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My name is Sara Paradise. I’m a fourth-year medical student at the George Washington School of Medicine in Washington, D.C., and a very soon-to-be emergency physician. Like 99 percent of you docs and future docs out there, I am 100 percent passionate about my chosen specialty and future patients, but have zero understanding of how government and health policy really works.
Which is why, after nearly four years of living only blocks from the White House and the epicenter of political drama, I was pumped to have the honor and privilege of doing an internship with the American College of Emergency Physicians. These are the premier group of people responsible for representing the policies, education, advocacy, and regulatory interests of emergency physicians.
Fast-forward five days, and I feel like I’ve gone from a toddler to a tween in my knowledge of health policy, being taken under the wings of the brilliant people working at ACEP in D.C. to amass a much deeper understanding of emergency medicine and our role in health policy.
So, let’s talk about how things work.
Much of my week has been devoted to meeting with members of Congress, who hold almost daily meetings to educate themselves on issues related to health care reform. The people in attendance tend to be lobbyists, or individuals hired to represent major medical specialty organizations such as ACEP. I was instantly struck by the important role that the medical lobbyists hold in these meetings compared to other public and private groups, often seated next to the Congressperson and directing the conversation. Lobbyists are not only experts in the nitty-gritty details of the Affordable Care Act and how it affects their specialty, but have an unparalleled adeptness in navigating Washington, D.C. politics to convey doctors concerns in a passionate, yet appropriate manner.
The Congresspeople who represent issues that your particular medical specialty cares about are the ones you meet with most frequently. In our case, that means anyone who champions funding poison centers, drunk driving prevention, and SGR reform (that is, ensuring that we as physicians are not fiscally-penalized for seeing Medicare patients). These legislators admit they are not experts, and fight for our doctors despite being stuck in a muddy Congress.
So other than rub elbows with political figures, what else do health policy people do? Apparently, they attend a lot of special panels and webinars that discuss details of healthcare-related legislation. They use their strong voices to bridge the gap between those creating health care-related laws, often non-clinicians, and America’s doctors. One such panel discussed the “Two Midnight Rule.” This rule, I learned, states that any Medicare patient who is marked as “Observation Status” – regardless of whether physically in the ER or an inpatient bed – does not automatically qualify to have their skilled nursing facility (SNF) stay covered, even if they are observed for the required three days and it is medically indicated; an unintended loophole, if you will [read more here]. The panelists were policy makers set on changing the laws for the better, with our local and national community’s input.
One of the highlights of my week was most definitely attending the release of the December issue of Health Affairs at the National Press Club on “The Future State of Emergency Care.”
My personal favorite was a talk by Dr. Maria Raven on the urban myth that Emergency Department “frequent fliers” guzzle our health care dollars faster than a non-hybrid SUV consumes gas. She and Dr. Billings’ research found that those patients utilizing the ED on a “frequent” basis (about 10 times per year) visited their Primary Care MORE frequently than the average ED patient. Perhaps they just have more complicated, and many comorbid conditions! Another talk, by Dr. Jeremiah Schuur, was on changing our emergency medicine infrastructure. Why not bring the right resources to the patient via tools such as Telemedicine, rather than dragging patient to the resource (which is often time-consuming, costly, and ineffective)? In the era of Facetime and Medicare reimbursement for Telemedicine consultation, makes sense to me.
One really informative meeting was with ACEP’s Quality & Health I.T. Manager. Even though I have an extensive background in Electronic Health Records, I felt as though she was speaking a foreign language. HL7? CCDA-1?? MU2? I nodded my head, thinking “What do these codes mean?!” Jumping on the Internet, I discovered the how we are standardizing the language of Electronic Health Records in hopes that Health Information Exchange can become a reality, outside of utilizing the same brand of system.
The moment I felt my voice really matter was when I had informal discussion with my new colleagues about what I had experienced as a third-year medical student. Fresh off the wards of OB-Gyn, Medicine, and Psych, I had some solid opinions about how the Emergency Department interacts with each of these specialties and ways we could improve our health care system. I was shocked that they not only took my input seriously, but wanted to know more, leading to a number of meetings with different specialists on their calendars.
Reflecting on my first week, I now feel a much stronger responsibility to “represent” each and every G.W. medical student, future Emergency Physician, and maybe even late 20-something woman starting her career. I also want to emphasize: You, too, can set a meeting with these tremendous people and discuss your observations and ideas. You, too, can become an advocate and leader in your field. It takes a simple e-mail to your respective governing body, and a will to fight for something you believe in.
I’m already looking forward to what lies ahead…affter a quick detour to L.A. for a residency interview, I’ll be back for more next week!
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By Dr. Fernando Mirarchi
A 68-year-old male presents with a history of diabetes, hypertension, dyslipidemia, and CAD s/p CABG 10 years ago. Patient is experiencing chest pain. He is clammy. He is in mild distress. Vitals: T: 36C; P:60; RR:22; SaO2: 98%RA. The family gives you his list of medications and living will. Abruptly, the patient becomes unresponsive without palpable pulses. The monitor shows ventricular fibrillation. What next? Read the article, click here to look at the Will and take a two-question quiz.
Advance directives were created with the best of intentions, aiming to protect patient autonomy and honor end of life wishes. Until recently, the risks posed to patient safety by the various incarnations of advance directives were unknown and thus, undisclosed. Often, these well-meaning documents have produced unintended consequences. The TRIAD studies (The Realistic Interpretation of Advance Directives) have disclosed this patient safety risk as reality and on a nationwide scale. The risk is attributable to variable understanding and misinterpretation of advance directives which then translates into over or under resuscitation. At present, this is an unreported safety concern and only by clarifying the terms of advance directives and developing systems to educate providers will we be able to respect our patients’ wishes while still protecting their safety.
The living will was first legalized in California in 1977 and was known as the Natural Death Act.1 It was created by an attorney and utilized to decline life saving measures, essentially intended to provide patients with greater autonomy in end of life decisions. 2 Unfortunately, it also resulted in increasing risks to patient safety. Further fueling this patient safety risk was the development of The Patient Self Determination Act 1990. 3 This mandate, which was never evaluated for safety, requires patients to be provided information regarding their right to execute an advance directive at institutions receiving Medicare/Medicaid funding. With 90 million living wills in existence in the United States, 4 incorrect interpretation can lead to deleterious impacts on the care and safety of patients who summon 911 or experience a medical emergency in a healthcare setting. Clarification of terms, education of providers and implementation of safeguards are needed to protect the safety and autonomy of patients. In the TRIAD III nationwide study, high percentages of participants reported receiving training related to advance directives. However, those indicating receiving education produced no benefit. As health care providers, we need to work together on a national level to improve this education process. To further facilitate understanding, the following terms need to be defined and standardized:
Terminal Illness defined by law
Reversible & Treatable Condition
An “Effective” Living Will
An “Enacted” Living Will
For purposes of clarification, the mere presence of a living will does not mean it should be followed. It simply indicates that this document is “effective,” or that it is valid and legal.5 It should not be followed at this point to guide the care and treatment of the patient.
An “enacted” or “activated” living will is one that has been activated by the triggers in the document, most commonly a terminal or end stage medical condition or a persistent vegetative state. 5 This “enacted” living will now necessitates adherence to its instructions regarding the care of the patient. A terminal or end stage medical condition has a legal definition which essentially states that a patient would be expected to die of their disease process despite sound medical treatment. Therefore, the mere presence of a living will “does not” dictate the care of a critically ill patient who presents with a reversible and treatable condition such as CHF or COPD; rather it applies when that same patient is permanently unconscious and has exhausted all treatment options. A do not resuscitate order (DNR) refers to an actual physicians order that directs health care providers not to intervene with CPR if the patient is found pulseless or apneic.6,7
Otherwise it should have no implication on the care and treatment that the patient is to receive.6,7
Despite the legal and societal definition of DNR, research reveals in the TRIAD studies that medical providers understand DNR to be synonymous with an order to provide comfort and end of life care.8,9,10 A relatively new document called the Physicians Orders for Life-Sustaining Treatment (POLST) is different as it is an order set to be followed that addresses the treatment options of a patient should they present in cardiac arrest as well as the patient’s preferences for care in a non-arrest situation.11
POLST is a national paradigm and its philosophy is being rapidly embraced on both a national and state level. Unfortunately, it is now being nicknamed the Pink DNR form. This nickname needs to be quickly clarified and resolved as patients can be designated as a Full Code or a DNR through the use of this form. This again is a situation where good intentions can have unexpected consequences. SafeGuards are created to promote patient safety. I would like to introduce the SafeGuard known as the Rescuscitation Pause (RP). The RP is a process similar to the surgical pause (time out is the correct term) which is already widely utilized to correctly identify patients and eliminate wrong site surgery. Resuscitation takes on many forms and is not limited to the cardiac arrest situation. Resuscitation takes place when a patient presents critically ill and requires active interventions for conditions such as respiratory distress, sepsis or GI bleeding, etc. Resuscitation takes place with conditions that require immediate evaluation and intervention such as trauma, cardiac and stroke system activations to define care and facilitate treatment. A Pause is a moment to quickly assess and reassess the situation to assure you are defining the appropriate care and treatment. Through the use of a secure, HIPPA protected and interactive educational platform, QuantiaMD, (www.quantiaMD.com) we have been able to educate over 24,000 medical providers and empower them with the RP as a patient safety tool. We have been able to confirm that the medical community nationwide supports the TRIAD concerns that there is a real and present risk to patient safety; they found the education and tool to be useful and have empowered it into their clinical practice.
Advance directives in their various forms have never been evaluated with regard to patient safety though they directly affect well over 90 million patients. This is a medical error and resolution of the issue will require increased awareness and education among medical providers of all disciplines. The Resuscitation Pause holds significant promise as a way to protect patient safety and autonomy. The importance of this issue cannot be overstated as understanding advance directives not only allows us to appropriately provide or withhold life-saving care, but also ensures that we safely honor our patient’s wishes in the process.
How to Interpret a Living Will <http://secure.quantiamd.com/player/yabhqcxpi?u=yxjzuqjvk>
What Do DNR Orders Really Mean? <http://secure.quantiamd.com/player/yafruujyt?u=yxjzuqjvk>
POLST: Physician Orders for Life-Sustaining Treatment <http://secure.quantiamd.com/player/ywebdxfnf?u=yxjzuqjvk>
Understanding Your Living Will; What you need to know before a medical emergency www.addicusbooks.com
Towers B. The Impact of the California Natural Death Act. J Med Ethics. 1978;4:96-8.
Kutner Luis. The Living Will: a proposal. Indiana Law Journal. 1969;44(1):539-554
Patient Self Determination Act http://nhdd.org/facts/
Source: U.S. Census Bureau, 2044 Population Estimates, Census 2000, 1990 Census (http://www.census.gov)
Mirarchi FL. Understanding Your Living Will. Addicus Books 2006
Do Not Resuscitate (DNR) Protocols within the Department of Veterans Affairs. Section 30.02
Code of Medical Ethics Opinion 2.22 Do-Not-Resuscitate Orders. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion222.shtml
Mirarchi FL, Hite LA, Cooney TE. TRIAD I – The Realistic Interpretation of Advanced Directives. J Patient Saf. 2008;4:235-40.
Mirarchi FL, Kalantzis S, Hunter D. TRIAD II: Do Living Wills Have an Impact on Pre-hospital Life Saving Care? J Emerg Med.2009;36:105-15
Mirarchi FL, Costello E, Puller J, Kottkamp N. TRIAD III: Nationwide Assessment of living Wills and DNR orders. J Emerg Med. 2012 May;42(5):511-20.
Physicians Orders for Life-Sustaining Treatment (POLST) http://www.polst.org/
The Annals podcasts are available here: http://www.annemergmed.com/content/podcast
The highlights for October are:
-What predicts ‘drug-seeking’ or prescription misuse among ED patients?
-hydromorphone 1+1 opiate dosing
-metoclopramide vs ketorolac for ED headaches
-Cost-effectiveness of helicopter EMS
-Attitudes toward sickle cell crisis management
And much much more…
I’ve noticed something.
At tertiary care hospitals, such as Level 1 trauma centers, there are all manner of specialists on call for the emergency department. In fact all specialties are represented. There’s no need to transfer patients to a higher level of care. It makes sense. After all, these hospitals are affiliated with medical schools, have residency programs, carry on teaching and research and act as referral centers for a certain geographical area.
At community hospitals, i.e. those that are not designated as tertiary care or Level 1 or Level 2 trauma centers, there is almost never a full complement of specialists. Often there is no neurosurgery, no cardiothoracic surgery , sometimes no plastics, maxillofacial or vascular services. In many of these hospitals, though a significant portion of the emergency population is children, there is no pediatric ICU.
In other words, in many hospitals in the USA, patients with serious medical and/or surgical problems have to be stabilized by the emergency physician and then transferred to a higher level of care.
Who manages these critical care emergency patients? Who manages the trauma patients, until they are transferred out? The emergency physician, of course. All this requires great skill and competence. Ask anyone who’s done it.
Who manages these types of patients at the Level 1 trauma center? The on-call specialists do.
It is believed, by some, that ACEP Legacy physicians are not competent enough to work in tertiary care hospitals and certainly not capable of teaching medical students and residents.
It is also believed, by some, that Emergency Medicine Residency-Trained (EMRT) doctors are more competent than their non-EMRT counterparts.
So, if the EMRT doctors are more competent, why aren’t they working in the community hospitals where a higher level of skill is required?
Why aren’t the non-EMRT docs working at the trauma centers, where all the back-up is available? If we’re less competent, don’t we need all the help we can get?
If the EMRT docs are more competent, shouldn’t they be working at the hospitals where there is less back-up, fewer resources?
Has someone got this whole thing bass-ackwards?
Why are only EMRT docs working at the tertiary care hospitals?
I’m just asking.
Marlene Buckler, MD, FACEP, CCFP(EM), DABUCM
Official Blogger for ACEP Emergency Medicine Workforce Section
Is it any easier now for ACEP Legacy Physicians to get jobs in American hospitals?
For the past 5 years I have been doing locum work abroad; in Canada, New Zealand and England and I’m currently looking at Australia. I haven’t applied for any jobs in US hospitals during that time. I live in Florida, have keep my medical license active and am considering exploring the possibility of working in Florida again in the near future.
Some of you might remember that previously I ran into problems applying for work in The Sunshine State, because I was not EM residency-trained nor ABEM-boarded. In spite of ACEP offering verbal support to the idea that Legacy physicians are an important part of the workforce and thus should be given consideration on merit and performance, in hiring situations, the reality was that most hospitals, especially those in desirable locations, were off-limits to doctors like me.
Numerous ads for ER jobs come into my email daily. A few years ago almost all of them “required” ABEM certification. Some even stipulated that applicants must be EM residency-trained, which, by the way, would exclude a number of ACEP past-presidents.
Lately there seem to be more than a few hospitals that will settle for certification in any primary care specialty, e.g. family medicine, internal medicine, etc. So, is the landscape changing? Are the realities of the workforce finally being realized by hospitals that find themselves in need of emergency doctors?
Do I have any hope of getting a job in a decent hospital in the Sarasota, FL area?
Is it any easier now for ACEP Legacy Physicians to get jobs in American hospitals?
I’m just asking.
Marlene Buckler, MD, FACEP, CCFP(EM), DABUCM
Official Blogger for ACEP Emergency Medicine Workforce Section
She was young, pretty, and dead. Another victim of a head-on collision on a stretch of winding road outside of town where we get the great majority of MVC’s in the rural hospital in which I work. We knew it was going to be bad when we heard the ambulance traffic call out the “Code Three with one” as it was en route from the accident site.
She was resuscitated, but after an hour we knew that nothing more could be done for her. After calling the code, my attention turned to the sometimes worst part of our job, notifying the next of kin. She had a cell phone in her bag, and on it “Mommy.”
I can still hear her voice as she cheerily answered “Hi! Good morning!” Had I been in a different frame of mind, I would have taken the time to try to figure out how to find the actual number in her contact list. But, Monday morning quarterbacking aside, I did what my instincts told me to do at that moment.
Once I said that her daughter had been in a serious accident, she immediately passed me off to the girl’s father “who was a doctor and would understand better.” I steadied my voice as I informed him that his daughter had died. I held the phone near my ear but somewhat away as the wails and cries filled the small space I was in. Their grief carrying across the hundreds of miles that separated us.
They would come right away, he reassured me. I told him to take his time and await our phone call. There were other calls that had to be made. To CHP. To the donor network. To the coroner. After about an hour, my nursing supervisor told me the family was coming and would like to stop by the hospital to talk to me.
Several hours and a multitude of patients later, they arrived. I spent some time with them explaining what I knew of the accident and about the resuscitation effort. As a doctor, he had a lot of questions and wanted to know everything in detail. Toward the end of the visit, I found out she had only recently moved and was actually working at one of our local shops.
Then I remembered her. A bright, smiling girl who helped me with a purchase not even a week ago. I tried to wrap my head around that image and not of the broken patient who had been brought to my ED just hours earlier. I’m still trying.
Please send your stories to Tracy Napper (firstname.lastname@example.org) today!
Late on April 21, 2006 I received a call from my son’s cell phone; it was not him, it was a social worker at the University of Michigan’s ED who picked up Alex’s phone and hit redial. “Do you have a son named Alex? He’s been in a bad car accident, can you come right down?” Countless times I have been on the other side of that phone call. I always imagined what it must be like to receive it; now I know. As emergency physicians we try to never tell someone over the phone that their loved one has died. Get the family to the ED first. This knowledge served to increase the fear and anxiety that Marion and I felt rushing to get up, rushing to the hospital and brings tears to my eyes just in the recollection. When we got to the ED a number of the attendings and students recognized me and their discomfort was palpable as they themselves seemed to vicariously feel what it was like to be on the other side. We found Alex intubated and on a ventilator. By then his injuries had started to be catalogued: Intracranial bleed, diffuse axonal shearing, fractured C3, sinus and orbital floor fractures, blood loss from major scalp and facial lacerations. Alex was having decerebrate posturing which seemed to increase as time went by.
Talk with the neurosurgery resident of a ventriculostomy was put on hold when Alex seemed to show some subtle improvements but I could not stop myself from thinking about how I could possibly cope when they ask me for organ donation signatures. Twenty years of hopes and dreams seemed to be shattered. During the next two days in the trauma ICU we dealt with a steady stream of grieving friends and an uninjured, responsible, teenage driver who sobbed and cried by Alex’s bedside for almost 24 hours before we insisted he leave to get rest. The second night Alex showed some purposeful movement and then the next morning, he woke up. Completely. He was extubated, pulled his own feeding tube, sat up, and demanded to go home. The following morning he was indeed discharged, not from the ICU, but from the hospital. He walked the two blocks to the car himself. Decerebrate to walking home in less than three days! Now at home, I cannot minimize his discomfort as he contends with bruises and broken bones and the inevitable feeling of self sorrow, but…my God…he can feel!
My family and my son were astoundingly lucky, to the point of giving meaning to the word “miracle.” I was able to see and feel what we as providers do from the perspective of our patients and their families.
Used with permission by EPMB.
Charles Grassie, MD
Send your story to Tracy Napper (email@example.com) today!
About two years ago, we had a lady come in with vague complaints who began to be hypotensive and tachycardic. Despite all interventions, her pressure continued to deteriorate until she actually went into PEA. Extensive resuscitative measures were carried out by myself and fortunately I was supported by a fellow in cardiology. After all measures were determined to be unsuccessful, the patient was pronounced dead. While discussing the case in an adjacent cubicle, the nurse noted that the patient on the monitor began to manifest an appropriate sinus rhythm and there was a pulse. More fluid was given and the patient who had spontaneously resuscitated herself was admitted to the floor. I later learned that the same scenario re-enacted on the floor where she lost her blood pressure and then her pulse and was once again pronounced dead. Amazingly the same event reoccurred, i.e., the patient developed a spontaneous pulse and respiration and was eventually discharged within several days.
What was very surprising about this case is that about two weeks after the incident, the patient walked into the emergency department, introduced herself to me and thanked me for helping resuscitate her and then told me that “I could hear everything you people were talking about and when you pronounced me dead.” She had no animosity, was not upset, and merely was pointing out a fact. That was a very chilling incident in my life and reminded me that my wife has repeatedly told me over the years that “hearing is the last to go.”
Bruce Janiak, MD
Dr. Krome graduated from the Wayne State University surgery residency in 1969 and was assigned staff-oversight responsibility for the Detroit General Hospital emergency room – a position that became necessary after the 1967 Detroit riots.
By the early 1970s, Dr. Krome had begun to develop an emergency physician staff that practiced exclusively in emergency medicine and the emergency department had become a formal part of the hospital’s administrative structure.
In 1971, he joined ACEP and ultimately became a life member. In 1972, he was chosen editor in chief of JACEP, which became Annals of Emergency Medicine in January 1980, due to the strong credibility established by the publication under Dr. Krome’s guidance.
He served as ACEP President from 1976-77 and was presented the John G. Wiegenstein Leadership Award in 1979 for effectively promoting excellence in emergency medicine education.
Dr. Krome was on the team that successfully negotiated recognition for emergency medicine as a specialty in 1979, and chaired the Test Committee appointed to develop the first certification exam. As an active chapter member, he served as a councillor from Michigan for nine years.
A decade after he was president, Dr. Krome received the John D. Mills Outstanding Contribution to Emergency Medicine Award in 1987 for his exemplary long-term contribution to both ACEP and the specialty.
Long after completing his tenure as an elected College leader, Dr. Krome continued to be diligent in striving for increased legitimacy of the specialty through expanding the body of research. His contributions to the Blue Ribbon Commission on the Future of Emergency Medicine and his commitment to Annals of Emergency Medicine has had lasting effects on emergency medicine, as has his work as a teacher and mentor of emergency physicians.
In addition to being a past president of ACEP, he was also a past president of the American Board of Emergency Medicine (ABEM).
He was the first recipient in 1983 of the Michigan ACEP chapter’s Meritorious Service Award, which was then named in his honor. He also published a book, “The Floaters’ Log,” about his emergency department experiences.
He served as chief of the division of emergency medicine at Wayne State University, Detroit, MI, as well as chief of emergency medicine at William Beaumont Hospital, Royal Oak, MI. He attracted many to the field, and mentored many physicians who have since achieved professional prominence.
In 2008, he was named one of ACEP’s Heroes of Emergency Medicine, and reported that his favorite saying was that he receives the greatest joy from seeing his students achieve successes even greater than his.
Contributions in his memory may be sent to the Emergency Medicine Foundation, PO Box 619911, Dallas TX 75261-9911 or online at www.emfoundation.org/donate.