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“Chinese researchers say they have identified a new virus
behind an illness that has infected dozens of people across Asia, setting off
fears in a region that was struck by a deadly epidemic 17 years ago.
There is no evidence that the new virus is readily spread by
humans, which would make it particularly dangerous, and it has not been tied to
any deaths. But health officials in China and elsewhere are watching it
carefully to ensure that the outbreak does not develop into something more
severe.
Researchers in China have “initially identified” the new
virus, a coronavirus, as the pathogen behind a mysterious, pneumonialike
illness that has sickened 59 people in the city of Wuhan and caused a panic in
the central Chinese region, the state broadcaster, China Central Television,
said on Thursday. They detected this virus in 15 of the people who fell ill,
the report said.
The new coronavirus “is different from previous human
coronaviruses that were previously discovered, and more scientific research is
needed for further understanding,” the report said.” (A)
“China released the genetic sequence of a new coronavirus
believed to be responsible for a cluster 0f unusual pneumonia cases in Wuhan.
Phylogenetic analysis shows the coronavirus to be closely related to SARS CoV,
the virus responsible for the SARS pandemic which began in China in 2003.
Further analysis is necessary, but this preliminary analysis
shows the virus is also quite similar to other SARS-related coronaviruses which
appear to be endemic to the area. Prior EcoHealth Alliance research has found
evidence that these viruses are spilling into human populations. We are also
conducting behavioral analysis with the goal of reducing risk for this
spillover.
The virus responsible for the current outbreak in Wuhan has
so far killed one person; fortunately it’s not currently believed that the
virus has the ability to spread human-to-human. Our work has shown that there
is a large diversity of coronaviruses that are endemic to China.” (B)
“Chinese officials confirmed Tuesday that six people have
died from a pneumonialike coronavirus, while raising the number of confirmed
cases of the illness to 300, sparking fears of an outbreak in the country. The
virus, which was first confirmed on Dec. 31 in the city of Wuhan, is believed
to have been transmitted from animals to humans, but Chinese health officials
now say they have evidence that human-to-human transmission is also possible,
potentially via saliva. The World Health Organization says the symptoms of the
virus are fever, cough, and respiratory difficulties such as shortness of
breath, all of which can, in serious cases, lead to pneumonia, kidney failure,
and, in the most severe cases, death.” (C)
“Officials in China are racing to contain the spread of a
new virus that has left at least six people dead and sickened more than 300,
after it was confirmed the infection can spread between humans.
Wuhan, the central Chinese city where the coronavirus was
first detected, announced a series of new measures Tuesday, including the
cancellation of upcoming Lunar New Year celebrations, expected to attract
hundreds of thousands of people.
Tour agencies have been banned from taking groups out of
Wuhan and the number of thermal monitors and screening areas in public spaces
will be increased. Traffic police will also conduct spot checks on private
vehicles coming in and out of the city to look for live poultry or wild
animals, after the virus was linked to a seafood and live animal market,
according to a report by state media outlet the People’s Daily, citing Wuhan’s
Municipal Health Commission.
The new measures come after Chinese President Xi Jinping
ordered “resolute efforts to curb the spread” of the virus Monday.
There are now fears, however, that efforts to contain it are
coming too late, hampered by a slow-moving Chinese bureaucracy which failed to
put sufficient measures in place in time.
In the coming days, hundreds of millions of Chinese are
expected to begin traveling across the country and overseas as the annual Lunar
New Year break gets fully underway, compounding concerns of a further spike in
cases.
Though infections were first detected in Wuhan in
mid-December, infrared temperature screening areas were not installed in the
city’s airports and stations until January 14, according to state media.
On Tuesday, China’s National Health Commission announced
that it had received 291 confirmed cases of the Wuhan coronavirus, with 77 new
cases reported on January 20.” (D)
“Earlier on Monday, Chinese authorities reported that the
number of cases had tripled over the weekend to 218. The outbreak has spread to
Beijing, Shanghai and Shenzen, hundreds of miles from Wuhan, where the virus
first surfaced last month.” (E)
Health officials in Thailand on Friday said they had found a
second case of the mysterious pneumonialike coronavirus in that country, in a
74-year-old Chinese woman. The woman is in good and stable condition, said a
spokesman for Thailand’s public health ministry, Rungrueng Kitphati.
The woman entered Thailand through Bangkok via a flight from
the central Chinese city of Wuhan, the epicenter of the outbreak. Investigators
were still trying to gather information from the woman but have been hindered
by a language barrier, Mr. Rungrueng said.
On Thursday, Japan’s Health Ministry said that a Chinese man
in his 30s tested positive for the coronavirus. The man, a resident of Kanagawa
Prefecture, just south of Tokyo, returned to Japan on Jan. 6 after traveling to
Wuhan. The man, who came down with a fever on Jan. 3, was hospitalized on
Friday but was discharged five days later because he had recovered, according
to the Health Ministry.” (F)
Ash Shorley, 32, was admitted in critical condition to a
Phuket hospital, where he’s being treated for pneumonia-like lung infections,
the Sun reported.
Doctors believe his symptoms are consistent with the new
Chinese coronavirus, which has killed three patients and infected hundreds of
others.
“They think he is the first Western victim of the Chinese
flu,” his father, Chris, told the outlet. “We are waiting on tests.”” (G)
“Airports in New
York, San Francisco and Los Angeles will begin screening passengers arriving
from Wuhan, China, for infection with a mysterious respiratory virus that has
killed two people and sickened at least 45 overseas, the Centers for Disease
Control and Prevention announced on Friday.” (H)
“Officials this week also confirmed that the new
coronavirus, which is linked to a seafood and animal market in Wuhan, is
transmissible between humans. This ultimately sparked fears that a person
infected with the virus and experiencing the most severe stage of infection
could be a super-spreader — someone who
transmits the virus to a considerable more amount of people than the average
infected person, the South China Morning Post reported…
In response to the outbreak, the World Health Organization
(WHO) is holding an emergency meeting on Wednesday to determine whether or not
it should be considered an international public health emergency, according to
the South China Morning Post…
Australia is taking similar measures, with officials there
announcing Tuesday that the country will also begin screening passengers who
are arriving from Wuhan, according to The New York Times. Japan and South Korea
also announced increased airport screenings.
But even with screening measures, “You cannot absolutely
prevent entry into the country of a disease like this,” Brendan Murphy, the
chief medical officer for the Australian government, said, according to the
newspaper. Some people who are infected may not show symptoms, he explained.” (I)
The CDC and Washington state officials said the man, in his
30s, was in good condition at Providence Regional Medical Center in Everett.
The symptoms presented Sunday and the diagnosis was confirmed Monday.
Nancy Messonnier, director of the National Center for
Immunization and Respiratory Diseases, called the news “concerning.”
“We’re still in the early days of this investigation,” Messonnier said.” (J)
“A SEVERE FLU PANDEMIC… could kill more than 33 million
people worldwide in just 250 days.” – “Boy, do we not have our act together.” —
Bill Gates”. (J)
ASSIGNMENT: Does your community have a seasonal flu
EMERGENCY RESPONSE PLAN? Do your community’s hospitals have SURGE CAPACITY and RAPID RESPONSE TEAMS? If not, develop a
plan!
EBOLA. PART 13. Ebola Treatment Centers are having
difficulty maintaining their ability to respond to Ebola cases that may come
again to the U.S.
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?
PART 4. CANDIDA AURIS. “.. nursing facilities, and long-term
hospitals, are…continuously cycling infected patients, or those who carry the
germ, into hospitals and back again.”
Germs that can cause serious infections are in every
healthcare facility. They can be on your healthcare provider’s hands and also
your own.
It’s OK to ask for clean hands. It could save your life.
Make sure everyone around you has clean hands to protect against infection.
SPEAK UP FOR CLEAN HANDS.
________________________________
Hand hygiene plays a critical role in preventing the spread of pathogens that can lead to healthcare-associated infections (HAI), yet many U.S. health systems are falling short on their hand hygiene compliance rates. The Centers for Disease Control & Prevention (CDC) estimates that healthcare providers clean their hands about half the times they should. Missing these hand hygiene opportunities puts patients at risk for HAIs.” (K)
ASSIGNMENT: Develop an evidence-based
hand-washing plan for your community hospital.
“Hand hygiene is described by many health care workers as
the single most important tool in preventing the spread of health
care-associated infections between patients…
Organisms found on HCW hands after such patient contact
range from Klebsiella spp., Staphylococcus aureus, Clostridium difficile, MRSA
and gram-negative bacteria. However, direct patient contact is not the only way
HCW hands can be contaminated. HCWs can acquire bacteria on their hands by
touching contaminated surfaces in the patient environment and simply by
touching a contaminated chart at the nurses’ station, according to the
literature.
Washing hands before and after patient contact seems like a
simple solution to prevent the spread of bacteria between patients. Most
hospitals have hand hygiene policies in place that guide their employees to do
just that. But it is not as simple as it seems.
“When we look at all of the things that we can do to prevent
infections in the hospital, one of the most important things about hand hygiene
is that it works for so many different types of organisms, and you get a lot of
bang for the buck,” …“The issue is that you have to practice it at a high level
of compliance for it to work. There are so many opportunities for hand hygiene,
and it is difficult to get to a level of compliance where we’re able to make
changes to infection rates.”” (A)
“What’s The Problem? Most germs that cause serious
infections in healthcare are spread by people’s actions. Hand hygiene is a
great way to prevent infections. However, studies show that on average,
healthcare providers clean their hands less than half of the times they should.
This contributes to the spread of healthcare-associated infections that affect
1 in 25 hospital patients on any given day. Every patient is at risk of getting
an infection while they are being treated for something else. Even healthcare
providers are at risk of getting an infection while they are treating patients.
Preventing the spread of germs is especially important in hospitals and other
facilities such as dialysis centers and nursing homes.” (B)
“How much hand hygiene is enough? Guidelines vary, but
according to Dr. Clifford McDonald, associate director for science at the CDC,
nurses or doctors in the intensive care unit may have to clean their hands over
100 times in an eight-hour shift.
SCVMC and many other hospitals are working on ways to
increase compliance. One strategy involves publicizing compliance data —
apparently, some hospital departments enjoy some healthy competition.
Another study being presented at APIC from the Henry Ford
Health System in Detroit found that hand-washing rates improved after hospital
staff members were shown images of millions of bacteria found on common
surfaces. Appealing to human emotions — like disgust — seems to have had a
meaningful impact.
On May 5, the CDC launched a “Clean Hands Count Campaign” to
promote hand hygiene adherence in hospitals. Part of their mission is to
empower patients to hold healthcare workers accountable for cleaning their
hands.
McDonald encourages patients to remind doctors and nurses to
sanitize their hands — even though it might feel like an uncomfortable shift
in the traditional power dynamic.
“If we can get the patients more involved in that — and get
them to be able to speak up, that is really the main thing,” he said. “A lot of
patients are nervous about that kind of thing — that’s another culture we’re
trying to change.”” (C)
“My colleagues and I have been studying how to prevent
hospital infections for years. Our research – which has included site visits to
over 50 U.S. hospitals as well as a large-scale collaborative effort involving
over 1,000 U.S. hospitals and several hospitals in Japan and Italy – found that
opposition to hospitals’ infection prevention initiatives comes from a type of
health care worker that we classified as active resisters.
Active resisters are people who like doing things a certain
way for the simple reason that things have always been done that way. During
one site visit, an infectious diseases doctor involved in preventing infections
told us:
Getting the surgeons to adopt things in general is
problematic …they’re like baseball players, they’ve got superstitions…in their minds
if it’s working, why should we change it.
But at least you know who these people are since they speak
up at meetings and actively resist changing behavior.
Active resister or organizational constipator?
The second type are what we termed organizational
constipators. These individuals often have nothing against an initiative per se
but simply enjoy exercising their power by refusing to change, albeit below the
radar. The challenging aspect about organizational constipators is that the
people above them think they are doing a good job, while those below them
cannot believe they still have a job.
Yet another barrier we found in our research is that many
hospitals have a culture of mediocrity rather than a culture of excellence.
These hospitals are content to be just good enough. Leadership is generally
ineffective. Overperformers are rewarded with more work…
If guidelines, personal bottles of hand sanitizer and
constant feedback aren’t enough, perhaps health care workers should heed the
words of Dr. Avedis Donabedian, an internationally known expert in health care
quality.
In an interview about health care and how to improve it. Dr.
Donabedian was clear:
Health care is a sacred mission…Doctors and nurses are
stewards of something precious…Ultimately, the secret of quality is love. You
have to love your patient, you have to love your profession…If you have love, you
can then work backward to monitor and improve the system.
If we have love, we will wash our hands before touching our
patients.” (D)
“What is the correct hand washing technique for good hand
hygiene?
It’s important that we know when to wash our hands before we
consider the best technique for doing so. Hand Hygiene Australia have
identified ‘5 moments for hand hygiene’ which include:
before touching a patient
before a procedure
after a procedure or body fluid exposure
after touching a patient
after touching a patient’s surroundings.
The commonly held thought is that it’s only before or after
direct patient contact that it becomes necessary to wash our hands but clearly
there are so many more instances where we can pick up infection carrying
organisms.
One of the key risks is that the organisms are invisible and
we cannot know they are there, it’s crucial that good hand hygiene becomes more
than a habit but second nature.
Despite the clear need for good hand hygiene, there are many
obstacles that appear to be preventing it becoming routine amongst healthcare
professionals. Some of these are down to poor perception – such as patient need
taking priority over hand washing, that gloves are an effective barrier or a
lack of understanding of cross contamination. Whereas institutional problems
can also be a barrier, such as not enough hand washing stations, staff
shortages, lack of policy, or simple forgetfulness.
The battle against hospital acquired infection continues,
and with antibiotic resistance ever increasing, there shows little sign of it
stopping soon. Effective hand hygiene is one of the simple steps every nurse,
midwife and medical professional can take to help combat infection and protect
their patients from harm.” (E)
“Walk into most manufacturing plants that are performing
well, perhaps winning the Malcolm Baldrige Award,1 and you will find robust leadership and
management systems focused on customer needs. Good leaders establish a bedrock
of values, a clear moral compass, and a compelling vision and inspire others to
embrace that vision. Good managers declare goals and measures and ensure that
both of these cascade through each level of the organization, with designated
processes and persons accountable for them. Workers know the behaviors needed
to achieve the goals, and management is visible in their work area and posts
performance on key behaviors.
Health care has not yet widely embraced these management
practices. Despite considerable clinical research to identify essential
behaviors and practices, health care processes are unreliable, for which there
are several reasons. First, we are still heavily practicing the “art” of
medicine, reflecting a failure to determine when art is needed and when more
disciplined science should be practiced.
Second, at most organizations, clinicians are not trained in
the tools and methods of Lean, Six Sigma, and change management—which Chassin
and colleagues, in their two articles in this issue of The Joint Commission
Journal on Quality and Patient Safety, 2,3 refer to collectively as Robust
Process Improvement® (RPI®).
Third, our accountability systems are grossly
underdeveloped, and low compliance with evidence-based practices is too often
tolerated.” (F)
“Five key categories of hand hygiene intervention (HHI)
emerged: (1) improving awareness with education (knowledge transfer,
evaluation, mentoring and feedback), (2) facility design and planning, (3)
unit-level protocols and procedures, (4) institution-wide programs, and (5)
multimodal interventions.
•Although some evidence-based HHI has been developed,
sustaining hand hygiene compliance remains challenging.
•Components like environmental psychology, behavioral
economics, and financial rewards should be used to better understand and
catalyze improved behavioral change in various contexts and environments to
improve hand hygiene.” (G)
“Recent trials have demonstrated that Surfaceskins,
self-disinfecting door push-pads and pull-handles designed to kill deposited
germs in seconds, promote hand hygiene awareness and significantly improve hand
hygiene compliance.
Surfaceskins Ltd, a company part owned by University of
Leeds spin off, NIRI (Nonwovens Innovation and Research Institute Ltd) believes
the latest trial, conducted in hospital theaters over six months with results
published in the Journal of Hospital Infection, is a watershed moment for the
company, as it shows that, in addition to the potential to eliminate doors as a
source of hand contamination, Surfaceskins can also have an additional
infection control benefit by improving hand hygiene awareness and compliance.”
(H)
“Ultraviolet sanitizing devices could be stationed around
hospitals to help prevent the spread of bacteria on workers’ devices like
smartphones, a small Canadian study suggests.
Researchers in British Columbia recruited staff at three
hospitals to disinfect their smart devices twice daily and found a drastic
reduction in the amount of bacteria growing on the devices afterward, according
to the report…
Smartphones and wearable devices are becoming the medium of
choice for doctors to communicate with staff and patients, Stephanie Huffman of
Island Health and the University of British Columbia in Vancouver and her
colleagues write in the American Journal of Infection Control.
Infections can spread by contact with unclean hands and
equipment like respiratory machines, but most hospitals have hand-hygiene rules
and systems in place to regularly disinfect medical instruments.
Routine and proper cleaning of smartphones and wearables
such as the popular Vocera Badge has not been well explored, the study team
writes. Using alcohol wipes is generally not recommended by smartphone makers.”
(I)
“Two hospitals in Singapore believe they have developed a
more effective hand hygiene program by focusing on handwashing compliance
throughout entire wards instead of just from staff member to staff member.
Ng Teng Fong General Hospital and Jurong Community Hospital
launched new hand hygiene programs a few years ago using World Health
Organization (WHO) guidelines, and the results are encouraging, reports
Infection Control Today.
As part of the program, staff trained in WHO methods audited
administrative staff that were not members of the ward staff, as well as
infection control liaison nurses and infection control nurses. Wards that
didn’t reach targeted compliance rates within the first month were asked to
increase their hand hygiene education. If the heightened education didn’t yield
results after the second month of monitoring, then the infection committee
chairperson was asked to take over the education. In the event of a third month
of failure, a special task force comprised of a doctor or nurse was created to
implement a compliance improvement strategy.
No ward exceeded four months of being below its compliance
target.” (J)
I taught full time in the Baruch MBA in Health Care Administration program from 1972 to 1975, then was a health care administrator for over thirty years, finishing for seventeen years as President & CEO of LibertyHealth/ Jersey City Medical Center, where we built a replacement safety-net hospital (it took 15 years), played a key role on September 11th, 2001, and once again became a medical school affiliated teaching hospital (having been free-standing for decades).
After retiring from LibertyHealth, I returned to the Baruch program for four years as Adjunct Professor and started writing case studies. I developed case studies based on my CEO experiences. Interestingly case studies on failures provided better Lessons Learned than cases on successes. I also used Harvard Case Studies, and invited “Visiting” Professors to present cases typically related to the new realities of Obamacare, mostly C-Level executives I was still in touch with from my first stint at Baruch. I was very proud of what they had accomplished and shared.
In retirement I have watched health care disruption become so complex that there are few, if any, up-to-date case studies. So I developed a method of “rapid response” content development by curating news articles into a coherent thread, after a topic has called out to me.
Now, my Career Capstone Project is to prepare content that can be used in real-time, meaning they can start a discussion for immediate use in class. .
D. Select topics to follow and make a folder for each
E. Then every day from News Feeds and Alerts select articles on your topics and move them to the appropriate folder.
F. When you are inspired to write a content bundle start a Word document, then go to the case folder and select key points from the articles, and cut and paste them to the Word document. As well capture article title, author and hyperlink.
G. Move the key points around until you have created a “story”.
H. Then label each point A,B.C…and move article title, author and hyperlink to footnotes at the end of the case.
Now, a 2017 U.S.
News analysis underscores a crucial factor that can tip the balance between
life and death: where the surgery is performed.
The analysis of four
years of data from hospitals across the country indicates that 26 percent of deaths
– more than 1 out of every 4 – that occur following surgery for the most severe
heart defects could be prevented by having the operation performed at hospitals
where surgical teams do the greatest numbers of procedures.” (A)
Little has changed, however, since the first research linked volume to outcomes in the 1970s. Smaller surgical programs continue to perform procedures best left to surgeons at more experienced institutions, even when there’s a high-volume hospital nearby.
The reasons for the health care industry’s reluctance to act
include the same forces that shape so much else in medicine: prestige and money.
Hospitals mindful of their reputation and bottom line encourage doctors to keep
patients in-house, rather than referring them to rivals with the experience and
resources to care for them. Surgeons also oppose efforts to limit the scope of
their practice.
Community leaders, too, may rebel at the notion of closing
low-volume services, because lost revenue could threaten a local hospital’s
survival. Plus, some smaller hospitals provide high-quality care and get
excellent results.
In 2015, U.S. News demonstrated that thousands of lives
could be saved each year if patients with certain conditions, including those
needing joint-replacement operations, were treated in high-volume settings.
Overall, knee-replacement patients who had their surgery in the lowest-volume
centers were nearly 70 percent more likely to die than patients treated at the
busiest centers. For hip-replacement patients, the risk was nearly 50 percent
higher…
Children who need complex congenital heart procedures face a
1 in 5 chance of dying before going home, while the risk for those needing
simple repairs is less than 1 percent, says Dr. Jeffrey Jacobs, chief of
cardiovascular surgery at Johns Hopkins All Children’s Hospital in St.
Petersburg, Florida. Jacobs also leads The Society of Thoracic Surgeons
Workforce on National Databases.” (A)
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
implications?
“The U.S. has more
than double the number of congenital heart surgery centers that it needs,
researchers said here.
Currently, the nation boasts more than 150 such centers: 116
participating in the Society of Thoracic Surgeons (STS) National Database as of
2018, and probably another 30-40 not reporting to it, said Carl Backer, MD, of
Ann & Robert H. Lurie Children’s Hospital of Chicago, and former president
of the Congenital Heart Surgeons’ Society (CHSS).
Among them are “problem institutions,” outliers
with unexpectedly high mortality rates, Backer told a standing-room-only crowd
at the American Heart Association (AHA) annual meeting…
The idea is that higher case volume is tied to lower patient
mortality in pediatric cardiac surgery, 300 cases per year being the inflection
point in one study cited by Backer.
This 300-case threshold held up in a separate analysis by
his group, which mined STS data and found that mortality rates adjusted for
case complexity came out to 1.7% for centers doing at least 300 cases annually
and 5.4% for others with 100 each year (P<0.01).
Regionalizing congenital heart surgery therefore should have
the goal of keeping case volumes above 300 per hospital while minimizing travel
distance. In addition, policies should allow for at least one program per state
that has over 2 million inhabitants, according to Backer.
His magic number: 71 sites scattered across the country.
Currently, Florida and Texas each already have 10 pediatric
heart surgery centers — and California 11. In Backer’s plan, this would be
reduced to six programs in Texas, four in Florida, and nine in California.” (B)
“A decision on the future of the Sydney Children’s Hospital
Network has been delayed four months after an independent review called for
urgent action amid protracted conflict over the state’s paediatric heart surgeries.
In July, Health Minister Brad Hazzard held a roundtable of
doctors and other healthcare workers from across the state after reviewers said
governance issues and tensions between the Randwick and Westmead hospitals
needed to be settled “as a matter of urgency”…
A NSW Health spokesman said Professor Henry’s review will
make recommendations on the governance and planning of healthcare services for
children for the next five years.
“These recommendations will obviously relate to
considerations of the governance of the Children’s Hospitals Network and the
configuration of paediatric cardiac surgery at the Sydney Children’s Hospital,
Randwick and Children’s Hospital at Westmead,” the spokesman said…
Westmead cardiologists believe patients will have better outcomes
if cardiac services are focused at one hospital, while doctors from Randwick
believe losing cardiac surgery would compromise other services.
“Our message has always been very clear, we believe
that cardiac surgery is a vital component of any children’s tertiary referral
hospital,” Chair of the Sydney Children’s Hospital Randwick medical staff
council Dr Susan Russell said after July’s roundtable.
Most clinicians at that roundtable – including paediatric
healthcare workers from rural and regional NSW – agreed the state would be best
served with one major children’s hospital providing cardiac surgery services.
But medical staff from the Randwick hospital disagreed.” (C)
“Johns Hopkins All Children’s Hospital has hired a familiar
face to help it restart its troubled heart surgery unit.
Dr. James Quintessenza will return as the department’s chief
surgeon and co-director, hospital leaders announced Tuesday.
Quintessenza, 62, oversaw the pediatric heart surgery
department at All Children’s for almost two decades. But he was pushed out
after the hospital became part of the Johns Hopkins system…
“We will spend the
next year recruiting additional doctors and staff, including for cardiac
intensive care, interventional and fetal cardiology,” Kmetz wrote. “We will
take whatever time is necessary to do this right.”..
The announcement comes after a tumultuous 11 months for the
hospital and its heart surgery unit.
The Times investigation, published last November, found that
the department’s 2017 death rate was higher than any other children’s heart
surgery program in Florida had seen in the past decade. Complication rates also
spiked, the Times found.
The problems began after Johns Hopkins took over All
Children’s in 2011 and started making changes to the heart department.
Quintessenza had performed the most difficult surgeries. But the hospital’s new
leaders wanted the cases evenly divided among its three heart surgeons.
Frontline workers noticed problems with surgeries performed
by the other two surgeons as early as 2015 and raised concerns to their
supervisors, the Times reported. But procedures continued as the hospital’s
leaders pushed to grow the Heart Institute.
Hospital leaders also made changes to the cardiologists and
critical care doctors who worked in the department.
Quintessenza disagreed with the hospital’s leaders, the
Times reported. The spike in deaths and complications happened after he left.
After the Times’ investigation, six top administrators
resigned, including the hospital’s CEO and the chief heart surgeon who had
replaced Quintessenza. Federal and state inspectors identified widespread
safety problems throughout the hospital and mandated sweeping changes…
“We made a mistake,
and we need to make sure we help support these families and make it right,”
Johns Hopkins Health System president Kevin Sowers told the Times in June.
Quintessenza, who graduated from the University of Florida
School of Medicine, was instrumental in growing the All Children’s heart
surgery program.
He performed the first pediatric heart transplant there in
1995. Two years later he became the chief of pediatric heart surgery. The heart
transplant program was ranked one of the nation’s best in a 1999 federal
government review.
After Quintessenza left in 2016, he was quickly hired by
Kentucky Children’s Hospital to help restart its pediatric heart surgery
program. The hospital had halted surgeries after its death rate increased in
2012.” (D)
“In just three years, Johns Hopkins All Children’s Hospital
has tripled the number of babies it treats born with congenital diaphragmatic
hernia – a hole in their diaphragm, a life-threatening birth defect.
The St. Petersburg pediatric hospital treated 50 children
with congenital diaphragmatic hernia in the third year of its CDH program, up
from 16 to 18 patients treated in the first year, said Dr. David Kays, medical
director of the program.
About half the patients are from families in Florida, and
about half travel from around the United States to St. Petersburg for
treatment.
Now, the hospital has a dedicated Center for Congenital
Diaphragmatic Hernia, a 15-bed unit that is believed to be the nation’s first
inpatient unit dedicated to the treatment of infants and children with
condition, said Thomas Kmetz, president of Johns Hopkins All Children’s
Hospital.
The center is staffed by an interdisciplinary team and led
by Kays, who was recruited to All Children’s in early 2016 from University of Florida.
At UF, he treated 321 children over 23 years – about 15 children a year, Kays
said at a dedication ceremony Thursday for the new center at All Children’s.
“I came here to build what I thought would be the world’s
best program in congenital diaphragmatic hernia,” Kays said. “There was a
trajectory to this children’s hospital that was perfect for this program. I
couldn’t take this program to Boston Children’s or Children’s Hospital in
Philadelphia. There were too many egos to accept me to come in and change the
paradigm. But this place was just right. It had the same vision to be a great
children’s hospital the way I wanted to build a great program.”..
Kays has a reputation in the pediatric surgical world as a
bit of a renegade, “a hard-driving guy with outcomes so great that some people
don’t even believe it,” said Dr. Paul Danielson, interim chair of the
hospital’s department of surgery.
Danielson describes Kays as a revolutionary, and the CDH
unit as truly interdisciplinary.
“It’s not multi-disciplinary, where different specialties
come and work together. It’s where different disciplines come together and
create their own new discipline,” Danielson said. (E)
“Johns Hopkins All Children’s Hospital in St. Petersburg and
Golisano Children’s Hospital of Southwest Florida have entered into an
agreement to expand care for kids across Florida’s west coast. The agreement
gives providers at both locations access to medical privileges to admit and
treat patients. Golisano Children’s Hospital will also be able to take part in
pediatric research studies and protocols through Johns Hopkins All Children’s
Hospital.
This relationship provides a process for collaboration
between the two hospitals, with a focus on increasing access to specialized
pediatric care. Through this agreement, Johns Hopkins All Children’s Hospital
and Golisano Children’s Hospital will work together to deliver the highest
quality care, leverage resources and create better value for families.” (F)
“Three cardiologists from outside the state have reviewed
the North Carolina Children’s Hospital pediatric heart surgery program and
concluded the program can resume complex pediatric heart surgeries there.
The six-page advisory report released this week by UNC
Health Care officials acknowledged that new leadership and investment in the
program has helped resolve some of the thornier issues exposed several months
ago in a New York Times investigative piece.
The external review panel also highlighted the program’s
precarious perch as a smaller-volume pediatric cardiology program aspiring to
grow in the shadow of a larger program only miles away at Duke University.
“The current pediatric cardiac surgical volume presents
challenges in a number of areas,” according to the report compiled by Catherine
Krawczeski, division chief of pediatric cardiology at Nationwide Children’s
Hospital Heart Center, Victor Morell, surgeon-in-chief and division chief of
the UPMC Children’s Hospital of Pittsburgh’s pediatric cardiothoracic surgery,
and Edward Bove, chairman of the University of Michigan medical school’s
cardiac surgery department.
The external panel suggests having two pediatric cardiac
surgeons at a minimum, able to provide coverage 24 hours a day throughout the
year.
UNC averaged slightly fewer than 120 “index pediatric
surgeries” in the last year, putting it in a “medium” category in terms of
volume. The panel found this “borderline for optimally supporting and
maintaining” two full-time pediatric cardiac surgeons…
Meanwhile, the panel noted UNC “must balance” its role as a
state hospital and being an important resource for patients with complex needs
while also considering whether a referral to another institution might produce
a better outcome.
“Complex patients with additional comorbidities that place
the patient at higher risk of poor outcome (either surgically or
postoperatively) should continue to be carefully evaluated by the medical and
surgical teams with referral to another center if deemed appropriate,” the
panel stated…
The panel suggested also considering programs that might
differentiate UNC from regional competitors, suggesting perhaps a comprehensive
multi-disciplinary single care unit that includes cardiac, liver, kidney and
neurodevelopment specialists, or an adult congenital heart program, a pulmonary
hypertension program or cardio genetics program.” (G)
“Wesley Burks, chief executive of UNC Health Care,
reportedly said Tuesday that North Carolina Children’s would be making “further
enhancements” to its program, “because we recognize the importance of caring
for very sick children with incredibly complex medical problems.”
The health system hasn’t announced a date for resuming
surgeries.” (H)
“The federal agency that oversees transplant programs said
it would investigate Newark Beth Israel Medical Center after ProPublica
reported that the hospital was keeping a vegetative patient on life support for
the sake of boosting its survival rate…
The team appeared to tailor medical decisions for at least
four patients because of these concerns. In the case of Darryl Young, a heart
transplant recipient, members of the medical staff didn’t offer options like
hospice care to his family because they wanted to make sure Young lived at
least a year after his surgery, according to current and former employees
familiar with his care. In an audio recording obtained by ProPublica, Dr. Mark
Zucker, the director of the heart and lung transplant programs, told the team
at an April meeting, “I’m not sure that this is ethical, moral or right,” but
it’s “for the global good of the future transplant recipients.”
In response to the concerns raised by the article, Newark
Beth Israel said that it would conduct an “evaluation and review of the
program, its processes and its leadership.” It later added that it had hired an
outside consultant to perform the review…
Dr. Herb Conaway, a New Jersey assemblyman and chair of the
Legislature’s Health and Senior Services Committee, called for the transplant
team’s actions to be reviewed. “The implicated doctors must face consequences
if the allegations are indeed accurate,” he said in a statement on Friday.
“Their actions are a stain on the entire medical community, and they must be
held accountable for what they have done to both this patient and his family.”
The editorial board of The Star-Ledger in Newark, which
co-published the ProPublica investigation, urged prompt scrutiny of the
hospital. “This is astoundingly unethical, and if true, should prompt firings
of those involved and a federal and state review,” the board wrote. “The Attorney
General’s Office should look into it, too, in case there’s something criminal
here.” (I)
“The heart transplant program at Oregon Health & Science
University Hospital will resume operations after a yearlong suspension, the
hospital announced Aug. 26.
Portland, Ore.-based OHSU voluntarily suspended its
transplant program last August after all four of the program’s cardiologists
resigned for unspecified reasons.
Since then, OHSU has hired three advanced heart failure
cardiologists to join the program. On Aug. 26, the United Network for Organ
Sharing approved the program’s new primary physician for heart transplantation,
which will allow the transplant program to resume operations.” (J)
“There was a life-threatening mistake at one of the largest
hospitals in the Delaware Valley, involving two patients waiting for a kidney
transplant. Last week, CBS3 received a tip that a patient at the Lourdes
Hospital Transplant Center received a kidney transplant meant for another
patient on the waiting list.
The hospital system confirmed that the surgery mix-up did,
in fact, take place last week. The two patients have the same name and are
around the same age.
After several follow-up conversations with Virtua Health,
which took over Lourdes Health System earlier this year, the hospital system
admits they gave the wrong person a kidney transplant last Monday.
Officials tell us the organ recipient was in need of a
kidney and the surgery was successful. But, they say, the next day a staff
member discovered the kidney recipient was out of priority order based on the
matching organ donor list.” (K)
ASSIGNMENT: After scanning From REPEAL & REPLACE to WRECK & REJOICE (from Obamacare to Trumpcare) https://doctordidyouwashyourhands.com/2018/04/from-repeal-replace-to-wreck-rejoice-from-obamacare-to-trumpcare/ , start tracking Medicare for All.
“On March 24th, 2017. “Speaker Paul Ryan (R-Wis.) on Friday
said his party “came up short” in a news conference minutes after pulling the
GOP healthcare bill off the House floor, acknowledging that ObamaCare will stay
in place “for the foreseeable future.””
Yet on December 20th, 2017 the INDIVIDUAL MANDARE was
repealed. ““When the individual mandate is being repealed that means ObamaCare
is being repealed,” Trump said…“We have essentially repealed ObamaCare, and we
will come up with something much better…””
At the end of this post there are links to a series of over 60 posts tracking the activity between March 24th and December 20th. Laws are like sausages,” goes the famous quote often attributed to the Prussian Chancellor Otto von Bismarck, “it is better not to see them being made.”
_______________________
“Senator Elizabeth Warren on Friday revealed her plan to pay for an expansive transformation of the nation’s health care system, proposing huge tax increases on businesses and wealthy Americans to help cover $20.5 trillion in new federal spending…
Under Ms. Warren’s plan, private health insurance — which
now covers most of the population — would be eliminated and replaced by free
government health coverage for all Americans. That is a fundamental shift from
a market-driven system that has defined health care in the United States for
decades but produced vast inequities in quality, service and cost…
Like Mr. Sanders, Ms. Warren would essentially eliminate
medical costs for individuals, including premiums, deductibles and other
out-of-pocket expenses. But it is not clear if her plan would cover the costs
of free health care for everyone. It relies on ambitious assumptions about how
much it can lower payments to hospitals, doctors and pharmaceutical companies,
and how cheaply such a large system could be run.” (B)
“Warren’s plan estimates that total health costs could be
held to $52 trillion and that $20.5 trillion in new federal spending would be
necessary…
Where the $20.5 trillion comes from:
Employers are one of the main sources of revenue in this
proposal. Warren says she would raise nearly $9 trillion here, a figure that
comes from the roughly $9 trillion private employers are projected to spend
over the next decade on health insurance. The idea here is that instead of
contributing to employees’ health insurance, employers would pay virtually all
of that money to the government.
In addition, she will boost her proposed 3% wealth tax on
people with over a billion dollars to 6% and also boost taxes on large
corporations. Altogether, she believes, taxes on the rich and on corporations
would raise an estimated $6 trillion. An additional $2.3 trillion would come
from improving tax enforcement.
But there are lingering questions about how much revenue
some of these taxes would bring in or how easy it would be to impose a wealth
tax in particular.
“Something like half of the wealth of the wealthiest
people in America are held in privately held corporations, privately held
businesses,” said Howard Gleckman, senior fellow at the Urban-Brookings
Tax Policy Center. “And it’s really hard to value those assets for tax
purposes.”
Warren also includes comprehensive immigration reform as
part of her plan. Giving more people a path to citizenship would mean more
taxpayers, which would mean more tax revenue.
While Medicare for All is Sanders’ plan, his bill does not
include set methods to pay for the plan. Rather, Sanders has included
“options” to pay for his health care plan. In a recent interview with
CNBC, he said “we’ll have that debate” over how exactly to finance
the plan.” (C)
“Here’s a summary of what Ms. Warren has proposed on either
side of the ledger.
To reduce the plan’s costs:
Change the way Medicare pays for certain types of hospital
stays, such as paying a package rate rather than different fees for surgical
services, and paying doctors in hospital-owned practices the lower prices paid
to those in private practices. ($2.3 trillion)
Assume that the Medicare for all program itself can operate
very leanly. The Urban Institute estimated that Medicare would devote about 6
percent of its health budget on administrators to decide what and how Medicare
would pay for things, and to prevent fraud. In Ms. Warren’s plan, that rate is
2.3 percent. ($1.8 trillion)
Assume very aggressive drug discounts. Ms. Warren believes a
government system will be able to reduce spending on drugs substantially,
including lowering the prices of branded prescription drugs by 70 percent.
($1.7 trillion)
Assume slower growth in health spending over time. The
federal government now thinks health spending will increase by 5.5 percent a
year; the Warren campaign assumes 3.9 percent growth under Medicare for all,
closer to the rate of growth in gross domestic product. ($1.1 trillion)
Assume lower payments to hospitals. The campaign believes
hospitals can be paid around 110 percent of what they are currently paid by
Medicare, a number that would cause some hospitals to operate at a loss.
Currently, private health insurers often pay a lot more to hospitals than
Medicare for similar procedures. ($600 billion)
What Warren Proposes
“Medicare for all” would shift a huge amount of health care
money to the federal budget, increasing federal spending by $34 trillion over a
decade, according to the Urban Institute. Here’s how Elizabeth Warren would
make the math work.
To pay for the plan:
Employers would be required to pay fees to the federal
government, equivalent to 98 percent of what they now spend on their employees’
health care. Some companies would be exempt, and companies with unionized work
forces would be able to lower this payment if they increased workers’ wages.
Currently, companies vary greatly in the cost and generosity of their health
benefits, so this fee would vary substantially by firm. ($8.8 trillion)
States and local governments would be required to make
payments to the federal government, similar to what they currently spend on
government employee benefits and their share of Medicaid expenses. ($6.1
trillion)
Corporate taxation would be increased. ($2.9 trillion)
Tax collections would increase through improvements to
I.R.S. enforcement, which Ms. Warren believes could raise a lot of money. ($2.3
trillion)
The top 1 percent of individual earners would pay new taxes
on their capital gains; they would pay taxes on increases in investment value
annually, instead of waiting until assets are sold. ($2 trillion)
Income tax collections would increase, since workers would
no longer pay part of their salaries for insurance premiums, which are not
taxed now. ($1.4 trillion)
Billionaires would pay a higher wealth tax than the rate Ms.
Warren has previously proposed: 6 percent, up from 3 percent. ($1 trillion)
A new financial transactions tax would be imposed on stock
trades. ($800 billion)
Pentagon spending from an overseas contingency fund, often
criticized as a slush fund, would be eliminated. ($800 billion)
Income earned by immigrants, following the passage of her
immigration overhaul plan, would provide new tax revenues. ($400 billion)
A risk fee on the liabilities of banks with more than $50
billion in assets would be introduced. ($100 billion)” (D)
“Displaying a new assertiveness toward her Democratic
opponents, Elizabeth Warren laced into her chief political rivals, warning on
Friday night that the country was in a “time of crisis” and arguing that
Democrats would lose in 2020 if they nominated “anyone who comes on this stage
and tells you they can make change without a fight.”
Speaking to thunderous applause during the party’s biggest
Iowa political event of the year, Ms. Warren denounced candidates in the
presidential race who opposed bold ideas in favor of more moderate solutions,
in veiled attacks on Joseph R. Biden Jr. and Pete Buttigieg.
“Fear and complacency does not win elections,” she said at
the Iowa Democratic Party’s fund-raising dinner. “Hope and courage wins
elections. I’m not running some consultant-driven campaign with some vague
ideas that are designed not to offend anyone.”..
“We need big ideas,
and here’s the critical part: We need to be willing to fight for them,” Ms.
Warren said. “It’s easy to give up on a big idea, but when we give up on big
ideas, we give up on the people whose lives would be touched by those ideas.””
(E)
“How does the Warren plan expand Medicare to cover everyone
without raising taxes on the middle class? There are four main components.
First, the Warren team argues that a single-payer system
would provide significant savings in overall medical costs — more than other
studies are assuming. Some of these would come from bargaining down prices,
especially on drugs. Others would come from a reduction in administrative
costs.
Are these savings plausible? Well, America does pay
incredibly high prices for drugs compared with other countries, and the
complexity of our system imposes a huge administrative burden — not just the
overhead of insurance companies, but the sheer number of people doctors and
hospitals have to employ to deal with multiple insurers. I’ve been puzzled at
the reluctance of other studies to credit Medicare for all with big savings on
these fronts.
And we should note that even with these assumed cost
savings, U.S. health spending per capita would remain far above that of other
advanced countries. So there’s a case — not an open-and-shut case, but a
reasonable one — for optimism here.
Second — and the cleverest item in the plan — the Warren
team would basically require employers who are now offering health insurance to
their employees to pay the cost of that insurance to the government instead.
Bear in mind that large employers are already required by law (specifically,
the Affordable Care Act) to provide insurance. So this would just redirect
those funds.
Third, state and local governments currently spend a lot on
health care, mainly but not only through their share of Medicaid spending. The
Warren plan would require “maintenance of effort,” basically requiring that
states continue to spend that money, but on supporting a national plan.
Finally, even with all this there’s a significant budget
hole. Warren’s team argues that this can be closed in two ways: some further
taxes on corporations and large fortunes, and — an important point —
strengthening the I.R.S., which we know fails to collect large amounts of
legally owed taxes, principally from people with high incomes, because Republicans
have starved the agency of resources.” (F)
“Whatever their many flaws, Medicare for All advocates used
to have a decent answer to the question of how they’d pay for it. Taxes would
go up, they’d admit, but these taxes would be de facto premiums, because they’d
replace the money Americans already spend on premiums and other health costs.
On top of that, the taxes would be progressive, increasing with income, unlike
normal premiums — and aggressive price controls would reduce costs overall.
I mean, good luck with that, both politically and
practically. But you can’t deny that there’s a logic to it.
For whatever reason, though, Elizabeth Warren today opted
for a different approach: one where premiums go away, middle-class taxes don’t
go up (not even a penny!), and taxes on the rich make up the difference. In
other words, it’s a system where everyone else gets their health care at the expense
of the wealthy. Even if that sounds appealing, her plan for doing this shows
how silly it is.
First, the plan doesn’t keep its promise. Nearly half the
funds come from redirecting the money that employers spend on health benefits
to the government. Sorry, but your health benefits are part of your
compensation. Sending that money to the state instead is a tax on you, not your
employer.
And second, in trying to force rich people to pay for (much
of the other half of) everyone’s health care, the plan basically blows every
dollar the government could hope to collect from the wealthy in the coming
years. The corporate tax goes back up to the uncompetitive 35 percent rate it
was before the tax reform, and would be collected far more aggressively too. (Part
of the burden of the corporate tax is borne by workers, by the way.) Warren’s
wealth tax for “ultra-millionaires” gets a new 6 percent annual rate for those
with more than $1 billion.
We already have a ton of debt and frightening obligations to
provide old-age entitlements to hordes of retiring Baby Boomers, and yet this
plan would eat up trillions in new revenue sticking the rich with the
health-care bills of middle-class Americans who say they like their current
insurance…
The easy solution is just to go back to the old argument,
where taxes do go up but they’re more progressive than premiums and lower on
average. But maybe middle-class Americans won’t want to give up their health
insurance unless you bribe them with buckets of rich-people money.” (G)
“Senator Elizabeth Warren vowed on Friday to pass major
health care legislation in her first 100 days as president, unveiling a new,
detailed plan to significantly expand public health insurance coverage as a
first step, and promising to pass a “Medicare for all” system by the end of her
third year in office that would cover all Americans.
The initial bill she would seek to pass if elected would be
a step short of the broader Medicare for all plan she has championed. But it
would substantially expand the reach and generosity of public health insurance,
creating a government plan that would offer free coverage to all American
children and people earning less than double the federal poverty rate, or about
$50,000 for a family of four, and that could be purchased by other Americans
who want it…
But under the plan she presented on Friday, she would not
seek passage of a single-payer system early in her presidency. The proposal
would instead move people into that system gradually — in a way she hopes would
build public support for full-fledged Medicare for all — while temporarily
preserving the employer-based insurance system that covers most working-age
adults today.
“I believe the next president must do everything she can
within one presidential term to complete the transition to Medicare for all,”
Ms. Warren, of Massachusetts, wrote in her plan. “My plan will reduce the
financial and political power of the insurance companies — as well as their
ability to frighten the American people — by implementing reforms immediately
and demonstrating at each phase that true Medicare for all coverage is better
than their private options. I believe this approach gives us our best chance to
succeed.”..
With her interim plan, Ms. Warren is attempting to offer
something attractive to both sides of the Democratic health care debate:
preserving her commitment to the single-payer vision that energizes voters on
the left, while offering a less disruptive set of proposals in the short term
to those who may be reluctant to give up their existing coverage…
Ms. Warren’s agenda would cost more than $30 trillion. She
plans to offset much of that cost through new taxes on the richest Americans
and on businesses.
But she would still rely on Democrats winning control of the
Senate, where Republicans currently hold a slim majority. And she is laying out
ambitious details for getting to a single-payer system even as voter support
for the idea is narrowing; polls suggest substantially more Americans prefer
the “public option” type of plans that Mr. Biden and Mr. Buttigieg have
proposed…” (H)
“Allowing more time underscores Warren’s — or any
candidate’s — difficulty in delivering on government-run universal health
coverage. Winning congressional approval would be a heavy lift, no matter which
party holds majorities in the House and Senate.
“Every serious
proposal for Medicare for All contemplates a significant transition period,”
Warren wrote in an online post. “My plan will be completed in my first term. It
includes dramatic actions to lower drug prices, a Medicare for All option
available to everyone that is more generous than any plan proposed by any other
presidential candidate, critical health system reforms to save money and save
lives, and a full transition to Medicare for All.”
Even as she continued to praise Medicare for All, though,
Friday’s announcement represented a move toward the political middle on an
issue that has been one of the most important to voters in the Democratic
primary — which begins Feb. 3 in Iowa…
Taking years to get to Medicare for All would give Warren
time to convince people happy with their current, private insurance to accept a
fully government-funded system. But Friday’s announcement seems sure to raise
more tough questions about health care for a candidate who has been struggling
with it lately — following her riding improved polling throughout the summer to
become one of the front runners in the crowded Democratic primary field…
She is also recognizing that incremental measures that
progressives often dismiss as not going far enough could have a real impact on
people’s lives. That view was reinforced by a recent study by the Urban
Institute and Commonwealth Fund policy centers, which concluded that Democrats
have more than one way to get to coverage for all.
“Warren’s proposals to shore up the Affordable Care Act,
lower drug prices, and create a public option would still provide substantial
health care cost relief for people,” said the Kaiser Foundation’s Levitt.” (I)
Back in 2010, as Obamacare was about to squeak through
Congress, Nancy Pelosi famously declared, “We have to pass the bill so that you
can find out what is in it.” This line was willfully misrepresented by
Republicans (and some reporters who should have known better) as an admission
that there was something underhanded about the way the legislation was enacted.
What she meant, however, was that voters wouldn’t fully appreciate the A.C.A.
until they experienced its benefits in real life.
It took years to get there, but in the end Pelosi was proved
right, as health care became a winning issue for Democrats. In the 2018
midterms and in subsequent state elections, voters punished politicians whom
they suspected of wanting to undermine key achievements like protection for
pre-existing conditions and, yes, Medicaid expansion…
The lesson I take from the politics of Obamacare, however,
is that successful health reform, even if incomplete, creates the preconditions
for further reform. What looks impossible now might look very different once
tens of millions of additional people have actual experience with expanded
Medicare, and can compare it with private insurance.
Although I’ve long argued against making Medicare for All a
purity test, there is a good case for eventually going single-payer. But the
only way that’s going to happen is via something like Warren’s approach:
initial reforms that deliver concrete benefits, and maybe provide a
steppingstone to something even bigger.” (J)
“Last week, President Donald Trump signed an executive order
titled “Protecting and Improving Medicare for Our Nation’s Seniors.” The order
is the latest example of how Trump says one thing while doing another. Rather
than strengthening Medicare, Trump envisions turning large swaths of the
54-year-old program for the elderly over to the private sector while directing
the federal government to dismantle safeguards on seniors’ health care access,
shift costs onto beneficiaries, and limit seniors’ choice of providers.
Among other things, the executive order lays out a path to:
Shift the Medicare program toward private plans
Expand private contracting between beneficiaries and
providers, putting seniors at risk for higher costs and surprise medical bills
Further restrict seniors’ choice of providers in Medicare
Advantage
Expand Medicare Medical Savings Accounts as a tax shelter
for the wealthy.. (K)
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.” *
Introduction
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
and Afghanistan…
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
for volunteers:
“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
quickly.” (A)
“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
medical staff.
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
lines.
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.[6]
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.[7] 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.[8]” (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..”
(B)
“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
among soldiers.
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)
“Many of
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
commonplace.
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.”
(C)
“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
isolation
Development of an ambulance system for evacuation of the
wounded
“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)
“On the
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
Lifesaver
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
lifesaver.
“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
gulf.”
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
Vietnam.
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.”
(B)
“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
looked grim.
Hastily, the corpsman transmits a map coordinate and a brief
request.
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
paper parachutes.
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
practitioner?
PART 1 before new Part 2.
ASSIGNMENT:
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
first operation.
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
surgeon.
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
[concurrent]
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.””
(G)
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
regulations… (A)
“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
physicians assistants…
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,
right?
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
room.
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
a dressing.
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.”
(E)
“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
issue.
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
Globe’s inquiries.
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
wrote.
“The mounting evidence all leads to the conclusion that even
if sections of the Stern report were once privileged, they no longer are,” she
continued.
In addition to ordering the hospital to turn over the
report, the judge directed it to provide all drafts of the document and backup
materials.
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
said.
