Who Goes Down With The Ship?

39-yr-old

The stories keep changing about who really screwed up at the Texas Health Presbyterian Hospital where the first US Ebola victim showed up and eventually died.   You can read this article where they touch on the flaws in the hospital EMR that I blogged about earlier.  The use of quick texting or using macros or using quick texts (whatever you want to call it) are just short cuts so that doctors don’t have to type or think.  We are literally taught this as we learn to use our EMR systems.  Osler would have been so proud. Add to this that nurses don’t talk to doctors anymore and you have a recipe for disaster.  Nowadays, nurses flag things in the computer.  That should work, right?  Well, my last EMR made every abnormal lab a red color.  Sounds great but almost EVERY lab was red because everyone had high cholesterol, a RDW that is off, a calcium that is 10.4, etc.   The consequence is that the doctor doesn’t get excited about the flag or red color and ignores it.  It’s human nature.  The same thing occurs when you put alarms in ICUs for every abnormality.  The nurses get “alert fatigue” because most of those beeps are false.  Who is to say what happened in Texas?  No one was thinking about Ebola then. Why a guy with a high fever from Africa was missed is ridiculous upon hindsight.  That being said, accusations of racism, as brought up by the deceased’s nephew, is utterly ludicrous.  That is all we need right now during this mess.  I believe the fallout in this could be huge.  There will be lawsuits.  Administrators will point fingers at doctors and be astonished that physicians fluff the charts.  Some doctors will be let go or quit.  It is going to get crazy but it really doesn’t matter.  The bigger issues, now that we have another person infected at this hospital  (a healthcare worker), are these:

  1. Why does this spread so easy?
  2. The CDC made it seem that Ebola is like Hep B and spread through bodily fluids.  Really?  I had never heard of Hep B spreading this quickly?
  3. This guy who died was not spurting bodily fluids everywhere.  How then did a healthcare worker get sick?
  4. Will we have another Mary Mallon on our hands?  You know her, right?  She was also called Typhoid Mary.

Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  24 comments for “Who Goes Down With The Ship?

  1. Princess of Problem Patients
    October 16, 2014 at 10:58 am

    I’m in the DFW area and in 2005-2007 I assisted area hospitals with getting bioterrorism hospital preparedness program funds from HRSA (the program changed to be under ASPR). Hospitals mainly purchased protective gear and equipment but some also held trainings/exercises with their allocated funds. Trainings included coordination between hospital staff and city/county/regional emergency management during a large scale event, chain of command for supply requests, and donning and doffing PAPRs, among other things. The then-director of EOC and emergency management for Texas Health (Texas Health Resources back then) was completely amazing, and she made sure all of the THR hospitals (including Presby Dallas) had staff trained properly for medical disasters. She’s been a consultant for some years so I have no idea what the exercises are like now for the system, but it makes me wish that hospitals had routine mass casualty drills once every quarter instead of every year or two. Wishful thinking, I know, but the knowledge of what people should do disappears with staff turnover.

    Fwiw, the latest news from Dallas: http://www.dallasnews.com/news/metro/20141015-dallas-officials-plan-new-limits-on-health-staffers-in-ebola-case.ece

  2. Keith
    October 16, 2014 at 9:52 am

    One other thing. Can we please stop blaming the EMR? Diagnoses have been missed since the beginning of medicine. Ultimately, the MD needs to obtain the history and perform the exam. He needs to review and confirm the information that has been entered by the nurse. That is what we do.

    • Doug Farrago
      October 16, 2014 at 9:59 am

      That is what we used to do. The EMR was built for billing. It is a behemoth that causes us to gloss over things. In the old days the doctors actually talked to the nurse. So, with all due respect, I will blame the EMR and the administrators and the current model of bullshit metrics. And I won’t stop.

      • Keith
        October 16, 2014 at 10:04 am

        Come on man. You are taking the easy way out. The EMR doesn’t prevent us from talking to the nurses. I agree that billing is a huge part of the EMR but EMR’s are not going away so we can either bitch, whine and complain or we can get get engaged and change the EMR and our workflows to better integrate the computers into our workday.

        • Doug Farrago
          October 16, 2014 at 10:18 am

          Sure, EMRs are here to stay but they should used for patient care. I agree, all the bitching, whining and complaining will change nothing except get you fired. We are pawns of the administrators; easily replaced. We are powerless in this current system because we gave the power away. Using the ADMINISTRALIAN term “engaged” means absolutely nothing to me. It is white noise to distract us from the fact that we practice “industrialized medicine”. By all means, join a committee on changing the EMR (like the hospital will pay for that) or workflow integration (mental masturbation) and spend a year fixing nothing. It is ALL built for billing and to make the hospital and CEO money. That is why they make you run faster, spread out nurses too thin, hire more and more PA/NPs, create nursing assistants, put in extra alarms, etc.

          What prevents us from talking to nurses is TIME. We don’t have enough of it because the new technology and extra staff was not created for our or the patient’s sake. It was created for sake of the CEO’s wallet.

          • Keith
            October 16, 2014 at 10:45 am

            Dang, you are bitter. I guess I am lucky to practice at a hospital that does respect our opinions. The docs here have made a difference here in both the EMR build as well as workflow. We are not powerless…we are wimps. Docs tend to be all bark and no bite. We complain a lot but when push comes to shove we fold. I think most docs are passive aggressive which does not lend itself to fruitful interaction with the suits. We do have power. Unfortunately, most docs just are not very good at harnessing it.

          • Doug Farrago
            October 16, 2014 at 11:16 am

            I guess you are new to my blog, eh? I am realistic (and bitter about how the system stole our power). I spent 20 years in that world and have blogged about it every day for the past 12 years. I know my stuff. Are you lucky? I don’t know enough about you. Maybe you are young? Maybe you are a medical director who drank the Kool-Aid? I do agree, though, that doctors are wimps and we can harness our power but ONLY by walking away. The golden rule is simple. Those that have the gold make the rules.

          • Steve_O'_
            October 17, 2014 at 7:59 am

            I am personally embarrassed about our medical system and our self-governance. Now that we have made human independence and competence impossible, we have embraced Scientism and Technopathy in the entirety of our culture, we have become a world of lazy Regulators with nobody to actually do the job, we have to realize a sad fact.
            What if you set up a perfect Fascist world, but you can’t find anyone competent to be Führer? Run an ad on Monster.com?

        • Bridget Reidy
          October 17, 2014 at 12:44 am

          It actually may not be that a responsible patient reported a travel history or that a clever nurse sought it, despite what this article says. But here’s what had been reported before that release, claiming the travel history was part of the nurse’s flu shot screening.
          http://www.medpagetoday.com/PracticeManagement/InformationTechnology/47936

          If that’s correct, they are blaming a doctor for not reading every detail of documentation, including the things that were only coincidentally relevant but asked not because considered important – part of a twenty question checklist concerning flu shots- who would read that? And if the nurse had no idea she knew how important it was, we can’t blame her for not verbally reporting it either. So it is still a problem with too much gobbledygook in the EMR, though not the one of known relevant information being hidden by the excess, but that excess irrelevant Information might come back to bite you in retrospect.

          Is it true the CDC had already put out instructions to all primary care to ask a travel history with “sx of Ebola”. Was abdominal pain on the list? Did it say every fever? Health Canada didn’t come out with it’s instructions till a few days later, and still didn’t include abdominal pain though I suppose it was the beginnings of organ failure.

  3. Keith
    October 16, 2014 at 9:49 am

    The patient who died was indeed spurting body fluids everywhere…diarrhea and vomiting. These are hallmark symptoms of the disease.

    • Steve_O'_
      October 17, 2014 at 7:42 am

      hall•mark
      1. an official mark or stamp indicating a standard of purity, used in marking gold and silver articles assayed by the Goldsmiths’ Company of London; plate mark.
      2. any mark or special indication of genuineness, good quality, etc.
      3. any distinguishing feature or characteristic: Accuracy is a hallmark of good scholarship.
      [Infoplease]
      Nausea and vomiting are the hallmark of nothing. They are useless as harbinger symptoms of Ebolavirus. However, now that America has developed its Internet Expertise to include every person who can work a keyboard, and a Shock-When-Wrong Skinnerian style of management, then let everyone with internet access become a Tele-ER physician, and let them all practice medicine. We no longer need doctors and other healthcare professionals – simply lots of beatin’ sticks.
      Copious nausea and vomiting in an ER are symptoms of new pregnancy, and I’ll bet the ER didn’t do a bHCG on him. They should be fined. Who failed? We, the demoi, are the New Gods, we can judge everything because we have become competent to do nothing. Simply beat those who are bad, and we shall eliminate badness.

  4. Chris
    October 16, 2014 at 9:19 am

    Everybody failed. First I fault the ER doc, this is the fever season (cold and flu), but when you do fast medicine you lose things like the travel history. The first rule is Trust no one and believe nobody. Always ask your own questions, the story changes. Then I fault the hospital that was apparently woefully unprepared to put a patient in isolation. Then the nurses for not stalwartly refusing to proceed until correct measures were available. Demand the patient be transferred if your hospital is incapable of giving the care needed. The second rule is always protect yourself. BTW where was the ID doc in all this. If they called for an Ebola patient, they should be there for when they reach the floor. Or did they see the mess and leave. Then the utterly inept CDC. What an ivory tower disconnect. “Every hospital can care for this” really. Most community hospitals are lucky to have a few isolation rooms, none have the decontamination areas necessary. Most don’t stock the protective gear needed, unless you raid joint surgery supplies, then you can properly rig something that will suffice. These cases need to be at major research hospitals, they are the only ones with facilities to handle it. Think about that next time you cut the medical budget. And try to come out of your ivory tower and see the real world. You paid for a Chevy and expected a Ferrari that runs on batteries only. Then the President, just shut up. Don’t prattle about things you know nothing about. Why is 101st Airborne, a first line combat unit, going to help with Ebola? Why not USAMRID from Fort Dietrich, this is their purpose? Why not send a CSH, this is perfect for them (CSH, is a Combat Support Hospital, a major medical center in boxes) USAMRID is the US Army Military Research Institute for Infectious Disease. In most of history more soldiers die of disease than actual combat. The three stooges couldn’t screw up this bad. We are playing politics with disease, this is basically allowing people to die and hope no one notices until after the election. But really, 101 does not do policing or crowd control, their task list is simply “survive and kill.” Really, I’ve seen it. So what skill do they have to operate in the Ebola situation.

    • Steve_O'_
      October 17, 2014 at 7:45 am

      Yes, of course. I long ago realized that the rest of the world is nowhere near as amazing as myself, so I routinely dole out F’s to those sluggards that try and fail. It is entertainment, pure entertainment. Bad outcomes are never the fruition of a natural process; they are always the failure of practice by men and women less amazing than me. How do they stand it?

  5. arf
    October 12, 2014 at 9:55 pm

    https://news.yahoo.com/ebola-patient-arrived-er-103-degree-fever-160922028.html

    “…..Duncan’s family provided his medical records to The Associated Press — more than 1,400 pages in all…..”

    One thousand, four hundred pages.

    How long was he in the hospital again? What was that, then…..a hundred pages of medical records a day? More?

    • Bridget Reidy MD
      October 17, 2014 at 12:23 am

      And they wonder why the doctor didn’t read the whole thing!?

  6. Dave Fitzpatrick MD
    October 12, 2014 at 9:03 pm

    I may be the only one, but I was shocked to read a CDC/ SC DHEC advisory to the effect that Ebola can be transmitted via sweat. Do all of you take the same precautions with sweat as with blood? What about the bedrail that had sweat on it?
    When the open invitation to every mobile person in the world with Ebola to come to the US for free care turns badly who will ask if it was hard to see coming?
    (Doug, you may cut this) When the outbreak in the USA comes to such dangerous proportions that open assembly is banned and (Oh, unfortunately!!!) November elections are canceled, you heard it here first…not that this will make me feel any better.

    • Melinda
      October 16, 2014 at 11:19 am

      Dave—
      Many decades ago, Edgar Cayce predicted that an American president would call off a presidential election to stay in charge because of a national crisis. I have been very concerned that it could be Obama….

      • Dave Fitzpatrick MD
        October 16, 2014 at 5:03 pm

        Um, Melinda, I appreciate that…but I was really hoping that someone would tell me that I was crazy…and give me a cookie and tell me to sit in the corner.. Instead I get this! Some friend that you turned out to be. After all we’ve been through (as documented herein)…
        I don’t wanna be grown up…Oh, I just read that my local (WAY TOO CLOSE) teaching hospital has boldly announced that they are eager to care for any EVD patients…What could possibly go wrong?
        Doug, Where is my cookie!?!??!

        • Melinda
          October 16, 2014 at 8:44 pm

          Dave, hey, if you can’t count on your friends to let you know how terrifyingly sane you are, who can you count on? ;)) Hmmmm, which is worse: a U.S. outbreak of Ebola or Obama being our King for unlimited time? Oh, yeah, if the first one happens, the second one may happen ALSO! At least I’m only a veterinarian, so I don’t have to be as concerned about Ebola as you MDs, although I read “The Hot Zone” about 20 years ago and have been horrified of Ebola ever since. I’m watching with interest how they study the situation with the dogs–they make antibodies to the virus but don’t get sick, but no one really knows if they can transmit it to a human. And actually I’m retired for medical reasons, which can put me in a hospital at any time, so I guess I do have to be concerned about personal risk, too. Anyway, this is one scary situation, and if this Ebola develops the ability to be transmitted airborne, the whole world is in deep fecal material.

  7. Dave Mittman, PA, DFAAPA
    October 12, 2014 at 2:14 pm

    Agree. The physicians on the news keep saying “we can contain this” as this is America. Meanwhile people are flying in from all over the world and we are taking their temperature. How about a full detailed history?
    We can’t contain this if people in full blown haz-mat suits catch it by caring for others. Imagine kids going to school, people in movies coughing, just sitting in an ER…..
    Dave

    • Steve_O'_
      October 12, 2014 at 6:42 pm

      And over the last twenty years, we have crippled the one most powerful test for Ebola virus infection – an undistracted history taken by a competent physician. Bayesian analysis shows that it’s the ONLY way to catch the virus early. Without a concentrating, undistracted history and a targeted physical, unrushed – there is no way of diagnosing viral hemorrhagic diseases until they turn lethal. No white count, no sed rate, nada.
      The Technocrats are shocked – what about the gizmos and iApps that you can use for whizbang medicine? Actually, Technological methods are most useful in confirming a diagnosis – the pathologist can make your autopsy diagnosis precise after you die from the disease. Gene sequencing, all that. Thanks.
      We have a system where uninsured sick people show up by the thousands to ER’s with sniffles – making the accurate diagnoses of serious infections much more difficult, fogging up the field.
      If we had a full-catchment system for low-throughput, specialized medical care to identify potentially infected persons regardless of their ability to pay, that would be more desirable. That used to be called independent primary care practice, and we have wiped that out. We deserve what we get.
      Everything crunches through the ER, everything – and it is getting worse.
      Is Ebola in time to save American healthcare from itself? Sadly, probably not. People will not see how this disease got foot in our ER’s – we will go back to the same tired excuses of maligning individual personnel and excusing the faulty system. The IOM published about this horrific trend fifteen years ago – we still ignore it. Understaffing and loss of independence, fragmentation of the system, STILL make for worse outcomes; but even the Ebola virus is not enough for us to stop our frenzied race to the bottom.
      We should rename the Ebolavirus to the 21st Century American Healthcare Virus. The chance of surviving through either affliction is dubious.

      • Dave Mittman, PA, DFAAPA
        October 12, 2014 at 9:17 pm

        You must have seen my text and therefore feel PAs are not competent. Maybe i am sensative or maybe you really meant it. Here we go again.
        Dave

        • Steve_O'_
          October 13, 2014 at 12:09 am

          Competence is an ability, a capacity – not a degree.
          A fragmented history taken by a cluster of scribes with advanced degrees is not competent.
          Whoever gets the diagnosis right and proceeds to activate the response is the one who is showing command initiative. The stripes on the shoulders mean nothing in this instance. If you excel, why should I be anything but delighted? The only score to be kept is the patient’s wellness. Everything else is ancillary.

  8. Steve_O'_
    October 12, 2014 at 12:12 pm

    NATO: “Command and control is the exercise of authority and direction by a properly designated individual over assigned resources in the accomplishment of a common goal.” See also “Understanding Command And Control” from the DoD Command and Control Research Program at http://www.dodccrp.org/files/Alberts_UC2.pdf
    A useful phrase from the introduction: “It is only by changing the focus from WHAT Command and Control is to WHY Command and Control is that we will place ourselves in a position to move on.”
    Medicine is being resculpted to resemble a Prada boutique – the delivery of well-defined and fashionable things in an appealing and comfortable manner, a delight to the customer. As the cost-no-object mandate of Prada is uncomfortable, we have dabbled in the concept of insurance to provide retail goods and services – a “clothing insurance” approach to healthcare that has brought our current state of American healthcare about.
    Something about annoyances like Ebola does not fit well in our satisfaction algorithms. How does Press-Gainey handle such things? So we have made recourse to our traditions – ignore, then blame, and finally litigate.
    Human healthcare tends to be messy and undignified, as Reality is often messy and undignified. As in the Court in Versailles, we do not wish to turn our bright minds to those things that are crude and unrefined, such as hemorrhagic fever epidemics.
    Let them, perhaps, eat cake, then. Let us continue treating Reality with the contempt it deserves. By God, it is Prada that the people demand – and Prada the people should have!
    There is no room in American Public Retail Medicine for such things as Command and Control, one of the elements necessary for efficient medicine in epidemics. We give it a frowny-face! We unfriend it!!
    Every single turn we make in American Public Retail Medicine avoids Reality, and insists upon the dual acknowledgment of Cost-No-Object and Wasteful-Spending-Control.
    We should celebrate the outbreak of American Public Retail Medicine in Dallas, then, and mark the date on our calendars. Finally, our will has trumped Reality!
    It is interesting to ponder how the principles of “Danger to self and others” fits with our new American Public Retail Healthcare mission. I think it does.

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