Saturday, July 12, 2008

And the Bow Sinks to the Waterline

A friend emailed me this. Let me take a wild flying guess at what happened here. Some poor soul got drunk or had been drinking. He was hurting and was convinced by family to go to the ER. This might have been at the advice of his physician who didn't have an afternoon appointment available for, hmmm, three months. The triage nurse did her job and sent him to a room, but did not believe he was anything other than drunk. Staffing cuts and bottom line thinking from people with suits and clipboards has their ER perpetually short and scrambling. These cuts are happening everywhere because of EMTALA

In the room he sat with a chief complaint of "abdominal pain with ETOH". He was then ignored through nursing shift change, a doctor never saw him because the chart was, thanks to JCHAO, somewhere other than the chart rack. The oncoming nurse did not know the room had a patient. A doctor never knew there was anyone in the room (HIPAA mandates closed doors when able). He was not put on a monitor, and the cleaning lady found him dead 12 hours later after he died from a massive MI or ruptured AAA. Thanks EMTALA, thanks HIPPA, thanks JCHAO. We will now watch as you fry a perfectly good physician and nurse for your bumbling idiotic policies which make every ER a ticking time-bomb. .


  1. Fill up the ER with loud people who have non-urgent complaints and this kind of stuff will happen.

    Staff the hospital with a skeleton crew that has hald of the workers they need and this kind of stuff will happen.



  3. Half the patients in our ER are always visible to staff. They're on gurnies in the hallways.....

  4. Wow, I don't know the whole story here (anymore than you do) but your excuses are amazing. It's JCHAO's fault, it's EMTALA's fault, it's HIPAA's (not HIPPA Einstein) fault, it's the PCP's fault, etc, etc. How old are you.....Twelve? Here is one who is hoping your "retirement" comes ASAP. Crap Ass attitudes like yours have no place in medicine.

  5. dear anonymous fuckstick,

    i have worked in ten ERs in fifteen years in four states. i have been an officer in the military multiply decorated, and have directed a very busy ambulance service for six years. i am boarded in EM with a subspecialty interest in wilderness medicine. i have played sports on the college level. in other words, i have done and continue to do important jobs. i have been taught how to run an organization and i do it well. right now, i have nothing to do and can not change the fact that our ER, and the one in the story, are chronically understaffed and flat-out dangerous. it's why i'm quitting in 7 weeks. i have no desire to end up in court trying to defend an indefensible case like this.

    by way of example i have been trying, at our particular facility, for four years, to get the lab to allow us to do urine dipstick tests rather than the $400 version which is almost never needed. i, as attending physician, have been unable to do this. the reasons is that people with clipboards make all of these decisions, just like they did in the linked story. it's micromanagement of the worst kind and, in this instance, killed someone.

    for four years at my facility we have lost nurses, doctors, and capabilities. this tragedy could have easily happened at our facility and probably will.

    why? because there are no nurses to hire and no specialists who want to move here and be on call. why? EMTALA. why can't we have video cameras in the rooms to alert us to just such a situation? HIPAA. why can't i find a patient's chart when i need it? JCHAO, which mandates that every chart be in physical possession of the nurse as they retrieve medicines from the pixis and administer medicine. verbal orders can not be given because of JCHAO.

    so take your ill-informed anonymous ass elsewhere or, better yet, go to med school and come play with us. but you won't, because you are a troll and a monday-morning quarterback. if you want me to post this again using smaller sentences and words just let me know you douchebag.

    go make someone else's day miserable.

  6. oh, i'm fourteen... they call me 'doogie'.

  7. I like your blog, but you missed the ball on this one with the excuse machine as anonymous mentioned.

    I can credential a turd, highly decorated military-grade BM, but that doesn't mean it won't stink. Credentials or not, the hospital fucked up on this one. If a guy presents to an ER and dies 12 hours later, that's pretty much the definition of a life threatening condition.

    Whatever really happened, it's pretty clear that a whole lot of people fucked up on this one and no amount of excuses can explain that.

    Which, by the way, is a phrase you might remember from your esteemed military days, I know I do: Excuses don't explain, and explanations don't excuse.

  8. As yes, anonymous, spoken like a lawyer. Or expert witness for the plaintiff.

    This is just another symptom of the collapsing system, not just another staff fubar. And it is going to happen a lot more. Closed Drew King in LA, and now other hospitals are on the brink.

    "We don't feel at any time we put the patient at risk for not having appropriate staffing" and "We're very comfortable that we provided very good care" said the guy from the carpeted section, despite being down at least 2 nurses.
    And what did state inspectiom find? The ER was short that day (but no cause - effect relationship), meds were left out in the open and there was dust on an infant warmer. And, I'll bet, some deficiencies in the policy and procedures manuals.

    So it's off to hhs/state mandated re-education for the staff... do everything for everybody no matter how short staffed and overwhelmed you are, make sure the meds are locked up and, oh yeah, dust off the damn infant warmer. Because that is all the various government investigations could find.

    Funny how hhs/state and JCHAO never, ever find a "cause-effect" staffing shortage problem. Funny how administrators in the carpeted section always say that staffing is "adequate" when something like this happens, and "policies and procedures of the hospital were not followed". No kaka! (I'll bet the only thing with with more dust is the policy and procedure manuals, because everybody is too fraking busy to read em).
    So, lets barbeque the staff. Roast a nurse or two. Toss a doc on the spit. Appease the angry (I went to this hospital for a hangnail and the care was abysmal) hoards with a firing or two. Make some money and file a big lawsuit. Hell, maybe, if you get the masses angry enough, get the hospital closed.

    Keep focusing on the moss on the tree in front of you, anonymous. You really don't want to see the forest fire behind the tree.

  9. igloodoc,
    thank you. very eloquent.

    anonymous #2,

    are you high? here's my point. yes, someone fucked up royally in this case. but this failure was set up, and failures just like it (soon to happen near you) are the direct result of removing personal responsibility from, really, the one place outside of combat where decisions are often life and death and time-critical.

    doctors have had these decision-making powers taken from them by the nanny-state over the last thirty years. so have nurses who actually practice nursing.

    thirty years ago this patient would either have died at home OR have been aggressively treated in a hospital that was not criminally short-staffed because the clipboard carriers, sleeping soundly every night, have taken money from some to pay for free care for all, and, as a consequence, have had to cut staffing to the bone because two and two is four in our world.

    add to this the idiocy of micro-regulation regarding charting, medication administration, where you can eat, whether someone's name can be displayed on a chalkboard with their medical problem, and whether a nurse can give a certain drug (or whether the doctor has to) and you get this.

    i will also point out to you, as i did in the post, that it appears that no physician ever saw this patient. i bet this is because the patient was placed in a room, and, due to HIPAA, this room had to measure at least x by x feet and had to be lit a certain way AND had to have a door which could be closed and COULD NOT have a video monitor and yes, someone forgot he was there.

    so he got placed in a bed after POSSIBLY a poor triage, and the clipboard carrying idiots who wrote the rules are now saying that nothing wrong took place. cowards. liars.

    THEY will not pay for this. whatever physician was on duty at the time with whatever nurses and whatever tech etc... THEY will pay.

    they will pay with tears, money, lost sleep, depression, law suits, and loss of job. i pray there will not be a suicide because, dear anonymous 2, the doctors and nurses i know, in my wide travels, get really down about failure. they care, they care so much it hurts. they went into medicine BECAUSE they care, and this case, well, it's going to hurt.

    it's going to hurt the family of the deceased and hurts them right now. it's going to hurt for years. why did he die?

    thirty years ago, without the ass-monkey regulations, we could have pointed to a nurse or a doctor and asked 'WHY'? thirty years ago IT WOULD HAVE BEEN THEIR FAULT.

    now, we go to the clipboard carriers, who shrug, consult their clipboards, review procedure, and answer without answering.

    strange cases make for bad law.

    personal responsibility and professionalism have been removed by blunt force trauma from our medical system.

    one more thing, anonymous 2, if you dig a little in this story you will find that most of the doctors who man this ER happen to be on staff at Vanderbilt University as well.

    i don't know much about vanderbilt except by reputation. vanderbilt is a top flight medical center with a top flight emergency department and top flight emergency physicians. they are on par with johns hopkins. these were not bumbling idiots in the ER out in the sticks, these were, and are, some of the top physicians in the field.

    it's hard to display your top skills and fine clinical accumen, however, when you are bound and gagged by flunkies.

    the medical world is ass-end up and this case, rather than pointing out the failure of systems and protocols where only compassion directed by expert knowledge and training can suffice, will instead be used to create more sysems and protocols to the point that we will not be allowed to scratch our butts without permission from 'above'.

    you misunderstand sir, i am ASKING for this responsibility. i am ASKING to be in charge where i work. i am not. neither were these physicians and nurses. that is the whole problem. that is why he died.

  10. "'We didn't follow our policies. We've made all the efforts we can to make sure we don't have that problem again,' said Bruce James, Sumner County Regional Medical Center hospital administrator."

    All the efforts we can - short of having adequate staffing and other common sense efforts.

    "He said the hospital's policy is to check vital signs at least every two hours."

    "When asked why Brazofsky's vital signs were checked one time, James said, 'I can't answer that. I was not the caregiver involved with that.'"

    So he makes it clear that it is his job to set up people to take responsibility for the inevitable consequences of his, and his cronies', staffing decisions. Yes, Virginia, there is a gravitational effect on fecal matter.

    "On top of the problems with his care, investigators discovered the emergency room was short staffed. Instead of seven registered nurses five were on duty most of the night."

    "'We don't feel at any time we put the patient at risk for not having appropriate staffing,' James said. 'We're very comfortable that we provided very good care.'"

    He refuses to consider that a lack of staff means a lack of people available for very good care.

    "Sumner is opening a new facility this month. It has a plan in place to correct the problems including the re-education of staff."

    Are they going to have camps for the re-education? Perhaps an archipelago of them? How much will be spent on having staff get their minds right, rather than on actual staff to provide care, maybe even to put away medication and dust?

    I do think that this could have happened under many other circumstances. A person presenting to the ED with alcohol on board and vague complaints is not going to be the center of attention. There may have been nothing that might have "prevented" his death in the ED. Was it an arrhythmia, AAA, stroke, acute exacerbation of CHF, ingestion of some toxin stronger than alcohol, hypokalemia, hyperkalemia, . . . ? The cause of death might as well have been given as failure of metabolism for all of the information it provides. Without staff to check on him, we have no idea what he looked like at any point during the night. Some things are preventable, maybe this wasn't, but the lack of assessments due to lack of hospital staffing makes it impossible for anyone to know.

  11. Dear MDOD readers and RM,

    I know a bit about this case for reasons I can not disclose, but I do know. As it turns out the guy was in a room, was seen, disconnected his monitor, went into the bathroom, and died.

    Because the bathrooms are really nice and separate from the patient rooms the staff thought he had walked out.

    Since he was drunk this was a reasonable assumption, but a wrong one.

    HIPAA calls for private rooms with closing doors, the ER is inundated, they are short staffed, this is not a surprise. It is a tragedy that should not have happened and the POS administrators are taking cover like you would expect.