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Posts Tagged Emergency Departments

Organ Recitals Jim McVeagh Apr 08

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There seems to be quite a lot of debate around the subject of organ donation at the moment. The Herald today warns people off looking for “bootleg kidneys“. The university of Victoria ran a conference yesterday on the issue and Eric Crampton at Offsetting Behaviour has run a series of articles here, here and here. At one point in Eric’s comments, Andy Tookey of LifeSharers joins in the discussion. Eric’s posts and their comments are an interesting read.

New Zealand does indeed have an appalling rate of organ donation. Eric thinks this could be solved by allowing some commercialisation of the organ market. In terms of cadaver donations, I have no real issue with the agreed sale of a deceased person’s organs – particularly if it is a pre-mortem agreement with the deceased, to provide for his estate. The notion of relatives auctioning off uncle Merv’s kidneys, post-mortem, to make a buck is somewhat distasteful to me, but that is purely personal. To me, the central issue here is whether the deceased has clearly indicated his/her intentions to be a donor and, if so, whether they wish to gift their body or not. That requires just two ticks on an organ donor card. Pre-mortem sales would have to be carefully constructed so that both parties are quite clear on the conditions. Certainly, it should be drafted legally as part of a will.

Eric does an able job of pointing out that this sort of bypassing of the queue has advantages to all – in that others on the list will now be bumped one forward. He is also correct in saying that commercialisation of  organ donation appears to attract new donors rather than reduce charitable donation. What he does not stress is that there is no reason at all why the public health service should not bid for the same organs. Bear in mind that, for instance, haemodialysis is an extremely expensive business costing at least $100,000 per annum. Bidding $20,000 for a kidney (if bidding actually went that high) would seem a good deal in comparison, even omitting the greatly increased quality of life a transplant patient receives.

Live donors are another matter entirely. I have an enormous amount of misgiving about purchasing a kidney from a living person. This goes against the ethic of first do no harm (actively harming the donor) but this is not a severe consideration. After all, we use family volunteers all the time, do we not? Should my children or my wife even need a renal transplant, there is no doubt in my mind that I would be willing to donate one of my kidneys and I am certain that most of my readers would be like-minded towards their families. There is no issue with this, so the imperative of first do no harm can be waived, simply because the donor wishes it so.

No, Hippocrates is not the problem here. The real reason that I have misgivings about live commercial donors is the issue of exploitation. The free market principle relies on everyone being free to make voluntary transactions. Unfortunately, when the transaction becomes asymmetrical, it potentially becomes unethical. The more asymmetry, the greater the potential. How ethical is it to offer a starving African $100 for his kidney, knowing he has little idea of the consequences and no access to any sort of medical monitoring or follow up? How ethical would it be to take part of the liver of a man with a gambling addiction in return for wiping his debt? Or how about offering $100,000 to that same man’s widow if he puts a gun to his head and donates his heart to you? How long will it be before we arrive at the nightmarish scenes of Michael Crichton’s Coma?

This is one can of worms we should not be opening.

And there is no need. I often hear that the reason New Zealand has a poor donation rate is that family members can veto the wishes of the deceased and that Maori consider the removal of organs tapu. While I agree that family members should not be able to counteract the wishes of the deceased, I think that this has very little to do with the lack of organ donation. I think that the lack of organ donation is almost entirely do to with the complete apathy of Organ Donation New Zealand. Organ donation is barely promoted. And there is no donation register which, to my mind , is a fatal flaw. In order to solve New Zealand’s organ donation problem, I would immediately promote an organ donation register (via media and mail) to which potential donors could sign up to online. This would be a legal transaction and would supersede the family veto. The same service could be promoted in general practices and hospitals with a free tissue typing service (allowing faster access to organs in an emergency). Each donor would be matched up to potential recipients on the transplant list. Should organs become available from a donor a list of potential recipients, their tissue typing and their level of need should be available at the press of a button.

There are hundred of organs from the suddenly deceased which are wasted every year, not because the family object to their use, but because it is just impossible to finalise matters of permission when someone dies suddenly. The vast majority of these cases are in the community and in the ED, not in the ICU. A proper binding register would enable the ED doctor/police/ambulance crew to immediately know that this person who has just died has harvestable organs. the transplant team could be calling in the recipient before the body has even arrived at the hospital. This might seem a little macabre, but it would give hundreds of people a year a new lease on life.

Surely that is worth a little effort.

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Two Tiers Jim McVeagh Jan 28

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Dr Tim Parke, the clinical director of the adult emergency department at Auckland City Hospital, puts his concerns into an article in the Herald today. He writes that, in his opinion, the proposed use of public facilities for extra private procedures will produce a two tier system where, eventually, richer patients will have better medical outcomes than poorer ones. He says:

Over time, the difference in survival would add up and eventually, more wealthy patients would survive heart attacks than less well off patients. The cumulative effect of a range of survival differentials in many diseases and injuries would eventually exaggerate the already marked differences in mortality rates between races and social classes.

Unfortunately for Tim’s argument it falls down at one very important point. The two-tier system, he is worried will develop, is already here and has been for many years. Insured and wealthy patients can already access a much greater choice of health care than uninsured ones. To use Tim’s example:

The scenario is thereby foreseeable where two young patients arrive in the emergency department with heart attacks in side-by-side cubicles. One gets the “budget” clot buster treatment option which is probably okay, but the guy next to him opens his wallet and gets the “elite” option of emergency angioplasty with direct opening of the blocked coronaries. Both of these treatments have been shown to work, but angioplasty is slightly better and is very much more expensive.

Currently most hospitals have limited budgets for angioplasties. In the above case the uninsured patient will have to meet a number of criteria (rather like the “points” you have to make for your specialist outpatient appointment). The insured patient can simply get his GP to call an interventional cardiologist in private practice and get his angioplasty – even if he doesn’t meet the “criteria”. As Tim points out, angioplasty does have slightly better results. The only reason that we don’t do it on everyone is because we can’t afford to.

The only difference in the proposal to allow private procedures to be done in public facilities is convenience. The insured person will still get his angioplasty, but he might have to travel a few hours to get it. This may reduce the outcome of his angioplasty – so the only result of disallowing the use of public facilities is to reduce the wealthier person’s chances of a good outcome. Truly equality of outcome – both bad.

Tim’s other point is superficially more worrying:

Furthermore, those patients paying in public hospitals simply to get the best treatment option will become more and more resistant to funding anything other than pure “safety net” bargain basement treatment for the non-paying patients out of their taxes.

This also has been occurring for a long time already. What do you think the phrase “value for our tax dollars” really means? Does anyone really think that the current public health system funds anything more than “bargain basement” treatment? (Unless by the phrase “bargain basement” you really mean “inadequate”; because that is a whole different ball of wax). There is and will always be a limited amount of money in state-provided health care. We will always be making decisions about rationing health resources. Allowing private patients into public facilities is not going to change this in any way. It is even possible that the extra funds may provide better health care for state patients.

The Two-Tier system is a present day reality. Instead of having angst about it, we should be trying to make it work for us.

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On the Turning Away Jim McVeagh Dec 15

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The news that Timaru Emergency Department is “turning away” patients (actually, sending them to their GPs) is exciting Labour’s health spokesperson, the barely noticeable Ruth Dyson.

Labour MP and health spokesperson Ruth Dyson believes essential frontline health services are being cut.

“You can’t get much more frontline than the emergency department. The Government promised there would be no cuts to frontline health services but I think Timaru is seeing the knife-edge of cuts to essential services.

Codswallop, Ms. Dyson. Had you known anything at all about emergency departments you would have know that they have always encouraged patients, who present to the emergency department with a problem that could be tackled by their GP, to go to the person most suitable – their GP. EDs have done this in a number of ways. Some have had a community campaign to discourage minor problems from attending the ED, but all have had some way of moving minor ailments out of the ED and back into general practice where they belong. The bigger EDs practice “attrition by waiting times” with nurses politely suggesting that a trip to the GP or the local A&M would be substantially faster than the four hour wait (on a good day) to see a harassed junior doctor. The smaller EDs, like Timaru, have lower waiting times in general and have to be more overt in their redirection. Note that nurses NEVER turn people away. They are redirected to their GP, with the nurse often making the appointment for them. They are also redirected only according to carefully worked out protocols. I should know, because I worked out one of the first sets of those protocols for Invercargill ED. And they were very, very conservative. In three years of use we had only one person return immediately from the GP (a man with appendicitis). He was inconvenienced rather than medically disadvantaged and the nurse had not followed the protocol properly.

Ms Dyson goes on:

Sure there will be some people that might be going to the emergency department that should be going somewhere else but they are going there because they need help. A lot of people can’t afford after-hours care.

Labour really should get themselves a new health spokesperson because this remark is just a confused, addled mess. Timaru has just negotiated the closure of their GP after hours service, so there is nowhere else except the ED. After hours is the only time the ED does not redirect patients. And if they need help during hours but are in the wrong place, surely it is better that they get help in the right place? Emergency departments are deplorably bad at managing chronic disease processes such as hypertension, sciatica and poorly-controlled diabetes (as opposed to diabetic emergencies). And if Ms. Dyson actually means that some people can’t afford a normal GP consultation, then that is an issue to be addressed in some way other than inundating expensive ED facilities with trivia.

Frankly, I find it fairly unbelievable that people say they have no money to pay their doctor but plenty to buy smokes and alcohol and play the ponies. But even should they be in the unfortunate position of truly not being able to afford the absurdly cheap medical care that New Zealand GPs provide, there is always WINZ, who are only too willing to provide. If all else fails, they only have to wait until the GPs have closed and then the ED has no choice but to see them. And yes, this is exactly what some do – even though they know they have a GP treatable condition. There; I feel better after my little rant.

This will not cure the enormous over-usage of emergency departments in New Zealand brought about by the abandonment of the part charge for ED visits. But it will at least remove some of the more egregious examples and allow the ED to be used for its original purpose – the provision of emergency treatment.

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First Aid Jim McVeagh Dec 13

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A recent high quality study in the Journal of the American Medical Association shows that the use of intravenous drugs in out-of-hospital resuscitation does not lead to better survival rates – just more admissions to hospital. This is a significant finding for two reasons. First, it emphasises that good quality CPR and early access to a defibrillator are the only things that make any difference to cardiac arrest survival in the community. And the evidence is that good quality CPR, administered as soon as possible, is more effective than standing with your hands in your pockets and waiting for the guys with the heart rebooter. You can’t do any serious damage doing CPR, even if you have never done it in your life. Middle of the chest; press hard; press fast. Simple as that. Oh, and keep your elbows straight and use your weight, otherwise you will get tired real fast.

If you ever find yourself in that very frightening situation, have a go. Neither of you have anything to lose.

The other thing about this study is that it tells us that all the fancy drugs we give in community resuscitation serve only to waste hospital resources, not save lives. This result needs to be confirmed by at least one more study as soon as possible. If it is verified by another study, then all resuscitation drugs should be abandoned in the out-of-hospital situation (I can hear the paramedics complaining already!). The extra 15% of people who survive to hospital admission are consuming expensive hospital ICU resources to no avail. Frankly, if I’m not going to survive anyway, I would much prefer a quick, drop-in-the-street death to a lingering week in ICU having my near-corpse poked and prodded. I suspect most of us feel that way.

As an ED trained doctor, I am enthusiastic about doing your absolute best in a resuscitation situation. But pointless interventions are not only pointless, they are cruel.

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Correct Diagnosis Jim McVeagh Dec 12

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It is always a tragedy when a young life is lost, but it is especially heart-wrenching when a young man dies from something you would not normally expect such a person to die from. Such is the case of Dean Carroll, the 22 year old who presented to an emergency department and left with a script for pain-killers, only to die from a spinal abscess the next day.

Unfortunately, his death was inevitable, according to the testimony of the three expert witnesses at the inquest. I agree with them. Dean not only had a rare condition, he was unusually young for an epidural abscess and had no unusual signs or symptoms at the time that might have warned his doctor. Coupled with a late night presentation to a busy ED and his demise was a forgone conclusion. Even if he had had suspicious symptoms, it is highly unlikely he would have had the MRI that would have made the diagnosis.

This is why the headline is inaccurate – “Correct diagnosis may not have altered outcome” is not precisely true. A correct diagnosis would have saved his life. The point the experts are making is that a correct diagnosis in this case is essentially impossible. Impossible for the young doctor who had the misfortune to be the one to examine Mr Carroll and impossible also for the senior doctor on that night. Literally, the only thing that would have produced a correct diagnosis and saved Mr. Carroll’s life, would be if we had a protocol to do an MRI on everyone who presents to the ED with back pain. This is simply not possible.

The dilemma of high tech medicine is that the pool of resources available to us is always finite. This is true even in the US, where they spend five times as much on health care as we do. Consequently, regardless of the system of care, doctors wind up making sub-optimal decisions, not because they are bad doctors, but because we simply can’t justify the expense. Mr Carroll might have been saved – but only at the expense of hundreds, if not thousands, of other lives elsewhere in the health system.

Consequently, and much as I respect Mike Ardagh, I cannot agree with his statement that “Dean Carroll’s care “was not good enough””. While there is always room for improvement in any situation, the reality was that Dean Carroll would certainly have died, even if the ED was quiet and the senior doctor had seen him and admitted him. As the outcome would have been unchanged, I submit that, by definition, the care must have been adequate. One can only consider care inadequate when the outcome could have been different. In the real, constrained world in which we live, Mr Carroll’s care was perfectly adequate – it was simply not enough to save him.

To suggest otherwise is to invoke the “rule of rescue”. Not a good idea in medicine.

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Emergency Clairvoyance Jim McVeagh Nov 23

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One of the hallmarks of emergency departments is the unpredictable nature of the throughput. Accidents, in particular, are relatively unforeseeable although certain types do tend to cluster. Cuts with knives seem to congregate around mealtimes (for obvious reasons) and minor traffic-related injuries have an obviously predictable flurry at rush hour. I recall analysing the data from a year of presentations to Invercargill’s Emergency department and getting some reasonable idea of the expected flow throughout the day and the week. It therefore does not surprise me that someone has devised software to make these predictions more efficiently and with more complete data.  I am also pretty sure I can guess where it will be useful and where it will be useless.

The biggest hospitals will undoubtably find it is very good at predicting inpatient loads at least a day or two in advance, allowing hospitals to open beds at a more leisurely rate than the normal “mad panic” mode that accompanies bed block. This alone will make the software worthwhile as it will greatly alleviate the bed block experienced in EDs as well as reduce the stress on overcrowded wards. The software may also be helpful at predicting theatre usage, enable elective surgery to avoid being bumped off by emergencies. It is also possible the software may be helpful in planning rosters, although this is less certain. Doctors and Nurses like reasonably set hours (don’t we all!). Staggered shifts, split shifts and short shifts simply do not appeal to anyone, let alone tired doctors and nurses.

When it come to accurately predicting ED throughput, however, I suspect that the software will not be particularly helpful. While you may predictably get four lacerations between 5pm and 7pm on a Thursday, it will not be possible to tell the extent of those laceration, nor the amount of time spent by doctors and nurses on them, except in the more general terms. I also suspect that the software will become increasingly useless , the smaller the hospital. The throughput of small EDs is vastly less predictable than the throughput of the larger ones.

It would seem that the software in question, CapPlan, will be a worthwhile addition to resource planning efforts. However, I do not imagine it will be particular helpful at rural level unless it has a built in clairvoyant capability.

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Heart Hit Jim McVeagh Oct 04

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I read with some horror that a Herald on Sunday investigation has found an energy drink with 3333mg caffeine per litre in it. The Demon Energy Shot, which contains this horrendous amount of caffeine, gets around the Food Standard Authority regulations (which restricts caffeine to a level of 320mg per litre) by calling itself a dietary supplement.

If every there was an argument to subjecting dietary supplements to the same regulatory regime as conventional drugs, this is it.

These “energy shots” are normally 2 fluid ounces (60ml), so the Demon energy shot will contain about 200mg of caffeine (about two and a half cups of expresso coffee). Unlike a double shot cappuccino, however, the energy shot is rammed full of Taurine, Glucuronolactone, and Guarana, all of which enhance the effects of the caffeine. The net result is a dangerously high level of stimulation from a single drink. Worse still, the volume of these “shots” are small enough to encourage the consumption of multiple doses over the course of a night.

The HoS tells the story of a young woman who suffered a heart attack after consuming daily amounts of 10-14 cans of Red Bull a day. The same effect is reached with only 4-5 of Demon’s “Shots”. I have had to deal with a number of cases of teenagers having psychotic episodes following multiple cans of energy drinks. This problem will almost certainly get worse with these types of “dietary supplements”. Caffeine in large amounts pushes up your blood pressure and reduces endothelial function dramatically, predisposing people to heart attacks. It is not a benign pick-me-up, nor is it a dietary supplement – it is a stimulant drug, pure and simple.

Unfortunately, when the caffeine wears off, you become extremely lethargic (and need to sleep), so the temptation is to take another dose. But this exacerbates the effect of eventual lethargy, setting up a vicious cycle, likely to end in collapse. These drinks are marketed directly to teenagers, the group most likely to abuse them and least likely to be aware of the dangers of excessive use.

I have no real objection to young people using energy drinks to keep themselves awake. For the most part, their consumption is pretty harmless. But the creation of these “shot” drinks are a deliberate and cynical ploy to encourage dangerous levels of use. We penalise the tobacco and alcohol companies when they encourage excess consumption. It is high time we closed the loophole on the energy drinks to ensure that they are consumed in a reasonably sensible manner. The FSA need to close this loophole in our dietary supplement laws immediately.

Nobody Home Jim McVeagh Sep 27

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The HoS reports that Waitakere Hospital’s emergency department closes its doors after 6.30 at night and emergencies are redirected to the Whitecross A&M or to North Shore Hospital, 25 minutes drive away.

Actually, this is not news at all. Waitakere hospital has been doing this for nearly a year. The only thing that has changed is that they are not paying for patients to be seen at the Whitecross A&M any more. They used to provide vouchers for this purpose but have now stopped. Presumably because, if they can’t afford to pay for doctors to run their emergency department, they can’t afford to pay for trips to the private A&M.

Waitemata District Health Board chief operation officer, Graham Dyer,  claims that:

Waitakere’s restriction was caused by a shortage of emergency staff – part of a national and international shortage in emergency medical specialists, he said.

“Many of the smaller emergency departments (in other hospitals) are experiencing this trouble.”

Actually, I know of no other hospital of Waitakere’s size that has had to close it’s doors, so this seems to be a purely local issue. And the hospital does not need ED specialists to run it – third year ED registrars and Medical Officers with a year or two of ED experience could run it quite well. Waitakere’s problem was they were trying to run it with inexperienced house surgeons, which is simply ridiculously dangerous.

As I have pointed out in other posts, the problem is almost certainly one of money. If Waitakere offered the same pay scales for night work as Whitecross, they would have no real difficulty in staffing the place overnight. They have the ability to access all the locum resources of the private A&Ms and also the pool of doctors at North Shore Hospital. It should not be particularly difficult to keep the service going. Frankly, there are no other services running at Waitakere that are as vital as the ED and it is an absolute disgrace that it closes. If you can keep small hospitals like Gore, Tokoroa and Bay of Islands going with 24 hour ED services, then surely you can keep a relatively large peripheral hospital like Waitakere going?

Small Emergency departments form a buffer against the inevitable lack of access to hospital services experienced by rural community. To allow any emergency department to close is a stunning indictment on the appalling management of the health services by the last government. The continued closure of Waitakere emergency department at night in an indictment on the current government and must be fixed immediately, not in a few years time.

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