Me and My A.E.D.

“Everyone should have BLS training. . . we’ll all be better off because of it”     -Me.

I arrived at my designated gate at Chicago’s O’Hare Airport.  The run there kept the adrenaline level up in my system, though the hubbub was now well behind. I pulled the crumpled boarding pass out of my pocket as I caught my breath. No that’s a hotel receipt. Check the other pocket, there it is, Zone 3, that can’t be that bad; I thought,  there’s gotta be, what maybe 6 or 7 zones, right? “Welcome aboard American Airlines flight to Flint, Michigan” the gate attendant announced. We welcome our platinum medallion, gold medallion, silver medallion, bronze high-flyers, copper star club, as well as plastic fantastic, and purple star members, followed by zones one and two” The last of the passengers was already through the jetway. “Now boarding zone three, welcome aboard”.

After handing over my crumpled boarding pass for scanning, I made my  down the jetway and onto what appeared to be a small but fairly packed little jet. Passengers on each side of the aisle eyed me as I walked past, a few noticed that my jeans were soaked from the knees down. Some caught the odor that  trailed behind, a light of recognition igniting in their eyes as they realized what it was. Does he really smell like that? Is he the one that’s dragging that awful scent through this cabin?

6 hours earlier things had been going very differently for me. My colleagues and I had just given a well received talk at the annual Chest convention. I had reconnected with old friends that I hadn’t seen since training.  I had just personally  thanked Kevin Pho (of KevinMD fame) in the hotel coffee shop for giving our keynote address and getting our membership fired up about the future of medicine and social media. It was with this sense of excitement and renewed enthusiasm that I boarded my plane to catch a connection at O’Hare.

I also distinctly recall that, at the time, my pants were absolutely one-hundred percent completely dry.

But that apparently wasn’t to last. As I made my way from one gate to the next at O’Hare,  I stopped to buy a cola. I spent a minute drinking it in before making the turn towards the terminal where my gate was located. After making my way through the circular hub towards my terminal, the call, faint and distant, came out. . “Doctor?” At that time it barely registered in my brain. “Doctor?” I think I heard that, but it sounds like it’s coming from the television in the bar I passed.

Is there a doctor, we need a doctor!” That’s no television. I wheeled around, walked quickly toward the sound, I saw a man laying  face down on the floor, and then my walk became a run.

A large, elderly man lay face down, un-moving, and not responding to my voice. I tried to turn him over but he must have been 400 pounds. All I succeeded in doing was sliding him on the tile floor. For about 30 seconds I tried, while being vaguely aware of someone taking a video on their phone. Just then a security person arrived, big and burly, we turned the man over easily.

“Sir, are you O.K?, can you hear me?!” I turned to the security guard, “call 911 and get me an AED!” A bystander arrived and felt for a radial pulse in the man’s wrist.. “I think I feel a pulse” he said. Which was strange as I did not feel a carotid pulse in his neck. I checked the other side of the neck and the other wrist. Nothing. “Are sure you feel a pulse there?” I asked.

He looked at me sheepishly “Well maybe not, I’m not really sure”

The man’s shirt had already torn open as we turned him. His face was ashen and quickly taking on a bluish tinge. On the chest.

“One, two, three. . . “ I started chest compressions.

A woman arrived, her calm, purposeful demeanor suggested that she worked in the medical field, or at least watched a lot of medical dramas.The fallen man was large enough that his dangling head didn’t even touch the floor. Even if he could breathe, he probably wouldn’t be able to breathe effectively with his head at that angle. She gently raised his head with her gloved hands.

Wait, where did she get those gloves from? I thought. “Twenty-five, twenty-six, twenty-seven!”  I completed a set of 30 compressions, but nobody was giving breaths, so I just kept going.

I’m the one with the bare hands on his bare chest, shouldn’t I be the one that gets the gloves? “Six, seven, eight!”  

More security had arrived, they cleared some space. An irate man was yelling at whoever was taking a video on their camera. “Nineteen, twenty, twenty-one!”

“Here’s the AED” I heard one of the security people say. Boy, really woulda been great to be wearing some gloves right now, I wonder why she didn’t offer me any?  “Twenty-eight, twenty-nine, thirty! Get that AED hooked up!”

The woman with the gloved hands now starting placing the AED pads, working around me. “Seven, eight, nine! Ok holding compressions while the AED analyzes rhythm. ‘Analyzing rhythm’” said the machine. “Shock advised” Awesome!, maybe this guy’s got a chance!

I got back on the chest while the machine charged. “twenty-six, twenty-seven, twenty-eight!”

“Press button to deliver shock” said the machine in it’s soothing male voice.

I moved back from the man, still on my knees.

“Sir can I have your I.D? said one of the security guards. Another chimed in, “We can’t shock him while he’s in that puddle”

“Ya, no problem!” I replied as I reached for my back pocket. Wait, what puddle? Was he talking to me?

“Sir you’re going to have to move back a bit to get out of that puddle”

“Ok, everybody clear!” I said,  I stood up from my knees, moving back from the man “Here’s my driver’s license” I motioned to the gloved woman to give a shock. Did somebody say something about a puddle?

The AED delivered the world’s most uneventful shock, nary a sound from the device or jolt in the victim. I knelt back down to my knees again and checked for a carotid pulse.

“He’s got a pulse!” I said.

“I feel it here, too!” said the sheepish bystander confirming a radial pulse

“Ya, real classy, asshole!” said the irate man, still chiding whoever continued to take a video.

Holy shit! This guys’s back! I think he’s going to make it!

I stood up again, my legs had fallen asleep after crouching in an awkward position to do compressions, and as the feeling raced  back into my legs, I felt something peculiar. My shins were soaked. I looked down to find out why, and there it was.

I had been kneeling in a puddle of piss.

If ever there was a time that the word “urine” was inadequate, this was it.  This was a well  demarcated puddle of yellow, filthy, stinky, festering piss. A puddle that I alone had not managed to avoid. There was nothing I could do, my other pants were in my checked baggage. And in any case, I was out of time, I could hear my flight being called overhead as the EMT’s arrived.  I sought out  the security guard who had my license, he had given it to another guard. He introduced me to the man’s daughter who was traveling with him.

“He was hurrying to catch his flight” she said. I explained to her that his heart stopped, and the AED brought him back, hopefully the doctors at the hospital would be able to help him. Planes don’t usually have AED’s, if this had happened once he had boarded, he might have never made it back.

After grabbing my carrying-on, and finally finding the security guard who had my license, I headed  for my gate.

I got home just after midnight. After chucking  my jeans in the washer, and chucking myself into the shower, I settled into an empty bed. Earlier that afternoon my wife had flown out of town to a conference of her own. I hoped that her trip was uneventful, and that when she returned her jeans were dry.

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Happy New Year from Caduceusblog!

Don’t worry, Caduceusblog is still here! I thought it best to take break through the rigmarole that was ABIM recertification.  I decided to extend my break through Chest2014 and the holidays. Now I’ve that I haven’t vented in a while, I’ve got a whole lot to holler about. The whining will return next week, see you then, and Happy New Year!

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September is Pulmonary Fibrosis Awareness Month, Learn More About This Deadly Disease.

Idiopathic Pulmonary Fibrosis  is a disease which involves progressive scarring of the lungs of unknown cause (hence the term idiopathic).  The median survival from the time of diagnosis is 2 to 3 years, though the course is variable and many patients deteriorate rapidly.

There is little in the way of effective treatment and no cure other than lung transplantation.

There are excellent resources available to learn about this disease.

For Patients: The Pulmonary Fibrosis Foundation and Coalition for Pulmonary Fibrosis. Both resources provide information regarding patient support groups,  fund raising, and advocacy.

For Physicians: The CHEST Foundation website includes information for patients and physicians. I have found this helpful in answering many common questions for patients with newly diagnosed IPF. The author is a pulmonologist whose father died from IPF.

In addition, the Pulmonary Fibrosis Foundation conducts numerous activities throughout the year and is a great resource for information about the disease.

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The Ones that Emory Didn’t Save

It was with much fan-fare that 2 American aid workers were airlifted from across the world and brought to Emory University Medical Center where they began experimental treatment for Ebola. We hope for a full and speedy recovery for them and others like them who do God’s work.

But it appears to me that lost in this conversation are myriad others who need help but never get it. Right now, humanitarian work is being done all over the world, and in very dangerous places. These people  knowingly put their life on the line for others. Yet  tragically, some of them are injured or sickened in the service of others. But for them, the call from the CDC offering to med-evac them out never came. There was a girl, who died of malaria while in Kenya. Or the young man who was serving in Egypt. Or a myriad other aid workers who die while serving their fellow human beings.

Also at issue, and it needs to be asked, at what cost are we saving lives? Who decides who gets what may have been, all told, a hundred thousand dollar medical evacuation? Susan Grant, the Chief Nurse for Emory Healthcare, in an article for The Washington Post rightly downplayed the infection risk posed by bringing these patients here. She went on to say:

“The purpose of any hospital is to care for the ill and advance knowledge about human health. . . As human beings, we all hope that if we were in need of superior health care, our country and its top doctors would help us get better”

This statement brings to mind others that need saving. They don’t work in far away lands, they live here in the U.S, right across town, in fact. They don’t have fancy, exotic diseases.  Their conditions have names like diabetes, heart disease, hypertension, and lung cancer. Right now many of them are getting collection notices for their inability to pay from medical centers like Emory University. Others have been trying to get appointments at tertiary centers  like Emory. Only they’re told that their insurance is not accepted there, or their co-pays and deductibles will be more than they can afford.

How would Ms. Grant justify the incredible expense spent on this endeavor to those people? What would she say about the necessity of this experiment, a clinical trial with an N = 2? Could she really  tell those sweating in the Atlanta heat after their electricity got shut off that this was all really for their benefit?

I don’t know how to solve the ethical dilemma here. While I am hope for a cure on the one hand, I cringe at the highlight this places on those at the bottom end of America’s healthcare disparity gap. Perhaps someday in the distant future they can take solace in knowing that they didn’t suffer for naught. Because if they ever contract ebola, there will be a cure waiting for them.

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3 Ways Obamacare is Destroying American Healthcare.

As I was watching CNN news recently, I noted in the headlines different ways Obamacare is failing.  Current problems discussed were the customers’ sticker shock of high deductible plans (up to $12,700 for families), the president blaming the insurance companies for having substandard plans, and the people blaming the president for losing their current insurance.

One patient even complained, “My new health care plan tripled in price, and now, it is like having a third loan to deal with, including my car and home loan.”

The current law and regulations being implemented under Obamacare will ultimately lead to sicker patients and low quality care for three reasons:

1.  Older doctors will retire early fed up with the system. These older doctors feel that the loss of a patient-physician relationship and the burdensome regulations (ie. paperwork) will choke off their ability to provide good care.  In addition, their expenses are increasing with these new regulations.  Add in the projected cuts in reimbursement up to 26%, and their livelihood will be threatened. These cuts could force these doctors out of practice or force them to stop seeing Medicare patients simply because their expenses (which rise yearly) are exceeding their declining reimbursement, which has declined steadily over the past several years already. Continue reading

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It’s Time to Move On From ACLS Certification.

I can recall, though it seems quite long ago, my first Basic Life Support (BLS) course as a first year medical student. The instructor dutifully demonstrated on a mannequin to eager young medical students what to do if someone is found unresponsive. Shaking the unmoving mannequin she said loudly,  “Sir, are you ok?” Then hearing no response she showed us how to check for a pulse and spontaneous breathing. “if not present” she said, “call for help and start CPR”. Me, ever the smart-ass, took my own approach. “Sir,  are you ok?” Then, grabbing the mannequin tightly to my chest “NOOOO! why? WHY?!”

This didn’t enamor me to the instructor very much and earned me most of the difficult clinical scenarios of the day.

Classes like these are now mandatory for those working in hospitals. Just about all employees have to go through BLS training, and many employees in more advanced clinical settings are also required to take Advanced Cardiac Life Support (ACLS). ACLS  is an advanced skill set taught to medical personnel who work in areas of the healthcare field who may have encounters with patients that require interventions beyond the scope of BLS.

Those of us in the medical field who are required to recertify ACLS have long dreaded the process of ACLS recertification. Part of that is because it can be an intense course that makes many feel nervous. Part of it is also because it is expensive and time consuming. But the greatest reason why most who undergo ACLS training  object  to it is for a different reason entirely: they feel that is simply unnecessary. Continue reading

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To Reform Healthcare, America Needs to Look to its Doctors.

Our healthcare system is sick and dysfunctional. A vicious cycle of blame is happening between Washington, health insurance companies, and the patients. And it is quickly demoralizing this nation and simply increasing costs with more administrative regulations. It is raising questions regarding the future of healthcare in the United States.

And we need answers.

Surprisingly, in all of this, doctors are rarely mentioned.  As if doctors do not know the intricacies of how the health care system works.  As if doctors are not there for their patients 24 hours per day, ordering tests or doing procedures that can benefit a patient’s well-being.  As if doctors are not dealing with denials from the insurance companies on a daily basis, losing valuable hours to menial paperwork that could be spent caring for our country’s sick.

Doctors have a duty to care for their patients and are the engines that put health care into motion. They yearn to maintain that physician-patient relationship that is important to the care of our patients.

Unfortunately, doctors are not being directly involved in the health care reform debate despite being on the front lines of care.  They have an opportunity to provide valuable insight into the day-to-day operations of this health care machine. Continue reading

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New Series: EMR Diaries.

Golive PicIt’s time. After thousands of hours of hard work by the IT department, and lots of fretting by pretty much everyone else, the time has arrived. Our hospital is going live with it’s EMR Stage 2 meaningful use system. And it’s starting during my turn in the hospital rotation. (I want to believe that this is purely coincidental, but if I see my office scheduler walking around with a new pair of shoes, I might have to say something.)

What is Meaningful Use? As part of the nearly $800 billion economic stimulus bill known as ARRA (American Recovery and Reinvestment Act) of 2009, the government sought to  electronify (yes, that’s a work, look it up!) medical records. To accomplish this CMS (Medicare/Medicaid) began giving out incentive payments to physicians and hospitals for electronifying their medical records, which would eventually transition into fines for not complying.

By now you’ve probably looked up “electronify” and found that it’s not really a word. My bad. But in a way, Medicare did the same thing. They realized that “electronic medical record” does not really have a definition, either. So they said “our bad” and came up with a set of parameters that would determine if your medical record could be used in a meaningful way, or whether it was just a note pad with a reading light attached to it. Continue reading

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“When I Was a Resident”: Duty Hour Rules Do Not Define Me

Recently, Rebecca Ulep wrote a rebuke of recent resident duty hour restrictions and their potential negative effects on physician education in a post entitled “When I Was a Resident”: How Duty Hour Rules Are Creating a Lost Generation of Physicians. Many practicing physicians agreed with these sentiments, while most residents did not. Our expanding #PulmCC community brought me  into the acquaintance of one the latter, who agreed to write a post taking the other side of the argument. Scroll down for the article, and hit the link above to read the original post. And follow the #PulmCC hashtag on twitter to keep up with relevant material and participate in future #PulmCC twitter chats. 

I argue with my father a lot. He works as an intensivist at a community hospital in Indianapolis while I am about to graduate from a highly academic internal medicine program in Chicago. Needless to say, we have very different perspectives.

He sometimes expresses views similar to those written in a previous article, “When I Was a Resident”: How Duty Hour Rules Are Creating a Lost Generation of Physicians. I started residency the first year that the new intern duty-hour regulations were put into effect. After explaining these rules to my father, he asked me: “How do you guys learn? When I was a resident, we did not have limits to how many patients we saw. I would be working until five or six in the evening on my post-call day and then stay to work a moonlighting shift.” I, then, delightfully asked him if that was before or after penicillin was discovered.

The field of medicine has undergone many changes (yet we still carry pagers…that’s for another rant), some for better and some for worse. There has been much debate over potential benefits and detriments that come with the changes in duty-hour regulations.  I can only speak to the culture at my own institution, but in my experience, there is one thing that has not changed: the pride we take in our work. This is why I take particular issue with the overly dramatized notions brought up in the aforementioned article. Continue reading

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“Doctor, can I record this conversation?”

It’s happened to me a couple of times already. But the question in the title of this post was never asked. Rather I was informed later on that my conversation with a patient or family was recorded without my knowledge. Smart phones have made it all too easy for patients to secretly record conversations with their healthcare providers. Simply hit a button,  lay it innocently down by your side in the office or hospital, and patients get an instant video or audio capture of a conversation with their physician.  When my medical team and fellow physicians found out about the unauthorized recording of our conversation, the news was met with a combination and anger and disgust.

That reaction, it seems,  is typical of what most physicians would feel in the same situation. Why would a physician be upset about a patient secretly recording a conversation with them?

Well, simple, really. Most physicians are in chronic fear that the next person to hear/view that recording will be a malpractice lawyer, dissecting it,  consonant by consonant,  probing for potentially actionable material. The recording, in the physicians mind, changes the nature of the physician-patient relationship. It makes the patient a potential adversary, it makes the doctor feel as if they are in front of a jury and can not speak frankly, it makes them feel as if they are unworthy of trust. In other words, physicians do not like being recorded because they assume that the person recording them has negative motivations.

But let’s pause for a moment and look at this a different way. . . what if they don’t have negative motivations? Continue reading

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