From 1967 to 1970, during the Vietnam War, my first
assignment as a junior Air Force 2nd Lieutenant, was as Administrative Officer
of the 4th Casualty Staging Flight attached to Wilford Hall USAF Medical
Center, Lackland AFB in San Antonio, Texas. We received combat casualties still
in battlefield bandages, often within 24 hours of injury, and either admitted
them to Wilford Hall or further transported them to hospitals near home.
Recently it occurred to me to look back at how battlefield
casualties were handled going back to the Revolutionary War and forward to
Iraq/ Afghanistan. BATTLEFIELD MEDICINE is now a medical discipline! (But
battlefield surgeon readiness may be at risk.)
BATTLEFIELD MEDICINE. “A war benefits medicine more than it
benefits anybody else. It’s terrible, of course, but it does.” *
SURGEONS IN EVERY branch of service in military hospitals
worldwide perform complex, high-risk operations on active-duty personnel, their
family members and some retirees in such small numbers that they may put
patients at risk, a U.S. News & World Report investigation has found.
Three decades of research has shown doctors and hospitals
with the highest volumes of certain complex surgical procedures achieve the
best results. But military surgeons serve a population that’s relatively young
and healthy. They lack the steady stream of older patients requiring surgery
that would allow the doctors to sharpen their skills and sustain their readiness
to help troops on the battlefield.
“You want to do more. In some cases, you’re begging to
do more,” says Dr. Scott Steele, chair of colorectal surgery at the
Cleveland Clinic, a West Point Graduate, former Army surgeon and Bronze Star
recipient with more than two decades of service, including deployments in Iraq
The U.S. News analysis suggests that the surgical case
shortage, coupled with the remoteness of some base hospitals from larger
military or civilian medical centers, prompts some surgeons to tackle cases
that may exceed their surgical skills…” (A)
“When the Revolutionary War began its actual skirmishes
in 1776, early attempts to prepare for the medical needs related to War were
made in the City of New York. During the spring and summer of 1776, Samuel
Loudon was publishing his newspaper the New York Packet, in which he included
numerous articles and announcements regarding the Continental Army. On July 29,
for example, came the following announcement written by Thomas Carnes, Stewart
and Quartermaster to the General Hospital of King’s College, New York. Anticipating
an increase demand for medically trained staff, he filed the following request
“GENERAL HOSPITAL New-York, July 29, 1776 Wanted
immediately in the General Hospital, a number of women who can be recommended
for their honesty, to act in the capacity of nurses: and a number of faithful
men for the same purpose…King’s College, New York” (A)
“One of the most famous surgeons, and the first, was
Cornelius Osborn. He was recruited in the Spring of 1776 and had little
training even as a physician. The Continental Congress was even concerned about
the well-being of the troops and the militia. They passed several ordinances
and helped establish the order for the several field Hospitals during the War.
The hospitals served about 20,000 men in the fight. Each hospital was required
for each surgery to have at least one physician or surgeon, and one assistant,
which was usually and apprentice of some sort. Each hospital’s staff numbers
varied on how many wounded it served and the severity of the wounds….
Most of the deaths in the Revolutionary War were from
infection and illness rather than actual combat. The common practice if a limb
was badly infected of fractured was to amputate it, where most amputees died of
gangrene a result of not properly cleaning instruments after surgeries. Only
35% of amputees actually survived surgery. There were no pain killers quite
developed back then. So at most the patient were given alcohol and a stick to
bite down on while the surgeon worked. Two assistants would hold him down, a
good surgeon could perform the entire process in a mere 45 seconds, after which
the patient usually went into shock and fainted. This allowed the surgeon to
stich up the wound and prepare for the next amputation. Another way they decided
to clean wounds, disease, or infection was by applying mercury directly to the
cut of injured space, and letting it run through the blood stream which usually
resulted in death.” (B)
“To seek treatment for any serious ailment, a soldier
would have had to go to a hospital of sorts. Military regiments had a surgeon
on staff to care for the men, so the soldier’s first stop would be with the
surgeon. During battles, the surgeon could be found in a makeshift or
“flying” hospital that consisted of a tent, an operating table, and
some medical equipment. If the surgeon could not treat the soldier, he might be
sent to a hospital. Many regimental hospitals were in nearby houses, while
general hospitals for more in-depth treatment were sometimes set up in barns,
churches, or other public buildings. The conditions were often cramped, which
resulted in the rapid spread of contagious illnesses and infections….
Woe to the soldier who required surgery after being wounded
on the battlefield! The conditions in “flying” hospitals were
deplorable. Not only was the operating room simply a table in a tent, but there
was little thought given to keeping the table and tools clean. In fact, wounds
were sometimes cleaned using plain water from a bucket, and the used water
would be saved to clean out the next soldier’s wounds as well.” (C)
“Hospitalization was a serious problem during the American
Revolutionary War. Plans were made quite early to care for the wounded and
sick, but at the best they were meager and inadequate. However on April 11,
1777 Dr. William Shippen Jr., of Philadelphia was chosen Director General of
all the military hospitals for the army. Consequently the reorganization of
hospital conditions took place…
After the battle of Brandywine, September 11, 1777, hospitals
were established at Bethlehem, Allentown, Easton and Ephrata. After the battle
of Germantown, October 4, 1777, emergency hospitals were organized at
Evansburg, Trappe, Falkner Swamp and Skippack. Hospitals at Litiz and Reading
were also continued. By December 1777, new hospitals were opened at Rheimstown,
Warwick and Shaeferstown. Yellow Springs (now Chester Springs) an important
hospital was organized under the direction of Dr. Samuel Kennedy. At Lionville,
Uwchlan Quaker Meeting House was also made a hospital for a time. Apothecary
General Craigie’s shop, Carlisle, was the source of hospital drugs….” (D)
“The big advances in military medicine were decades
away. William Morton would develop ether
anesthesia for surgery, but not before 1846.
Florence Nightingale would create the professional nurse and reform the
British hospital, but not until 1857.
Robert Koch would put forth his germ theory in 1890. Although the War of 1812 took place well
before these advances, there were many skilled military surgeons, most of them
aware of the salutary effects of cleanliness.
At one Army hospital in Burlington, Vermont for example, the
ward master had a long list of rules: chamber pots were to be cleaned at least
three times a day and lined with water or charcoal. Beds and bedclothes were to be aired daily
and exposed to sunlight when possible. Once a month the straw in each bed sack
was to be changed. If a patient died, the straw was to be burned…
Skilled as some practitioners were, the war took place in a
period when some medical attention could kill you. Army doctors used emetics to cause vomiting
and cathartics to cause diarrhea, both as stomach cleansers. Patients were sometime bled
intentionally. These cures often left
the patients weak, dehydrated and unlikely to survive.
Battle injuries, of course, just compounded the misery. A bullet in the head, chest or abdomen meant
almost certain death. A bullet in the
limbs meant a twenty percent chance of death if the wound was cleaned and in
most cases the limb amputated…
Stoicism seemed to be the watchword of the day. There are accounts of soldiers singing,
joking, and even smoking during an amputation.
People at this time were familiar with pain, and soldiers were expected
to rise to the occasion. Recovery took place in the hospital, where, in some
units, a soldier received half-rations and half-pay as an incentive to get well
“Military surgeons often resorted to so-called “heroic”
treatments. Those treatments often seem crude and sometime barbaric to modern
eyes. Bleeding, the deliberate opening of vein to remove blood from a patient,
was thought to reduce blood volume and reduce fever and infection. Blistering,
the practice of creating a skin infection on the patient, was thought to lead
to pus that would carry away infection. Other physicians deliberately induced
vomiting in an attempt to combat disease. Such practices were seldom helpful
and often made the patient’s condition worse.
Among the items found in a surgeon’s medicine chest were
opium and alcohol, useful for pain management, and quinine, found to be
effective in treating malaria. But many drugs were either unhelpful or, in the
case of the mercury used to treat syphilis, quite toxic.
Army medicine also suffered from some basic organizational
shortcomings. The War Department was ill prepared when the conflict broke out
in 1812. Officials had no standardized system of accounting for or replenishing
its medical supplies, or for evaluating the competency and training of its
But as the conflict wore on, army medicine improved
noticeably. Congress created the post of surgeon general and outlined
professional qualifications for selecting surgeons. In addition, the Congress
attempted to improve cleanliness among soldiers through better camp sanitation,
and tried to alleviate hospital overcrowding. Over time, the contents of the
surgeon’s medicine chest became standardized, and a better system of hospitals
emerged. Permanent hospitals were located well to the rear, away from the
fighting, and linked to more mobile, “flying hospitals” closer to the front
But in many ways, the most intractable problem remained the
scientific unknowns. Solutions to the fundamental puzzles—the nature of
disease, how it was transmitted, and how to prevent infection—remained several
decades away. More often than not, army doctors found themselves groping in the
dark for answers.” (B)
“Disease posed far greater threat than the battlefield. In
addition to ubiquitous camp diseases like dysentery that had hounded Taylor’s
army before it ever crossed the Rio Grande, the rainy season and its
mosquito-borne malaria came directly on the heels of the city’s occupation and
further compounded public health woes for all of Matamoros’ residents.
Smallpox, too, carried off its share of victims. Although all American soldiers
were supposed to have been vaccinated against the disease upon entering the
army, volunteers sometimes fell through the cracks in the rush to deploy troops,
and one army surgeon complained his supply of the vaccine had been ruined by
the Mexican heat. Most to be feared was the deadly yellow fever, and with
the help of correspondents on other battlefronts in Mexico and from coastal
U.S. cities like New Orleans and Mobile, the bluntly titled English language
newspaper The American Flag carefully tracked the fever’s progress throughout
the Gulf of Mexico.” (A)
To care for the many sick in General Taylor’s command,
surgeons set up eight regimental hospitals, each sheltered in two or three
large hospital tents, and a general hospital, housed in a large frame building
in Corpus Christi. In the latter facility, those whose illness was likely to be
prolonged joined the overflow of patients from the regimental hospitals. The
medical staff manning these hospitals included the medical director for
Taylor’s force, Presley H. Craig, Jarvis as director of the general hospital, a
purveyor, and thirteen more department physicians. Three civilian doctors were
hired until more Regular Army surgeons could be assigned to Taylor’s command..”
“From the founding of the nation and throughout the first
half of the 19th century, drugs were not regulated by the federal government.
Problems with drug impurity were episodic, and when occurring, they were
usually contained within a state or a region. The usual reaction to a case involving
impure or bogus medicine was a call for reform at state houses with individual
states instituting laws governing aspects of drug manufacture and trade, but these
regulations were spotty at best. The situation changed during the
MexicanAmerican War, which began in 1846 and ended in 1848…
Although the high death rate had many contributing factors
from compromised food provision and poor living conditions to infectious
diseases, public outrage focused on the medical care given to soldiers. It was concluded
that adulterated drugs supplied to the Army had caused the large numbers of deaths
This enraged the public, and the outcry led Congress to pass
the Drug Importation Act of 1848, the first federal drug law. It was very
limited in scope and addressed only the purity of drugs imported into the
United States. Congress charged Customs with enforcing the law. Special
examiners were appointed at six major ports of entry—New York, Boston,
Philadelphia, Baltimore, Charleston, and New Orleans. They checked the
“quality, purity, and fitness for medical purposes” of imported drugs using the
major pharmacopoeias (publications
describing drugs) and dispensatories for standards.” (C)
America’s modern medical accomplishments have their roots in the legacy of
America’s defining war.”
“During the 1860s, doctors had yet to develop
bacteriology and were generally ignorant of the causes of disease. Generally,
Civil War doctors underwent two years of medical school, though some pursued
more education. Medicine in the United States was woefully behind Europe.
Harvard Medical School did not even own a single stethoscope or microscope
until after the war. Most Civil War surgeons had never treated a gunshot wound
and many had never performed surgery. Medical boards admitted many
“quacks,” with little to no qualification. Yet, for the most part,
the Civil War doctor (as understaffed, underqualified, and under-supplied as he
was) did the best he could, muddling through the so-called “medical middle
ages.” Some 10,000 surgeons served in the Union army and about 4,000
served in the Confederate. Medicine made significant gains during the course of
the war. However, it was the tragedy of the era that medical knowledge of the
1860s had not yet encompassed the use of sterile dressings, antiseptic surgery,
and the recognition of the importance of sanitation and hygiene. As a result,
thousands died from diseases such as typhoid or dysentery…
Battlefield surgery…was also at best archaic. Doctors often
took over houses, churches, schools, even barns for hospitals. The field
hospital was located near the front lines — sometimes only a mile behind the
lines — and was marked with (in the Federal Army from 1862 on) with a yellow
flag with a green “H”. Anesthesia’s first recorded use was in 1846
and was commonly in use during the Civil War. In fact, there are 800,000
recorded cases of its use. Chloroform was the most common anesthetic, used in
75% of operations. ..A capable surgeon could amputate a limb in 10 minutes. Surgeons
worked all night, with piles of limbs reaching four or five feet. Lack of water
and time meant they did not wash off hands or instruments
Bloody fingers often were used as probes. Bloody knives were
used as scalpels. Doctors operated in pus stained coats. Everything about Civil
War surgery was septic. The antiseptic era and Lister’s pioneering works in
medicine were in the future. Blood poisoning, sepsis or Pyemia (Pyemia meaning
literally pus in the blood) was common and often very deadly…” (A)
“Early on, stretcher bearers were members of the
regimental band, and many fled when the battle started. Soldiers acting as
stretcher bearers rarely returned to the front lines. As the war evolved,
stretcher bearers became part of the medical corps. At the battle of Antietam,
there were 71 Union field hospitals. As the war went on, these were
consolidated. There were ambulances here that were used to bring the wounded to
temporary battlefield hospitals, which were larger, often under tents, and out
of artillery range. Later in the war, patients were transported to large
general hospitals by train or ship in urban centers. These did not exist when
the war began. There was no military ambulance corps in the Union Army until
August of 1862. Until that time, civilians drove the ambulances. Initially the
ambulance corps was under the Quartermaster corps, which meant that ambulances
were often commandeered to deliver supplies and ammunition to the front…
Large general hospitals were established by September of
1862 (11). These were in large cities, and soldiers were transported there by
train or ship. At the end of the war, there were about 400 hospitals with about
400,000 beds. There were 2 million admissions to these hospitals with an
overall mortality of 8%. In the South, the largest general hospital,
Chimborazo, was in Richmond, Virginia. It was built out of tobacco crates on 40
acres. It contained five separate hospitals, each made up of 30 buildings.
There were 150 wards with 40 to 60 patients per ward. The census was as high as
4000. They treated about 76,000 patients with a 9% mortality (12)…” (B)
Most of the major medical advances of the Civil War were in
organization and technique, rather than medical breakthroughs. In August of
1862, Jonathan Letterman, the Medical Director of the Army of the Potomac,
created a highly-organized system of ambulances and trained stretcher bearers
designed to evacuate the wounded as quickly as possible…
A system of triage was established that is still used today.
The sheer number of wounded at some of the battles made triage necessary. In
general, the wounded soldiers were divided into three groups: the slightly
wounded, those “beyond hope”, and surgical cases. The surgical cases
were dealt with first since they would be the most likely to benefit from
immediate care. These included many of the men wounded in the extremities and
some with head wounds that were considered treatable. The slightly wounded
would be tended to next, their wounds were not considered life-threatening so
they could wait until the first group was treated. Those beyond hope included
most wounds to the trunk of the body and serious head wounds. The men would
have been given morphine for pain and made as comfortable as possible…
Due to the sheer number of wounded patients the surgeons had
to care for, surgical techniques and the management of traumatic wounds
improved dramatically. Specialization became more commonplace during the war,
and great strides were made in orthopedic medicine, plastic surgery,
neurosurgery and prosthetics. Specialized hospitals were established, the most
famous of which was set up in Atlanta, Georgia, by Dr. James Baxter Bean for
treating maxillofacial injuries. General anesthesia was widely used in the war,
helping it become acceptable to the public. Embalming the dead also became
Medical technology and scientific knowledge have changed
dramatically since the Civil War, but the basic principles of military health
care remain the same. Location of medical personnel near the action, rapid
evacuation of the wounded, and providing adequate supplies of medicines and
equipment continue to be crucial in the goal of saving soldiers’ lives.”
“Many misconceptions exist regarding medicine during
the Civil War era, and this period is commonly referred to as the Middle Ages
of American medicine. Medical care was heavily criticized in the press
throughout the war. It was stated that surgery was often done without
anesthesia, many unnecessary amputations were done, and that care was not state
of the art for the times. None of these assertions is true. Actually, during the
Civil War, there were many medical advances and discoveries..
Medical Use of quinine for the prevention of malaria
Use of quarantine, which virtually eliminated yellow fever
Successful treatment of hospital gangrene with bromine and
Development of an ambulance system for evacuation of the
“In the three decades between the Civil War and the Spanish-American
War, virtually all practical experience of trauma medicine evaporated. Yet in
those years, medicine advanced. The 1893 appointment of George Sternberg to
Surgeon General allowed the rise of bacteriology and many other vogue
advancements to be incorporated into trauma medicine. Additionally, the opening
of 200 nursing schools across the United States kept attendant medical
practitioners well-versed on germ theory and sterilization…
The Spanish-American War of 1898 was brief, with relatively few
battle casualties, but epidemic disease, especially typhoid fever, devastated
the volunteer troops. Post-war investigations and commissions generated better
understanding of the problem of asymptomatic carriers and a series of
recommendations that greatly improved military medicine. The new practices,
including the development of a typhoid vaccine, saved thousands of lives during
World War I. Studies that established the role of the mosquito in yellow fever
spawned preventive measures that ended the huge epidemics of that disease in
the Western Hemisphere; this in turn made possible successful construction of
the Panama Canal…
New forms of surgical dressings especially designed for
field use, composed of sterilized, sublimated, and iodoform gauze; sterilized
gauze bandages, absorbent cotton, catgut, and silk, sterilized and packed in
convenient envelopes; tow, compressed cotton sponges, and plaster of paris
bandages were also prepared under the immediate supervision of this office…” (A)
“Despite the lessons learned in the Civil War, the
government had taken no concerted steps toward establishing a skilled nursing
service to care for the sick and wounded during wartime…
The war with Spain was quickly demonstrating the important
need for trained nurses as hastily constructed army camps for more than
twenty-eight thousand members of the regular army were devastated by diarrhea,
dysentery, typhoid fever, and malaria— all of which took a much greater toll
than did enemy gunfire.
As a result of their work in the Civil War, religious
sisters were recognized for providing skilled nursing services. In view of the
urgent need for medical assistance in the summer of 1898, it was no surprise
when the government called for every nursing sister who could be spared.
Official government records indicated that the various orders furnished around
250 sister nurses, with the Daughters of Charity (originally referred to in the
United States as Sisters of Charity), providing the majority of nurses.8
Although members of other orders were represented, their numbers were
considerably less” (B)
Medicine, in World War I, made major advances in several
directions. The war is better known as the first mass killing of the 20th
century—with an estimated 10 million military deaths alone—but for the injured,
doctors learned enough to vastly improve a soldier’s chances of survival. They
went from amputation as the only solution, to being able to transport soldiers
to hospital, to disinfect their wounds and to operate on them to repair the
damage wrought by artillery. Ambulances, antiseptic, and anesthesia, three
elements of medicine taken entirely for granted today, emerged from the depths
of suffering in the First World War…
Antiseptics and anesthesia saved lives once they arrived at
the hospital, but without motor ambulances and hospital trains to get them
there, wounded soldiers stood little chance. From the impromptu rescue of
soldiers from Meaux in September 1914, the American Ambulance Field Service
grew to number more than 100 ambulances by the end of the first year of the
war. Philanthropists such as Anne Harriman Vanderbilt bought cars, as did civic
groups from cities around the United States. The Ford Motor Company donated 10
Model-T chassis to be converted into ambulances…
What inspired these major advances in medicine? There was a
deep need, and people stepped up to find solutions. The new technology of
war—heavy artillery, long-range cannons, barrage shelling, and machine
guns—rained devastation at unprecedented levels. Medicine had to try to keep
up. One good example of this evolution is in facial reconstruction surgery.
Soldiers survived having jaws and noses shattered by artillery fragments, so
surgeons at the American Hospital and Val-de-Grace Hospital pioneered maxillofacial
techniques, and at the same time, brought dentistry into the medical sciences
in France.” (A)
battlefields, physicians employed recently invented medical technology in
addressing their patients’ injuries. The X-ray machine, which had been invented
a couple decades before the war, was invaluable for doctors searching for
bullets and shrapnel in their patients’ bodies. Marie Curie installed X-ray
machines in cars and trucks, creating mobile imaging in the field. And a French
radiologist named E.J. Hirtz, who worked with Curie, invented a compass that
could be used in conjunction with X-ray photographs to pinpoint the location of
foreign objects in the body. The advent of specialization within the medical
profession in this era, and the advancement of technology helped to define
those specialized roles.” (B)
“Battlefield medicine evolved considerably between World War
I and World War II. In the former, approximately 4 out of every 100 wounded men
could expect to survive; in the latter, the rate improved to 50 out of 100…
A number of new drugs and medical techniques developed in
the years between the world wars dramatically improved the survival rate among
the sick and injured. For example, combat medics (and even men in the field)
carried packets of sulfanilamide and sulfathiazole to coat wounds as a first
line of defense against infection. Antibiotics such as streptomycin and
penicillin also helped save the lives of countless soldiers…
American servicemen were also inoculated for a wide variety
of diseases before being shipped overseas. The most common vaccinations were
for smallpox, typhoid, and tetanus, though soldiers assigned totropical or
extremely rural areas were also vaccinated for cholera, typhus, yellow fever,
and, in somecases, bubonic plague.” (A)
“World War Two was a time where medicine began catching up
with evolving technology. In World War
One infection took the lives of many soldiers along with disease. The number of deaths from injury complications
motivated scientists and doctors to determine cures for infection…
One development was the creation of Penicillin. It was created pre-war but was not used in
large quantities till World War Two. The
first batches in 1939 were weak, but through determination a new version, 20
times more strong, came out in 1945 ().
On D-Day penicillin was used en masse, saving thousands of lives and
strengthening America’s cause. It saved
many lives, but still left many to die because the time lapse between injury
and treatment still remained very broad.
However, the number of people being infected was vastly decreased and
survival chances were greatly increased…
The mediocre blood transfusion process was also greatly
improved upon in World War Two.
Primitive techniques became more advanced, and the system of storing and
distributing blood became more efficient.
With a better system of storing blood, blood was usually available when
a soldier needed it. The blood was also
most likely fresher and less contaminated since the containers were better
constructed. However, blood was often in
short supply.” (B)
“A major contribution of the 20th century was the widespread
recognition and treatment of what we now call post-traumatic stress disorder,
or PTSD. It has probably existed back into history. There are case reports from
the Civil War, for example. During World War I, it was sometimes called “shell
shock,” which probably included cases of actual brain damage. More often
soldiers suffering from PTSD were diagnosed as “cowardice.” Soldiers were shot
for it in the British, French, German, Austrian, and Russian armies. As the war
dragged on, it became better recognized, but its treatment varied widely. The
Russians tried to treat near the front lines, sending the soldiers back to
their units as early as feasible. We adopted that practice, and in fact, armies
today still treat psychiatric casualties this way. What may seem heartless,
actually proved to be the most effective way to treat PTSD and to prevent long
term sequelae. The recognition of PTSD as a psychiatric disease of war was not
firmly established until World War II. They called it “combat fatigue.” But
whatever they called it, they recognized it and treated it.” (C)
“Though the Korean War came to be regarded as a failure by
many because of its unsettled conclusion, in one area it was an unreserved
success: the care and treatment of wounded soldiers. In World War II, the
fatality rate for seriously wounded soldiers was 4.5 percent. In the Korean
War, that number was cut almost in half, to 2.5 percent. That success is
attributed to the combination of the Mobile Army Surgical Hospital, or MASH
unit, and the aeromedical evacuation system – the casualty evacuation (casevac)
and medical evacuation (medevac) helicopter. Both had been developed and used
to a limited extent prior to 1950, but it was in the Korean War that both –
particularly the helicopter – came into their own, and as Army Maj. William G.
Howard wrote, “fundamentally changed the Army’s medical-evacuation doctrine.”
Helicopter medevacs transported more than 20,000 casualties during the war. One
pilot, 1st Lt. Joseph L. Bowler, set a record of 824 medical evacuations over a
10-month period. Another example tellingly highlights the impact of the
helicopter. The Eighth Army surgeon estimated that of the 750 critically
wounded soldiers evacuated on Feb. 20, 1951, half would have died if only
ground transportation had been used…
The Korean War also provided an opportunity to study and
test new equipment and procedures, many of which would go on to become
standards of care in both the military and civilian medical communities. These
included vascular reconstruction, the use of artificial kidneys, development of
lightweight body armor, and research on the effects of extreme cold on the
body, which led to development of better cold weather clothing and improved
cold weather medical advice and treatment. The newest antibiotics were used
widely, and other drugs that advanced medical care included the anticoagulant
heparin, the sedative Nembutal, and the use of serum albumin and whole blood to
treat shock cases. In addition, computerized data collection (in the form of
computer punch cards) of the type of battle and non-battle casualties was used
for the first time. The extensive detail and accessibility of this data allowed
for the most thorough and comprehensive analysis of military medical
information yet…” (A)
Medical professionals made significant changes to the way
they treated injured troops during the Korean War, which led to fewer
casualties as well as medical advancements for civilians. The war set the stage
for how medical professionals treat trauma patients today.” (B)
“Both the Korean and Vietnam wars proved to be
severe challenges to the medical system, the former for cold weather
operations, and the latter for tropical and jungle warfare. The medical
services gradually adapted to these challenges. By the time of the Vietnam war,
for example, operations could be done in contained, air-conditioned operating
theaters that were containerized so as to be moved close to the battlefield.
(See Figure 6.) Helicopter evacuation supplemented ground ambulances, and air
transport replaced hospital trains. The system of progressive levels of
casualty care has turned into doctrine, and remains the guiding principle for
casualty care. Operation during the 40 years since Vietnam have produced far
fewer casualties, yet have challenged the military medical services in
different ways. Small unit operations at greater and greater distances have
increased reliance on medical corpsmen, who are now trained to at least the
level of civilian Emergency Medical Technicians, and often higher. Casualty
care and evacuation in a hostile civilian environment, always a problem in
warfare, has been made more complex by opponents who refuse to respect the
non-combatant status of medical facilities and personnel.” (A)
“In the Vietnam War, with its close quarters and heavy use
of helicopters, the time between hurt and help averaged two hours but could be
as little as 30 minutes. With the improved speed came a reduction in deaths
among the wounded, from 8.5 percent in World War I to 1.7 percent in Vietnam.
In the Persian Gulf, “many of the wounded may have to
be carried first by litter from the field, then by truck back to a station
where helicopters may evacuate them to a surgical hospital,” General
Blanck said. “It could take hours in some situations.” The Platoon
Because of potential delays, the military now gives all
soldiers training in a few emergency medical techniques like clearing
respiratory blockage. “A wounded soldier’s survival may depend on his
buddy’s ability to initiate lifesaving care on the battlefield,” wrote
Lieut. Col. James A. Martin, commander of the Army Medical Research Unit.
“Each soldier should possess the skill to clear an airway, control
bleeding and start an intravenous fluid line to control shock.”
Foot soldiers do not have that full training, but in many
platoons, General Blanck said, one soldier has been trained and designated the
“We did not have this in Vietnam,” he said,
“and it may really be needed in the kind of warfare we may have in the
Other changes since the Vietnam War include new vaccines and
treatments, including one for Hepatitis A and one to prevent septic shock from
a sudden invasion of certain types of bacteria in people who are most seriously
wounded. There are vaccines against local diseases, and one against anthrax to
protect troops who may be targets of biological warfare.
Once they reach a hospital, soldiers will benefit from
improved techniques to repair torn blood vessels and treat burns. CAT scanners
will be available in the larger hospitals of each corps, General Blanck said.
Heat Is a Serious Factor” (A)
“Injured veterans of the Iraq and Afghanistan Wars can give
credit to the medical personnel of earlier wars, including the Vietnam War, for
their care and recovery.
Surgeons, anesthesiologists, nurses, and other staff
advanced medical practices for soldiers receiving care in the areas of trauma
care and blood supply, repair of blood vessels to save limbs, and studying the
effects of a range of weapons.
The contributions of medical personnel improved the outcomes
of those wounded not only in Vietnam, but also subsequent wars.
A technique in trauma care in the use of topical
antimicrobial chemotherapy for the care of burns and other wounds was available
for the first time in the theater of operations.
Another practice that evolved during the Vietnam War was the
use of universal donor, or Type O, blood banks in various stations throughout
Techniques that were developed during World War II and the
Korean War greatly reduced the need for amputations in the field by tying the
major artery to the affected limb.
The improvements in emergency responses and trauma care
techniques that were developed during the Vietnam War are still relevant now.”
“The Navy corpsman
was overwhelmed. Dozens of Marines lay injured at the casualty collection point
following a devastating artillery bombardment—and the corpsman didn’t have
nearly enough to blood at hand to treat them all.
A soldier’s odds of survival increase nearly threefold if
they receive a blood transfusion within an hour of being injured.
Unfortunately, the Medical Battalion’s field hospital and its copious blood
supplies was over a dozen miles away. With the combat zone interdicted by enemy
fire, the odds that medical supplies or evacuation would arrive anytime soon
Hastily, the corpsman transmits a map coordinate and a brief
Fifteen minutes later, a swarm of drones comes swooping down
at over a miles per minute. Hatches in their bellies flip open, releasing not
bombs but small boxes which come floating down near the collection point using
Inside each box is some bubble wrap—and three units of blood
ready for transfusion.
Overhead, the drones bank around and soar back to the
medical battalion and glide towards a large trapeze-like contraption on the
ground. Precise maneuvers allow a hook on the drone’s tail to snag onto the
trapeze, bringing the unmmaned aircraft to a halt.
As the drones are recovered, staff swap out their spent
lithium-ion batteries for recharging, replacing them with fresh batteries—and
new cargo boxes in their bellies.
In a few minutes, the drones are ready to deliver even more
life-preserving blood products.
The above battle may never have happened—but it was
simulated in a series of exercise in Australia involving a U.S. Marine Corps
Air-Ground Taskforce, the Australian Defense Force…and a gaggle of
forward-deployed commercial drones.” (A)
ROBOTIC SURGERY“U.S. Army physicians, located far from a field hospital,
could soon be performing delicate, highly specialized surgery on wounded
soldiers using robotics and other forms of telemedicine.
Army Surgeon General Lt. Gen. Nadja West said recently that the demands of future battlefields will force the military medical community to prepare for operational environments that are vastly different.
“We might not have the
life-saving ‘golden hour’ evacuation system we have been accustomed to for the
past 17 years,” West told an audience recently at an Association of the
United States Army function.
“Our soldiers may be isolated
for 72 hours or more, requiring prolonged field care if injured in an austere
environment,” she said.
Enemy air superiority may not allow
the U.S. military to fly critically wounded soldiers to well-equipped hospitals
in far-off countries, so field hospitals may have to rely on new, robotic
technology to save patients, West added.
Robotic surgery, which is currently
used in non-invasive procedures, could be adapted to meet the Army’s
battlefield needs, she said.
“There is robotic surgery that’s
going on right now,” West said, adding that the challenge will be
“how quickly we can scale it all throughout our enterprise.” (A)
Over twenty years ago a general surgeon at one of our
community hospitals left the OR to operate at a competing hospital and told a
nurse to close the incision. He claimed OR nurses could train and be certified
as “closers”. Problem was the nurse hadn’t been certified and we did not have
hospital privileges for this competency. The nurse was fired and the surgeon
fought disciplinary action although up to the Board of Trustees. Recollection
is that he had been suspended from the medical staff, by me for over six months
and that became his penalty as well as a long period of probation.
There are many areas in the hospital where it may be hard
for a patient to discern who is actually providing care: an attending or a
resident? An anesthesiologist or a nurse anesthetist? an orthopedic (foot)
surgeon or a podiatrist for ankle surgery?; a primary care physician or a nurse
PART 1 before new Part 2.
You are the CMO of your local teaching and the CEO wants to know if you should
prohibit double-booking? And you are instructed to make sure patients know who
is treating them, so what do you do?
PART 1. December
5, 2017. Should surgeons be
allowed to operate in more than one OR at a time?
“Dr. Kirkham Wood arrived in the operating room at
Massachusetts General Hospital before 7 one August morning with a schedule for
the day that would give many surgeons pause.
Wood, chief of MGH’s orthopedic spine service at the time
and a nationally renowned practitioner in his specialty, is a confident,
veteran surgeon. He would need all of his talent and confidence this day, and
then some, as he planned to tackle two complicated spinal surgeries over the
next many hours — two patients, two operating rooms, moving back and forth from
one to the other, focusing on the challenging tasks that demanded his special
skills, leaving the other work to a general surgeon, who assisted briefly, and
two surgeons in training.
In medicine it is called concurrent surgery, and the
practice is hardly unique to Wood or MGH. It is allowed in some form at many
prestigious hospitals, limited or banned at many others. Hospitals that permit
double-booking consider it an efficient way to deploy the talents of their most
in-demand specialists while reducing wasted operating room time.” (A)
‘Known as “running two rooms” – or double-booked,
simultaneous or concurrent surgery – the practice occurs in teaching hospitals
where senior attending surgeons delegate trainees – usually residents or
fellows – to perform parts of one surgery while the attending surgeon works on
a second patient in another operating room. Sometimes senior surgeons aren’t
even in the OR, but are seeing patients elsewhere.
The decision about whether to allow the practice is left to
hospitals, which are primarily responsible for policing it. Medicare billing
rules permit it as long as the attending surgeon is present during the critical
portion of each operation – and that portion is defined by the surgeon. And
while it occurs in many specialties, double-booking is believed to be most
common in orthopedics, cardiac surgery and neurosurgery.” (B)
American College of Surgeons – Overlapping Operations-
Statements on Principles (C)
“Overlap of two distinct operations by the primary attending
surgeon occurs in two general circumstances.
The first and most common scenario is when the key or
critical elements of the first operation have been completed, and there is no
reasonable expectation that the primary attending surgeon will need to return
to that operation. In this circumstance, a second operation is started in
another operating room while a qualified practitioner performs noncritical
components of the first operation—for example, wound closure—allowing the
primary surgeon to initiate the second operation. In this situation, a
qualified practitioner must be physically present in the operating room of the
The second and less common scenario is when the key or
critical elements of the first operation have been completed and the primary
attending surgeon is performing key or critical portions of a second operation
in another room. In this scenario, the primary attending surgeon must assign
immediate availability in the first operating room to another attending
The patient needs to be informed in either of these
circumstances. The performance of overlapping procedures should not negatively
affect the seamless and timely flow of either procedure.””
“The Centers for Medicare and Medicaid Services does allow
surgeons to bill for concurrent surgeries under certain circumstances but
requires that the attending physician is “present during all critical and key
portions of both operations.”
Surgeon Matthew Indeck, president of the American College of
Surgeons’ central Pennsylvania chapter, said he “certainly would not support
cases being done in distant hospitals” or keeping a patient under
anesthesia longer than necessary.
But he acknowledged that a line delineating what’s
appropriate and what isn’t “is very fuzzy.”” (D)
“……transparency and patient consent. Wrong is the only way
to describe the fact that secretaries, nurses, anesthesiologists, residents,
and fellows knew but the patient did not. If you defend double-booking, tell
the patient. Sometimes I wonder why doctors don’t see themselves as patients.
To us, the experienced professional, medical, and surgical practice is rote.
It’s hardly so to the person being wheeled onto a narrow table on which they
will be cut open. Would any surgeon-patient consent to this practice?” (E)
“Swedish Health has decided to largely prohibit its doctors
from conducting overlapping surgeries, responding to the concerns of patients
who were troubled by the practice…
Under the new policy, implemented Monday, surgeons must be
present for the “substantial majority” of each surgical procedure. They are not
required to be present for the very end of the case — closing the surgical
incision once the planned procedure is completed — as that can be delegated to
a qualified fellow assisting on the case.
Some smaller aspects at the beginning of a surgery, such as
the harvesting of healthy blood vessels that would later be used in a
coronary-artery bypass surgery, can also be delegated while the attending
surgeon is out of the room, according to the policy. There is also flexibility
for unexpected emergencies.
Staff will document the times surgeons enter and exit the
operating room — something that didn’t previously appear in the records of many
surgical patients.” (F)
“Patients whose hip surgeries were performed by surgeons
overseeing two operations at once were nearly twice as likely to suffer serious
complications as those whose doctors focused on one patient at a time,
according to a large Canadian study, the first research to show that
overlapping surgery can pose health risks.
The study of more than 90,000 hip operations at some 75
hospitals in Ontario also found that the longer the duration of overlap between
surgeries, the more likely patients were to suffer a serious complication
within a year, including infections and a need for follow-up surgery.
“If your surgeon is in multiple places, there’s an increased
risk of having a complication,” Dr. Bheeshma Ravi, a hip surgeon at Sunnybrook
Health Sciences Centre in Toronto and lead author of the study to be published
Monday in JAMA Internal Medicine, told the Globe. “I think that just makes sense.””
Massachusetts is the first state to approve such requirements,
according to board members. A spokesman for the Federation of State Medical
Boards, which represents the nation’s 70 state medical and osteopathic
regulatory boards, said it was unaware of any other states with similar
“Beginning next month, all surgeons in Massachusetts will be
required to document every time they enter or leave the operating room, and for
how long, for any reason. That’s according to a new rule passed Wednesday by
the Massachusetts Board of Registration in Medicine. Along with documenting
their entry or exit, surgeons will also be required to identify the names of
any participating “physician extenders” including residents, fellows, and
Candace Lapidus Sloane, chairwoman of the medical board,
told The Globe, “As a doctor and as a patient, I know that when you undergo a
serious surgery, or your loved one undergoes a serious surgery, you find the
best doctor you can. You’re going there for that surgeon’s skill. And if it’s
not going to be that surgeon [who actually does the operation], the patient has
a right to know.” Basically, it comes down to getting what you’re paying for,
The only opposition to the rule, as stated by The Globe, was
from the Massachusetts Medical Society which deemed it too hard to identify all
“physician extenders” because, especially at teaching hospitals, things can
switch in an instant. But at that point, the patient should be informed and it
should be their prerogative to move forward with the procedure or not.” (B)
“The issue was catapulted into public consciousness in
October 2015 by an exhaustive investigation of concurrent surgery at Harvard’s
famed Massachusetts General Hospital by The Boston Globe. The validity of the
story has been vehemently disputed by hospital officials who defend their care
as safe and appropriate…
Patients who signed standard consent forms said they were
not told their surgeries were double-booked; some said they would never have
agreed had they known…
Critics of the practice, who include some surgeons and
patient-safety advocates, say that double-booking adds unnecessary risk, erodes
trust and primarily enriches specialists. Surgery, they say, is not piecework
and cannot be scheduled like trains: Unexpected complications are not uncommon.
All patients “deserve the sole and undivided attention of
the surgeon, and that trumps all other considerations,” said Michael
Mulholland, chair of surgery at the University of Michigan Health System, which
halted double-booking a decade ago. Surgeons might leave the room when a
patient’s incision is being closed, Mulholland said. A computerized system
records the doctor’s entry and exit…
Some surgeons say they are troubled by the resemblance of
double-booking to a practice known as “ghost surgery,” in which patients learn,
usually after something goes wrong, that someone other than the surgeon they
hired performed their operation…
Rickert and others advise patients who want to avoid overlap
to ask detailed questions well in advance and to put their request in writing
and on the consent form.
“If you say, ‘I want only you to do the surgery,’ doctors
will typically do it,’” Rickert said. “They want the business.”
He also recommends asking, “Are you going to be in the room
the entire time during my surgery?” and then repeating that statement in front
of the OR nurses the day of surgery. “If the doctor’s not willing to say yes,
vote with your feet.”
If a surgeon says he or she will be “present” or
“immediately available,” a patient should ask what that means. It may mean that
the surgeon is somewhere on a sprawling hospital campus but not in — or even
near — your operating room. (C)
“I certainly knew that for many procedures, residents
might be involved,” said Arthur Caplan, a professor of bioethics at NYU
School of Medicine. (NYU Langone Medical Center does not permit concurrent
surgery.) “But I was a little taken aback that the attending surgeon was
not in the room.” (D)
“A recent trial resulting in a $2 million malpractice
verdict pulled back the curtain on a Syracuse orthopedic surgeon’s routine of
doing 14 operations in a single day.
A state Supreme Court jury in Syracuse unanimously found Dr.
Brett Greenky and his practice, Syracuse Orthopedic Specialists, negligent July
2 for his handling of a hip replacement surgery performed six years ago. The
lawsuit says the operation permanently injured Dorothy G. Murphy, 63, who is
still limping, using a cane and in pain. She is a former Camillus resident who
now lives in Florida.
The trial shined a light on a controversial hospital
practice in which a doctor leaves the operating room after completing the most
critical part of an operation to start surgery on another patient in a second
Murphy was the sixth of Greenky’s 14 patients on Sept. 9,
2013 at St. Joseph’s Hospital Health Center…
During the trial Robert Lahm, Murphy’s attorney, likened
Greenky’s surgical approach to an “assembly line.” A copy of Greenky’s schedule
for that day shows most of the operations were total knee and hip replacements.
Patients were staggered across two operating rooms. Greenky
would cut open a patient, put in an implant, close up part of the incision,
then leave before the operation was over to start surgery on another
anesthetized patient in a second room. Meanwhile, a resident physician in
training or physician assistant closed the previous patient’s wound and applied
Sometimes Greenky does overlapping surgery in three
operating rooms. In a deposition, he said he performs about 600 knee and hip
replacements annually and each operation takes, on average, 45 minutes…
Murphy said she cannot understand why surgeons performing
complex operations are allowed to work more than 14 hours a day when bus
drivers are prohibited by federal regulations from driving more than 10 hours.”
“A judge has ordered Massachusetts General Hospital to
release a secret 2011 report written by a lawyer whom the hospital hired to
investigate its practice of letting some surgeons oversee more than one
operation at a time.
Suffolk Superior Court Judge Rosemary Connolly said that —
pending a possible appeal — the hospital must share an unredacted copy of the
report with an orthopedic surgeon fired by Mass. General in 2015 after he
complained about concurrent surgeries…
Burke, who now practices at Beth Israel Deaconess Hospital
in Milton, worked for Mass. General for 35 years until he was dismissed in
August 2015. The hospital said he was fired for improperly releasing patient
records, with names redacted, to the Globe. Burke contends he was sacked
because he blew the whistle on what he considered a serious patient-safety
In 2011, the hospital hired a former US attorney, Donald
Stern, to investigate Burke’s complaints to Mass. General officials about
concurrent surgeries, also known as double-booking. The hospital never made the
report public, but Dr. Peter Slavin, the hospital’s president, told the Globe
in 2015 that Stern “found no basis to support Dr. Burke’s concerns.”
Burke’s attorneys have repeatedly requested the report. But
Mass. General’s lawyers have insisted it contains legal advice from Stern to
the hospital and is protected by attorney-client privilege.
The judge rejected that argument. She said Mass. General
hired Stern to conduct an internal review, not to provide legal advice. She
also noted that the hospital shared the report with a public relations firm,
Rasky Baerlein Strategic Communications, which it hired to respond to the
And, the judge wrote, the hospital allowed the report to be
stored on a computer server at Simmons College, which employed a dean who
headed Mass. General’s Board of Trustees.
“MGH has used the report as both sword and shield,” Connolly
“The mounting evidence all leads to the conclusion that even
if sections of the Stern report were once privileged, they no longer are,” she
In addition to ordering the hospital to turn over the
report, the judge directed it to provide all drafts of the document and backup
Ellen J. Zucker, Burke’s lead counsel, was pleased. “In the
end, based on MGH’s own words and conduct, this is not a close call,” Zucker
“It’s never an easy business to predict which flu viruses
will make people sick the following winter. And there’s reason to believe two
of the four choices made last winter for this upcoming season’s vaccine could
be off the mark.”
“Flu circulation “remains difficult to predict and flu
viruses are constantly breaking rules that we try to establish for them,”..”
“No battle plan survives contact with the enemy” *
Health Officer: Where vaccination sites should be
established? Is there a special plan to monitor restaurants and food shops
where flu-related safety guidelines need to be strictly enforced? Who will
start preparing a Community Education plan?
Hospital: What is the back-up plan if hospital becomes
“contaminated” and is closed to admissions, or if nursing staff is depleted by
flu-related absenteeism, etc.? ICU triage? Availability of respirators?
screening centers if hospital ER is on overload
Hoboken Volunteer Ambulance Corps: “mutual assist” plan
Hoboken Police Department & Hoboken Fire Department:
back-up plan if the ranks get depleted by the flu
BOE: criteria in deciding whether or not to close schools
Stevens Institute of Technology: surveillance and plan for
“Field Manual” for the Mayor outlining all variabilities and
Why was there no swine flu surge in NJ/ NYC metro area?
maybe “herd” immunity” from prior year’s flu?
“Australia had an unusually early and fairly severe flu
season this year. Since that may foretell a serious outbreak on its way in the
United States, public health experts now are urging Americans to get their flu
shots as soon as possible.
“It’s too early to tell for sure, because sometimes
Australia is predictive and sometimes it’s not,” said Dr. Daniel B. Jernigan,
director of the influenza division of the Centers for Disease Control and
Prevention. “But the best move is to get the vaccine right now.”..
In 2017, Australia suffered its worst outbreak in the 20
years since modern surveillance techniques were adopted. The 2017-2018 flu
season in the United States, which followed six months later as winter came to
the Northern Hemisphere, was one of the worst in modern American memory, with
an estimated 79,000 dead.” (A)
“Maryland health officials on Tuesday confirmed the first 11
influenza cases of the flu season. Officials urge Marylanders to get vaccinated.
“We don’t know yet whether flu activity this early indicates
a particularly bad season on the horizon,” Maryland Department of Health
Secretary Robert R. Neall said in a statement. “Still, we can’t emphasize
strongly enough – get your flu shot now. Don’t put it off. The vaccine is
widely available at grocery stores, pharmacies and local health clinics, in
addition to your doctor’s office.”
Most of the 11 cases recorded since Sept. 1 have been
subtyped as influenza A, with a few classified as influenza B. Though most
influenza cases are mild, the virus can pose a serious risk for young children,
seniors, pregnant women and people with compromised immune systems.
During last year’s flu season, 3,274 people were
hospitalized and 82 died as a result of the flu in Maryland, according to state
health officials.” (B)
“The first pediatric influenza-associated death of the
2019-20 flu season has been reported in California. According to a statement
issued by Riverside University Health System a 4-year-old child who tested
positive for the flu and had underlying health issues passed away from his
According to the US Centers for Disease Control and
Prevention (CDC) a total of 130 influenza-associated pediatric deaths were
reported during the 2018-19 flu season. This number was a decrease from the 187
pediatric deaths reported during the 2017-18 season.
CDC investigators hypothesize that the real-world impact of
the flu is being underreported. “Using mathematical modeling to account for
under-detection, CDC estimates that the actual number of flu-related deaths in
children during [the 2017-18] season was closer to 600—nearly 3 times what was
reported through existing mechanisms,” the authors of a recent report wrote in
a flu spotlight.
Cameron Kaiser, MD, public health officer of Riverside
County, says that this early season death could be predictive of a severe flu
“The overall effectiveness of last flu season’s vaccine was
only 29% because it didn’t protect against a flu virus that appeared later in
the season, according to the U.S. Centers for Disease Control and Prevention.
It said the vaccine was 47% effective into February, but
that dropped to just 9% after the late strain showed up, the Associated Press
Flu vaccines are created each year to protect against flu
strains predicted to be circulating in the upcoming season.
The effectiveness of last season’s vaccine was the second
lowest since 2011. The vaccine for the 2014-15 flu season was only 19%
effective, the AP reported.” (D)
It’s never an easy business to predict which flu viruses
will make people sick the following winter. And there’s reason to believe two
of the four choices made last winter for this upcoming season’s vaccine could
be off the mark.
Twice a year influenza experts meet at the World Health
Organization to pore over surveillance data provided by countries around the
world to try to predict which strains are becoming the most dominant. The
Northern Hemisphere strain selection meeting is held in late February; the
Southern Hemisphere meeting occurs in late September.
The selections that officials made…for the next Southern
Hemisphere vaccine suggest that two of four viruses in the Northern Hemisphere
vaccine that doctors and pharmacies are now pressing people to get may not be
optimally protective this winter. Those two are influenza A/H3N2 and the
influenza B/Victoria virus…
Flu vaccine is a four-in-one or a three-in-one shot that
protects against both influenza A viruses — H3N2 and H1N1 — and either both or
one of the influenza B viruses, B/Victoria and B/Yamagata. Most flu vaccine is
made with killed viruses, and most vaccine used in the United States is
quadrivalent — four-in-one…
“A shortage of high dose flu shots is concerning some older
The Vanderburgh County Health Department says people older
than 65 are recommended to take a high dose flu shot.
Director of Clinical Outreach, Lynn Herr, says there is an
option rather than not getting the shot at all.
“Then we need to have a conversation with our primary caregiver
saying go ahead and get the regular or go ahead and wait for the higher dose
According to the CDC, the high dose vaccine helps people 65
years or older have a better fight against the flu.
This shot contains four times the antigen than a regular flu
“DEFINITION OF EMERGENCY RESPONSE
“Emergencies”? Emergencies are incidents that threaten public safety, health
and welfare. If severe or prolonged,
they can exceed the capacity of first responders, local fire fighters or law
enforcement officials. Such incidents
range widely in size, location, cause, and effect, but nearly all have an
environmental component.” (G)
Medical surge capacity refers to the ability to evaluate and
care for a markedly increased volume of patients—one that challenges or exceeds
normal operating capacity. The surge requirements may extend beyond direct
patient care to include such tasks as extensive laboratory studies or
Because of its relation to patient volume, most current
initiatives to address surge capacity focus on identifying adequate numbers of
hospital beds, personnel, pharmaceuticals, supplies, and equipment. The problem
with this approach is that the necessary standby quantity of each critical
asset depends on the systems and processes that:
Identify the medical need
Identify the resources to address the need in a timely
Move the resources expeditiously to locations of patient
need (as applicable)
Manage and support the resources to their absolute maximum
In other words, fewer standby resources are necessary if
systems are in place to maximize the abilities of existing operational
resources. Moreover, the integration of additional resources (whether standby,
mutual aid, State or Federal aid) is difficult without adequate management
systems. Thus, medical surge capacity is primarily about the systems and
processes that influence specific asset quantity.
Basic example: If a hospital wishes to have the capacity to
medically manage 10 additional patients on respirators, it could buy, store,
and maintain 10 respirators. This would provide an important component of that
capacity (other critical care equipment and staff would also be needed), but it
would also be very expensive for the facility. If the hospital establishes a
mutual aid and/or cooperative agreement with regional hospitals, it might be
able to rely on neighboring hospitals to loan respirators and credentialed
staff and, therefore, might need to invest in only a few standby items (e.g.,
extra critical care beds), minimizing purchase and maintenance of expensive
equipment that generate no income except during rare emergency situations.” (H)
Today, Rapid Response Teams (RRTs) are a crucial component
of many hospitals. Implementing a RRT
was one of the six strategies that defined the Institute for Healthcare
Improvement (IHI) 100,000 Lives campaign.
Most RRTs consist of critical care nurses, but they can also include
respiratory therapists, pharmacists, and physicians.
Research consistently shows that patients exhibit signs and
symptoms of deterioration for several hours prior to a code. These symptoms include changes in vital
signs, mental status, and lab markers. The goal of a RRT is to intervene
upstream from a potential code. They
reach the patient before deterioration turns into crisis. This is different than a code blue team that
typically responds to a patient that has already decompensated to cardiac
Historically, most hospitals relied on busy bedside nurses
to identify crashing patients and call for rapid response. With 49 states having no limits on the number
of patients assigned per nurse, many medical-surgical ward nurses are caring
for 6 or more patients per shift.
Placing this additional responsibility on their already over-flowing
plate is challenging at best. Providing
a RRT empowers bedside nurses to trigger an escalation of care earlier and
“… even the U.S. is disturbingly vulnerable—and in some
respects is becoming quickly more so. It depends on a just-in-time medical
economy, in which stockpiles are limited and even key items are made to order.
Most of the intravenous bags used in the country are manufactured in Puerto
Rico, so when Hurricane Maria devastated the island last September, the bags
fell in short supply. Some hospitals were forced to inject saline with
syringes—and so syringe supplies started running low too. The most common
lifesaving drugs all depend on long supply chains that include India and
China—chains that would likely break in a severe pandemic. “Each year, the
system gets leaner and leaner,” says Michael Osterholm, the director of the
Center for Infectious Disease Research and Policy at the University of
Minnesota. “It doesn’t take much of a hiccup anymore to challenge it.”” (J)
“One hundred years ago, in 1918,
a strain of H1N1 flu swept the world. It might have originated in Haskell
County, Kansas, or in France or China—but soon it was everywhere. In two years,
it killed as many as 100 million people—5 percent of the world’s population,
and far more than the number who died in World War I. It killed not just the
very young, old, and sick, but also the strong and fit, bringing them down
through their own violent immune responses. It killed so quickly that hospitals
ran out of beds, cities ran out of coffins, and coroners could not meet the
demand for death certificates. It lowered Americans’ life expectancy by more
than a decade. “The flu resculpted human populations more radically than
anything since the Black Death,” Laura Spinney wrote in Pale Rider, her 2017
book about the pandemic. It was one of the deadliest natural disasters in
history—a potent reminder of the threat posed by disease.” (K)
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Over time JCMC was
designated as: a Regional Perinatal Center; Level II Trauma Center; Teaching
Hospital Cancer Program; a Children’s Hospital; and approved to start cardiac
surgery/ interventional cardiology. With these programs JCMC became a major
teaching affiliate of Mount Sinai School of Medicine and a total replacement hospital
was opened on a new site in 2004.
cardiac surgery problems at Johns Hopkins All Children’s Hospital and North
Carolina Children’s Hospital are due, in part, to the disappearance of most state
CON regulations resulting in hospitals opening “trophy” services that lead to
low volume programs. Funding becomes a challenge.
ASSIGNMENT: What are the Lessons Learned from the Johns
Hopkins All Children’s Hospital and North Carolina Children’s Hospital
pediatric open cardiac surgery program failures? What are the regulatory
After New PART 4 are excerpts from Parts 1-3, as well as an unabridged chronology.
PART 4. Johns Hopkins All Children’s Hospital and North
Carolina Children’s Hospital pediatric cardiac surgery programs at
Family members were never told that Navy veteran Darryl
Young was in an irreversible vegetative state after his heart transplant last
year, and staff never offered hospice, other palliative care services or a Do
Not Resuscitate directive, ProPublica revealed.
Meanwhile, behind the scenes, doctors were secretly recorded
discussing how Young needed to be aggressively cared for despite their belief
that he would never wake up or recover function, the ProPublica report said.” (H)
“The North Carolina
Children’s Hospital got a bit of good news last week from a state agency that
sent a team of investigators on-site for 11 days of questioning and review of
the pediatric heart surgery program.
The state Department of Health and Human Services says the
program currently is in compliance with U.S. Centers for Medicare and Medicaid
An external review board was tapped to evaluate the program
and new Quality and Safety reporting procedures were put in place.
The external review board has had one telephone conference
meeting, according to Alan Wolf, a spokesman for the health care system, and
has plans to meet in person soon.
Despite the state health department’s findings, the UNC
Health Care system has no plans to schedule those types of surgeries before the
external review is complete, according to Wolf.” (A)
“The families of two children who were paralyzed after heart
surgeries at Johns Hopkins All Children’s Hospital will receive $26 million and
$12.75 million in settlements with the hospital, state records show.
Although the identities of the children are not public, the
records describing their cases match two of the patients featured in a Tampa
Bay Times investigation into the hospital’s troubled heart unit. Both families
were struggling with the costs of caring for a permanently disabled child with
no relief in sight.
A third family that lost a child after heart surgery will
In June, Johns Hopkins Health System CEO Kevin Sowers told the
Times that he and hospital leaders had reached out to the families of children
who died or were injured in the hospital’s heart surgery unit.
“We made a mistake, and we need to make sure we help support
these families and make it right,” he said… (B)
“UNC Hospitals in Chapel Hill is on probation after the
system received preliminary denial of its accreditation.
Preliminary Denial of Accreditation is recommended when
there’s an immediate threat to health and safety, a submission of falsified
documents or misrepresented information, a lack of a required license, or
significant noncompliance with Joint Commission standards, according to the
“To be clear: There was no finding of any immediate threats
to patient health and safety,” UNC Health Care spokesman Alan Wolf said in an
The Joint Commission recently conducted the triennial
accreditation survey, when surveyors examined the main hospital in Chapel Hill.
UNC Health Care credited the slide in accreditation to new
standards by the Joint Commission. The hospital will remain on preliminary
denial of accreditation status until the hospital undergoes a new survey and
satisfies the requirements.
The hospital network says it has already put plans in place
to fix each problematic area…
UNC Health Care said the Joint Commission accepted its plans
of correction, and expects the validation survey to take place next week.” (C)
UNC Hospitals is one step closer to regaining its clean
reputation, but concerns remain.
After completing follow-up inspections, the Joint Commission
lifted its preliminary denial of UNC Hospitals’ accreditation and upgraded the
hospital to “accreditation with a follow-up survey.”
UNC Hospitals was originally placed on probation because it
failed to meet the suicide prevention standards of the Joint Commission…
Most of the serious problems revolved around the treatment
of mental health patients, particularly those at risk for suicide attempts or
for being abused and exploited. The Joint Commission demanded better management
of ligature risks — places where a patient could hang or choke themselves — and
better identification of potential victims of abuse.
The Joint Commission only recommends Preliminary Denial of
Accreditation when there’s an immediate threat to health and safety, a
submission of falsified documents or misrepresented information, a lack of a
required license, or significant noncompliance with Joint Commission standards…
The clean bill of accreditation means the Joint Commission
is satisfied with UNC Hospitals’ response to its performance issues. But the
hospitals will probably face added scrutiny.” (D)
A North Carolina children’s hospital that stopped performing
complex heart surgeries in recent months after high death rates were disclosed
may now resume the procedures, according to an advisory board that was
examining the hospital’s practices.
The board noted “significant investment and progress” had
been made at North Carolina Children’s Hospital while suggesting areas for
improvement, including increasing the number of surgeries performed, a factor
associated with better outcomes.
The external board made its recommendations in a six-page
report released on Tuesday by UNC Health Care, which runs the hospital and is
affiliated with the University of North Carolina…..
The advisory board did not seem to address conditions at the
hospital when doctors voiced concerns several years ago, but noted that “team
dynamics and interactions appear to be strong.” Recommendations it made to the
hospital’s board of directors included continuing to publicly report mortality
data; hiring a second full-time pediatric heart surgeon; and considering a
joint venture with another hospital to increase the volume of surgeries.
Concerns about the quality of pediatric heart surgery
programs have been disclosed at hospitals across the country, especially at
institutions with a smaller number of surgeries. Several programs have been
suspended or shut down; other hospitals have merged their programs with larger
ones to achieve more consistent results.
The advisory board was composed of three doctors from
outside institutions: Nationwide Children’s Hospital in Columbus, Ohio; the
University of Michigan School of Medicine; and Children’s Hospital of
Two doctors leading UNC’s pediatric heart program previously
worked at two of those institutions: Dr. Timothy Hoffman, chief of pediatric
cardiology, came to UNC from Nationwide Children’s Hospital. Dr. Mahesh Sharma,
chief pediatric cardiac surgeon, joined UNC from Children’s Hospital of
“The News & Observer reports the outside review board’s
report was announced Tuesday. It noted ongoing improvements in the unit, though
it advised the hospital to consider if patients with complex heart problems
along with additional illnesses should be referred to other hospitals.” (F)
“Rumors floated around a children’s heart surgery unit in a
major hospital of a major city. Babies operated on for complex heart problems
were dying, and dying at rates far higher than those of comparable hospitals.
Doctors and cardiologists feared, even avoided, referring young babies for
surgery at the unit — a culture of silence surrounding it all…
But this is not UNC. And this is not 2019. This was thirty
years ago at Bristol Royal Infirmary, the flagship hospital of Bristol, a city
of about 500,000, in the United Kingdom.
“It would be reassuring to believe that it could not happen
again,” wrote Sir Ian Kennedy, chair of the public inquiry into the tragedy
that claimed the lives of dozens of babies at Bristol. But he didn’t sound
particularly reassured, and sadly his doubt has been borne out. It has happened
The parallels between the two scandals are uncanny. At both
hospitals, the cardiac surgery for very young babies was malfunctioning, and
babies were dying at appalling rates. At both hospitals a culture of silence
surrounded a growing sense among staff that something was going
And at both hospitals it took outsiders to blow the whistle:
at UNC someone leaked recordings of the conversations held by a group of
concerned cardiologists (doctors who refer patients to cardiac surgery) in June
2016 to the New York Times. Dr Kevin Kelly, leader of the children’s hospital
at UNC, had convened the meeting to discuss the “crisis.” “When you walk out of
here,” he says in the recordings, “stop talking about it outside of this room.”
At Bristol thirty years ago, a young new anesthetist named
Stephen Bolsin grew concerned about eight-hour operations instead taking
twelve. He began to collect data on the outcomes of babies at the unit. When he
sensed the numbers didn’t look good, he took his concerns to the head of the
unit, surgeon James Wisheart, who shut him down.
When Bolsin went over his head
to the hospital manager, Wisheart got wind of this breach in the strict medical
hierarchy and said this amazing – and terrifyingly similar – thing: “If you
wish to remain in Bristol you should not disclose the results of pediatric
cardiac surgery to people outside the unit ever again.”” (G)
PART 1. Brand names don’t always signify the highest quality
“Sandra Vázquez paced
the heart unit at Johns Hopkins All Children’s Hospital.
Her 5-month-old son, Sebastián Vixtha, lay unconscious in
his hospital crib, breathing faintly through a tube. Two surgeries to fix his
heart had failed, even the one that was supposed to be straightforward.
Vázquez saw another mom in the room next door crying. Her
baby was also in bad shape.
Down the hall, 4-month-old Leslie Lugo had developed a serious
infection in the surgical incision that snaked down her chest. Her parents
argued with the doctors. They didn’t believe the hospital room had been kept
By the end of the week, all three babies would die…
The internationally renowned Johns Hopkins had taken over
the St. Petersburg All Children’s Hospital six years earlier and vowed to
transform its pediatric heart surgery unit into one of the nation’s best.
Instead, the program got worse and worse until children were
dying at a stunning rate, a Tampa Bay Times investigation has found.
Nearly one in 10 patients died last year. The mortality
rate, suddenly the highest in Florida, had tripled since 2015…
Times reporters spent a year examining the All Children’s
Heart Institute – a small, but important division of the larger hospital
devoted to caring for children born with heart defects…
They discovered a program beset with problems that were
whispered about in heart surgery circles but hidden from the public.
Among the findings:
All Children’s surgeons made serious mistakes, and their
procedures went wrong in unusual ways. They lost needles in at least two
infants’ chests. Sutures burst. Infections mounted. Patches designed to cover
holes in tiny hearts failed.
Johns Hopkins’ handpicked administrators disregarded safety
concerns the program’s staff had raised as early as 2015. It wasn’t until early
2017 that All Children’s stopped performing the most complex procedures. And it
wasn’t until late that year that it pulled one of its main surgeons from the
Even after the hospital stopped the most complex procedures,
children continued to suffer. A doctor told Cash Beni-King’s parents his
operation would be easy. His mother and father imagined him growing up, playing
football. Instead multiple surgeries failed, and he died.
In just a year and a half, at least 11 patients died after
operations by the hospital’s two principal heart surgeons. The 2017 death rate
was the highest any Florida pediatric heart program had seen in the last decade.
Parents were kept in the dark about the institute’s
troubles, including some that affected their children’s care. Leslie Lugo’s
family didn’t know she caught pneumonia in the hospital until they read her
autopsy report. The parents of another child didn’t learn a surgical needle was
left inside their baby until after she was sent home.
The Times presented its findings to hospital leaders in a
series of memos early this month. They declined interview requests and did not
make the institute’s doctors available to comment.
In a statement, All Children’s did not dispute the Times’
reporting. The hospital said it halted all pediatric heart surgeries in October
and is conducting a review of the program.
“Johns Hopkins All Children’s Hospital is defined by our
commitment to patient safety and providing the highest quality care possible to
the children and families we serve,” the hospital wrote. “An important part of
that commitment is a willingness to learn.” (G)
The top three leaders of Johns Hopkins All Children’s
Hospital in Florida resigned Tuesday following a Tampa Bay Times investigation
that revealed increasing mortality rates among heart surgery patients.
The resignations from the 259-bed teaching hospital in St.
Petersburg included CEO Jonathan Ellen, M.D., and Vice President Jackie Crain,
as well as Jeffrey Jacobs, M.D., who is the heart institute’s deputy director,
the Tampa Bay Times reported. Paul Colombani, M.D., stepped down as chairman of
the department of surgery but will continue working in a clinical capacity, a
statement from the health system said…
Johns Hopkins, which owns and operates the hospital, said it
would install Kevin Sowers, who is president of the Johns Hopkins Health System
and executive vice president of Johns Hopkins Medicine, to lead the hospital in
a temporary capacity while a plan for interim leadership is put into place.
Johns Hopkins’ board also said it commissioned an external
review to examine the heart surgery program and said it would share its lessons
from the review to help hospitals around the country avoid the same mistakes.
The moves come following the Tampa Bay Times investigation
that highlighted a growing number of heart surgery deaths at the hospital amid
warnings about safety from staffers that went unheeded. (H)
“Three additional senior administrators have left Johns
Hopkins All Children’s Hospital in the wake of a Tampa Bay Times investigation
into high mortality rates at the hospital’s Heart Institute, the hospital
A total of six senior officials have left since the Times
report, including the hospital’s CEO, three vice presidents and two surgeons
who held leadership roles at the Heart Institute. A seventh official stepped
down as chairman of the surgery department but remained employed at the
hospital as a doctor.
The resignations announced Wednesday included vice
presidents Dr. Brigitta Mueller, the hospital’s chief patient safety officer,
and Sylvia Ameen, who oversaw culture and employee engagement and served as the
hospital’s chief spokeswoman.
The hospital also said Dr. Gerhard Ziemer, who started as
the Heart Institute’s new director and chief of cardiovascular surgery in
October, would leave the hospital. The hospital never publicly announced Ziemer
had been hired, and he had not yet obtained his Florida medical license when
the Times investigation was published at the end of November. At that point,
the hospital said the Heart Institute had already stopped performing surgeries.
Sowers also announced that Johns Hopkins had hired external
experts to develop a plan to restart heart surgeries at All Children’s.
That is a separate effort from an external review of the
problems in the Heart Institute, which Johns Hopkins announced its board had
commissioned last month, spokeswoman Kim Hoppe said…
Johns Hopkins is one of the most prestigious brands in
medicine and is internationally renowned for developing innovative patient
safety protocols that are used at hospitals across the world. But last weekend,
the Times published a story detailing a series of safety problems at hospitals
across its network. In response, the health system pledged to “do better.” (I)
“The Johns Hopkins Medicine Board of Trustees has appointed
a former federal prosecutor to lead its investigation into the Johns Hopkins
All Children’s Hospital’s heart surgery unit, the health system announced late
F. Joseph Warin, of the global law firm Gibson Dunn, and his
team will review the high mortality rates and other problems at the hospital’s
Heart Institute and report back to a special committee of the board of trustees
by May, the health system said.
Once the review is complete, the health system said it would
also name an independent monitor at All Children’s to “make sure that the
hospital is being held accountable for taking corrective action where
The announcement was accompanied by a video of Johns Hopkins
Health System president Kevin Sowers, who acknowledged for the first time that
the hospital had been warned about problems by frontline workers.
“I know personally that many of you courageously spoke out
when you had concerns but were ignored or turned away,” he said. “That behavior
is unacceptable and will not be tolerated going forward.”
Sowers, who is also interim president at All Children’s, said
he hoped to meet with the families of patients affected by problems in the
Heart Institute in the coming days to share his “profound sadness for the
failures of care they experienced.” (J)
“State and federal
inspectors descended on Johns Hopkins All Children’s Hospital this week,
following sharp calls for an investigation into problems in the hospital’s
heart surgery unit, the Tampa Bay Times has learned.
The scope of the inspection is unclear. But hospital
regulators had been criticized in recent weeks for their lax response to early
signs of an increase in mortality at the hospital’s Heart Institute…
State and federal regulators knew the institute was having
problems months earlier. In April, the hospital’s CEO told the Times that the
institute had “challenges” that led to an uptick in mortality, and acknowledged
the hospital had left surgical needles inside two children.
In May, state regulators cited the hospital for not properly
reporting two medical mistakes, which is required by state law. Days later, a
spokeswoman for the federal agency told the Times that it would perform its own
But state regulators didn’t fine the hospital, and
overlooked several subsequent warnings that its surgical results had been poor.
And federal inspectors later changed course and decided not
to undertake a comprehensive review of the heart surgery program, the Times
reported last month. One reason was that state inspectors hadn’t found any
violations of federal rules, a spokeswoman said. Another was that a nonprofit
hospital accreditor was due to perform a scheduled review.” (L)
showcases the promise of a much-touted but little understood collaboration in
health care: alliances between community hospitals and some of the nation’s biggest
and most respected institutions.
For prospective patients, it can be hard to assess what
these relationships actually mean – and whether they matter.
Leah Binder, president and chief executive of the Leapfrog
Group, a Washington-based patient safety organization that grades hospitals
based on data involving medical errors and best practices, cautions that
affiliation with a famous name is not a guarantee of quality.
To expand their reach, flagship hospitals including Mayo,
the Cleveland Clinic and Houston’s MD Anderson Cancer Center have signed
affiliation agreements with smaller hospitals around the country. These
agreements, which can involve different levels of clinical integration,
typically grant community hospitals access to experts and specialized services
at the larger hospitals while allowing them to remain independently owned and
operated. For community hospitals, a primary goal of the brand-name affiliation
is stemming the loss of patients to local competitors…
In some cases, large hospital systems opt for a different
approach, largely involving acquisition. Johns Hopkins acquired Sibley Memorial
and Suburban hospitals in the Washington, D.C., area, along with All Children’s
Hospital in St. Petersburg, Fla. The latter was re-christened Johns Hopkins All
Children’s Hospital in 2016…
Although affiliation agreements differ, many involve payment
of an annual fee by smaller hospitals. Officials at Mayo and MD Anderson
declined to reveal the amount, as did executives at several affiliates.
Contracts with Mayo must be renewed annually, while some with MD Anderson
exceed five years…
“It is not the Mayo Clinic,” said Dr. David Hayes, medical
director of the Mayo Clinic Care Network, which was launched in 2011. “It is a
Mayo clinic affiliate.”
Of the 250 U.S. hospitals or health systems that have
expressed serious interest in joining Mayo’s network, 34 have become members.
For patients considering a hospital that has such an
affiliation, Binder advises checking ratings from a variety of sources, among
them Leapfrog, Medicare and Consumer Reports, and not just relying on
“In theory, it can be very helpful,” Binder said of such
alliances. “The problem is that theory and reality don’t always come together
in health care.”
Case in point: Hopkins’ All Children’s has been besieged by
recent reports of catastrophic surgical injuries and errors and a spike in
deaths among pediatric heart patients since Hopkins took over. Hopkins’ chief
executive has apologized, more than a half-dozen top executives resigned and
Hopkins recently hired a former federal prosecutor to conduct a review of what
“For me and my family, I always look at the data,” Binder
said. “Nothing else matters if you’re not taken care of in a hospital, or you
have the best surgeon in the world and die from an infection.” ” (Q)
PART 2. June 1, 2019. “The situation that the New York Times
described in North Carolina parallels that at Johns Hopkins All Children’s
Hospital in St. Petersburg, which stopped performing heart surgeries after the
Tampa Bay Times reported on problems in the unit
“Tasha and Thomas
Jones sat beside their 2-year-old daughter as she lay in intensive care at
North Carolina Children’s Hospital. Skylar had just come out of heart surgery
and should recover well, her parents were told. But that night, she flatlined.
Doctors and nurses swarmed around her, performing chest compressions for nearly
an hour before putting the little girl on life support.
Five days later, in June 2016, the hospital’s pediatric
cardiologists gathered one floor below for what became a wrenching discussion.
Patients with complex conditions had been dying at higher-than-expected rates
in past years, some of the doctors suspected. Now, even children like Skylar,
undergoing less risky surgeries, seemed to fare poorly.
The cardiologists pressed their division chief about what
was happening at the hospital, part of the respected University of North
Carolina medical center in Chapel Hill, while struggling to decide if they
should continue to send patients to UNC for heart surgery…
That March, a newborn had died after muscles supporting a
valve in his heart appeared to have been damaged during surgery. At least two
patients undergoing low-risk surgeries had recently experienced complications.
In May, a baby girl with a complex heart condition died two weeks after her
operation. Two days later, Skylar went in for surgery.
In the doctors’ meeting, the chief of pediatric cardiology,
Dr. Timothy Hoffman, was blunt. “It’s a nightmare right now,” he said. “We are
in crisis, and everyone is aware of that.”
That comment and others – captured in secret audio
recordings provided to The New York Times – offer a rare, unfiltered look
inside a medical institution as physicians weighed their ethical obligations to
patients while their bosses also worried about harming the surgical program.
In meetings in 2016 and 2017, all nine cardiologists
expressed concerns about the program’s performance. The head of the hospital
and other leaders there were alarmed as well, according to the recordings. The
cardiologists – who diagnose and treat heart conditions but don’t perform
surgeries – could not pinpoint what might be going wrong in an intertwined
system involving surgeons, anesthesiologists, intensive care doctors and
support staff. But they discussed everything from inadequate resources to
misgivings about the chief pediatric cardiac surgeon to whether the hospital
was taking on patients it wasn’t equipped to handle. Several doctors began
referring more children elsewhere for surgery.
The heart specialists had been asking to review the
institution’s mortality statistics for cardiac surgery – information that most
other hospitals make public – but said they had not been able to get it for
several years. Last month, after repeated requests from The Times, UNC released
limited data showing that for four years through June 2017, it had a higher
death rate than nearly all of the 82 institutions nationwide that do publicly
The best option, Dr. Kelly said, was to combine UNC’s
surgery program with Duke’s. For years, physicians at both children’s hospitals
talked informally about joining forces, but nothing came of it. They were
“basically destroying each other’s capacity to be great,” Dr. Kelly said, by
running competing programs less than 15 miles apart. But even combining the
programs wasn’t an instant fix: It would take at least a year and a half, he
“The situation that the New York Times described in North
Carolina parallels that at Johns Hopkins All Children’s Hospital in St.
Petersburg, which stopped performing heart surgeries after the Tampa Bay Times
reported on problems in the unit…
UNC Health Care only made some of its death rate data public
to the New York Times after numerous requests from the newsroom. The statistics
showed that UNC’s children’s heart surgery program had one of the highest
four-year death rates in the country…
UNC Health Care told the New York Times that the physicians’
concerns had been handled appropriately.
After the New York Times started reporting, the hospital
ramped up efforts to find a temporary pediatric heart surgeon and reached out
to families whose children had died or had unusual complications to discuss
The turmoil at UNC underscores concerns about the quality
and consistency of care provided by dozens of pediatric heart surgery programs
across the country. Each year in the United States about 40,000 babies are born
with heart defects; about 10,000 are likely to need surgery or other procedures
before their first birthday.
The best outcomes for patients with complex heart problems
correlate with hospitals that perform a high volume of surgeries – several
hundred a year – studies show. But a proliferation of the surgery programs has
made it difficult for many institutions, including UNC, to reach those numbers:
The North Carolina hospital does about 100 to 150 a year. Lower numbers can leave
surgeons and staff at some hospitals with insufficient experience and resources
to achieve better results, researchers have found.
“We can do better. And it’s not that hard to do better,”
said Dr. Carl Backer, former president of the Congenital Heart Surgeons’
Society, who practices at Lurie Children’s Hospital of Chicago. “We don’t have
to build new hospitals. We don’t have to build new ICUs. We just need to move
patients to more appropriate centers.”
Studies show that the best outcomes for patients with
complex heart problems correlate with hospitals that do a higher volume of
surgeries – several hundred a year.
At least five pediatric heart surgery programs across the
country were suspended or shut down in the last decade after questions were
raised about their performance; a Florida institution run by the prestigious
Johns Hopkins medical system stopped operations after reporting by The Tampa
Bay Times in 2018. At least a half-dozen hospitals have merged their programs
with larger ones to achieve more consistent results. And more institutions are
considering such partnerships.” (E)
“North Carolina’s secretary of health on Friday called for
an investigation into a hospital where doctors had suspected children with
complex heart conditions had been dying at higher than expected rates after
undergoing heart surgery.
Dr. Mandy Cohen, the secretary, said in a statement that a
team from the state’s division of health service regulation would work with
federal regulators to conduct a “thorough investigation” into events that
occurred in 2016 and 2017 at North Carolina Children’s Hospital, part of the
University of North Carolina medical center in Chapel Hill…
The investigation is in response to an article published by
The New York Times on Thursday, which gave a detailed look inside the medical
institution as cardiologists grappled with whether to keep sending their young
patients there for surgery.” (H)
PART 3. Hopkins All Children’s Hospital/ North Carolina
Children’s – pediatric cardiac surgery debacles.
“Johns Hopkins All Children’s Hospital has begun
implementing some of the dozens of recommendations from a law firm hired to
identify deficiencies at the hospital and its parent organization, Johns
Hopkins Medicine, in the wake of high death rates in the St. Petersburg
hospital’s pediatric cardiology program…
The recommendations focus on four key areas, said Dr. Kevin
Sowers, president of Johns Hopkins Health System and executive vice president
of Johns Hopkins Medicine.
He outlined those four areas in a video posted online. They
are: strengthen the management and culture at Johns Hopkins All Children’s
Hospital; improve processes for evaluating patient clinical quality and safety;
clarify and streamline the reporting structure between the six Johns Hopkins Hospitals
and the Johns Hopkins Health System; and review the ways in which the boards of
Johns Hopkins All Children’s Hospital and Johns Hopkins Medicine should advance
their governance responsibilities…
…In the coming weeks, the board of Johns Hopkins Medicine
will appoint a monitor to track and report regularly back to them on the
hospital’s progress.” (A)
“The recommendations for improvement include:
Prioritize a culture of absolute commitment to patient
safety and of raising and addressing problems and concerns, including
throughout the process of hiring and evaluating senior executives
Give physician leaders a stronger voice, create a more
robust check-and-balance on the president
Better educate staff and faculty about JHM’s commitment to transparency
and a culture of “see something, say something” and to improve channels to
submit complaints and provide for independent review
Separate the medical staff office responsibilities from the
patient safety and quality department responsibilities, which previously were
overseen by a single vice president of medical affairs…
In the coming weeks, the board of Johns Hopkins medicine
will appoint an external monitor to track and report back regularly to them on
the hospital’s progress,” he said.
The initial focus will be on the St. Petersburg hospital, a
team will go to the other five hospitals in the network to ensure the changes
are taking place.” (B)
“The review recommended a commitment to patient safety and
said the “see something, say something” culture is a vital part of that.
The hospital published the report on its website along with
a video of Sowers talking about the results.
“Above all, we must work each and every day to support a
culture in which each of us is supported and empowered to speak up and speak
out,” Sowers said in the video.
He provided a toll free number where employees can
anonymously report any issues: 1-844-SPEAK2US.” (C)
surgery departments across Florida will soon be subject to more oversight.
Gov. Ron DeSantis signed a bill late Tuesday that will let
physician experts visit struggling programs and make recommendations for
The bill signed into law Tuesday makes significant changes.
It lets a committee called the Pediatric Cardiac Technical
Advisory Panel appoint physician experts to visit Florida’s 10 children’s heart
surgery programs. They will be able to examine surgical results, review death
reports, inspect the facilities and interview employees.
Dr. David Nykanen, the chairman of the advisory panel and a
pediatric cardiologist at Arnold Palmer Hospital for Children in Orlando,
called site visits “crucially important,” especially when departments are
He said visits could start within the next six months…
The hospital has not yet resumed heart surgeries. The
results of a review commissioned by the Johns Hopkins Medicine board are
expected soon.” (E)
“A state regulatory process that limited the number of
hospitals and some specialty services like transplant programs are going away
on July 1.
Despite attempts by two hospitals, Central Florida doesn’t
have a pediatric heart transplant program. But that could change in the coming
years because a state regulatory process that limited the number of hospitals
and some specialty services like transplants is going away on July 1.
For nearly five decades, the program known as certificate of
need has required hospitals to get authorization from the state before building
new facilities or offering new or expanded services — a complicated process
that’s costly, includes reams of paperwork and potential challenges from
competitors, and can take months or years…
Starting July 1, general hospitals are no longer required to
obtain a certificate of need to build a facility or to start services such as
pediatric and adult open heart surgery, organ transplant programs, neonatal
intensive care units and rehab programs…
The second part of the bill goes into effect on July 1,
2021, when the certificate of need requirement will be eliminated for certain
specialty hospitals such as children’s and women’s hospitals, rehab hospitals,
psychiatric and substance abuse hospitals and hospitals that offer intensive
residential treatment services for children.” (F)
“Cohen announced late last week that she had assembled a
team from the state Division of Health Service Regulation, which licenses and
oversees health care facilities, to “conduct a thorough investigation into
these events.” They are coordinating with the U.S. Centers for Medicare &
Medicaid Services, a federal oversight agency…
Kelly Haight Connor, a spokeswoman for the state health
department, said Monday it’s difficult to know how long an investigation will
take. In other DHHS investigations, a team often interviews a range of people,
from caregivers, staff and those in their care.
Wesley Burks, CEO of UNC Health Care since December 2018 and
dean of the UNC School of Medicine, sent a five-paragraph email to staff on May
30 at 10:16 a.m. and attached the Times’ article he described as “critical of
UNC Medical Center’s pediatric congenital heart surgery program.”
“While this program
faced culture challenges in the 2016-2017 timeframe, we believe the Times’
criticism is overstated and does not consider the quality improvements we’ve
made within this program over many years,” Burks wrote in the email. “As the
State’s leading public hospital, UNC Medical Center often gets the most complex
and serious cases in its pediatric congenital heart program. For many of these
very sick children, we are often parents’ last hope…
On Monday, UNC Health Care spokesman Phil Bridges released a
“timeline of Continuous Quality Improvement within the program over the past 10
The timeline mentions a four-month period from June to
September in 2016 in which “concerns and allegations against specific
individuals in the Congenital Heart Program” were “independently investigated
and reviewed” by the dean’s office and the chief medical officer.
“Allegations of misconduct and concerns determined to be
unfounded,” the document states, adding “allegations against specific
individuals and results of the investigations constitute personnel records,
which may not be disclosed,” citing public records law.
An ongoing initiative, according to the document, calls for
a Department of Pediatrics review after every death in the Pediatric Intensive
Care Unit, including pediatric cardiac patients, to assess the care provided
and evaluate any opportunities for improvement.” (G)
“UNC Health Care officials announced Monday they are halting
the most complex pediatric heart surgeries following a report that raised
serious safety concerns over a number of child deaths at UNC Children’s
Officials from UNC HealthCare said in a statement they plan
to create an advisory board of external medical experts and “pause the most
complex heart surgeries” until that board and regulatory agencies review the
The external advisory board, which is expected to have
members from the University of Southern California, the University of Michigan,
University of Pittsburgh Medical Center and Nationwide Children’s Hospital,
will examine the efficacy of the UNC Children’s Hospital pediatric heart
surgery program and make recommendations for improvement. The group will report
to the UNC Health Care Board of Directors.
UNC Healthcare officials said they are also developing a new
structure to support internal hospital reporting and plan to publicly release
Society for Thoracic Surgeons’ (STS) patient outcome data, make a $10 million
investment in new technology and bring in new specialists as part of their
efforts to “restore confidence” in its pediatric heart program.
“Our pediatric heart program cares for very sick children
with incredibly complex medical problems, and our clinical team works
tirelessly to help those patients return to normal, healthy and productive
lives,” Wesley Burks, M.D., CEO of UNC Health Care said in a statement. “We
grieve with families anytime there is a negative outcome and we constantly push
to learn from those tragic instances.
UNC Health Care’s board also endorsed the creation of a
pediatric heart surgery family advisory council to provide a voice for
patients, family members and staff directly to hospital leadership…
Most recently, Johns Hopkins’ All Children’s Hospital came
under fire for increasing mortality rates among heart surgery patients at the
259-bed hospital following a Tampa Bay Times investigation. Top leaders of that
hospital ultimately resigned and Johns Hopkins’ board also said it commissioned
an external review to examine the heart surgery program.
In 2015, St. Mary’s Medical Center in Florida closed it’s
pediatric heart surgery program after a CNN investigation revealed it had a
mortality rate of more than three times the national average. In 2009,
Massachusetts General Hospital suspended its pediatric surgery program in the
wake of surgical errors.” (H)
Hospital should merge its pediatric heart surgery program with the same work
being done at Duke Health’s Children’s Hospital, just 10 miles away. A common
program would greatly enhance the treatment of children and babies in need of
complex heart surgery.
As it is, UNC Children’s does 100 to 150 pediatric heart
surgeries a year, a rate considered low volume. That makes it harder to recruit
and retain surgeons and limits surgeons ability to hone their skills. It also
makes it harder to maintain the other parts of the program, cardiologists,
anesthesiologists and staff for a pediatric heart intensive care unit.
East Carolina University’s hospital faced similar challenges
as it provided pediatric heart surgery at a low-volume level of 50 to 75
surgeries a year. Eighteen months ago, ECU started sending all its pediatric
heart surgery patients to Duke. The change helped boost Duke’s volume to where
it has done more than 800 surgeries in 18 months. During the same period, Duke
has posted a 1 percent mortality rate, despite a caseload in which a third of
the operations are high risk.
Unfortunately, UNC Children’s Hospital appears uninterested
in combining resources despite overtures from Duke. In a statement Thursday,
the hospital said, “While there have been discussions with Duke Health over the
years about ways to collaborate across various pediatric specialties, there are
no plans to combine our programs. Patients in this region benefit from having
two world-class medical institutions located so close together. Our clinicians
frequently collaborate with colleagues at Duke. We sometimes transfer patients
to them and vice versa.
UNC Children’s would prefer to run its own pediatric heart
surgery program as a matter of institutional pride and money — the most complex
operations can cost a half-million dollars. But pride and money aren’t — or
shouldn’t be — the primary concerns. What matters most is how to get the best
care for children in this highly specialized and high-stakes area of medicine.
To do that, North Carolina’s best hospitals should combine their resources and
Typically, with complex medical procedures, outcomes are strongly
correlated with volume. That means that if a program does more procedures, it
has more expertise, the healthcare team has more experience working together —
and as a result, patients have better results. Larger programs often have
better equipment and more personnel. Sadly, the pediatric surgery program at
North Carolina Children’s Hospital was a low-volume center…
Powerful forces stand in opposition to the closure of
low-volume centers. Low-volume centers are attractive because they are
geographically convenient; patients do not have to travel long distances for
their care. Some insurance coverage is regionally-restricted, and families
without resources are unable to access high-volume centers. Low-volume centers
are often staffed by entrepreneurial physicians who don’t want restrictions on
their right to practice medicine. And their goals are often closely aligned
with those of local political officials, who would like to imagine that
low-volume programs can replicate the results at large medical centers. Perhaps
most importantly, hospital administrators at low-volume centers do not wish to
see their revenues slashed — and their leadership positions eliminated.
So the problem of decentralized medicine and low-volume
centers is getting worse, not better. To an increasing degree, a larger and
larger proportion of specialized procedures in the United States are being done
at low-volume centers…” (N)
E.In North Carolina, the New York Times reveals another
heart surgery program in trouble, by Kathleen McGrory and Neil Bedi,
In 2016 The World Health Organization identified the top 8
emerging diseases that were likely to cause severe outbreaks in the near
future: Crimean-Congo haemorrhagic fever; Ebola; Marburg; Lassa Fever; MERS;
SARS; Nipah; and Rift Valley fever. (Q)
The Ebola epidemic in the Democratic Republic of Congo is
breaching its contiguous borders with South Sudan, Uganda, and Tanzinia; it
also borders four other countries.
“…If the purse
strings tighten, however, and the WHO cannot continue its work, the outbreak
will almost certainly pick up speed. It’s only a matter of time until the virus
There are a few possible explanations for this (funding)
shortcoming. The first is unspoken, but (is) true of the world’s largest
outbreak of the disease in West Africa — Ebola has not yet spread to rich
Are we ready?
ASSIGNMENT: As Ebola spreads from Congo to
contiguous countries In Africa, is the United States prepared for Ebola and
other known and unknown emerging viruses?
“It sounds like an improbable fiction: a virulent flu
pandemic, source unknown, spreads across the world in 36 hours, killing up to
80 million people, sparking panic, destabilising national security and slicing
chunks off the world’s economy.
But a group of prominent international experts has issued a
stark warning: such a scenario is entirely plausible and efforts by governments
to prepare for it are “grossly insufficient”.
The first annual report by the Global Preparedness
Monitoring Board, an independent group of 15 experts convened by the World Bank
and WHO after the first Ebola crisis, describes the threat of a pandemic
spreading around the world, potentially killing tens of millions of people, as
“a real one”.
There are “increasingly dire risks” of epidemics, yet the
world remained unprepared, the report said. It warned epidemic-prone diseases
such as Ebola, influenza and Sars are increasingly difficult to manage in the
face of increasing conflict, fragile states and rising migration…
measles – the most severe disease outbreaks usually occur in the places with
the weakest health systems,”.. “As leaders of nations, communities and
international agencies, we must take responsibility for emergency preparedness,
and heed the lessons these outbreaks are teaching us. We have to ‘fix the roof
before the rain comes.’” (A)
“On Wednesday (July 17), the World Health Organization
declared the Ebola outbreak in Democratic Republic of Congo a global health
A WHO committee that decided the outbreak would be a PHEIC
lays out specific recommendations in a statement, including keeping borders
open and not placing restrictions on trade and travel. The members call for a
“coordinated international response” and for neighboring countries to work with
partners to prepare for detecting and managing imported cases.
The emergency committee writes that, nearly a year into the
outbreak, “there are worrying signs of possible extension of the epidemic.”
Robert Steffen, who chaired the group, tells STAT that WHO is now declaring a
PHEIC in part because disease transmission in the DRC city of Beni has
increased, there is a risk to response workers’ safety, and that the disease is
still actively transmitted in large geographical areas of the country.” (B)
“South Sudan has stepped up surveillance along its porous
southern border after an Ebola case was detected just inside DR Congo, an
health official in Juba told AFP Wednesday…
It is the closest Ebola is known to have come to South Sudan
since a major outbreak began in Congo last August.
Dr Pinyi Nyimol, the director general of South Sudan’s
Disease Control and Emergency Response Centre, said a team of reinforcements
had been sent to the region to bolster surveillance after the case was
“We are very worried because it is coming nearer, and
people are on the move so contact (with Ebola) could cross to South
Sudan,” he told AFP.” (C)
“Uganda’s ministry of health announced late on Thursday a
second Ebola outbreak in the western district of Kasese, about 472 km from the
capital Kampala, following an imported case from the neighboring Democratic
Republic of the Congo (DRC).
Joyce Moriku Kaducu, minister of state for primary health
care, said in a statement that a 9 year-old female Congolese who entered the
country with her mother on Wednesday through the Mpondwe border to seek medical
care at Bwera Hospital has tested positive of the deadly virus.
The minister said the child was identified by the point of
entry screening team with symptoms of high fever, body weakness, rash, and
unexplained mouth bleeding…
“Since the child was identified in Uganda at the point
of entry, there are no contacts in Uganda,” she said…
In June, Uganda confirmed three index cases of the highly
contagious disease who visited the neighboring DRC. The outbreak was declared
finished after 42 days of close monitoring.” (D)
Congolese girl who tested positive for Ebola in neighbouring Uganda has died of
the disease, as the World Health Organisation (WHO) warned that the current
outbreak was approaching the grim milestone of 3,000 cases and 2,000 deaths.
Her death makes her the fourth case to cross into Uganda
amid the continuing struggle to contain the deadly outbreak.” (E)
The World Health Organization issued an extraordinary
statement Saturday raising concerns about possible unreported Ebola cases in
Tanzania and urging the country to provide patient samples for testing at an
The statement relates to a Tanzanian doctor who died Sept. 8
after returning to her country from Uganda; she reportedly had Ebola-like
symptoms. Several contacts of the woman became sick, though Tanzanian
authorities have insisted they tested negative for Ebola.
But the country has not shared the tests so they can be
validated at an outside laboratory, as suggested under the International Health
Regulations, a treaty designed to protect the world from spread of infectious
It is highly unusual for the WHO, which normally operates
through more diplomatic means, to publicly reveal that a member country is
stymying an important disease investigation.
“The presumption is
that if all the tests really have been negative, then there is no reason for
Tanzania not to submit those samples for secondary testing and verification,”
Dr. Ashish Jha, director of the Harvard Global Health Institute, told STAT…”
“The statement comes hard on the heels of similar remarks by
the US health secretary, Alex Azar, last week amid mounting concern that
Tanzania may be in breach of its international commitments to share critical
data relating to global health security.
Although Tanzania has insisted that its own tests showed
negative for the Ebola virus, international health organisations have raised
the alarm about not being given access to samples.
According to unconfirmed reports, the woman, in her mid-30s,
had been conducting health research and had visited several health facilities
in central Uganda before her death, after showing symptoms of a serious febrile
The patient, who died on 8 September, had not been to the
Democratic Republic of the Congo or had contact with Ebola cases, leading
international health monitoring organisations to initially rule out the Ebola
However, as several more reported cases emerged, including
the initial patient’s sister, Tanzania’s response to the issue has prompted
alarm about the country’s willingness to share either its test results or allow
secondary testing of samples.
Azar voiced his own criticism during a visit to Uganda,
telling reporters that he and others are “very concerned” as he urged
Tanzania’s government to share laboratory results regarding the case.” (G)
A team of specialists at Emory University will never forget
Aug. 2, 2014. That’s the day Kent Brantley, an American missionary based in
Liberia, became the first of four patients with the Ebola virus to arrive at
its Atlanta facility.
The eyes of the world watched as the Serious Communicable
Diseases Unit — in hazmat suits, successfully treated Brantley and three
other patients with the highly infectious disease.
The team at Emory is innovating on what they learned five
years ago to help treat the disease now. “ (H)
“This fall, the University of Nebraska Medical Center is
scheduled to open a cutting-edge center for training, simulation and quarantine
to prepare federal workers to address highly infectious diseases. Creation of
the National Center for Health Security and Biopreparedness is timely and
important, given the troubling new Ebola outbreak in Africa.
As a result, the infectious disease initiative at UNMC and
clinical partner Nebraska Medicine is taking on particular importance. UNMC
received a $19.8 million federal grant for creation of the new biopreparedness
center. A team of infectious disease experts from UNMC and Nebraska Medicine
was in Uganda last year to train local health care workers in infection
response and control…
During 2014-15, the med center treated three Ebola patients
and monitored several others who were exposed but did not develop the disease.
On Dec. 29 last year, an American doctor who had been treating patients in the
Democratic Republic of Congo arrived in Omaha, where he completed the last 14
days of a 21-day monitoring period in UNMC’s biocontainment unit.” (I)
“During the outbreak five years ago, 56 hospitals across the
U.S. were designated Ebola treatment centers, or ETCs. The idea was to increase
national capacity to care for patients who contracted this highly infectious
disease. These hospitals are mostly clustered around major airports where
travelers from West Africa are likely to arrive, including Chicago’s O’Hare
International Airport. They were initially equipped with dedicated clinical
care resources, specialized infrastructure and trained staff to safely manage
and treat patients suspected or confirmed to have Ebola. Since its inception in
2014, fewer resources have been allocated to this hospital network. As a
result, the ETCs are having difficulty maintaining their
ability to respond to Ebola cases that may come again to the U.S., and
other infectious diseases that may follow.
Outbreaks are costly. Public health responses to Ebola,
Zika, MERS, SARS and other diseases cost tens of billions of dollars, much of
which can be avoided by taking preventive action. Congress can wait until Ebola
or some equally deadly infectious disease arrives in our country, overwhelms
state, local, tribal and territorial health care and public health capacity,
and threatens lives and then provide billions in emergency supplemental
funding. Or Congress can now recognize that these significant disease events
will continue to occur and proactively take steps to ensure we can respond by
creating a standing response fund.” (J)
“… In the past two years, the Trump administration has
dissolved the federal government’s biosecurity directorate, scaled back its
infectious disease prevention efforts, restricted development aid for countries
like Congo, made several attempts to rescind foreign aid, including for global
health, and pulled C.D.C. workers from Congo’s outbreak zones without a clear
plan to send them back.
The administration has also announced policies meant to
scare legal immigrants off public assistance programs, including for health
care, to which they are legally entitled. Such policies imperil everyone: The
more people who don’t have access to vaccines or antibiotics, the greater the
risk that an infectious disease will spread. That applies to diseases like
Ebola that might arrive on American shores from other countries, but it also
applies to diseases that are already here, like flu and measles. The only
reliable way for a country to protect itself from these threats is for it to
help other countries do the same.
The new medications for Ebola and tuberculosis are the
product of years of investment and careful work. That investment could continue
to pay off, but only if the United States and its partners around the world
increase their global health efforts, instead of shrinking away from them.” (K)
“I’m not a social scientist. I have zero data on which to
lean here. Someone who actually does this sort of research may conclude that
donor fatigue, or the financial straits some countries and most media outlets
currently face, or the turning inward that has accompanied the rise of populism
can explain why this Ebola outbreak isn’t as front burner an issue as it would
have been a decade ago, why organizations struggling to stop it are finding
fewer donors writing smaller checks.
At last month’s G20 summit in Japan, high-income countries,
including the United States, declared their full support for the Ebola
response. They must now make good on that promise to the WHO. If countries
procrastinate, the world risks a repeat of the 2014–16 Ebola outbreak, in which
a slow response contributed to the loss of more than 11,300 lives in Africa and
a cost to taxpayers of more than $3 billion. The WHO needs just a fraction of
this to prevent a horrific repeat of history.” (N)
“A dispute between two major players in the epidemic
response — Doctors Without Borders and the W.H.O. — erupted on Monday, just as
the W.H.O. announced that a new vaccine, the second to be deployed, would be
introduced into the region.
On Monday, Doctors Without Borders accused the World Health
Organization of “rationing Ebola vaccines and hampering efforts to make them
quickly available to all who are at risk of infection.”
The W.H.O. quickly fired back, saying it was “not limiting
access to vaccine but rather implementing a strategy recommended by an
independent advisory body of experts and as agreed with the government of the
D.R.C. and partners.”..
The approach so far has relied on a traditional strategy
called ring vaccination that has been used successfully against other diseases.
It involves vaccinating everyone who has had contact with an infected person,
and all the contacts of those people, as well.
Officials from Doctors Without Borders say the strategy has
not worked in Congo, in part because it has not been possible to track down
every person who has come into contact with someone infected with Ebola, and
because some contacts have refused to cooperate. The group has urged more
widespread vaccination in regions where the disease is spreading, whether
people are known contacts or not.
But it says that instead the W.H.O. has doled out limited
amounts of vaccine. About 225,000 people have been vaccinated, but Doctors
Without Borders says 450,000 to 600,000 should have received the vaccine by
“The United States has warned its citizens to take extra
care when visiting Tanzania amid concerns over Ebola, adding to calls for the
East African country to share information about suspected cases of the deadly
U.S. travelers should “exercise increased caution”, the State Department said on Friday in an updated travel advisory that cited reports of “a probable Ebola-related death in Dar es Salaam”.” (P)
“The medical response to an Ebola infection is markedly more
challenging than many other diseases. It is one of the most deadly viruses with
a 60% – 90% mortality rate compared to 2% for measles.
The Ebola virus is extremely infectious and highly communicable. Treating the disease is resource intensive. Patients must be kept in isolation in specialised, well-designed treatment centres. Health care workers are at high risk of exposure and must take extreme precautions to examine patients. Breakdown in personal protection and infrastructure can be fatal. In fact, approximately 6% of the victims have been involved in looking after patients.” (R)
“Today (June 12, 2019) the U.S. Centers for Disease Control
and Prevention (CDC) is announcing activation of its Emergency Operations
Center (EOC) on Thursday, June 13, 2019, to support the inter-agency response
to the current Ebola outbreak in eastern Democratic Republic of the Congo
(DRC). The DRC outbreak is the second largest outbreak of Ebola ever recorded
and the largest outbreak in DRC’s history. The confirmation this week of three
travel-associated cases in Uganda further emphasizes the ongoing threat of this
outbreak. As part of the Administration’s whole-of-government effort, CDC
subject matter experts are working with the USAID Disaster Assistance Response
Team (DART) on the ground in the DRC and the American Embassy in Kinshasa to
support the Congolese and international response. The CDC’s EOC staff will
further enhance this effort.
CDC’s activation of the EOC at Level 3, the lowest level of activation, allows the agency to provide increased operational support for the response to meet the outbreak’s evolving challenges. CDC subject matter experts will continue to lead the CDC response with enhanced support from other CDC and EOC staff.” (S)
“…if we want to prevent Ebola cases evolving into wider
outbreaks, then we’ll need to move beyond reactionary responses and address the
factors that pave the way for epidemics.”..
To prevent future outbreaks, and to support the health of
local communities in the poorest parts of the world, we need to invest in
strengthening primary care and medical education. Otherwise, we will be here
again in another five years, once again having failed to learn from our
May 15, 2017
Lesson Learned from recent EBOLA and ZIKA episodes. We need
to designate REGIONAL EMERGING VIRUSES REFERRAL CENTERS (REVRCs).
1. There should not be an automatic default to just
designating Ebola Centers as REVRCs although there is likely to be significant
2. REVRCs should be academic medical centers with respected,
comprehensive infectious disease diagnostic/ treatment and research capabilities,
and rigorous infection control programs. They should also offer robust,
comprehensive perinatology, neonatology, and pediatric neurology services, with
the most sophisticated imaging capabilities (and emerging viruses “reading”
3. National leadership in clinical trials.
4. A track record of successful, large scale clinical Rapid
5. Organizational wherewithal to address intensive resource
Health care “disruption”
is well underway with most attention focused on paradigm-challenging players like:
Amazon, Berkshire Hathaway and JPMorgan Chase forming an independent health
care company for their employees; and the CVS Health Aetna Acquisition.
meantime, under-the-radar, Walmart’s strategy has been “based on the hospital
inefficiency in innovation and the business theory of bundling and unbundling
Now Walmart is leveraging its 1.5 million employees and 4,769 stores throughout the United States (90% of Americans live within 10 miles of a Walmart store) to launch its major health care initiatives.
the world’s biggest retailer, is moving deeper into the primary care and mental
health market, opening a new clinic called Walmart Health in Georgia.
recently updated its website with a link to Walmart Health, describing its
“newest location in Dallas, GA.” It also went online with the site
“Walmarthealth.com,” where patients can set up appointments. Walmart is testing
the concept with the initial clinic and could open more in the future,
according to people familiar with the matter who asked not to be named because
the plans are confidential.
indicates that first appointments are available on Sept. 13, and the company
will offer primary care, dental, counseling, labs, X-rays and audiology, among
clinic will have on-site health providers, including nurses, to offer
consultations, immunizations and lab tests, people familiar with the matter
said. Added services include hearing tests, 60-minute counseling sessions and
vision tests.” (A)
new Georgia location opening comes as rivals CVS Health and Walgreens Boots
Alliance push further into outpatient healthcare services through various
models. The retailers see 10,000 baby boomers aging into Medicare coverage each
day and are also looking to fill emptying space in their brick and mortar
stores in the face of changing consumer shopping habits driven by online retail
giant Amazon, which is also exploring new ways to get into the healthcare
business but has yet to offer face-to-face personalized healthcare services for
CVS has said its new health hub concept store will reach four U.S. metropolitan
areas and 50 locations by the end of this year as part of a major expansion.
CVS said the HealthHub rollout will grow to 1,500 locations by the end of 2021,
or about 500 HealthHubs a year…
has a joint venture with the big health insurer Humana, opening senior clinics
in certain markets and the drugstore chain has a partnership with UnitedHealth
Group’s MedExpress urgent care subsidiary that has opened centers that include
X-rays and are staffed by physicians with a door connecting to an adjacent
says the new Walmart Health centers aren’t designed to increase foot traffic
and customer volume into their stores… Walmart has a different approach.
trying to solve problems for our customers,”… “We already have the volume. We
have the locations and the right people.” (B)
“Here we see
two rival strategies to marketing healthcare services. Walmart’s strategy is
based on price competition. Patients know what services will cost before they
walk into the physician’s office. Prices are rock-bottom. This directly
benefits patients, who will come again. Word will get out. In contrast, the
hospital’s strategy is based on billing insurance companies for services whose
prices are not revealed to patients in advance. Patients have no economic
incentive to seek lower-cost services elsewhere.
strategies reflect different organizational legal structures. Walmart is a profit-seeking
corporation. Profit-seeking enterprises whose business plans seek a growing
market, as Walmart’s business plan always has, are forced by price-sensitive
consumers to compete by cutting costs and then lowering prices. In contrast,
the hospital is a non-profit enterprise. By law, non-profit enterprises have no
owners. Employees may not profit directly from innovations that lead to higher
profits. In non-profits, everyone is salaried. There is therefore far less
incentive to cut costs and reduce prices.” (C)
moves deeper into primary care, the retail giant wants to ensure there is a
skilled healthcare workforce to fill critical roles in its 20 care clinics…
announced Tuesday its 1.5 million associates will be able to apply for one of
seven bachelor’s degrees and two career diplomas in health-related fields for
$1 a day through Live Better U, Walmart’s education benefit program…
degrees and certificate programs will provide Walmart employees with a path to
higher-paying careers in the growing healthcare field, Walmart executives said..
and wellness courses include career diploma programs for pharmacy technicians
and opticians through Penn Foster and seven bachelor’s degrees in health
science, health and wellness and healthcare management/administration offered
through Purdue University Global, Southern New Hampshire University, Bellevue
University and Wilmington University.
education program will arm employees with training to fill critical healthcare
roles across Walmart and Sam’s Club, which includes more than 5,000 retail
pharmacies, 3,000 vision centers and 400 hearing centers, the retailer said in
a release. The upskilled workforce will help the retailer make quality
healthcare more affordable and accessible to customers in the communities it
health care’s allure for Walmart? Medical services typically have higher
margins than store products. Since they are often provided in person, there is
more opportunity for consumers to pick up other items while visiting the store.
And usage is growing, especially as the United States’ population ages.
Walmart is eyeing both the Medicare and Medicaid markets since many of its
customers are senior citizens and lower-income Americans. Its prices are
generally lower than at pharmacy chains, such as CVS.
expands its health care menu, it builds even more ties with its shoppers. Its
deal with Anthem, for instance, lets the insurer’s Medicare Advantage customers
use their plan benefits to purchase over-the-counter medicine, first aid
supplies, support braces and pain relievers from a store.
can market its healthy grocery items to certain Medicare Advantage enrollees
since the federal government recently allowed insurers to cover such products
as a supplemental benefit. This has given the company another advantage over pharmacy
chains, which have much more limited food selections.
retailer’s locations blanket the nation. Many are in rural areas where there
are few other health care options. Walmart often operates as a community
center, with customers dropping in a few times a week. And it serves as a
one-stop shop, where people could access medical services and pick up whatever
other items they need.” (E)
heels of Walmart offering health clinics in certain locations, the big-box
retailer is adding on a digital healthcare site—WalmartHealth.com—so consumers
can make doctor, dentist, and behaviorial health medical appointments, in
addition to scheduling hearing tests and immunizations…
some true loyalty-generating opportunities in extending your ambulatory
offerings with select regional retail clinics, utilizing technology to improve
your digital front door and provide real-time patient obligations.” (F)
Centers of Excellence program gives associates access to world-class
heart surgeries, like cardiac bypass and valve replacements. Certain spine
surgeries, like spinal fusions and removal of spinal discs (discectomy). Hip
and knee joint replacements. Breast, lung, colorectal, prostate, and blood
cancers (including myeloma, lymphoma, and leukemia). Certain weight loss
surgeries, like gastric bypass and gastric sleeve procedures. Organ and tissue
transplants (except kidney, cornea, and intestinal), ventricular assist devices
(VADs) and total artificial hearts, and CAR-T cell therapy. Outpatient
radiology, which will be reviewed automatically through the pre-authorization
partnered with several world-class health systems across the country to serve
the Centers of Excellence program, and a few of these include: Cleveland
Clinic, in Cleveland, Ohio, for cardiac surgery. Johns Hopkins Hospital, in
Baltimore, Maryland, for joint replacement surgery. Mayo Clinic in Minnesota,
Florida and Arizona, for transplants and cancer care. Geisinger Medical Center,
in Danville, Pennsylvania, for weight loss surgery. Mercy Springfield, in
Springfield, Missouri, for spine surgery..
to the full cost of treatment for many conditions, the benefit includes travel
and lodging expenses for both the patient and a companion caregiver. Travel and
lodging are not included for the weight-loss-surgery benefit.” (G)
has earned designation as a Radiology Center of Excellence by Covera Health, a
New York City-based company that uses advanced clinical analytics to
objectively measure quality in radiology.
With its new
distinction, Geisinger joins a national program that integrates with
self-funded insurers’ existing health networks to steer community members
toward local radiology providers based on their diagnostic accuracy — not price
— to curb misdiagnoses. Danville, Pa.-based Geisinger is also a member of Covera
Health’s Quality Care Collaborative, in which participants receive practical,
actionable feedback to improve their clinical practice.” (H)
“Walmart’s retail strategy in health care is based on the
hospital inefficiency in innovation and the business theory of bundling and
The vast majority of hospital revenue is rooted in the fee-for-service business
model: rather than make money for improving health (a reimbursement model that
is much harder to design than it sounds), providers are paid more for the
number of services provided — hampering incentives for innovation. Providers
are thus incentivized to provide a high-volume, high-cost standard of care,
squeezing money from insurance companies. In turn, those costs are passed down to
consumers in the form of higher premiums. However, as hospital operational
costs ballooned, health systems began to treat their departments like a public
investment portfolio. They unbundled (divested from) low-end services that
required all the same operating expenses but didn’t turn a profit.
primary care is a prime unit to be unbundled from traditional health care
delivery systems, i.e. hospitals, for two reasons:
patients that visit primary care physicians don’t need the resources of an
expensive medical center on-hand for each visit, and would be better served by
an experience that emphasized price, convenience, and attention.
rates for most primary care services, e.g. a blood pressure checkup or physical
exam, are much lower than specialty care (imaging, biopsies, intensive
procedures, etc) and thus provide a lower short-term return on invested capital…
us to the biggest loser of Walmart’s foray into health care: traditional health
systems. Walmart’s strategy notably doesn’t utilize any ownership of inpatient
hospitals; all incentives are aligned to provide the highest value care at the
lowest possible cost in outpatient settings, ultimately decreasing utilization
of expensive health care services like inpatient hospitalizations. (I)
than a decade of transforming health care for its roughly 1 million workers and
huge and loyal customer base, Walmart plans to play an even larger role. Marcus
Osborne, vice president of transformation and wellness for the retail giant,
made that point clear in a recent talk with the Health Care Council of Chicago.
Walmart will continue to expand its health care services for customers and
employees until or unless the company “hits a third rail” by entering
a space in which it can’t compete effectively. To date, he emphasized that
every significant initiative the company has undertaken to address its
customers’ top three health care concerns — cost, convenience and access — has
delivered value for employees and customers and a return for the company.
reported that all projects that Wal-Mart Stores Inc. undertook over the last
two years, including a pilot with its Boston-based partner Beacon Health to
bring affordable, behavioral health care to customers, performed better than
expected. He said Walmart’s most successful venture recently has been its
partnership with Quest Diagnostics to provide in-store testing services to
customers, providing a level of convenience that has increased patient
compliance with their physicians’ directives by 50 percent or more.
Osborne addressed include: Access to care; Variation in clinical practice; Solving
obesity; Scaling success. (J)
a retail warehouse club operated by Walmart, is teaming up with healthcare
companies to offer four bundled healthcare service offerings for its members,
ranging from $50 to $240 per year.
called Care Accelerator, is in tandem with payer Humana and on-demand primary
care app 98point6. Bundles vary in included services, but each offers free
prescriptions on some generic medications, low-cost dental and vision services,
prepaid health debit cards for use within the network and unlimited telehealth
for $1 a visit.
stressed that Care Accelerator is not a health insurance plan. Participating
Sam’s Club members will still have to pay their healthcare provider at the
point of service, though it will be at a discounted rate.
bundle, for example, costs $240 a year and covers up to six family members. It
includes access to preventive lab screenings for early detection of heart
disease and diabetes, a 10% discount on hearing aids and up to a 30% discount
on chiropractic, massage and acupuncture services.
By comparison, the “Starter A” bundle only includes free select generic medications, $1 telehealth visits, $60 eye exams and a $5 prepaid health debit card. Medications must be filled at Sam’s Club pharmacies and eye exams must be done at Sam’s Club, guaranteeing business for the retailer and its 566 pharmacy locations.” (K)
2005, a memo from Walmart’s then-Vice President of Benefits, Susan Chambers,
outlined a strategy for how the company could remove sick workers from the
payrolls and avoid paying healthcare benefits. More recently, premiums on
Walmart’s health plans have soared, and the company has cut eligibility
2015, Walmart cut coverage for anyone working less than 30 hours per week.
In the last
five years, the cost of Walmart’s cheapest healthcare plan has more than
Hundreds of thousands of Walmart workers and their family members qualify for publicly funded health insurance.
health care plans fail to cover hundreds of thousands of associates. In 2009,
Walmart claimed that 52% of associates were covered under its healthcare plan.
The company has refused to disclose coverage rates for its 1.5 million U.S.
employees since then.
years, Walmart has made it even more difficult for associates to get quality
health care for themselves and their families. The company stopped offering
health insurance to part-time employees working less than 24 hours per week in
2012, and starting in 2015, it cut coverage for anyone working less than 30
hours per week, including those who had previously been grandfathered in. In
the last five years, the cost of Walmart’s cheapest healthcare plan has more
than doubled. The cost of many of the company’s family plans has more than
quadrupled over that time period.
employees earning Walmart’s starting rate of $9.00/hour working an average of
34 hours per week, the deductible alone on Walmart’s cheapest plan for workers
with children is over a third of the employee’s annual gross income.” (L)
ASSIGNMENTS TO CONSIDER.
You are the CEO of a suburban community hospital, the only one in town, two block away from a big Walmart store that just opened a Walmart Health clinic.
the hospital purchased a second MRI and started an interventional cardiology
program. University Medical School, 50 miles away, has just opened a local
cancer program satellite.
The Board is
in a panic as Walmart is hiring your biggest physician admitters and senior
technical staff. Admissions are falling.
There is a
Board meeting next week.
Where do you start?
Compare WalmartCare with CVSCare, AppleCare, GoogleCare, MicrosoftCare, AmazonCare, and other nontraditional models.
PART 1: January 31, 2019. “If you’re shot, stabbed, hit by a
car, fall off a roof or suffer any other major injury in San Francisco, you’ll
be whisked to San Francisco General Hospital, the only trauma center in the
PART 2: February 20, 2019. A new bill would outlaw the big,
surprise bills that Zuckerberg San Francisco General Hospital has sent to
hundreds of patients.
PART 3: April 18, 2019. “Zuckerberg San Francisco General
Hospital announced Tuesday it has overhauled its billing policies…
PART 4: August 20, 2019. Hospitals kept ER fees secret
ASSIGNMENT: How do other states address financial
sustainability for their “safety-net” hospitals?
PART 1: January 31, 2019. “If you’re shot, stabbed, hit by a
car, fall off …
“If you’re shot, stabbed, hit by a car, fall off a roof or
suffer any other major injury in San Francisco, you’ll be whisked to San
Francisco General Hospital, the only trauma center in the city. …But you may
leave with a very unpleasant side-effect: a shockingly high bill. …That’s because
S.F. General – whose patients are overwhelmingly poor and are on Medicare or
Medi-Cal, or have no insurance at all – lacks a good way to deal with patients
who are actually insured.” (A)
“Under a new state law, if you visit an in-network facility
– such as a hospital, lab or imaging center – you will only be responsible for
your in-network share of the cost, even if you’re seen by an out-of-network
The new law covers Californians with private health
insurance plans that are regulated by the state Department of Managed Health
Care, or DMHC, and the state Department of Insurance, which includes roughly 70
percent of the state’s private insurance market, according to the California
Health Care Foundation.
It does not cover some 5.7 million people whose
employer-sponsored insurance plans are regulated by the U.S. Department of
The key point to remember is that you shouldn’t pay more
than your in-network copayment, coinsurance or deductible, as long as you
visited an in-network facility for non-emergency services.” (B)
“The trauma center has no contracts with private insurance
companies. If it did, there would be agreements with those insurers on how much
a particular drug or a particular procedure costs.
Instead, the hospital charges the highest rates approved by
the Board of Supervisors and the mayor, receives whatever amount the patient’s
insurance company decides to pay, and bills the patient for the rest.” (C)
On April 3, Nina Dang, 24, found herself in a position like
so many San Francisco bike riders – on the pavement with a broken arm.
A bystander saw her fall and called an ambulance. She was
semi-lucid for that ride, awake but unable to answer basic questions about
where she lived. Paramedics took her to the emergency room at Zuckerberg San
Francisco General Hospital, where doctors X-rayed her arm and took a CT scan of
her brain and spine. She left with her arm in a splint, on pain medication, and
with a recommendation to follow up with an orthopedist.
A few months later, Dang got a bill for $24,074.50. Premera
Blue Cross, her health insurer, would only cover $3,830.79 of that – an amount
that it thought was fair for the services provided. That left Dang with
$20,243.71 to pay, which the hospital threatened to send to collections in
Most big hospital ERs negotiate prices for care with major
health insurance providers and are considered “in-network.” Zuckerberg San
Francisco General has not done that bargaining with private plans, making them
“out-of-network.” That leaves many insured patients footing big bills.
The problem is especially acute for patients like Dang:
those who are brought to the hospital by ambulance, still recovering from a
trauma and with little ability to research or choose an in-network facility.
A spokesperson for the hospital confirmed that ZSFG does not
accept any private health insurance, describing this as a normal billing
practice. He said the hospital’s focus is on serving those with public health
coverage – even if that means offsetting those costs with high bills for the
“It’s a pretty common thing,” said Brent Andrew, the
hospital spokesperson. “We’re the trauma center for the whole city. Our mission
is to serve people who are underserved because of their financial needs. We
have to be attuned to that population.”
But most medical billing experts say it is rare for major
emergency rooms to be out-of-network with all private health plans. (D)
On its web site, ZSFG declares that “everyone is welcome
here” regardless of their financial situation or immigration status:
Everyone is welcome here, no matter your ability to pay,
lack of insurance, or immigration status. We’re much more than a medical
facility; we’re a health care community promoting good health for all San
We’re part of a large group of neighborhood clinics and
healthcare providers, the San Francisco Health Network. In partnership, we
provide primary care for all ages, specialty care, dentistry, emergency and
trauma care, and acute care for the people of San Francisco…
“Our mission is to serve people who are underserved because
of their financial needs,” the spokesperson also stated. “We have to be attuned
to that population.” (E)
“More than half of U.S. adults “have been surprised by a
medical bill that they thought would have been covered by insurance,” according
to a new survey from research group NORC at the University of Chicago…
The big picture: Drug prices have been in the crosshairs of
lawmakers, and health insurers have always been a punching bag. But hospitals
and doctors aren’t attracting any large-scale movement to rein in pricing and
“There’s a huge amount of trust in the providers people
choose to go to,” said Caroline Pearson, senior fellow at NORC. “I think we’ve
got a long way to go until we have backlash against those providers. But as
insurance gets more complicated and out-of-pocket costs rise, we’re going to
see more and more surprise bills.” (F))
“U.S. Sen. Bill Cassidy, R-La., said federal lawmakers on
both sides of the aisle are moving closer to an agreement on legislation to
prevent surprise medical bills, according to a Bloomberg Government report…
Republicans and Democrats have been working to address the
issue, and bipartisan legislation is predicted for early 2019, Mr. Cassidy told
There have been legislative efforts related to surprise
medical bills. In September, a bipartisan group of senators unveiled the
Protecting Patients from Surprise Medical Bills Act. Then on Oct. 11, Democrat
Sen. Maggie Hassan of New Hampshire introduced the No More Surprise Medical
Bills Act of 2018. The first draft bill focuses on preventing out-of-network
providers from charging patients more for emergency care than what they would
pay using insurance. The second bars healthcare providers from out-of-network
billing for emergency services, according to the report.
Meanwhile, Bloomberg Government notes, insurers and
hospitals are pointing the finger at each other over who is at fault for the
Mr. Cassidy told the publication there are “bad apples with
both groups” and anticipates both sides “are going to have to give a little
bit” when it comes to changes.” (G)
“Payer groups, including America’s Health Insurance Plans,
are joining forces with employers, consumers and other stakeholders in support
of a plan they say will tackle surprise billing.
The groups signed on to a set of guiding principles aimed at
protecting consumers from the practice. The guidelines are: inform patients
when care is out of network, support federal policy that protects consumers
while restraining costs and ensuring quality networks and pay out-of-network
doctors based on a federal standard.
Meanwhile, the American Hospital Association and the
Federation of American Hospitals released a joint statement saying hospitals
and health systems also support patient protections from surprise billing but
place blame on insurers, not providers…
AHIP said surprise billing happens because providers aren’t
participating in certain networks. “When doctors, hospitals or care specialists
choose not to participate in networks – or if they do not meet the standards
for inclusion in a network – they charge whatever rates they like,” the group
In their statement, the hospital groups also backed consumer
protections, but pointed the finger at payers for the issue. “Inadequate health
plan provider networks that limit patient access to emergency care is one of
the root causes of surprise bills. Patients should be confident that they can
seek immediate lifesaving care at any hospital. The hospital community wants to
ensure that patients are protected from surprise gaps in coverage that result
in surprise bills, and we look forward to working with policymakers to achieve
this goal,” they wrote…” (H)
“I’ve read emergency room bills from all 50 states and the
District of Columbia. I’ve looked at bills from big cities and from rural
areas, from patients who are babies and patients who are elderly. I’ve even
submitted one of my own emergency room bills for an unexpected visit this past
Some of the patients I read about come in for the reasons
you’d expect: a car accident, pains that could indicate appendicitis or a heart
attack, or because the ER was the only place open that night or weekend….
I’ll stop collecting emergency room bills on December 31.
But before I do that, I wanted to share the five key things I’ve learned in my
year-long stint as a medical bills collector.
1) The prices are high – even for things you can buy in a
2) Going to an in-network hospital doesn’t mean you’ll be
seen by in-network doctors
3) You can be charged just for sitting in a waiting room
4) It is really hard for patients to advocate for themselves
in an emergency room setting
5) Congress wants to do something about the issue.. (I)
“Zuckerberg General’s emergency room fees are also higher,
on average, than ERs nationally, in the state of California, and in the city of
San Francisco. In the city, they’ve charged up to five times as much. The fees
are set by the San Francisco Board of Supervisors, which has voted for steady
increases, doubling the charge since 2010.
When asked about the fees, board members admitted that they
hadn’t kept a close eye on the prices and said they plan to hold hearings on
“It turns out we should have been monitoring this much more
closely,” says Aaron Peskin, a supervisor who has previously voted in favor of
the hospital prices and who is now calling for the hearings…
The city of San Francisco manages Zuckerberg General and
sets the prices the hospital charges.
The task falls to the San Francisco Board of Supervisors, an
11-member board that oversees city policies and budgets. Every year or two,
they approve a lengthy document that lists hospital prices for everything from
an emergency room fee to a day in the obstetrics unit to a primary care exam.
The document describes the fees as “proper reasonable amounts.”
The current prices were approved at a board a meeting in
July 2017. A video recording of that meeting shows there was no debate or
discussion of the prices. Instead, the board of supervisors unanimously
approved the ZSFG charges in a voice vote that latest less than a minute…
But there is little record of public discussion or debate
over that increase. Meeting records for each vote on the hospital prices since
2010 show that the fees have always been approved unanimously.
“I cannot recall there ever being any discussion of them,”
says Peskin, a board member who has served on and off since 2001. “I don’t
think there has ever been a split vote, and that’s been true as long as I’ve
been on the board of supervisors. But that will probably change now.”..
The San Francisco Board of Supervisors now plans to bring
greater scrutiny to the hospital’s billing practices in light of Vox’s
“Zuckerberg San Francisco General Hospital is reducing a
bike crash patient’s $20,243 bill down to $200 – only after the case drew national
attention to the hospital’s surprising policy of being out-of-network with all
private health insurance…
The San Francisco Board of Supervisors, which oversees the
hospital, now plans to hold hearings on Zuckerberg General’s billing practices
as well.” (K)
“Momentum is building for action to prevent patients from
receiving massive unexpected medical bills, aided by President Trump, who is
vowing to take on the issue…
Trump gave a boost to efforts on Wednesday.
“[People] go in, they have a procedure and then all of a
sudden they can’t afford it, they had no idea it was so bad,” Trump said at a
roundtable with patients about the issue.
“We’re going to stop all of it, and it’s very important to
me,” he added.
But the effort still faces obstacles from powerful health
care industry groups – including hospitals, insurers and doctors. Those groups
are jockeying to ensure that they avoid a financial hit from whatever solution
lawmakers and the White House back.” (L)
Emergency rooms argue that these fees are necessary to keep
their doors open, so they can be ready 24/7 to treat anything from a sore back
to a gunshot wound. But there is also wide variation in how much hospitals
charge for these fees, raising questions about how they are set and how closely
they are tethered to overhead costs.
Most hospitals do not make these fees public. Patients
typically learn what their emergency room facility fee is when they receive a
bill weeks later. The fees can be hundreds or thousands of dollars. That’s why
Vox has launched a year-long investigation into emergency room facility fees,
to better understand how much they cost and how they affect patients…
We found that the price of these fees rose 89 percent
between 2009 and 2015 – rising twice as fast as the price of outpatient health
care, and four times as fast as overall health care spending.” (M)
“San Francisco, CA
-Today Mayor London N. Breed, Supervisor Aaron Peskin, the Department of Public
Health and Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG)
announced immediate steps to improve billing practices at ZSFG for patients who
have gotten stuck in the middle of disputes between the hospital and their
insurance provider, including a temporary halt to the practice of balance
Temporarily halt all balance billing of patients
Effective immediately until a better plan is determined
Make financial assistance easier to get
Proactively begin the process of assessing a patient’s
eligibility for assistance, rather than waiting for them to apply
Improve patient communications
Proactively reach out to patients who are receiving large
bills to explain the situation, remove the element of surprise, and offer to
Create a Frequently Asked Questions document to clear up
many of the routine questions about billing and financial assistance
Publicize the patient financial services hotline, (415)
206-8448, so that people know where to go for help
Increase communication with patients and provide information
about financial assistance opportunities
Additional elements of a comprehensive plan to be developed
within 90 days
Make financial assistance easier to get
Adjust charity care and sliding scale policies to expand the
number of people who are eligible
Revise ZSFG catastrophic high medical expense program to
support more patients who are faced with high, unexpected bills for
Streamline the process of applying for assistance
Protect patients’ financial health
Establish an out-of-pocket maximum for patient payments to
Pursue agreements with private insurance companies
Work with state partners to explore additional efforts to
improve insurance payments
Ensure ZSFG prices and practices are fair
Undertake a study of hospital charges regionally, comparing
trauma centers, academic medical centers, San Francisco and Bay Area hospitals
Research billing and financial assistance practices of
California public hospitals to identify opportunities for improvement
Conduct financial analysis of impact on the City of proposed
PART 2: February 20,
2019. A new bill would outlaw the big, surprise bills that Zuckerberg San
Francisco General Hospital has sent to hundreds of patients.
“California lawmakers will introduce legislation Monday to
end surprise emergency room bills like those that left one patient with a $20,000
treatment bill after a minor bike crash – a move they say was inspired by Vox’s
reporting on the issue.
The new bill, introduced by Assemblyman David Chiu and Sen.
Scott Wiener, would bar California hospitals from pursuing charges beyond a
patient’s regular co-payment or deductible. The ban would apply even if a
hospital was out-of-network with a patient’s health insurance…
California actually has some of the country’s strongest
protections against surprise medical bills – but the state’s laws never anticipated
a hospital with billing practices like Zuckerberg San Francisco General.
In 2016, California passed a law that protected patients
from surprise bills from out-of-network doctors they didn’t choose.
This might happen if, for example, a patient went to an
in-network hospital and then received a bill from an out-of-network
anesthesiologist or radiologist they never even met.
That law covered patients receiving scheduled care like
surgery or delivering a baby. Separately, a decade-old California Supreme Court
ruling provided similar protections for emergency room patients.
Neither the court ruling nor the 2016 law anticipated a
situation like Zuckerberg San Francisco General, where the entire hospital is
“out of network” with all private health insurance.”..
This new legislation would tackle that rarer situation where
a hospital is not in network, and then sends the patient a bill for whatever
balance their insurer won’t pay.
There are two key parts to the proposal. First, the bill
would prohibit hospitals from pursuing any balance that the patient owed beyond
their regular co-payment or contributions to the health plan’s deductible.
Second, the bill would regulate the prices that the hospital
could charge for its care, limiting the fees to 150 percent of the Medicare
price or the average contracted rate in the area, whichever is greater.” (A)
“Publicity over “balance billing,” a practice that at
Zuckerberg San Francisco General Hospital has left some patients with insurance
on the hook for thousands of dollars in bills, has prompted San Francisco
lawmakers to call for a ban.
SF General made headlines recently for being out of network
with all private insurance companies and charging its insured patients high
bills — in one case $20,000 for a broken arm — without informing them first of
Assembly Bill 1161, introduced by Assemblymember David Chiu
and state Sen. Scott Wiener, would mandate that insured patients across the
state owe the same copayment or deductible they would normally pay for their
in-network emergency care.
The ban would apply regardless of whether or not the
emergency room is in-network or out-of-network with a patient’s insurer.
Patients receiving non-emergency care already benefit from
protections of a similar state law. However, the law does not apply to
Preferred Provider Organization (PPO) patients.
Some 6 million people across the state have federally
regulated self-insured plans, and some 1 million have plans regulated by the
California Department of Insurance who don’t benefit from this protection, per
He said that the bill is a response “in regard to what we
learned is happening at [ZSFGH] — but also across California — this is the
situation of patients who get a surprise bill after visiting an emergency
Dear Congressional and Committee Leadership: (C)
On behalf of our member hospitals, health systems and other
health care organizations, we are fully committed to protecting patients from
“surprise bills” that result from unexpected gaps in coverage or medical
emergencies. We appreciate your leadership on this issue and look forward to
continuing to work with you on a federal legislative solution.
Surprise bills can cause patients stress and financial
burden at a time of particular vulnerability: when they are in need of medical
care. Patients are at risk of incurring such bills during emergencies, as well
as when they schedule care at an in-network facility without knowing the
network status of all of the providers who may be involved in their care. We must
work together to protect patients from surprise bills.
As you debate a legislative solution, we believe it is
Define “surprise bills.” Surprise bills may occur when a
patient receives care from an out-of-network provider or when their health plan
fails to pay for covered services. The three most typical scenarios are when:
(1) a patient accesses emergency services outside of their insurance network,
including from providers while they are away from home; (2) a patient receives
care from an out-of-network physician providing services in an in-network
hospital; or (3) a health plan denies coverage for emergency services saying
they were unnecessary.
Protect the patient financially…
Ensure patient access to emergency care…
Preserve the role of private negotiation…
Remove the patient from health plan/provider negotiations…
Educate patients about their health care coverage…
Ensure patients have access to comprehensive provider
networks and accurate network information…
Support state laws that work…
American Hospital Association, America’s Essential Hospitals,
Association of American Medical Colleges, Catholic Health Association of the
United States, Children’s Hospital Association, Federation of American
PART 3. April 18, 2019. “Zuckerberg San Francisco General
Hospital announced Tuesday it has overhauled its billing policies…
The hospital has for years made the rare decision to be out
of network with all private health insurance plans. This created an acute
problem for patients like like Nina Dang, 24, who made an unexpected trip to
the hospital’s emergency room, the largest in San Francisco. An ambulance took
Dang to the trauma center after a bike accident last April. She is insured by a
Blue Cross plan, but she didn’t know that the ER does not accept insurance. She
received a bill for $20,243.
After the Vox story ran, the hospital reduced Dang’s bill to
$200, the copay listed on her insurance card.
Now, Zuckerberg San Francisco General Hospital (ZSFG) is
essentially making the same change for all future patients: Its new billing
policies will no longer charge those with private coverage “any more than they
would have paid out of pocket for the same care at in-network facilities, based
on their insurance coverage.”
This will put an end to the hospital’s use of a
controversial practice call “balance billing,” when a hospital sends a patient
a bill for the balance that an insurer won’t pay.
ZSFG will also create a new out-of-pocket maximum on what
patients could end up owing for their treatment. The maximum is tethered to a
patient’s income and ranges from zero dollars for the lowest earners to a
$4,800 maximum for those with the highest incomes (1,000 percent of the poverty
line, or $251,400 for a family of four).” (A)
“The changes are aimed at shielding patients from large
bills by removing them from payment disputes between the hospital and the
insurance company, said Rachael Kagan, director of communications with the
“We don’t have a large number of privately insured patients
at Zuckerberg San Francisco General Hospital, but some of those who have been
in that situation in the past have had a terrible experience and we want to
rectify that,” said Ms. Kagan.
“We don’t want that to happen in the future. We know that
it’s very stressful to get a large bill and we consider our responsibility to
the patients to care for them in all ways. They will have gotten excellent
medical care from us, and we want to protect their financial well-being also,”
The hospital estimated that up to 1,700 of its 104,000
patients a year may have received a balance bill…
Zuckerberg hospital will also set a maximum out-of-pocket
cost for patients at all income levels, with any insurance status, and this
maximum will be income-based. No one will be charged more than 5 percent of
Additionally, the hospital will make its patient financial
assistance programs easier to qualify for so more people will get financial
assistance. This involves increasing the threshold to qualify for the
hospital’s charity care program. The threshold to qualify will increase from
350 percent of the federal poverty level to 500 percent of the federal poverty
The hospital is also adjusting the “sliding scale” financial
assistance program for San Francisco residents. Previously, Zuckerberg hospital
assessed eligibility for the program based on income and assets but will now
only take income into account…
Overall, she said she’s pleased the hospital is taking these
steps to better align its billing with its values and mission.” (B)
PART 4: August 18, 20129. Hospitals kept ER fees secret.
Zuckerberg San Francisco General and the University of
California San Francisco are two of the city’s busiest hospitals, about 4 miles
apart. But if you have private insurance and visit Zuckerberg General, you
could end up paying a lot more for the same treatment.
For an especially serious visit, Zuckerberg General charges
a facility fee of $11,176, 46 percent more than UCSF, which charges an average
The hospital is also out-of-network with all private
insurance, leaving patients responsible for the fee and the cost of treatment.
UC San Francisco, meanwhile, accepts insurance from most big providers.
Insurers generally negotiate lower prices for patients, and many plans cover ER
visits in part or in full…
When asked about the fees, board members admitted that they
hadn’t kept a close eye on the prices and said they plan to hold hearings on
“It turns out we should have been monitoring this much more
closely,” says Aaron Peskin, a supervisor who has previously voted in favor of
the hospital prices and who is now calling for the hearings…
“I cannot recall
there ever being any discussion of them,” says Peskin, a board member who has
served on and off since 2001. “I don’t think there has ever been a split vote,
and that’s been true as long as I’ve been on the board of supervisors. But that
will probably change now.” (A)
“Frustrated by waiting for federal lawmakers to act, states
have been trying to solve this issue. As of December 2018, 25 states offered
some protection against surprise billing, and the protections in nine of those
states were considered “comprehensive,” according to the Commonwealth Fund.
California, New York, Florida, Illinois and Connecticut are among the nine.
New state laws also have been adopted since, including in
Nevada, which will limit how much out-of-network providers, including
hospitals, can charge patients for emergency care, starting next year.
In California, a 2009 state Supreme Court ruling protects
some patients against surprise billing for emergency care, and a state law that
took effect in 2017 protects some who receive non-emergency care.
But millions remain vulnerable, largely because California’s
protections don’t cover all insurance plans. The California Supreme Court
ruling applies to people with plans regulated by the state Department of
Managed Health Care. That leaves out the roughly 1 million Californians with
plans regulated by the state Department of Insurance and the nearly 6 million
people with federally regulated plans, most of whom have employer-sponsored
The state law governing non-emergency care also doesn’t
apply to the millions of residents with health plans regulated by the federal
The California Hospital Association opposes the measure,
which would limit the amount hospitals could charge insurance plans to a
certain rate for each service, varying by region…
“We fully support the
provision of the bill that protects patients. It is the rate-setting piece that
is our concern,” she said.” (B)
“Legislation to prohibit California hospitals from sticking
patients with huge emergency room bills that their insurers won’t cover has
cleared a crucial hurdle in the state Capitol.
Lawmakers in the Assembly voted 48-9 on Thursday to approve
AB1611, which would prohibit hospitals from “balance billing” patients if their
insurance won’t cover the full cost for care.
Assemblyman David Chiu and state Sen. Scott Wiener, both
Democrats from San Francisco, co-wrote the legislation. The bill now moves to
AB1611 would prohibit hospitals from billing patients for
any cost beyond their insurance deductible and co-payment. It also spells out
rules for how hospitals and insurers resolve cost disputes.” (C)
their opposition on a provision of the bill that would have limited charges for
out-of-network emergency services.
The proposal would have required hospitals to work directly
with health plans on billing, leaving the patients responsible only for their
in-network copayments, coinsurance and deductibles.
Citing fierce pushback from hospitals, California lawmakers
sidelined a bill Wednesday that would have protected some patients from
surprise medical bills by limiting how much hospitals could charge them for
emergency care.” (D)
The legislation, which contributed to the intense national
conversation about surprise medical billing, was scheduled to be debated
Wednesday in the state Senate Health Committee.
Instead, the bill’s author pulled it from consideration,
vowing to bring it back next year.
“We are going after a practice that has generated billions
of dollars for hospitals, so this is high-level,” said Assemblyman David Chiu
(D-San Francisco). “This certainly does not mean we’re done.” (E)
want you to know that they’re fully on board with the idea that emergency room
patients shouldn’t be hit with thousands of dollars in surprise billings
because the ER isn’t in their insurance plan’s network.
You should also know, however, that the hospitals just
killed a measure in Sacramento that would have accomplished that goal, and that
the reason they did so was to protect their own revenues….
The state’s hospitals went to the mattresses over the
payment provision, cursing it as “government rate setting” that they would
Hospital executives inundated legislators with warnings that
rate-setting would force their institutions to shut down.
We have 450 hospitals in California,” says Anthony Wright,
executive director of Health Access, “and every hospital CEO has the cellphone
number of his state senator and assemblyman. A hospital saying it would close
would give pause to any lawmaker.”
The proponents were aware that they were poking a stick into
a tiger’s cage. “We’re going after a practice that has generated billions of
dollars in profits for hospitals, Chiu told me, “and hospital CEOs around the
state waged very aggressive lobbying to protect those profits.”” (F)
“San Francisco’s health network has finalized its first
contract with a private health insurer, Canopy Health Canopy — meaning
Zuckerberg San Francisco General Hospital, long perceived as the hospital of
last resort, is now in the business of wooing expectant mothers to choose to
deliver at its Family Birth Center…
Department of Public Health staff said the signing of this
contract was not a reaction to billing controversies at ZSFGH that erupted
earlier this year, when it was revealed that even insured patients were being
hit with crippling debts through the practice of “balance billing.” Because the
hospital was out-of-network for private insurance companies, there was often a
great divergence between what ZSFGH billed the insurance and what the insurance
company would deign to pay — leaving individuals responsible for the “balance.”
This situation, however, did highlight the hospital’s
unhealthy and precarious “payer mix.” With few privately insured patients,
ZSFGH ministers mostly to Medi-Cal recipients or the marginally insured. Deals
like the one initiated July 15 with Canopy would begin to change that mix,