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Wednesday, October 30, 2013

Third trip to Haiti: inspiring projects on La Gonave

I just got back from the Haitian island of La Gonave (lagonav in Creole) after 8 days there visiting people who work on projects we help to fund. I'm glad to be home, because this is where I live and I missed toast with jam, my dog, and not being sticky sweaty all the time. Still, it was a wonderful trip and full of things to get excited about.

I first visited Haiti in 2010, about 3 months after the big earthquake hit the main island and killed 250,000 plus people, primarily in Port Au Prince. I went to La Gonave, 35 miles off the coast of Haiti, on a trip that was planned before the earthquake and which had nothing to do with the acute worsening of misery associated with the widespread destruction of the main island's marginal infrastructure. La Gonave was definitely affected by the earthquake, but nobody was killed, mainly due to the fact that there were very few large buildings and very few people inside in the late afternoon in the few places that did collapse. Poorly constructed houses did fall down or become uninhabitable, so some people were homeless or had to live in rickety structures of wood or palm leaves or in cramped quarters of their extended families or in chicken coops. Many were anxious or grieving because of the loss of friends or family members in Port Au Prince. People came to the island from Port Au Prince to get away from the destruction, with injuries, needing food and water and medical care, but by the time we got there most had gone home and life was returning to its baseline.

Baseline for La Gonave is very rural. It is about 8 by 25 miles and is home to about 200,000 people, most of whom live in the main town of Anse a Galet.  There is very little tourism, and almost all of the non-Haitian faces belong to aid workers of some sort or another, and there are very few of those. We visit a community in the mountains above Anse a Galet, 6 miles away, though it takes 1 1/2 hours by truck due to terrible roads. In the mountains there is no running water, no electricity and very little cash economy. The island was once a tropical paradise, I hear, but the French and then the Haitians deforested it and when it was brown and ugly, sent undesirable people there to suffer. There is very little in the way of government programs. Apparently it is possible to get a policeman to come eventually if something happens, but I have never seen a policeman. There is a hospital in the main town which is charitably funded by Episcopals, I think, and is slimly staffed. It is beyond the financial means of most of the people who live there, and so they get very little medical care. Foreign aid groups such as World Vision provide for some services like vaccination, but a minority of people are able to access care.

Human beings are amazing, though. Put them on a brown hot deforested island and they make communities, build schools, grow gardens, they organize for the rights of women and children, they make music. The people who live on La Gonave descended almost entirely from African slaves. Their common language became Haitian Creole, which combines a kind of phonetic French with words from English and other languages. After France recognized Haiti's independence, the country was saddled by crippling debt to both the US and France, hindering its ability to become economically viable. Haiti has also had terrible and cruel leadership for decades, and political unrest and official corruption has resulted in very poor infrastructure, despite huge amounts of aid which pours in on the heels of the various disasters (hurricanes, droughts, earthquakes) which befall them. La Gonave gets only a very tiny amount of that aid, though in the 2 years since I was last there, a UK based charity, Concern Worldwide, has built over 100 deep water pumps which have drastically improved everyday life for people who spent hours a day fetching a few gallons of water from the few springs scattered around the island. Church organizations give some money to support churches and schools that have a religious mission. The most energetic of young people make their way to Port Au Prince for education and then to the US, wiring money home to families which bolsters the tiny cash based economy of the island. There are essentially no exports, except sometimes fruit or fish which go to Port Au Prince. It is a subsistence culture, but it is also green and beautiful, and safe and welcoming to someone like me.

My thoughts in visiting La Gonave have evolved significantly since I first visited. I initially supposed that I should just bring as much medicine and medical testing equipment as was practical because I was sure to see lots of people dying because of lack of medical care. It turns out that there was some ill health, but more just discomforts of being human and working really hard, and there was very little I could treat. The sickly die in childhood, those who are left are pretty tough. Older folks couldn't really get to where I was, and many people who might have been helped by my services, like those with hypertension and diabetes, would have needed those services long term for me to have done any good. I did save a goat who was sick and maybe a baby who had pneumonia survived due to an antibiotic I gave her, but I was unable to do anything for the woman with advanced breast cancer or the one with the non-healing wound or the grandmas whose blood pressures were upwards of 200/140. There are drug dispensaries on the island, with various medications which might be useful, but people can rarely afford even the very reasonable prices for these. What really improves the lives of people in developing countries (the US, around the industrial revolution, was a good example) is clean water. Diarrhea, mostly transmitted by contaminated drinking water, kills more babies than any other disease. In Haiti, AIDS also kills people, and starvation is a significant part of the disease syndromes that shorten peoples' lives. Anything I might do for my Haitian friends would tend to be temporary, but anything they can do for themselves sustainably might make a long term difference. This time I focused on projects that could be made to be sustainable, without unacceptable long term financial support from aid agencies or our Haitian focused nonprofit, Paloma Institute.

We provide some financial support and ongoing intellectual collaboration with a group of master gardeners and community leaders called JLLP (jaden legim selavi paysen--vegetable gardens are the life of the people.) They, in turn, support gardeners, a school, education and sanitation projects and do some micro-lending for various other community projects. During this visit we walked through several gardens which were much larger and more lush and productive than they were the last time we visited, and brought some gardening equipment which is not available there. Transporting seeds to Haiti is theoretically strictly regulated, but vegetable seeds are what they need most, so I may or may not have brought various organic and non GMO seeds of the type that grow well in a hot humid environment. One of the master gardeners, Eligene Deravil, is particularly knowledgeable and devoted to garden experimentation and educating other people who want to have successful gardens. He has a huge garden with beautiful compost piles, grows 3 crops per year and has 3 people who work for him. He was a very poor child, a restavek (domestic slave) when he was small, but is self motivated, unselfish and tireless in all the projects I've seen him take on. It is inspiring to watch him work.

We also try to mentor people in art and craft projects, because most people have very little ability to make money, are very motivated to create things, and La Gonave could sure use an export. We worked with women who were making beaded jewelry and purses out of recycled waste to find items that would potentially sell to US consumers. There is clay, and we worked to find a good source and have, in past trips, explored sustainable pit firing, but have been hindered by lack of good quality material in the area we visit. One man, though, took the clay idea and created a form out of the rather crumbly clay that is easy to find and began to make vessels out of concrete. He was excited about creating large sturdy buckets to be used as composting toilets. He was able to make a very solid and culturally acceptable container during this visit which can be used by families who can't afford a pit toilet, and which can be covered while composting begins, then used as humanure compost for gardens. This will require ongoing experimentation, but in any case is an improvement on what those families do now, which is to poop on the ground, without regard to groundwater contamination or hygiene. He could make one of these for $5 US dollars, which is affordable to people there, and we gave him some startup money to make some to give away to families with no money. He will eventually paint them, and perhaps have deluxe models that will sell for more money to families that are more financially comfortable.

My traveling companion does wild animal rehabilitation at home and we both keenly feel the tragedy of the domestic creatures who get even less TLC than their poorly fed owners. It is fine to be a chicken in La Gonave, since there are plenty of bugs and nobody cares where you wander. Eventually you become food, but it is in everybody's best interested that you be treated well and kept comfortable before that happens. It is not so good to be a dog. Dogs are dependent on humans for food, and there are very few scraps, and nobody has ever heard of dog food. Puppies routinely starve after they are weaned and this is part of the ecology of the place since there is no doggy birth control. Goats do pretty well, much like the chickens, though they are tied up to keep them from raiding peoples' gardens. Donkeys have the worst lives. They exist only to carry heavy loads so it is not necessary that they be treated with any kind of consideration beyond that which keeps them on their overburdened feet. There are people trained in animal medicine, not real vets, but people with training. One of our friends had attended a 2 year animal medicine course given by the aid organization World Vision, but had had little opportunity to use his skills. We came upon a donkey with a saddle sore that was so severe that it was liable to have ended in the animal's painful death before too long. We were able to give him $20 to buy some standard veterinary pharmaceuticals and then give the donkey a little love and debridement, some penicillin and worm medicine and a chance to live a few more years. The owner got a chance to have a functional donkey again and some education in animal care, the under-employed animal medicine technician got practice and publicity, and stories like this travel. We had another such patient in a couple of days, with more people wanting to see how to care for it, and maybe some good will come of all of this.

Birth control and safe sex are vitally important in the developing world and are very tricky due to cultural norms and deeply believed misinformation. I had a terrific translator, a man who had worked in the US for 9 years before being deported due to a visa violation. His understanding of the language and culture made it possible for him to translate not only what I said, but what I meant, and his winning personality made people hear a message that they might have tended to reject. I gave a talk to about 30 people, many of them community leaders, about how wonderful condoms are, and gave out about 1000 very attractive but quite inexpensive (for me--I bought them in bulk online) condoms for distribution. We talked about AIDS, unwanted pregnancy, the way they work and that they don't break and go to your heart and kill you. I talked about personal experiences and people laughed and had a good time. Condoms are not hard to get, and many organizations are set up to provide these free of charge if there is demand. In my tiny way, I hope to create demand, which will mean that use of condoms will be potentially sustainable without me. At the very least, we talked about sex in a way that was open and honest and the 1000 condoms represent 1000 opportunities to not get pregnant or contract a sexually transmitted disease.

The visit also offered an opportunity to learn about schools in rural Haiti. There are many. They are usually not free. The cost per year is $25-$30 USD, and most parents pay this. There are no standards for teaching, and beating and yelling at students is common. Sexual contact between male teachers and female students is frowned upon but not unusual. There is a standardized test at the sixth grade level, which has some influence on the content of what is taught. Haitian Creole is the language used in most schools up until third grade, French thereafter. Some schools are religious and are supported by churches outside of the country. Schools sometimes pay teachers a little bit, but teachers often work for nothing but the promise of someday being paid and the opportunity to have a job in their community. Schools really want money from outside because it is very difficult to make a school self sustaining. Students learn better if they are fed, and making beans and rice for everybody in a small school costs a lot of money. School supplies are less expensive in Haiti than in the US, but in La Gonave they are in short supply, as are books. It is hard to know, as an outsider, which schools deserve supporting. We talked to the leaders of several schools in our area about forming a school district to share resources and ideas, and our translator expressed his desire to start a program to teach adults skills such as teaching and translating so that the quality of education could improve. In our area many of the schools incorporate teaching gardening and crafts so that students might develop practical skills. Education is key to allowing these rural poor children to have real choices in their lives and so we will try to support their efforts.

I saw very few actual patients, since I didn't advertise my visit that way, but did see some. An old woman with a stroke provided an opportunity to talk about high blood pressure prevention and treatment. Hypertension is common in older Haitians and results in the usual complications that we see in the US. Regular treatment with medications is usually not affordable, but high salt diet and late life obesity are modifiable risk factors. Painful knees and backs from hard work on steep terrain with heavy loads were common, and people were grateful for a few aspirins, since over the counter medications are hard to find and expensive. I saw a couple of people who truly needed acute medical care, a baby with probable malaria and a young woman with a severe leg infection, and recommended immediate transfer to the hospital in Anse a Galet, but I have no idea what happened. Both patients would have been hospitalized immediately in the US. I was able to do a few ultrasounds with my handheld machine, and everyone loved looking at babies, who were appropriately positioned and appeared to be healthy. These procedures were primarily to open up conversation about healthy pregnancy, and ultrasound always seems to have the ability to make people appreciate their bodies. I would love to do a more widespread screening for hypertension and cardiac disease, but would prefer to do this as part of a larger effort that might potentially include treatment. I would also need easy access to an electrical outlet, which I did not have.

I'm home now, glad to eat toast with jam and wear thick wool socks and sweaters. E-mail will allow me to see some of the projects that happen in La Gonave, and the miracle of wire transfers will make contributions from me and other people who find this stuff inspiring possible.

Monday, October 14, 2013

The Green Journal speaks out on Bedside Ultrasound

I frequently throw away the American Journal of Medicine (the "Green Journal") without reading it because it is not one that I actually ask for and it doesn't address questions that I find interesting. Lately, though, the quality of the material is better and I am more likely to pick it up and page through the articles.

Today I found that there were two editorials on the use of handheld ultrasounds, specifically the Vscan, the little pocket model that I have used for the last nearly 2 years as a diagnostic tool at the bedside. One article, by Julie Kim MD and colleagues from Northwestern University in Chicago, IL presented the opinion that these devices should only be used as part of clinical trials or for evidence based indications. They based this view on a review of the literature which showed few prospective trials showing improved patient outcomes.

The following article, by Roy Ziegelstein, MD and David B. Hellmann, MD points out that "wise use of hand-carried ultasound may provide valuable information more quickly and less expensively, and thereby benefit both clinicians and patients." Furthermore, they point out that this "may enable clinicians to have a more active role in patient care, may facilitate patient education at the bedside, and may well restore joy and greater satisfaction to the life of health professionals." They do, however, agree with the first authors that before these devices are used by non-specialists in a widespread manner, there must be well conducted trials that demonstrate clinical benefits to patients.

When I first read the editorials I was frankly very irritated. Both the for and the against positions came out against actually doing routine bedside ultrasound as part of the physical exam. The specific argument was that bedside ultrasound would identify internal abnormalities which were not clinically significant, leading to overdiagnosis and over-testing and probably over-treatment. Dr. Kim et al pointed out that we know that screening for pancreatic cancer and ovarian cancer in patients without symptoms does not change the outcomes of these diseases, and that people with a little ultrasound in their pocket would not be able to resist finding these things. My experience with the Vscan is that it is a fine machine for looking for fluid in the wrong place and for examining the basic functions of the heart, and occasionally for examining abnormalities like tumors that more detailed imaging procedures or blatant symptoms had already pointed out, but that it is not at all easy to find an ovarian cancer or a pancreatic cancer with any degree of certainty, even if I look really hard, which I don't. The point that these authors completely miss is that we physicians are all using our physical exam skills to identify the diagnoses I look for with my little ultrasound, and we know that our physical exam skills have terrible sensitivity and specificity. We really can't tell if a person has heart failure or fluid overload or ascites (fluid in the belly) or pleural effusions (fluid around the lungs) which are vital to giving appropriate treatments.  We are taught how to detect these things with our hands and ears and stethoscopes, but good studies show that, even if we are skillful and attentive, we are not much better than chance at identifying these things with any degree of certainty. Nevertheless we continue to use our physical exam skills to make these diagnoses and treat or test the patient based on educated guesses. Ultrasound, even performed inexpertly, is better than this.

I stepped back a bit from my desire to scream and thought about the issues these authors brought up. Yes, there is a potential for overdiagnosing various conditions of little or no clinical significance or finding diseases that no amount of early treatment can cure. We are going to need to figure out what to do with our new level of confidence in our diagnostic abilities. We will need to figure out how to define competence in this new technology so we don't find ourselves becoming convinced by blurry images of findings that aren't real. But there are many physicians who employ bedside ultrasound successfully and already use their pocket ultrasounds to "have a more active role in patient care and facilitate patient education at the bedside" and are even now restoring joy and satisfaction to their calling. These doctors are not involved in clinical trials, at least not most of them, but are on the forefront of discovering what this technology is really good for. Many medical schools consider performing and interpreting ultrasound at the bedside to be a core competency, and medical students are trained to make it part of their practice. Dr. David Tierney directs IMBUS (Internal Medicine Bedside Ultrasound program) at Abbott Northwest Hospital, the largest hospital in Minnesota's twin cities, which teaches all of the medical residents to be competent to use bedside ultrasound. This program combines extensive practice with wireless communication and frequent conferences to share expertise and produces internists who will most likely seamlessly incorporate ultrasound into whatever patient care field they eventually pursue. Like the stethoscope or the computer, bedside ultrasound, and pocket devices that make it more convenient, have already transformed medical practice, and now the most interesting question is not "should we?" but "how do we?"

It was gratifying that a journal that is one of the standards of Internal Medicine is addressing the issue of handheld ultrasound. It is a little disappointing that the doctors giving their opinions don't seem to actually do bedside ultrasound, which would make their opinions a bit more significant.

Tuesday, October 8, 2013

Medical Errors: Do 400,000 people really die from these every year in America? What does it look like from the inside of a hospital?

I just read an article in the Journal of Patient Safety by a NASA toxicologist and patient safety advocate, John T. James PhD, which addressed the question of medical errors in hospital settings. Dr. James evaluated the results of 4 studies of patient adverse events (PAE's) and extrapolated the results to estimate that 400,000 deaths yearly are associated with preventable patient harms. The Harvard Medical Practice study which reviewed records from several New York hospitals in 1984 estimated that deaths due to medical error numbered about 98,000 per year, and that number has been quoted widely and embraced as the truth by the Institute of Medicine, a nonprofit organization which seeks to advise patients and decision makers about important issues in medicine. This current article uses different methods and suggests that the number may be much higher.

After reading the article about the article on a public interest site on the internet, I perused the comments, which were primarily outrage, interspersed with a doctor or two who seemed pretty defensive and said unpopular things that were on the order of, "What do you expect? We're doing the best we can!" My first reaction was to wonder what exactly the study meant, how was it done and what were the definitions. I found the article and read it and came to some conclusions that probably ought to be part of the discussion.

How did they reach their conclusions?

The 4 studies that were evaluated were in hospitals in various areas of the country in which a "Global Trigger Tool" was used to identify patients who might have had an adverse event, something bad that happened in the hospital. This could have been a missed lab test, a procedure complication, a drug reaction, a hospital acquired infection. The charts of the patients who were identified this way were then reviewed by doctors and the doctors determined if it looked like the adverse event contributed to that patient's death. Each of the studies was performed a little differently, but they shared this general method. They found that about 0.65-1.4% of patients who were hospitalized had an adverse event that contributed to their death. Overall, in the 4 studies, 4252 randomly selected patients' charts were reviewed, and of that number, adverse events contributed to the deaths of 38 people. Based on other studies, 69% of these adverse events were felt to be preventable, and multiplied over the 34.4 million patients hospitalized yearly, they came up with 210,000 people yearly for whom preventable adverse events contributed to their deaths. Since their methods did not include errors of diagnosis or errors of omission, that is not figuring out what was wrong or not treating it according to accepted guidelines, and medical errors are not always well documented in the medical records, the author rounds this 210,000 up to about 400,000 patients who died partly because of medical error.

Why this is somewhat misleading

This is a big and very important issue. I see medical errors and, more often, adverse events from decisions that, in retrospect, were wrong, on a daily basis when I work in hospitals. But there is something very wrong in the way that this article is being reported. The author himself labels adverse events that contribute to death as "lethal errors." Some of them are, but some of them just contribute to the lethal cascade of events, from life choices to decisions to pursue aggressive treatments, which end in death. The overdose of insulin that kills a patient is a rare event. The blood clot in the leg because of failure to order prophylactic heparin that leads to full anticoagulation that leads to gastrointestinal bleeding which leads to intensive care unit stay which leads to ventilator associated pneumonia and death due to drug resistant organisms because the patient was a diabetic who also dabbled in intravenous drugs, or some version of this narrative, is common. The failure to prescribe heparin in the first place should hardly be called a lethal error. In fact, the prescription of heparin in the first place, itself, might have lead to a life threatening complication.

The outrage which is beginning to erupt is taking the form of "doctors kill 400,000 people a year in hospitals due to negligence." That is not what this paper says. It says that 400,000 people who die each year in hospitals are made sicker by the things we do to them. Another issue brought up in this article is that 10 to 20 times this number of patients are significantly impacted by medical error in hospitals. These events might be a hospital acquired infection or a surgical wound complication or a drug error from which a patient recovered, though not without suffering. If the estimate is correct, we are making 4-8 million people sicker in hospitals yearly in our attempts to heal them. We need to pay good attention to all of these things and identify the processes that make them happen and look for practical solutions. This falls under the heading of patient safety. Much is actively being done in hospitals to improve patient safety, but the complexity of what we do limits our ability to protect those in our care from harm.

Swing shift in the hospital yesterday: a day in the life...

I admitted 4 patients to the hospital yesterday and so had ample opportunity to make life altering mistakes in the lives of 4 individuals. The first was a morbidly obese woman with new diabetes who had developed a severe leg infection related to the fact that her legs were always swollen. The infecting organism was probably a staph or strep, and given the community in which I am working, it might be MRSA, the methicillin resistant staph. I started her on two antibiotics, both of which might cause a life threatening allergic rash, and one of which might cause kidney failure. Both might also lead to a life threatening Clostridium Difficile infection of the colon. Starting insulin might lead to a hypoglycemic reaction that could result in death or disability. Simply putting the patient to bed might lead to bedsores, especially if I treat her pain with intravenous opiate medications which could lead to respiratory depression and death or disability.

I then moved on to the man who had been monthly to this hospital due to complications of ongoing methamphetamine abuse with diabetes for which he usually failed to take his medications and endstage liver failure from hepatitis C. This time he wasn't very sick, just had a very high blood sugar level and a very low potassium level. I gave him potassium first, because giving insulin would lower his potassium further and might cause a fatal heart arrhythmia. I gave lots of potassium, because the level was very low, and I risked raising the potassium level to a point where it might cause a fatal arrhythmia. The pharmacy called to see if I really wanted to give all of that potassium and I said yes, and thanks for checking on me. Pharmacy monitoring of physicians' orders is standard, and they catch errors all the time and I really appreciate it. I had to decide whether to give intravenous fluid, and decided not to, despite some kidney failure, because of a long history of going into heart failure with just a little fluid overload.

I then headed to my third patient, a woman with chronic pain and ongoing alcohol abuse, a quart of whiskey a day, who was feeling like she was going into alcohol withdrawal again and also was short of breath because of her chronic lung disease and new pneumonia. She had just quit smoking but was using some kind of nicotine nebulizer she got in a tobacco shop. She was on warfarin, a "blood thinner", which she said had been perfectly stable for months. I ordered the antibiotic for her pneumonia which could cause tendon rupture and antibiotic associated diarrhea, the asthma meds which could make her heart beat erratically and make her delirious, decided against the sequential compression devices for her legs since she had known arterial occlusive disease with recent arterial clot which nearly resulted in amputation, even though I did risk her developing a clot in a vein. I ordered her regular warfarin dose and checked her protime. The pharmacy called a couple of hours later to tell me the protime (monitoring of the effectiveness of the warfarin) was dangerously high, so I thanked them and discontinued the warfarin, asking the pharmacy to monitor it and restart when appropriate. I ordered high dose lorazepam, an antidote to the effects of alcohol withdrawal, which might lead to breathing problems with resultant need for a ventilator which could lead to pneumonia and intensive care unit related dementia.

Then up the stairs to the transfer patient, a 39 year old man who used IV and subcutaneous methamphetamine and had developed abscesses all over his skin and a heart valve infection. He had been in hospital improving from this for 3 weeks, and now was in my care with a central line (intravenous catheter in his internal jugular vein) and open wounds on both hands and both legs after surgical treatments of his abscesses. He was on high dose pain meds and still complained of pain. He had a fever. His fever might have been from his known severe heart valve infection, from an internal abscess as yet undiagnosed or from the central line. I ordered blood cultures which could only be obtained from the central line because he had no accessible peripheral veins and considered the option of replacing the central line with a new one which would not be a nidus of infection but the insertion of which could cause injury to an artery or puncture the lung, which might kill him. Another option would be a peripherally inserted central catheter (a PICC line) which would have a pretty high risk of resulting in a blood clot in the arm which could migrate to the lung and cause his death. I ordered most of the medications which had been working at the previous hospital. They included drugs that could cause kidney failure, respiratory failure and allergic reactions of all kinds. He was also on an antipsychotic medication that could cause a permanent neurological impairment called tardive dyskinesia in which the tongue involuntarily keeps sticking out of the mouth. When he didn't take that, he had apparently been extremely anxious and agitated.

Keeping patients safer

And that wasn't even a big day. Clearly protecting patients from harms in the hospital is a priority. The most important way to protect patients is to keep them out of the hospital and keep their treatments as streamlined as is possible without risking errors of omission. Keeping patients out of the hospital means assigning priority to resources that keep people healthy. It also means having important conversations with patients about what they really want done and what being in a hospital means. Presenting every patient with the list of the all of terrible things our treatments can do to them is impractical, but we need to bring them in to the conversation. We need to have the time to do this, which means backing off on something else which fills our time. Deliberately simplifying care would help, and we could make this an item for action. If there were fewer medications prescribed, fewer specialists consulted, fewer intravenous lines inserted, fewer surgical procedures offered and performed, there would be fewer medical errors. We can make this happen, but it will involve a concerted decision by patients, families, doctors and hospitals that it is something we all value. Doing less will redirect the revenue stream which will be uncomfortable and disruptive, but so very worthwhile.

Sunday, October 6, 2013

What to do with ancient people

A 100 year old woman is brought to the emergency room by a concerned friend because she can no longer get out of bed to get food or go to the bathroom. Other than being unwashed and a little confused, she is fine. Her electrolytes are pristine, her electrocardiogram the definition of normal, her blood count and chest x-ray perfectly mirror the expected physiology for her age. Even her urinalysis is normal. She takes no medications and hasn't been to the doctor for a decade. She has no living family and her friends have their own lives and problems. She can't go home because she has just gotten too old. What shall we do with her?

When the law establishing Medicare was enacted in 1966 as title XIII of the Social Security Act during the presidency of Lyndon Johnson only half of seniors had health insurance and many had no access to healthcare because they couldn't afford it. Now nearly all seniors in the US have insurance coverage for both ambulatory and hospital care. Medicare also covers a limited amount of time in nursing homes as a bridge between hospital and home. This is truly intended to finish the work of an acute hospitalization and get a patient back home, when an acute illness has made them weak enough that going straight back would risk failure and return to the hospital. Medicare was never intended to pay for long term care, but then how is a person expected to afford care in a nursing home?

Nursing home costs are now around $220 per day or over $80,000 per year. It is pretty rare to find a person who has savings and pensions adequate to cover this much money. The way it usually goes is that a person spends their income and their assets, not including their house, if there is a spouse in it or an intention to return to it, a car and a few other odds and ends such as a wedding ring and a burial plot, down to a certain small amount after which time he or she applies for Medicaid, a state run medical funding agency. Some nursing homes don't accept patients with Medicaid funding because they are either not certified by Medicaid or don't want to accept the smaller amount of money that Medicaid spends for care compared to what a private patient pays. In Idaho, Medicaid pays nursing home expenses for 60% of the patients in these facilities. After a patient spends down their assets and ends up on Medicaid they usually remain in a nursing home for the rest of their lives, and Medicaid picks up the tab. After becoming destitute it would be impractical to return to independent living, even if one were to be miraculously made well again.

So back to our centenarian. She has been brought into the emergency room and, lacking a traditional multigenerational family living together to take on her care, she clearly needs a nursing home. The wheels of nursing homes work slowly, though, as do the gears and engines of the Medicaid program. She needs somewhere to sleep TONIGHT. She is in a hospital, and in that hospital she will remain until a safe place can be found for her to stay. Unfortunately there is nothing really wrong with her except that she has had an excess of birthdays. Medicare, which she probably has, will only pay for her hospital stay if she is acutely ill or we are suspicious that she might be acutely ill for some documentable reason. If she really is ill in such a way that she would need hospital care, not like a cold or a sore back or a urinary tract infection, we can make her an inpatient. As an inpatient, most of her costs will be paid by Medicare. If we think she might be ill, for instance if she has chest pain that might indicate a heart attack, we can admit her under observation for a day or at most 2 days while we make absolutely sure she is fine. If she is an inpatient for 3 days, Medicare will pay for skilled (usually nursing home) care, that is care to rehabilitate her to go home, for a maximum of 20 days. If rehabilitative care is necessary for longer, Medicare will pay a portion of nursing home costs up to a lifetime maximum of 100 days. If it becomes clear that she will never be able to return home, Medicare will no longer pay, and if she can't pay the nursing home costs, she will need to apply for Medicaid which will then pay for her. Once she is at the nursing home, usually they won't just kick her out, even if her Medicaid application is slow to be accepted.

Our patient in question is not sick and can't be badgered into complaining of anything life threatening. She is admitted to the hospital because we can't put her out on the streets and it is not safe for her to be at her home anymore. Since doctors are trained to look for disease, we look really hard and think that maybe her confusion is actually delirium and that perhaps she looks just a touch out of breath so we document anything that goes along with that and then the billing staff attempts to bill Medicare for her stay. If Medicare pays for this hospitalization and later audits the account and finds that she was actually fine, we have committed fraud and the penalties are steep. Deep in our hearts we have intended no fraud, but feel that this hospital stay is unavoidable and that Medicare should pay for it, but they see it quite differently. Our billing specialists have become much more vigilant in avoiding false claims since enforcement agencies have been coming down hard on cases of fraud. Still, they spin their wheels and struggle with verbiage and try to get us to document what seems like exaggeration or hyperbole in order to minimize the amount of uncompensated care that the hospital provides.

This grand old woman who has finally reached our emergency room deserves a gold medal for being not only healthy but for costing the healthcare system close to nothing for decades. If she had seen physicians for every wart and ingrown toenail she might have been gradually transitioning to a higher level of care as she aged, and some of her financial issues would be well in hand. We see few healthy 100 year olds, but stories similar to this are not uncommon and the problem of what to do with the not quite sick and yet not well enough to go home plagues hospitals, in particular emergency room doctors and hospitalists. Emergency room staff spend scads of time trying to arrange dispositions for these patients that don't involve an admission, and then have to explain to the admitting physician why admission is the only option. The hospitalist needs to care for the patient, often while trying to also care for the truly sick. We must also respond to the concerns of the billing specialist who wishes that any money at all would come in to defray the hospital costs that will come of this stay which might be prolonged depending on the willingness of a nursing home to accept the patient.

This is all so very complicated. Humongous amounts of energy are wasted. Social workers battle processes that are designed to make things more difficult and physicians lament that there aren't systems in place to deal with the very real needs of people who age and need help. Hospitals try to bill for the hours of care and problem solving that they do, requesting money from Medicare which was never intended to fund this sort of thing.

I think that this hasn't been solved because it is too painful to look at and the people who suffer the most, the very old and very disabled, don't have an effective voice. The chunk of money that would need to be set aside to do this right would be significant, in a political environment that is already making loud squeaking noises (justifiable) about what medical care costs. What is being ignored is the fact that we are paying for this, and probably paying more because the routines are so horribly inefficient. Hospitals are paying physicians and billers and social workers and those costs are defrayed by higher charges for everything else that the hospitals do. Communities are paying law enforcement officers who are the first responders for folks who fail at home.

I would like to be able to present this ancient patient who presented to the emergency room with her medal of honor for an excellent and healthy life and seamlessly tuck her into a bed with clean sheets and regular meals, if that is what she wants. I would like her never to have to spend 12 hours in an emergency department getting tests she doesn't need with physicians who will someday, if they are lucky, be in her shoes, arguing about who has to take care of her. There are many organizations and individuals thinking about the nuts and bolts of solving this problem, including ways to keep folks in their own home with the help they need and alternatives to governmental funding of nursing care and other great ideas. It is so vitally important to get important stakeholders from hospitals, in conjunction with Medicare and Medicaid, to look honestly at the problem and commit to coming up with some solutions.

Friday, October 4, 2013

Why it is cool to have an ultrasound in my pocket and the Second Annual World Congress on Ultrasound in Medical Education

I admit it. I am an ultrasound nerd. Zealot would be another word. I am someone whose enthusiasm for bedside ultrasound is strong enough to overwhelm my desire not to bore other people. Still, it has taken me to very interesting places and put me in contact with good, devoted people whose passion to make medical care and teaching better and more accessible mirrors my own values...even the values I had when I thought that ultrasound was something that technicians did in little dark rooms which produced un-readable blur-o-grams.

After learning the basics of bedside ultrasound in an introductory course 2 years ago and working on becoming proficient through hours of practice and other formal training I got to go with medical students from UC Irvine to Tanzania to teach basic ultrasound and practical anatomy to students in Clinical Officer training school and other physicians. They have kept in touch and presented their work in a meeting in Columbia, South Carolina, the Second Annual World Congress in Ultrasound in Medical Education. This was a gathering of physicians and students from around the world who push the concept of using ultrasound in the hands of caregivers at the bedside to both teach students to understand anatomy and physiology and to diagnose and treat patients more effectively. It was a great meeting. There were almost no dry and boring talks delivered by people who would clearly rather be elsewhere. People were passionate about their desire to have bedside ultrasound become more common, and presented lots of the research about how it improves our safety and effectiveness. Nobody talked about how it can make us more money. That piece was conspicuously absent. The reason it was absent was because that isn't something these people were passionate about, and it doesn't usually make us any more money. There were people from Italy who use it routinely for diagnosing lung conditions and wanted to make sure that everyone knew how to do that and how useful it was. There were people from the Middle East and Africa who use it to deliver healthcare where there are no CT or MRI scanners and where basic imaging of a trauma victim or a pregnant woman can routinely save lives. There were American physicians who have been pioneers of using it, swimming against the current because it doesn't increase the revenue stream and makes folks whose livelihoods rest on the overuse of expensive imaging very uncomfortable.

Columbia is the capitol of South Carolina, the largest city in South Carolina at 129,000+ people, and the home of the University of South Carolina and its School of Medicine. The meeting was held in the convention center, just next to the university and near art galleries and shops, restaurants and bars and not too far from the Congaree River that runs through town. The medical school is one of a small but growing number which teach ultrasound to the medical students as part of their curriculum, and so they were an appropriate and gracious host for a meeting devoted to ultrasound in medical education. The Dean of the medical school, Dr. Richard Hoppman, was a personable guy who gave one of the short, sweet and useful speeches at the plenary session, and he was clearly devoted not only to ultrasound but to all kinds of projects that would benefit people domestically and in other countries who have very little. Since ultrasound is a technology that gives excellent value and costs nothing after the price of the machine, it is an excellent tool for doctors who want to take their skills to some place where people need medical care but where there is little to no infrastructure to deliver it. The meeting was packed with such doctors.

In addition to people talking about what they were doing in their hospitals and on their travels and presentation of research in various aspects of teaching ultrasound and documenting that it was accurate as a diagnostic tool, there were hands on sessions where doctors who had a tremendous amount of practical expertise shared how they did what they did. I learned about basic obstetrical ultrasound and something called transcranial doppler which actually looks at the brain through the very thin area of the skull at the temple to determine blood flow in the cerebral arteries.

Next year the meeting will be held in Portland, Oregon, which is much closer to my stomping grounds, and will use the new teaching facilities at Oregon Health and Sciences University. The ultrasound champion there who will facilitate the meeting is Dr. Jenny Mladenovic, an internist and long time academic administrator who recognized that ultrasound makes internists better and happier doctors and that the best time to introduce all of us to it is as medical students.

Since I was hanging out with medical students and ER physicians at the meetings, the evenings were not boring. Also the companies that produce ultrasound machines, companies like Fujifilm and General Electric, funded a dinner at the Columbia Art Museum and  at the zoo. This is part of the unholy industry physician connection, but was also an opportunity to make meaningful connections with cool people who were doing groundbreaking things. After the dinners there were bars with good ambiance and excellent live music which conspired to get me back to bed later than would have been optimal. I got the idea that Columbia produces really good musicians, which is supported by the wikipedia entry on the city.

On my way home I was sitting in my airplane seat trying to decide whether to watch a movie on the pay per view tiny screen in front of me or study medicine when the flight attendants asked for a doctor. I went to the aid of a very old man who was just regaining consciousness after walking back to his seat with his daughter from the bathroom. Losing consciousness when one is very old is a bad thing, often a sign of something life threatening. The story the daughter gave lead me to a differential diagnosis that included dehydration, heart attack, arrhythmia or blood clot to the lung. We were still 4 hours from our destination with a full flight and, although it would have been nice to have this man be on the ground and at a hospital there was no chance of this happening expeditiously. Airplanes have little first aid kits that are bigger than the one I carry, and have blood pressure cuffs, intravenous fluids and some basic pharmaceuticals. I could tell that the patient's blood pressure was very low but the exam was otherwise limited by loud engine noise and no room to move around. Luckily I had my handheld ultrasound and could determine that he was not suffering from a heart attack or a blood clot to the lung, because these two events, when severe enough to cause a person to lose consciousness would usually show characteristic changes on the images, and that he was definitely dehydrated, which fit best with the history that he gave me. He perked up nicely with an anti-diarrheal pill, some 7-up and the old time doctor's best remedy, tincture of time. He was able to get off the plane looking much better and see his own doctor who knew him rather than be rushed to an emergency room in an unfamiliar city where they would have to piece together his medical history and probably do a bunch of potentially unnecessary tests. Hooray for ultrasound and tough little old people!