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.



Now It's A Normal Saline Shortage

If you ever wonder about the US health care system's ability to scale up for a mass epidemic or disaster all you have to do is look at its ability to handle season fluctuations in demand.

Short answer: Not very well.

Over the past two years we have found our self short, or out of many basic drugs needed to treat our patients. (For the current drug shortage list, Click Here)

None of these medications is as profitable as Viagra, so there is not a lot of incentive to invest in infrastructure for making them. The latest shortage is also the most basic. Normal saline, the IV fluid used as a front-line prevention and treatment for shock, has been in short supply.

Here's the lastest from the Emergency Nurses Association that showed up in my mailbox just now:
The Emergency Nurses Association (ENA) is closely tracking reports from hospitals across the country of a shortage of IV saline solution. According to the Food and Drug Administration (FDA) and the drug manufacturers, the increased demand from a harsh flu season and temporary shutdowns at some manufacturing plants are the cause of the shortage. 
The FDA is aware of the problem and is working with the three U.S. manufacturers of IV saline solution - Baxter, Braun Medical and Hospira - to increase the supply of this product. It is also looking at alternative sources, including importation from overseas.
The American Society of Health-System Pharmacists has stated that suppliers are now
operating at full production capacity in an attempt to meet the increased demand.  
In a January 17 letter to customers, Baxter said they “anticipate gradual improvement in the weeks ahead and are confident that these steps will enable us to achieve expected service levels.” Baxter also stated they are manufacturing a greater amount of IV solutions than in previous years and are taking steps to further increase capacity in 2014.
ENA is monitoring the situation closely and communicating information we receive regarding the shortage of IV saline solution to the FDA.  
In addition, ENA is working closely with other national healthcare organizations to ensure that the Food and Drug Administration Safety and Innovation Act (FDASIA), which was signed into law on July 9, 2012, is fully implemented so it provides the FDA with the tools to minimize future shortages of drugs or biological products. 
The key provisions of FDASIA dealing with shortages include:
• Broadening the scope of the early notification requirements by requiring manufacturers to notify the FDA of potential drug discontinuances; and
• Clarifying that the notification requirement applies to drugs that are used in emergency medical care or during surgery.

For more information on drug shortages and the FDA’s efforts to alleviate the shortage of IV saline solution, please visit: http://www.fda.gov/Drugs/drugsafety/DrugShortages/default.htm


Warm Blankets in an Emergency

not our blanket warmer
The blanket warmer in the Emergency Department is dead. There is no doubt about that. Dead as a door-nail

It has been dead for a while. Most of December at least. The thin industrial blankets kept there are as cold as a fish, offering little comfort. An "Out of Order: Cold Blankets Only" sign hangs on its door.

We still have the two warmers in our trauma rooms, but they are on the far side of the department from triage and you have to intrude on the patients in those rooms to fetch them.

Long ago, I made it my habit to stop by the blanket warmer to grab one for any patient I brought to a room. A warm blanket was my one consolation after unceremoniously pointing to a hospital gown and saying "it opens in the back."

The ice machine is down too. So it is hard to get ice chips for patients when mouths are dry.

There are worse things, and more important pieces of equipment. Heaven knows we can't bill insurance for the price of a warm blanket. Yet, it is one of the acts of nursing that has a great deal of influence on a patient's visit.

When people come in to the hospital, they are suffering from more than just pain or illness. They are anxious, often struggling with fear of the unknown and loss of control.

Few who come into the emergency room planned this as part of their day. Their world is disrupted and no longer operating at their direction - even if their emergency is minor. Most of us these days operate on tight schedules and coveted interludes of weekends and vacations. Moments are precious and thus organized for consumption. Disruption by an illness or accident throws everything up the air. Who will let the dogs out; get the kids off the school bus; cover for me at work?

Then there is the fear of the diagnosis. Is it serious? Will I need an operation? How will I pay for this? Cold beds, long waits, hurried doctors combine with the unkowns to stretch taut fraying nerves.

Stress and pain are intricately linked. While we are still learning about the relationship, the physiological response to stress appears to increase our receptivity to pain and reduce our immunological response. Long term, stress can increase our susceptibility to a number of different disease processes. If we can -- in little ways -- reduce the stress of a emergency room visit, it is one more tool we have to help patients get better.

While I can no long grab a warm blanket on the way back to the room, I can address a patient's fear and stress in other ways. I give information and reassurance and that is another tool I have.

We who live and breathe the hospital air have a good idea what the doctor is going to want and what will happen soon, and what we will have to wait for. The patients usually has no idea. So I tell them what to expect the best I can and prepare them if they are going to have to wait for tests to come back. I offer myself as a guide to their visit and offer to answer questions.

"I don't know"  -- when it is the truth -- is a perfectly good answer as well. Explaining the variables, the known and unknown helps build trust in the patient, which in turn reduces stress and allays fears.

While the practice of medicine gains ever more sophistication in science and technology, we always must remind ourselves that our profession is an art as well as a science. Our interactions with patients influence the success of our brief role in their care.

So when you look at it from that perspective, the blanket warmer can be a pretty important piece of equipment after all.

Further Reading:
Stress and Anxiety backgrounder from New York Times Health Guide


Carrying The Old Woman

I often find myself thinking of an old zen story. 

In the story, two traveling monks reached a river where they met a woman. The woman was wealthy and had porters for her litter, but the porters were afraid to cross the river carrying their mistress. The woman was bitter and cursed the servants. When she saw the two monks, she angrily demanded that they carry her to the other side. 

The young monk hesitated, uneager to help someone who appeared so spiteful, yet the old monk silently picked her up onto his shoulders, transported her across the water, and put her down on the other bank. She did not thank him. Instead she continued to spit venom at the monk, complaining and cursing as he walked away. 
As the monks continued on their journey, the young monk was brooding and preoccupied. 

Unable to hold his silence, he spoke out.
"That woman was cruel, and when you helped her, she offered you no gratitude. Instead she cursed you. You should not let her treat you that way."
"Brother," the second monk replied, "I set her down on the other side, while you are still carrying her."

I learned long ago that the way people treat you has little to do with your actions or your value as a human being. Our ego, constantly insists that we deserve respect. So much so, that we think this is the calculation of our worth. 

What I have found in my two careers as a journalist and as a nurse is quite different:

People will yell at you whether you do the right thing or the wrong thing.
People will resent you whether you tell them the truth or a lie.
People will treat you cruelly whether you help them or harm them.

Thus, if their treatment of you is independent of your actions, you should not let their attitude dictate how you proceed in the world. Particularly in nursing, people come into our care with a lifetime of emotional pain that we cannot expect to repair in our short encounter with them. Some live lives so fettered by darkness that they develop antibodies to kindness and light. 

People so often treat the world based on their pain and their ego, not on the human being in front of them. So we should not let their behavior dictate ours. Nor should we take personally the condition of their soul. They may have been broken long before you encountered them and they likely will be broken when you walk away. 

In the meantime, you do what is right, because it is right not because of expected praise or gain. The elder monk did not expect kindness from the rich old woman, nor did he let it bother him. 

We should help, we should be kind, we should tell the truth, we should do the right thing not in some expectation of reward, but rather, because it is the right thing. 

It is OUR actions that define us. Because we are kind, because we are truthful, we do not allow others to germinate unkindness, mendacity or cruelty within us. 

It is easy to allow mistreatment to fester in us, to claw at our awareness such that we do not see everything good around us. Resentment is a handicap to living. 

The is a cross post from my other blog TheebbTIDE, where I usually write about non-medical things.

Ed's Note: The version of this story is from Zen Shorts a book by John J. Muth. The original story referred to a religious prohibition of monks touching women. Muth's version is much more helpful and the book is wonderful.