerpted below:

"Unknown Illness Forces SLU Emergency Room To Divert Patients"

An unknown illness in a patient caused doctors and health officials to shut off access to the emergency room at St. Louis University Hospital.

Around noon Thursday, a female was admitted with symptoms including a fever and a rash. Doctors initially suspected it might be Monkeypox, a rare disease that is less deadly than the similar Smallpox.

However, after faxing pictures of the woman's symptoms to the Centers for Disease Control in Atlanta, the CDC gave SLU Hospital the go-ahead to re-open the emergency room.

Doctors now say it is highly unlikely that the woman has monkeypox, but they don't yet know what she does have. The patient is being kept in isolation.

The emergency room started accepting patients again a few hours after patients were diverted.

Precription for Doctors: E-mail

An excellent article from USA Today, excerpted below:

"Prescription for doctors: E-mail"

In a 2002 survey by Harris Interactive, 90% of adults with Internet access indicated they want to communicate with their physicians via e-mail. But a survey last year by Manhattan Research, a marketing information and services firm, found that less than 20% of physicians communicate via e-mail.

The top reason doctors give for withholding their e-mail address is the fear that it will lead to "too much access" and they will be barraged with messages about "trivial matters," according to a Journal of Family Practice article in 2001.

In other words, patients can't be trusted not to abuse our doctors' time. But if doctors finally moved into the high-tech age, they'd soon discover that many of their concerns about e-mail are misplaced.

Hospital Construction Kickbacks

Another interesting story from Modern Physician, excerpted below:

"Ill. construction exec pleads guilty in kickback scandal"

A Chicago construction company owner pleaded guilty yesterday to paying bribes to the former vice chairman of Illinois' certificate-of-need board to direct hospital and medical school construction projects to his company.

In his plea, Kiferbaum confessed to paying Levine millions in bribes to steer building contracts to his company and to inflating the projects' costs to cover those kickbacks. Kiferbaum and his successor company, Design+Build, agreed to pay $7 million in restitution by July 1. His sentencing hearing was postponed until after the cases against his co-defendants have been completed and the extent of his cooperation with U.S. District Judge John Grady in Chicago can be established.

EMTALA Violations

Excerpted from Modern Healthcare:

Four hospitals and health systems collectively paid $105,000 to settle alleged violations of the Emergency Medical Treatment and Active Labor Act with HHS' inspector general, Modern Healthcare has learned.

Florida Hospital Heartland Medical Center, a 186-bed hospital located in Sebring, and owned by the Winter Park, Fla.-based Adventist Health System Sunbelt Health Care Corp., paid $20,000 for allegedly failing to provide appropriate medical screening and stabilization to a 21-year-old patient three times over a 12-day period. The patient later died of a rare and difficult-to-diagnose parasitic infection. The University of Alabama at Birmingham paid $40,000 to settle allegations that in September 2000 a member of the ER staff at its 226-bed UAB Medical West failed to provide a complete screening to a woman suffering from kidney infections and associated fevers and chills.

When a Hospital is a Bank

Fascinating article from the Pittsburg Post-Gazette, excerpted below:

"Q: When is a bank not a bank? A: When it is a hospital

UPMC's mission is patient care, but its lending and investments make it a financial institution, too"

With 19 hospitals, a for-profit health insurance subsidiary and a huge network of physicians' offices, UPMC's business clearly is health care. But in many ways, it also is banking -- handling, lending and investing the money that comes through its myriad doors, an estimated $5 billion alone in the fiscal year that ends this month.

In many ways, UPMC is a symbol of modern medicine, which these days seems as much about finance as it is about patient care. Across the country, major health systems have invested in real estate, entrepreneurial ventures and loans for businesses and physicians. They have taken these steps not only to grow their enterprises but to protect what they have from other investors, said Mark Pauly, an economist at the University of Pennsylvania.

UPMC last month released its annual filings with the Internal Revenue Service that show about $460 million in loans and other notes receivable held at the end of fiscal 2004 by UPMC, its 19 hospitals and two physician groups.

While much of the $460 million involves debt financing arrangements between UPMC and its hospitals, there are also loans to recruit and retain physicians as well as loans to related subsidiaries.

EMedForum

A new resource, perhaps of interest:"EmedForum is a free cyber-community for Emergency Medicine providers to discuss topics relevant to Emergency Medicine. Our goal is to make it easy for us to talk to each other and share our thoughts and insights."

I was tipped off to the site by GruntDoc

EMTALA in Iowa

Excerpted from a Des Moines Register article:

"Hospital accused after boy loses fingers"

In a rare move, the federal government has threatened to pull Medicare funding from a Cedar Rapids hospital accused of denying care to emergency-room patients who were uninsured.

The Iowa Department of Inspections and Appeals began investigating Mercy Medical Center earlier this year in response to a complaint that an uninsured child was denied emergency care and subsequently had two of his fingers amputated.

The case involving the child began the night of Jan. 29, when the youth's grandparents took him to Mercy's emergency room for treatment of two seriously injured fingers. Under federal regulations, Mercy was required to either assess the injury and provide appropriate treatment or stabilize the child and transfer him to another hospital for treatment. But after the child's grandparents informed the staff that they were uninsured, the staff allegedly bandaged the injured fingers and sent the family home with no surgical consultation.

About an hour after the family arrived home, the grandparents noticed the fingers hadn't stopped bleeding. The family returned to the emergency room, where the child's fingers were rebandaged, but again there was no surgical consultation. Eventually, the family took the child to University Hospitals in Iowa City, where the two injured fingers had to be amputated.

A few days before that incident, a different patient had come to Mercy's emergency room complaining of pain and swelling in his jaw. A nurse diagnosed an abscess, indicating an infection in the jaw.

The oral surgeon who was on call at the time allegedly refused to come to the emergency room and see the patient and asked that he be transferred to a different hospital for treatment. At the time, the emergency room's written schedule of on-call doctors allegedly stated "No trauma calls" for that particular surgeon.

In March, the state inspections department completed its investigation of the two incidents and referred its findings to the federal Centers for Medicare and Medicaid Services. The federal agency concluded that there was an immediate and serious threat to the health and safety of Mercy's emergency-room patients and, on May 18, it threatened to cut off Medicare funding for the hospital. Within a week, the hospital implemented a formal plan of correction.

Last week, federal officials determined that the threat to patient safety no longer existed. To verify ongoing compliance with federal regulations, a state inspection of the hospital will take place sometime before Aug. 16.

In the meantime, the Centers for Medicare and Medicaid Services is referring the matter to its Office of Inspector General , which has the ability to impose civil fines against hospitals for violating federal health care regulations. The agency also is referring the case to its Office for Civil Rights , which investigates allegations of illegal refusal of health care services.

David Werning, spokesman for the inspections department, said that so far this year there have been five investigations into denial of emergency care at Iowa hospitals. All five have resulted in federal officials threatening to shut off Medicare funding because of regulatory violations. In each case, the hospitals submitted plans of correction that resulted in them keeping their Medicare funding.

Werning said the Mercy case is unusual in that it involved two instances of denial of care for physical injuries, as opposed to the more common complaint of denial of psychiatric services. Also, he said, the decision by authorities to verify compliance through another inspection this summer underscores the serious nature of the matter.

"The Centers for Medicare and Medicaid Services wants to be very sure that their message has been received by Mercy Medical Center," Werning said.

100,000 Lives Campaign in Wisconsin

From the Wisconsin Hospital Association's website. We're researching ED Physician's involvement in one of the initiatives, Rapid Response Teams

"Saving 100,000 Lives By June 2006"

Seven Wisconsin health care organizations have come together to form what is referred to as a "node" in the Institute for Healthcare Improvement’s (IHI) 100,000 Lives Campaign. Organized by MetaStar, the node will disseminate improvement tools and provide support to health care providers throughout Wisconsin as they seek to improve the care provided to Wisconsin patients. Joining MetaStar in the node are the Pharmacy Society of Wisconsin, Rural Wisconsin Health Cooperative, Wisconsin Hospital Association, Wisconsin Medical Society, Wisconsin Nurses Association, and Wisconsin Organization of Nurse Executives.

The 100,000 Lives Campaign aims to enlist thousands of hospitals across the country in a commitment to prevent unnecessary deaths through the implementation of six changes in health care. These changes and the Wisconsin node member taking the lead for each are:

Acute Myocardial Infarction Care: MetaStar
Prevention of Surgical Site Infections: MetaStar
Prevention of Ventilator-Associated Pneumonia: MetaStar
Prevention of Central Line Infections: MetaStar
Medication Reconciliation: Pharmacy Society of Wisconsin and the Wisconsin Hospital Association
Rapid Response Teams: Wisconsin Organization of Nurse Executives
Through the Rural Wisconsin Health Cooperative Roundtables, rural hospitals will have an opportunity to discuss interventions in various areas of the campaign.

The challenge put forth by IHI is to implement these changes in 18 months, from December 2004 to June 2006, to prevent 100,000 avoidable deaths. Wisconsin hospitals are not required to formally join the IHI 100,000 Lives Campaign to utilize the information that will be organized and distributed by the Wisconsin node.

Pain Response to Nitroglycerin Does Not Predict Cardiac Etiology

From Medscape / Reuters, excerpted below:

"Pain Response to Nitroglycerin Does Not Predict Cardiac Etiology"

The degree to which chest pain responds to sublingual nitroglycerin is not useful in determining if the pain stems from a cardiac cause, according to a report in the Annals of Emergency Medicine for June.

Previous reports looking at the predictive value of the response to sublingual nitroglycerin have yielded conflicting results. However, unlike the present investigation, many of these studies did not use validated pain measures.

The findings are based on a study of 664 patients who presented to a tertiary care emergency room with chest pain between May 24, 2001 and April 30, 2002. The pain was graded with an 11-point numeric descriptive scale before and after the subjects were treated with sublingual nitroglycerin.

The median patient age was 52 years with a nearly even ratio of men to women, the report indicates. Cardiac-related pain was defined as a discharge diagnosis of acute MI or a diagnosis of coronary artery disease through measures such as noninvasive imaging or cardiac catheterization.

Eighteen percent of patients had cardiac-related chest pain, lead author Dr. Deborah B. Diercks, from the University of California in Sacramento, and colleagues note.

Nineteen percent of patients had no change in their pain with nitroglycerin, 31% had a slight reduction, 22% had a moderate reduction, while 28% had major or complete resolution of their pain. However, none of these responses was useful in identifying pain of cardiac origin.

Although sublingual nitroglycerin is a useful treatment for suspected cardiac chest pain, the response to this agent is not particularly helpful in differentiating cardiac- from noncardiac-related pain, the investigators conclude.

Computers in Exam Rooms

Excerrpted from a Modern Physician article (Free, registration required)

"Computers in exam rooms lead to high patient satisfaction: study"

Does putting a computer terminal in the exam room help the physician-patient relationship or does it add a distraction? According to Kaiser Permanente scientist John Hsu, M.D., "when used well," computers help improve patients' satisfaction and boost their understanding about their individual conditions.

Hsu's view on the matter follows his recent study of how 313 patients reacted when eight physicians at a primary-care medical office building in the Portland, Ore., area installed terminals in their exam rooms. Physician-patient encounters were videotaped and patients were interviewed before computers were added, the first month they were added and seven months later.

In a report published in the Journal of the American Medical Informatics Association, Hsu stated that patients rating their satisfaction as excellent rose to 62.8% from 55.3%.

"Computers in the exam room are a potential barrier: They can suck away the physician's attention and potentially slow things down as physicians enter data or document their activities," Hsu said. "Fortunately, we found that those two things did not happen."

"Physicians seem to be using the tools effectively and the patients did seem to respond very well," he said, explaining that doctors used the terminal to show patients copies of their X-rays or to look at line graphs of how their blood pressure may be responding to medication.

Using the computer this way led to improved patient understanding of their conditions and treatment. According to the study, the percentage of patients reporting excellent satisfaction in the comprehension of their diagnosis or treatment rose to 57.3% from 46.4%.

More Detail About the University of Iowa Stroke Trial

AbESTT II: Abciximab in Emergent Stroke Treatment Trial II (Phase III)



It might be of interest to read up on AbESTT Phase II as well

People With Insurance Pay for Those Without, Study Shows

From Medscape (free, registration required)

Excerpted from "People With Insurance Pay for Those Without, Study Shows", with emphasis added.

The average premium for family health coverage in 2005 is $922 higher to help cover the costs of care for the uninsured, according to a study released Wednesday. Caring for those without coverage also added $341 to the average individual health insurance policy.

Officials of the consumer group Families USA said their study is the first to attempt to quantify how much the insured pay for the uninsured.

Using data compiled by Emory University Health economist Ken Thorpe, the study calculated that the uninsured themselves pay for about a third of their care from their own pockets, and government programs pay another 22%. The rest is passed along to health care providers, who in turn pass it on, to the degree they can, to insurance companies.

"The large and increasing number of uninsured Americans is no longer simply an altruistic concern on behalf of those without health coverage," said Families USA Executive Director Ron Pollack. "These costs clearly affect everyone."

It is a myth that those without health insurance do not get health care, said Kansas Democratic Gov. Kathleen Sebelius. "But they are getting the most expensive, least effective care," such as that delivered in emergency rooms, she said.

ReoPro for CVA's

The University of Iowa is recruiting patients for participation "in a large multinational study testing Abciximab (ReoPro) in patients with acute ischemic stroke."

Here's a bit more about the study, excerpted from a News-Medical.net article.

Unlike other investigational treatments to open blocked arteries in stroke beyond three hours, abciximab can be given into a vein in the arm and requires no additional invasive procedures. "Abciximab has been used for years by cardiologists to help keep diseased coronary arteries open," explains Dr. Bernstein. "If this treatment proves safe and effective in acute stroke, it could be used in any emergency room throughout the country. This could fundamentally change the way we treat this common and devastating disease."

Participants are potentially eligible for this trial if they can receive study drug or placebo within 6 hours of stroke onset, or if they wake up from sleep with a stroke and can receive study drug or placebo within three hours of waking up.

Surgical Tools Washed in Hydraulic Fluid

As reported on CNN.com

"Surgical Tools Washed in Hydraulic Fluid"

RALEIGH, North Carolina (AP) -- About 3,800 patients at two hospitals run by Duke University Health System were operated on last year with instruments that were washed in hydraulic fluid instead of detergent, hospital regulators said.

Duke Health Raleigh and Durham Regional hospitals put patients in "immediate jeopardy" in November and December by not detecting the problem, despite complaints from medical staff about slick tools, according to a report by the Centers for Medicare & Medicaid Services.

The hospitals did not fix the problem for weeks, said the agency, which oversees patient care at hospitals that receive payments from federal insurance programs.

The mix-up apparently occurred when an elevator company drained hydraulic fluid into empty detergent barrels last summer. The detergent supplier later picked up the barrels and mistakenly redistributed them as washing fluid.

Duke Health officials assured patients in January that the likelihood of infection from the tools was "no more than the risk normally associated" with the procedures that the patients underwent.

However, dozens of patients who were exposed to the surgical instruments have reported lingering health concerns ranging from fatigue and joint pain to problems requiring hospitalization, the The (Raleigh) News & Observer reported Sunday.

At least 50 patients who developed complications have taken their concerns to lawyers, though no one has sued Duke or the hospitals. Two lawsuits have been filed against the elevator company and the detergent supplier.

Duke Health officials declined to comment further, citing possible lawsuits.

Helping Families Cope With Sudden or Unexpected Death

This is the text of a Medscape Webcast Video Editorial (you have to register, but it's free)

"Helping Families Cope With Sudden or Unexpected Death"

Physicians often do save lives, and their work as a healer is retold within the narrative of that person's life and by their family. What role then should the physician play when, instead, death comes?

Sudden, unexpected death can deeply wound the lives of those left behind. Families of decedents become a physician's "extended patient" in desperate need of care. The manner in which death is communicated has an indelible effect on the future well-being of families. Research demonstrates significant, often permanent, coping and adjustment difficulties from poorly delivered death notification. This moment is a one-time only opportunity for physicians to treat a wound that's responsive only to kind humanity.

What can you do?

Accept death as the predictable, ultimate outcome of every patient's life story.

Expand the meaning of being a healthcare professional to include working with death.

Learn to heal through caring when a cure is no longer possible.

Comprehend the lasting effect you have on families during death notification.

Realize the potential to reduce litigation by unhappy families through sensitive communication at this troubled time.

Recognize the tangible lifesaving benefits of increasing organ and tissue donation through compassionate death notification of potential donor families.

Identify the death notification opportunity to increase autopsy rates.

Develop standards for death notification procedures in your institutions.

Establish mandatory death notification training within your institution to assure competency and proficiency of all residents and other personnel whose task it is to notify next of kin of a death.

Physicians can be a positive or a negative component of a family's death story. Be the positive.

ACUTE CARE Summer Newsletter Available Online

We've published our quarterly newsletter online. You can view the ten page document by clicking on this link. If you'd like a hard copy version, just drop me an e-mail.

Some highlights:
"Chest Pain, A Call to Action" by Dr. Ken Schultheis, ACUTE CARE's Chief Medical Officer

"Adult Intraosseous Access" and "Critical Access Hospitals: Selected Requirements", my contribution

New Practice Opportunities, Information about our new, improved Locum Tenens division, and

"Financial Strategies for Emergency Department Physicians" an article about our affiliation with Financial Designs and the availability of insurance and retirement planning

Paramedics Instructed to Use Expired Meds

I'm a little ambivalent about this post, as it seems rooted in a labor dispute, but thought it would be of interest. I'll be looking for the other side of the story. The story, excerpted below, was published on the Washington Times website.

"Medics Resort to Expired Drugs"

D.C. paramedics say their supervisors directed them to use expired medications this month because fresh supplies were unavailable.

The medications included such lifesaving drugs as epinephrine, which is used to treat asthmatics and allergic reactions, and nitroglycerin, which is used for heart-attack victims.

"ER", South Africa Style

I found this article interesting for two reasons:
1. The fact that the reality series is based in South Africa (excerpted below)

Forget about ‘reality’ television programmes like Survivor and The Block. If you want to see real life television, tune into SABC 3’s new reality series Trauma Call, which premieres on 8 June and explores the gritty reality of the world of emergency medical care in South Africa and the fascinating breed of individual who works within it.

The 13-part series, which has been commissioned by Vodacom and Netcare 911, handles a variety of fascinating topics including mine rescues, fire rescue, aeromedical evacuations, drownings and newborn baby transportation and surgery.

Netcare 911 Director, Kgati Malebana says that the series takes the reality concept much further by following medical emergencies right through from the accident or emergency situation and the response of the paramedics to theatre and the intensive care unit (ICU) where injuries and medical conditions are managed definitively.

“As a result of a special relationship with the emergency workers and facilities, Trauma Call camera crews were able to capture never before seen footage that ensures the unfolding of real-life drama in every episode,” says Kgati. “Cameras are taken right into the ‘belly’ of trauma medicine: the advanced life support paramedic response vehicles, the aircraft of the Netcare 911 Aeromedical Division and into the hospital emergency units and operating theatres that handle these emergencies. It makes for gripping and at the same time informative viewing.”

and 2. The involvement of the mobile phone company in the production and promotion of the show (excerpted below). I'd heard of the way that countries lacking the traditional "wired" infrastructure for comprehensive telecommunications services have embraced wireless communication.

Vodacom’s Chief Communication Officer, Mthobi Tyamzashe, points out that cell phones have revolutionised the handling of medical emergencies because of the immediate access to voice and data communication they offer from almost anywhere within SA. Emergency crews are getting to scenes faster and as a direct result are saving more lives.

“Vodacom has recognised the importance of the cell phone for South Africans in emergency situations and has made emergency services available to all contract subscribers at no charge,” says Tyamzashe. “Vodacom and Netcare 911 have formed a close alliance to deliver first world emergency services in South Africa and optimise response times to emergencies. We are also making an effort to inform the consumer of the importance of calling the correct emergency number, 082 911, to ensure a swift response.”

Fireworks

I've excerpted an excellent Washington University article about the risk of injury from fireworks. The article provides some immportant facts for patient teaching and injury prevention efforts.

"Fireworks safety? There’s no such thing says emergency medicine specialist"

Fireworks can be beautiful against the night sky on July 4th, but a Washington University emergency medicine specialist at St. Louis Children's Hospital says, for safety's sake, parents and children should leave the fireworks to professionals.

All fireworks are dangerous, especially to children. In 2003, the last year for which numbers are available, 9,300 people were treated in U.S. emergency departments for fireworks-related injuries. Five percent required hospitalization. Four of those people died. Typically, about two-thirds of all fireworks injuries occur in the days around the July 4th holiday.

"Firecrackers, rockets and sparklers account for most of the injuries we see during that period," says Bo Kennedy, M.D., associate professor of pediatrics and associate director of the Emergency Department at St. Louis Children's Hospital. "Sparklers actually cause the highest number of injuries in children under 5. Sparklers burn at more than 1,000 degrees, and when a sparkler is burning, what it's releasing is essentially molten metal. That can cause some very serious burns."

According to figures from the Centers for Disease Control and Prevention, 63 percent of fireworks injuries involve burns. About 45 percent of fireworks injuries occur in children 14 or younger, and boys make up 72 percent of the kids who require some form of treatment at the hospital.

About a quarter of all injuries involve the hands and fingers. Some 21 percent are eye injuries. The head and face are involved 18 percent of the time, and most of the injuries occur at homes.

Restructuring the ER

This is a very interesting link. You can read the transcript of a program presented on PBS' NewsHour, or - if you prefer - listen to a streaming audio file or watch the video segment. Pretty cool. The transcript is excerpted below:

"Restructuring the ER"

Studies show that more than half the nation's emergency rooms are facing overcrowding, a problem that has led to patients being turned away at the door and one that may cause avoidable deaths, according to some doctors.

At Boston Medical Center, Litvak set to work figuring out the causes of the diversion problem. His work there was funded through a grant by the Robert Wood Johnson Foundation, which also provides financial support to the NewsHour's health unit.

Litvak first looked at all the ways patients were flowing into and through Boston Medical Center. As is typical in hospitals, many seriously ill patients came in through the emergency department. Once treated and stabilized, many would then be transferred to a bed on the general floor. Other patients would come into the hospital's operating rooms for scheduled or elective surgeries, such as heart bypass operations. If they needed to recover afterward, they'd be transferred to beds on the floor, too.

Based on the data he reviewed, Litvak quickly rejected one hypothesis: That the emergency department was being flooded with unpredictable surges of seriously ill patients. In fact, says Litvak, those numbers were steady.

Tort Reform and Physician Supply

While we noted with some interest the article about defensive medicine published in teh June 1st issue of the Journal of the American Medical Association (JAMA), another item in that same issue also has a pertinence to our practice. Full text access to the web-based version of JAMA is restricted to subscribers, but you can read the abstract (excerpted below) by folloing this link.

"Impact of Malpractice Reforms on the Supply of Physician Services"

The adoption of "direct" malpractice reforms led to greater growth in the overall supply of physicians. Three years after adoption, direct reforms increased physician supply by 3.3%, controlling for fixed differences across states, population, states’ health care market and political characteristics, and other differences in malpractice law. Direct reforms had a larger effect on the supply of nongroup vs group physicians, on the supply of most (but not all) specialties with high malpractice insurance premiums, on states with high levels of managed care, and on supply through retirements and entries than through the propensity of physicians to move between states. Direct reforms had similar effects on less experienced and more experienced physicians.

The Doctor is Logged In

A well written Los Angeles Times article about physicians who blog, excerpted below:

The family pictures on the desk. The diplomas on the wall. A few magazine subscriptions, perhaps, or some sailing, tennis or golf memorabilia scattered around the office. In the past, a curious patient could only turn to these bits of evidence to try to know more about the individual behind the medical degrees, the white coat and the carefully scripted bedside manner.

The temptation is understandable. After all, when someone holds your life in his or her hands, it would be nice to know a bit more about what makes them tick. But today, anyone with an Internet connection can have access to the fevered, funny, angry and very human thoughts of these men and women who help us navigate the perilous shoals between illness and health. The vehicle? The doctor's blog. A blog is the name used to describe a weblog, the constantly updated platform for the idiosyncratic and highly personal musings (or rantings) of anyone who wants to set one up in cyberspace.

"It's a direct line to see what doctors think that you won't pick up in the office or from television shows," says Michael Ostrovsky, a cardiac anesthesiologist in Daly City, Calif., who blogs as medgadget.

He says doctors often want an outlet for discussing patient issues and the social and political problems they face on the job, or to gripe about HMOs or Medicare reimbursement rates. "They can vent their frustrations through their websites and learn from other doctors."

In one entry, Dr. Craig Hildreth, who writes "The Cheerful Oncologist," offers some tongue-in-cheek prescriptions on how to get your doctor to listen to you. Another blogger, Medpundit, dissects the hype around medical announcements. And still another, Gruntdoc, written by an emergency room physician, posts and analyzes news articles on subjects as varied as undocumented workers and stroke treatment in the ER.

Airbags and Young Teenagers

Excerpted from the Minneapolis Star Tribune

"Air bags endanger young teens in front seat, study finds"

A new study suggests teens are better off staying out of the front seat of air-bag-equipped cars until they're almost old enough to get behind the wheel.

While current federally mandated warning labels in cars flag a risk for air-bag injuries for children 12 and under, researchers at Oregon Health Sciences University found that the injury risk from passenger air bags remains high through age 14.

"Eight years ago, when the National Highway Traffic Safety Administration issued its recommendations, they were based on the best information (about air-bag safety) available at the time,'' said the author of the new study, Dr. Craig Newgard, an assistant professor of emergency medicine at the university's Center for Policy and Research in Emergency Medicine.

"Those warnings worked in reducing injuries to children, but as a parent and emergency physician, I felt it was time to study whether more children could be at risk and assess whether age or body size were good measurement guidelines,'' he added.

Motor-vehicle crashes overall remain the leading cause of death for Americans aged 3 to 33, but research on restraint systems and safety for older children has been limited.

In research published today in the journal Pediatrics, Newgard looked at what happened to 3,790 children aged 1 month to 18 years who were seated in the right front seat of a vehicle and involved in a crash.

The information came from a nationally representative database of police reports on crashes over an eight-year period maintained by the National Highway Traffic Safety Administration. The agency reports that more than 150 children through age 11 have died from air-bag injuries as of mid-2004, but information on teens has been sparse.

The study found that children 14 and younger were at high risk for serious injury from air bags when they sat in the front passenger seat during car crashes.

In contrast, air bags had a protective effect for teens aged 15-18. And the study showed that age may be a better indicator of risk from air-bag injury than height or weight.

Patient Satisfaction in the ED

This is excerpted from a Montefiore Medical Center press release, but I found it pertinent because of the mention of the techniques employed in addressing patient satisfaction:

"Tea Times and a NOD Result in Improved Patient Satisfaction"

To make patients more comfortable in its ED, Montefiore has also adopted a range of new initiatives to provide more personal TLC. Doctors, for example, are encouraged to prop up patients with pillows; nurses roll out a "tea time" beverage cart for waiting patients and families and bring them hot meals at lunch and diner; and, all staff greet each patient with a friendly NOD, "name, occupation and duty." As a result, visits keep climbing and patient satisfaction is at an all time high.

Prehospital Vocabulary Roundup

I was tipped off to this feature of the Journal of Emergency Medical Services (JEMS) website by GruntDoc. As a paramedic, I feel compelled to share.

Past Words That Should Be in the EMS Dictionary But Aren't.

A couple of favorites...

Yelp-Swerve: n. A sudden act by civilians to avoid an emergency vehicle, characteristically presented as a wild turning of their steering wheel to the right or left (whichever is most dangerous). Also referred to as “Siren Shock.”

Proximity pain: n. Discomfort that increases and is expressed more loudly as an EMT, triage nurse or doctor approaches, rapidly dies away as providers recede, and rapidly and loudly recurs when providers return. Rapid and effective relief is obtained when the patient can no longer see any medical personnel at all.

Drama alert: n. Any minor complaint that is exacerbated by numerous family members/friends believing it to be life-threatening (aka the infamous stubbed toe call). Usually results in having a hysterical patient on your hands.

Judge Says Physician Assets Off-Limits in Liability Claims

From the ACEP website:

A bankruptcy judge in April signed an order preventing malpractice plaintiffs from collecting judgments from the personal assets of physicians contracted with the now-defunct PhyAmerica Physician Group.

Several plaintiffs’ attorneys had tried to satisfy their claims with physician’s personal items after PhyAmerica’s bankruptcy left an insurance shortfall.

ACEP opposed the effort, along with Sterling Healthcare, the physician’s group that now holds the contracts of those physicians. On April 28, US Bankruptcy Judge E. Stephen Derby signed an order issuing a permanent injunction protecting physicians’ assets.

“We won and we’re thrilled,” said Stephen J. Dresnick, M.D., President and CEO of Sterling Healthcare, which is based in North Carolina. “I think the judge issued the ruling because it obviously wasn’t fair that these physicians were covered by their policy and for whatever reason there was not enough insurance to go around.”

At least 2,000 physicians, including many ACEP members, worked as independent contractors for PhyAmerica before the group went bankrupt in 2003. A dispute resolution agreement with PhyAmerica’s malpractice claimants limited the claims to the available insurance, which was believed to be enough to cover the outstanding claims.

About a year later, however, the Official Committee of Tort Plaintiff Creditors discovered there was a shortfall of nearly $7 million in the insurance pool, which exposed physician’s personal assets to make up the difference.

The bankruptcy court issued a preliminary injunction in December 2004 to prevent physicians’ personal assets from being taken by the claimants.

ACEP, in an effort to prevent setting a precedent with this unique case, filed an amicus memo in March supporting the injunction to exclude physicians’ personal assets. The College argued in favor of a permanent injunction during a Baltimore bankruptcy hearing in April, as did Sterling’s attorneys.

In his opinion, Judge Derby wrote that the problems arose because the dispute resolution agreement was “based on faulty assumptions as to funding,” and “attempted to respond to too many malpractice constituencies by being all things to all holders of malpractice claims.”

JACHO Patient Safety Standards

From Modern Physician:

The Joint Commission on Accreditation of Healthcare Organizations set its same annual patient-safety goals for 2006 but asked hospitals to take three additional steps to reach them.

The JCAHO will require hospitals to implement and evaluate the effectiveness of a program to reduce patient falls, one of the overarching goals. To the mandatory steps for improving caregiver communications, another goal, the JCAHO added implementation of a standardized approach to "handing off" patients between caregivers, including giving caregivers the opportunity to ask and answer questions. And to improve medication safety, the JCAHO said hospitals should label all medications and medication containers, such as syringes and solutions, in procedure areas.

Here's a link to the actual standards

Defensive Medicine

As published in the Kansas City Star

"Malpractice fears put doctors on defense"

A survey published today in The Journal of the American Medical Association found that 93 percent of doctors in high-risk specialties in Pennsylvania engage in such defensive practices as ordering unnecessary medical tests, avoiding risky procedures and even refusing to treat litigious patients.

...researchers from Columbia and the Harvard School of Public Health surveyed 824 Pennsylvania physicians in six high-risk specialties, including obstetrics, neurosurgery and emergency medicine. The researchers chose Pennsylvania because physicians there have been hit particularly hard by rising malpractice insurance premiums.

Fifty-nine percent of the surveyed physicians said they often ordered more tests than were medically indicated, 52 percent often needlessly referred patients to specialists and 32 percent often suggested invasive procedures such as biopsies to confirm a diagnosis.

Thirty-two percent of physicians said they often avoided performing certain procedures. For example, some obstetricians had quit delivering high-risk babies, some radiologists had stopped reading mammograms and some neurosurgeons had refused to treat trauma cases.

Thirty-nine percent of doctors said they often avoided treating patients they thought were more likely to sue, such as patients covered by workers' compensation or medical assistance programs.

More, from WebMD

Harvard researcher David M. Studdert, LLB, ScD, MPH, and colleagues went to a state -- Pennsylvania -- in the middle of a malpractice insurance crisis. From 2000-2003, several major insurers left the state. Premiums for medical liability policies shot up.

Studdert and colleagues asked 825 doctors from the six specialties at highest risk of malpractice lawsuits -- emergency medicine, general surgery, orthopedic surgery, neurosurgery, obstetrics/gynecology, and radiology -- to answer pointed questions about how they practiced medicine.

The bottom line: 93% of the doctors say they practice "defensive medicine." It means that to protect themselves against possible malpractice lawsuits, doctors do two things. On the one hand, they may order what they feel are additional yet unnecessary tests and procedures. On the other hand, they may distance themselves from treatments -- and patients -- that might put the doctors at risk of a lawsuit.

Studdert's team found that:

92% of the doctors ordered tests, diagnostic procedures, or referrals for specialist consultations that they did not think were needed.
43% of the doctors say they ordered imaging tests they didn't think necessary.
42% of the doctors stopped performing procedures prone to complications (such as trauma surgery), avoided patients with complex medical problems, or avoided patients they thought might be likely to sue them.