Human Factors: Electronic Medical Records and Ebola

One of the muddy reports coming from the first case of the Ebola virus diagnosed on US shores is why the patient was initially sent home -- to potentially expose hundreds of people -- when he first presented to the Emergency Department.

Reportedly the triage nurse screened him for recent travel and he told the nurse that he had just arrived from Liberia. After that something broke down -- either two EMR systems didn't talk to each other, or the doctor and charge nurse didn't read that part of the chart. Initially hospital officials said there was a flaw in the system, then they said there wasn't.

Slate notes that billions of dollars have been spent trying to get the US to adopt electronic medical records in the Emergency rooms and hospitals. That sort of makes it sounds like there is one computer program that everyone is using. There isn't.

Athenahealth CEO Jonathan Bush told HeathcareITnews. "The worst supply chain in our society is the health information supply chain," Bush told CNBC regarding the incident. "It's just a wonderfully poignant example, reminder of how disconnected our healthcare system is."

We currently use two computer charting programs in our ED and there is a third program -- supposedly to replace the other two -- coming in the next year or so. That system is EPIC which is the same system used at the Texas hospital. Epic can be customized by the hospital for different applications, but that customization costs. Given the penny-wise pound-foolish nature of the American hospital system, I am not optimistic

The American College of Emergency Physicians recently weighed in on the issue in a paper detailing the unintended consequences of using Emergency Medical Records systems that may not be optimized for emergency medicine and hospital systems seeking the lowest cost option.

That said, you can't blame the medical records if you don't talk to the patient. However, we are seeing increasing patient loads every hour with decreasing resources to do so. Computer records systems are supposed to make our jobs easier, but they actually add to the time and stress of each patient.


Sharpen Your Ax

There are always times when we do too much, take on too much and allow the weight of the world to be placed upon our shoulders.

We think we are strong and can power through anything and we suffer in silence, warped in the warm steam of our own stress. Our ego is swollen and fed by our labors. We tell ourselves that no one else knows how hard we are working. No one else has their nose to the grindstone like we do. We are martyrs. We look around and everyone is enjoying the sun, laughing while we slave away.

When I was trying to get into nursing school I took a college algebra class with a friend who was trying to get into dental school. It was summer session, so after a long class, we would go to the tutoring center at the college to grind through hours of homework while the world lolled about in the sun. I wanted to be home with my family and my new-born daughter Grace. I hated math, hated that I was in my late 30's and starting from scratch trying to build a new career to support my family.

I would grind away at the homework, never taking a break or allowing myself a moment of daydreaming. "I have to get this done," was the mantra that a mouthed with each new problem.

Each day my friend and I would start our homework at the same time and each day we would finish within a few minutes of each other, closing our books and walking out together.

Yet my friend would punctuate his homework with frequent stretches and walks around the building to enjoy the sun. One day while walking out I asked how he manged to get the same work done while finding time to sit on the grass while I was working.

His response is one of my favorite parables - one which my friends have often heard me repeat.

Two lumberjacks went into the woods one day, he said. One was young and ambitious, the other was old and wise. The young lumberjack was eager to prove how much stronger and faster he was and so he worked furiously throughout the day, never taking a moment of rest. As the day progressed, he often found the old lumberjack sitting on a stump relaxing while he worked. He felt sure that his dogged efforts would outstrip the old man when the tally was made at the end of the work day. 

Yet when the work was totaled, the old lumberjack had equaled the work of the strong young man. 

How could this be, he asked in frustration. It seemed like every time I looked around you were taking a break. How could you possibly chop as much wood as I did? 

The old man smiled and said: 

"Whenever I took a break, I was sharpening my ax



The Zen of Nursing

Life is not fair.

If you haven't noticed that by now, either you haven't been paying attention or you don't have enough birthdays under your belt.

Life was never fair, and never meant to be.

While whole religions have erupted from the minds of men to address this one issue, the fact remains, there is no divine justice wrought here upon the Earth.

I learned this lesson while I was very young, but had it reinforced by a decade as a newspaper reporter.  I saw cold-blooded killers set free, saw liars triumph and the honest punished for their honesty. Mendacity rules at all levels of power. Inhumanity and incompetence are promoted. Debased actions and bullying are rewarded. Being a reporter is to strive for truth in the face of lies. Journalists comfort the afflicted and afflict the comfortable.

In journalism, fairness is a watchword and justice is what every young wide-eyed new reporter seeks. Yet, the pay is barely minimum wage and you are disposable to your employer and community. After seven years at one paper -- winning awards and working 60 hour weeks, I was told to move on because the corporation didn't want to start paying reporters more than $18,000 a year.

"You've had too many raises," the executive told me from the hollow of his tailored suit. "You've reached the pay ceiling."

Everyone hates you when you tell them the truth anyway.

I had few illusions when I went into nursing.

Sure, there are golden moments when all is right. When your patients are healed by your actions and grateful for your kindness. Those moments must carry your for six months to a year before you might encounter them again. In the interim, the kind nurses will be cursed at and shat upon, denigrated and abused. They will work long hours and then be mandatoried over to work more -- punished for showing up to work.

They will cast themselves upon the rocks of the suffering and pestilent, the addicted and debauched, to be broken, yet to stand again.

At least the pay is better.

Moreover, as emergency room nurses we see the inequality of life's whims on full display. Children suffer, criminals get out of jail by malingering. The drunk driver murders children, then staggers away without a scratch. The kind die in pain and suffering while the cruel survive again and again. Sickness is not tied to sin.  The good die and suffer for no good reason. The gift of survival falls heedless of whether the recipient deserves another breath.

It is a hard lesson for a nurse to learn. The zen of nursing is learning to heal without judging, without a care about justice. Your job is to make the sick better, not to make the world fair.

No, there is no fairness in this business nor in life.

Yet in our larger lives, we must still strive for justice -- for justice is a thing wholly created by humanity. It is our humane reaction to the unfairness of life. Justice is the perfection we seek but may never attain. Striving for justice, fairness and equality are the only tools we have to battle back against the empire of fates that seek to pound us into submission.

The world is not fair.

It never will be.

Unless by our hands we make it so.



How Capitalism is Failing Health Care

This week the New York Times reported that Nitroglycerin is in short supply.

Nitro is what you take when you are having a heart attack. That's how serious this is getting. Other drugs impacted by drug shortages in the US include morphine, cancer medications just about everything we've used in the hospital -- including normal saline!

Baxter is the only supplier now. Despite the fact that this is a life saving medication used in critical care, it is not a big profit maker.

That's the basis for the drug shortages. Factories are getting old and drug companies - despite huge bankrolls and profits -- don't want to invest in factories that aren't producing high-profit drugs.

It's just another example at how the free market fails when it comes to healthcare. The medications we need most are not always the medications that turn the biggest profit. Moreover, drug shortages are getting worse, according to the most recent GAO report:
The number of drug shortages remains high. Although reports of new drug shortages declined in 2012, the total number of shortages active during a given year—including both new shortages reported and ongoing shortages that began in a prior year—has increased since 2007. Many shortages are of generic sterile injectable drugs. Provider association representatives reported that drug shortages may force providers to ration care or rely on less effective drugs.

As expected, those of us who working health care are flabbergasted. As the NYT noted:
Several doctors said they found the unpredictability of the shortages frustrating. “You want to feel that we’re living in a land where if you come into the hospital with a heart attack, that you can get the best of care,” said Dr. Ann Toran, chief of cardiac surgery at North Shore Medical Center, a hospital in Salem, Mass., whose pharmacy is down to a small supply of nitroglycerin. “To have that hanging over you as a doctor — a critical shortage of this essential medication — I just don’t know what to say.”


Keep it Simple - the French Way

Good article on the contrast between care for cancer in France vs the United States.

In it the author talks about cancer care her father received in the US and in his native France.
I also didn’t know what the French healthcare system would be like. I’d read it was excellent, but assumed that meant there was better access for the poor and strong primary care. Not better cancer specialists. How could a public hospital in Paris possibly improve on Sloan Kettering’s cancer treatment?
One way, the health insurance system isn't a maze to trap the ill and dying in. With less focus on paying for care, there is more time and attention that can be paid to the patient.

The French Way of Cancer Care is by Anya Schiffrin and worth reading.