Peds Grand Rounds is up

Over at Emergiblog


I wonder if she actually has a job, what with all the postings over there…

ER Overcrowding: View from the Outside

I guess they just got their journals, but this week both DB’s Medical Rants and Notes from Dr. RW have decided to denounce the Institute of Medicines’ recommendations to help ease ED overcrowding, specifically the IOM’s recommendation (poorly worded, IMHO) to “…achieve this goal by adopting operations-management techniques and related strategies to enhance efficiency and improve patient flow.”  Kevin, MD calls this an “asinine tactic”.

Essentially, they don’t think this is a workable solution to easing ED overcrowding.  Dr. RW doesn’t actually give a solution, but DB does:

The solutions are all economic. We need better access for health care outside of ERs. We can only get that if we fund primary care better and subspecialties less well. We need to recognize the importance and difficulty of delivering excellent primary care.

The lack of adequate reimbursement for primary care (relative to subspecialties) leads to serious externalities on our system. But then, do we really have a system?

Uh, huh.  No, we don’t have a system, we can agree there. 

A few things.  First, people who are being admitted to the hospital cannot be cared for in the internists’ office.  If they could, we’d gladly send them there.  I know how the argument goes: if we could just get more people funded for primary care, they wouldn’t get sick as often, and admissions would go down.  Sounds great, but I sincerely doubt it works that way with an aging population.  Most of the ill patients I admit have seen internists, are taking their 3-20 medicines, and still need to come into the hospital.  Add in the monkey-with-a-gun and fear of missing anything, and patients will be admitted.

Second, what’s so magic about the ED?  Only the ED and OB have rubber walls and are infinitely flexible, to try our best to care for every patient ho needs our help.  Except, see, our walls really aren’t made of magic rubber, we can’t just snap our fingers and make more rooms, beds, monitors or nurses appear.  Every patient who should be admitted to the hospital but isn’t is a) not getting the specialized nursing care available on the ward where they belong and b) is taking up a bed in the ED we need to see then next 1-12 patients.  The linked commenters in the first paragraph give a ‘suck-it-up ED’ subtext that rankles.  We’re doing that.

To make things worse, our county drank the potion and decided none of the ED’s would go on diversion for medical cases unless an internal disaster was invoked (and it’s not easy: it involves waking the VP’s, etc).  What that means from an operational standpoint is a never-ceasing tide of patients, and now permanently occupied hallway beds, and since we don’t have that many rooms, we have a lot of hallway beds.  Sick people in hallway beds, because we don’t have enough room, or rooms.

Lastly, I know that ‘hallway protocols’ to put admitted patients into ward hallway beds work.  We started it at our joint last year (about the time we stopped ambulance diversion), and we found some amazing things (predicted by the consultants from places that had done it before us): tell a ward they’re getting a hall patient, and magically a bed opens up on their ward, someone already dismissed but the bed status hadn’t changed.  When there really are no rooms on the ward, each ward gets exactly one hallway patient.  You only need to move hallway patients to about 10 wards and it has a tremendous positive impact on our flow in the ED, and from the feedback the extra workload isn’t that great on the nurses upstairs.  (There are very strict criteria for hallway patients: no ICU, not too sick, etc).

So, fellows, while it’s just a temporizing measure, the IOM recommendation works, for now.  I expect the numbers of patients requiring admission to go up, not down.  We all await your workable solution to today’s problem.

Medscape Discusses Euthanasia in Disasters

I’m late to the party on this one, but there’ s been a discussion over at MedScape by several docs (incidentally they’re all very good bloggers: Robert W. Donnell of Notes from Dr. RW, Pennie Marchetti of Medpundit, Roy Poses,  of the group blog Health Care Renewal and Robert Centor, of DB’s Medical Rants, which for my money has excellent medical content but needs more rants).

Unsurprisingly, all a) can’t say what they’d do in a serious disaster situation but b) think euthanasia is a bad solution.  It’s not really a discussion amongst the named participants, more a series of well written short monographs about the above.  It’ll take you about 5 minutes to read.

My rant-critique of a trivial but annoying point: three of the five invoked the Hippocratic Oath, which I find more than a little hackneyed, and silly.  First, I know of no physician who gets up in the morning and runs through the oath to make sure it’s ‘all still in there’.  Second, for those who profess they do, are they really “…swear(ing) by Apollo the physician, by Aesculapius, Hygeia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and judgment the following oath:?”  No.

And, let’s not forget that many medical student graduates don’t take the Hippocratic Oath (I never have), but one of the others.  My class took the Oath of Geneva (enacted after medical complicity in Nazi atrocities compelled the World Medical Association to write a new oath in 1948).  (It’s been modified a few times; here’s the original version, which leaves out the ‘from conception’ part).

So, invoking Hippocrates doesn’t really get me onboard with an argument; I understand what is meant, but it’s not quite the Ten Commandments for me and my practice.  (First Do No Harm is).


And, I think if we as a society cherish duration of life over quality of life, so be it.  Be prepared to suffer for your last days; and to what end?  We still, all, die.

Me?  To paraphrase Dr. Oscar London, “Let me go, embraced in the arms of morpheus, and not strapped to a chair in the day room.”

Change of Shift #8

is up, here: cooltext190913551.jpg

Dr. Pou goes to the Grand Jury

per CNN: ORLEANS, Louisiana (CNN) — A New Orleans grand jury will decide if a doctor and two nurses intentionally killed patients with injections before the hospital was evacuated in the wake of Hurricane Katrina, Orleans Parish coroner Frank Minyard said Tuesday.

The Orleans Parish District Attorney’s Office would not officially confirm the report, saying only that the matter is still being investigated.

“We won’t confirm it, but I’m not going to deny it either,” Assistant District Attorney George Bourgeois said.

Minyard offered no details and refused to comment on whether he had completed his review of the four patients who died at New Orleans’ Memorial Medical Center in September.

After looking at these booking photos, I’m not having any problems choosing sides.


I’m with these three.

MedBlogs Grand Rounds 3:2

Welcome to the Grand Rounds. October 3, 2006.

It is my pleasure to host the third edition of Grand Rounds, a weekly best of the medical weblogs. That’s already the 3rd year of the famous Blog carnival

The first one was published exactly on Tuesday, September 28, 2004

Nick kindly interviewed me at Medscape pre-rounds. I am really impressed by how he is able to maintain such high quality process of gathering everybody in medical community for several years straight with no interruptions. It’s like a full time job.

Over the years there were different forms of the presentations
There was letters (to son), there were staged performances.
The previous one was the magnificent party.
Many thanks to Nick for giving me the opportunity to host this edition of Grand Rounds. (Look Medscape’s Pre-Rounds)

Well, I will probably just describe the submitted entries and what I liked about them. You will taste yourself and I am sure you will like the entries too. There are many fascinating articles this week.

Several entries are about food, several about politics. Also read about too much drugs and antibiotics.
As Dr. Choi said the week before: join the party and add to the buzz!

Freakonomics Finds Wayne Weirdness

Freakonomics Blog ? The next time your daughter brings home a new boyfriend, be sure to ask his middle name

Funny. Guess what my brothers’ middle name is.

hat tip to the brother!