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Emergency Medicine, Global Health, Health Policy, Stanford News, Videos

A look at “India’s medical miracle,” the largest ambulance service in the world

A look at "India's medical miracle," the largest ambulance service in the world

A patient in shock arrives via ambulance at Gandhi Hospital in Hyderabad, India with a gaping wound in his right hand, blood spattered on his blue jeans and T-shirt. Emergency medical technicians wheel him into a dark room in the government-run hospital, where clinicians move quickly to irrigate the wound and pump fluids into the man, who appears to be in his 20s.

With luck, the patient might survive. Ten years ago, he would not have had a chance.

Thanks to some passionate philanthropists, businessmen and medical experts, India today has what we have long taken for granted in the United States: a modern, emergency 911-type system and a cadre of trained emergency responders who have helped save an estimated 1.4 million lives. Begun in 2005, it is now the largest ambulance service in the world and serves more than 750 million people in cities and villages across the Indian sub-continent.

I saw the system in action first-hand in August when I traveled to India, together with about 10 other faculty and staff from Stanford’s School of Medicine, including Dean Lloyd Minor, MD, to celebrate its 10th anniversary amid much color and fanfare. I was there to write a story about the new system for Stanford Medicine magazine.

Begun in August 2005 in the south Indian metropolis of Hyderabad, the service, known as GVK EMRI (Emergency Management and Research Institute), is operated as a public-private partnership, providing its services free of charge, mostly to the very poor. It is a remarkable achievement, given the diversity of India, with its 29 states and more than 120 major languages, and the bureaucracy and corruption that can sometimes impede progress in this vast country of 1.2 billion souls.

“It’s hard to fathom what this system has done in 10 years,” S.V. Mahadevan, MD, interim chair of Stanford’s Department of Emergency Medicine, told me while stationed in one of EMRI’s ambulances. “It could be regarded as one of the most important advances in global medicine in the world today.”

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Emergency Medicine, Health Policy, Patient Care

Improving patient satisfaction and turn-around time in an emergency department

Improving patient satisfaction and turn-around time in an emergency department

Emergency Room SignWhat could a manufacturing philosophy concocted by a car maker have to offer a beleaguered emergency department staff? More than you would expect.

“Lean manufacturing” is a method used in the 1960s and 1970s by Toyota to improve quality on its assembly lines. The idea was to empower all the workers to have the authority and confidence to stop the line and address quality and efficiency issues. In the decades since, it’s made its way to other industries beyond manufacturing, including software development.

When Amir Dan Rubin, MHSA, MBA, came on board four years ago as president and CEO of Stanford Hospitals and Clinics, he brought the lean management mentality with him.

Marlena Kane, MPH, executive director for performance excellence & medicine services at Stanford Hospital described the process as “looking at things from the patient’s perspective and getting people to talk to each other.”

The hospital’s emergency department implemented the lean methodology, and a year later, wait times dropped dramatically and patient satisfaction shot up. Kane, along with David Pickham, PhD, director of research at Stanford Hospital, and their colleagues reported their experience in a paper in the Journal of Nursing Administration last month. And Rubin spoke about the changes they’ve implemented at this year’s Medicine X conference.

The median length of stay in the ED fell by 17 percent, despite a 7 percent increase in patients. And there was virtually no increase in the cost of running the department. “We all want the same thing, to take care of patients well,” Kane said.

The main change the department made was to teach front-line staff to solve problems as they cropped up. Those front-line staffers were able to have discussions with other groups when they noticed inefficiencies or slow-downs. This required several teams to work together to find solutions – from nurses and residents to transporters, housekeepers and translator services.

Training the teams on the new approach was no small feat. For the day-long trainings, additional staff had to be called in to back-fill staff members who would be away from the emergency department.

She pointed out that the lean approach has to have leadership buy-in and commitment to work. “You have to start with the executive team,” she said. “They have to be invested and give time to let staff do it. It can’t be grass roots.” When the lean approach fails at an organization, it’s often because the leadership team isn’t fully invested in the process.

Kane noted that handing the power to solve problems to front-liners frees up leadership staff to tackle long-term problems. “If we keep solving problems for our teams, they won’t be empowered,” she said. “We are always fire-fighting, not thinking strategically.”

Previously: Speed it up: Two programs help reduce length of stay for emergency-room visitorsStanford’s “time banking” program helps emergency room physicians avoid burnout, and An emergency medicine physician’s take on honoring your emotions
Photo by KOMUnews

Emergency Medicine, Pregnancy, Research, Surgery, Videos

Self-propelled powder moves against blood flow to staunch bleeding in hard-to-reach areas

Self-propelled powder moves against blood flow to staunch bleeding in hard-to-reach areas

If you nick your skin, it’s easy to stop the bleeding by applying a coagulant powder directly to the cut. Yet, bleeding wounds inside the body are beyond the reach of such blood-stopping powders.

Now, Christian Kastrup, PhD, an assistant professor at the University of British Columbia, and a team of researchers, biochemical engineers and emergency physicians, have developed a way to clot internal wounds by creating a self-propelled powder that moves against the flow of blood.

“Bleeding is the number one killer of young people, and maternal death from postpartum hemorrhage can be as high as one in 50 births in low resource settings so these are extreme problems,” Kastrup explained in a UBC press release. “People have developed hundreds of agents that can clot blood but the issue is that it’s hard to push these therapies against severe blood flow, especially far enough upstream to reach the leaking vessels. Here, for the first time, we’ve come up with an agent that can do that.”

To give blood-clotting powder a push, Kastrup and his colleagues added calcium carbonate to the coagulant powder. The carbonate forms porous micro-particles that latch onto the clotting agent (tranexamic acid). As the particles release carbon dioxide gas, fizzing and moving like mini-antacid tablets, they launch the clotting agent toward the source of bleeding.

More rigorous testing and development needs to be done before this agent is ready for use in humans, as the press release and study explain. But it’s possible that in the near future this powder could be used to treat otherwise unreachable cuts such as those in postpartum hemorrhages, sinus operations and internal combat wounds.

Previously: New obstetric hemorrhage tool kit released todayIn poorest countries, increase in midwives could save lives of mothers and their babiesTeen benefited by Stanford surgeon’s passion for trauma care
Video courtesy of UBC

Emergency Medicine, Health and Fitness, Mental Health

Stanford’s “time banking” program helps emergency room physicians avoid burnout

Stanford's "time banking" program helps emergency room physicians avoid burnout

saving_timeFor emergency room doctors, few things are more important than time. They’re trained to work quickly and efficiently to gain the moments, minutes and hours that can be the difference between life or death for a patient. Yet, few ER doctors have the luxury of time in their personal lives.

According to a 2012 study, physicians’ work weeks are roughly ten to 20 hours longer than that of other professionals. This means that it would take the average professional about a year and a half to accomplish what a hard-working physician does in a single year. With a schedule like this, it’s no wonder that burnout is an issue for many physicians.

So, Stanford’s Department of Emergency Medicine adopted a “time banking” program that allows doctors to log the time they spend doing often under-valued activities, such as mentoring and covering colleagues’ shifts, to earn credits for the work and home-related services that would normally gobble up their free time.

Recently, the Washington Post highlighted this time-saving initiative in a story featuring emergency physician Gregory Gilbert, MD. “This gives me more bandwidth at work,” Gilbert said. “And because I can hang out with my kids and not be exhausted all the time, I’m able to be the kind of parent I’d always hoped to be.” From the Washington Post story:

Stanford’s time bank, part of a two-year, $250,000 pilot funded largely by the Sloan Foundation, showed big increases in job satisfaction, work-life balance and collegiality, in addition to a greater number of research grants applied for and a higher approval rate than Stanford faculty not in the pilot.

And for the first time, this year there are no openings for new fellows in the Department of Emergency Medicine. “All our spots have been retained,” Gilbert said. “There’s been no turnover.”

Previously: Surgeon offers his perspective on balancing life and workProgram for residents reflects “massive change” in surgeon mentalityLess burnout, better safety culture in hospitals with hands-on executives new study shows and Using mindfulness interventions to help reduce physician burnout
Photo by: mbgrigby

Behavioral Science, Emergency Medicine, Health Disparities, Pain, Patient Care, Pediatrics, Research

Blacks, Hispanics and low-income kids with stomach aches treated differently in ERs

Blacks, Hispanics and low-income kids with stomach aches treated differently in ERs

crying-613389_1280When a child arrives in the emergency room complaining of a stomach pain, appendicitis is the last thing you want to miss, says KT Park, MD, assistant professor of pediatrics.

“The question is, ‘Does this patient have appendicitis – yes or no?,” he said. It is the most common immediate emergency that could bring a child into the emergency room with abdominal pain. If not treated in a timely manner, the appendix can burst, leading to infection or a host of other serious complications.

But kids arrive in the emergency room complaining of stomach aches all the time; most with perfectly healthy appendices. And what if you’re a doctor who has seen seven kids with more minor stomach problems one day? It might be tricky to spot that first case of appendicitis.

Unfortunately, misdiagnosis happens more often when the pediatric patient is black, Hispanic or low-income, according to a study published today in PLOS ONE led by Park and Stanford medical student Louise Wang.

“Our goal in this study is getting the word out about abdominal pain and appendicitis and the importance of the decisions made in the emergency room,” Wang said.

The researchers analyzed national data from 2 million pediatric visits to emergency rooms between 2004 and 2011 complaining primarily of abdominal pain. They found that blacks, Hispanics and low-income children were less likely to receive imaging that could help their physicians diagnose serious conditions like appendicitis. These patients were also less likely to be admitted to the hospital, but more likely to suffer perforated appendicitis, a clue that perhaps they didn’t receive adequate treatment in time, Park said. For example, low-income blacks were 65 percent more likely to have a perforated appendix compared to other children.

The study was not able to precisely determine why these disparities exist, Wang said. “What is the driving influence of these outcomes? Are these kids being mismanaged in the emergency department, or are they presenting at a later time in a more serious condition?,” she asked.

She and Park have a few ideas, based on other findings and their personal experience. Minorities and low-income families are more likely to use the emergency room as a first-stop for more minor conditions, rather than visiting their primary care doctor or pediatrician.

“This is a very delicate topic,” Park said. “Physicians are humans and there is potentially some intuitive thinking that goes on about the probabilities of various diagnoses more common in certain patient groups, potentially leading to differences in how clinicians perceive the acuity of a patient’s status.”

Appendicitis can be tricky to diagnose, a task made even harder when patients are young and unable to clearly describe their pain, Park said.

“The psychology of physicians is an area needing further evaluation,” Park said. “We have internal biases that we often are not even aware of. We want to be objective, but it’s never a black-and-white decision making tree.”

Previously: A young child, a falling cabinet, and a Life Flight rescue, New test could lead to increase of women diagnosed with heart attack and Exploring how the Affordable Care Act has affected number of young adults visiting the ER
Photo by amandacatherine

Addiction, Emergency Medicine, Health Costs, Patient Care, Research

Questionnaire bests blood test at identifying patients with risky drinking behaviors

Questionnaire bests blood test at identifying patients with risky drinking behaviors

3144132736_9de39a590d_zAs many as half of the patients who visit the emergency room with traumatic injuries have alcohol in their bloodstream, and roughly 10 percent of these patients will return to the ER within a year. Today, many emergency rooms use blood alcohol tests to screen for patients with risky drinking behaviors. Yet a new study by researchers from Loyola University Medical Center suggests that a questionnaire may be a better way to identify at-risk patients.

In the study, researchers reviewed 222 records from patients 18 years of age and older that were admitted to Loyola University Medical Center’s level I trauma center between May 2013 and June 2014. Each of the patients in the study had a blood alcohol test and had answered the World Health Organization‘s 10-point questionnaire, called the Alcohol Use Disorders Identification Test (AUDIT). The research team compared the results of the blood test to that of the AUDIT test and found that the questionnaire was 20 percent more effective at identifying at-risk patients with dangerous drinking habits than the blood test.

As the researchers explain in their study, blood alcohol tests only provide “a snapshot of the patient’s recent drinking behaviors” by measuring of the amount of alcohol in the patient’s system at the instant the test is taken. In contrast, the questionnaire assesses the patient’s overall drinking behaviors by asking questions such as, how often they drink, how much they drink per day and if they have feelings of guilt or remorse after drinking.

These findings are significant because blood alcohol tests are often the only tool used to assess at-risk drinking behavior in ER patients. Their findings call this common practice into question and suggest that the AUDIT questionnaire may be a better way to identify, and ultimately prevent, potentially dangerous drinking behaviors.

Previously: Alcohol-use disorder can be inherited: But why?Could better alcohol screening during doctor visits reduce underage drinking? and How to make alcoholics in recovery feel welcome this holiday season
Via: Business Wire
Photo by: Julie °_°

Emergency Medicine, Ethics, Global Health, Medicine and Society, Patient Care

After Haiyan: Stanford med student makes film about post-typhoon Philippines

After Haiyan: Stanford med student makes film about post-typhoon Philippines

Multi-talented Stanford Medicine student Michael Nedelman has been featured on Scope before for his filmmaking and storytelling abilities. His new film, “After Haiyan: Health narratives in the aftermath of the typhoon,” is a series of vignettes about the November 2013 disaster in the Philippines. The film, which will be released soon, connects socioeconomic and structural issues of access to health in times of crisis.

It was filmed primarily in Tacloban, Leyte, in July and August of 2014, and Nedelman made a follow-up visit in November and December to premiere and promote the project. Despite his busy end-of-school-year schedule, Nedelman answered some questions for me about his work in a recent email exchange.

What was it like filming in the wake of a tragedy? 

Phil Delrosario said it best. He’s the cinematographer and editor I met here at Stanford. Knowing when to turn on the camera was a “huge balancing act” between our drive to document the truth, and our obligation to be compassionate storytellers. We couldn’t ignore the emotional weight of Typhoon Haiyan, and we couldn’t ignore the fact that we weren’t part of the communities we were documenting. So we sought out people who not only wanted to share their stories with us, but who could also provide some insight as to how they wanted those stories to be seen… For one of the videos, Deaf advocates like Noemi Pamintuan-Jara reached out to us first, not the other way around… That was really special for us, to be able to work alongside a community that has been promoting Deaf accessibility and culture long before we ever arrived on the scene. And we had these new partners who could give meaningful feedback on our filmmaking decisions.

Filming in the wake of a tragedy doesn’t mean everything is tragic. The shadow of Haiyan is still there, but there’s also a sense of living in the moment and moving forward. All over the city, you’ll see posters and graffiti that say, “Tindog Tacloban!” (“Rise Tacloban!”) That’s something that really resonated with our team and the ethos of our project. You can’t tell the full story of Tacloban without optimism and resilience.

How does this film link storytelling and health, and what is special about that for you?

When I was first discussing the project with one of the producers, Roxanne Paredes, we asked ourselves a similar question: How would our project add to or nuance the coverage of the typhoon? Right after the storm, Haiyan was all over the news. Tacloban was in survival mode. But months later, after many of those cameras had left, there was a different set of long-term challenges and a focus on recovery. Those were the issues we wanted to explore, which tend to be less covered by the media but still have profound implications for community health and future disaster preparedness. In short, just because the cameras stopped rolling doesn’t mean there weren’t more stories to tell. That really broadened the way in which I think of health stories.

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Emergency Medicine, Medical Education

“We are a team”: Advice for new residents from chief residents, in their own words

"We are a team": Advice for new residents from chief residents, in their own words

1024px-Flickr_-_Official_U.S._Navy_Imagery_-_U.S._Naval_Academy_plebes_carry_a_log_as_part_of_teamwork_training_during_Sea_Trials.There are many things chief residents want new residents to know right out the gate, but much of that goes unsaid. So the blog Academic Life in Emergency Medicine recently put together a list titled “Dear Residents: 10 Things Your New Chiefs Want You to Know.” Each one was written by a different chief resident, as part of the blog’s Chief Resident Incubator project.

It’s a thoughtful collection of reflections that offers an interesting mix of poignant comments and practical advice. The full list is worth a read, but a few stand out:


…Know that every one of your attendings and senior residents continue to go through these same trials. When you find yourself on the ropes and feeling utterly alone, call us. We might not be able to make that Surgical ICU rotation any less painful, but we’ll at least buy you a beer and share some stories from our own days working the surgery salt mine.

(Rory Stuart, Chief Resident, Wright State University, Dayton, OH)


…Our learning should not only take place during scheduled conference time; we can all learn from each other. Share your successes and failures. Teach us all what you know, and what you wish you would have known. When we get out on our own, we all represent this residency program. Together we can make each other and this program better.

(Valerie Cohen, Chief Resident, Christiana Care Health System, Newark, DE)


…Your week long string of night shifts was not borne of malice or vendetta. We try to make decisions that are in the best interest of the program and we ALWAYS consider your requests.

Your faculty, chiefs, and colleagues are paying attention to how you react to these perceived slights. When you take that extra shift in stride, we’ll notice. When you take on a task that nobody else stepped up for, we’ll notice. When you swap into a weekend night shift so a co-resident can celebrate an anniversary or birthday, we’ll notice.

(Jimmy Lindsey, Chief Resident, University of Chicago, Chicago, IL)

Previously: Soon-to-be medicine resident reflects on what makes a good teacher, Keeping an even keel: Stanford surgery residents learn to balance work and life and A call to action to improve balance and reduce stress in the lives of resident physicians
Via Wing of Zock
Photo by U.S. Navy

Emergency Medicine, Nutrition, Pediatrics, Rural Health

Study finds arm circumference is accurate measure of malnutrition in children with diarrheal illnesses

Study finds arm circumference is accurate measure of malnutrition in children with diarrheal illnesses

Malnutrition is a leading cause of mortality in children under the age of five, contributing to approximately 3.5 million child deaths worldwide each year. Currently, the World Health Organization and Doctors Without Borders recommend using calculations based on the patient’s body weight or arm circumference to assess their nutritional status. But, it’s not known if they are reliable measures of malnutrition in children that suffer from diarrhea and dehydration — two symptoms that can affect body weight and are common in undernourished kids.

Now, a study (subscription required) published this month in the Journal of Nutrition shows that mid-upper arm circumference can accurately assess malnutrition in children with diarrhea and dehydration and it’s better at assessing malnutrition than weight-based measures.

In the study, Rhode Island Hospital emergency medicine physician Adam Levine, MD, and his team analyzed 721 records of children (under the age of five) who were examined at an urban hospital in Dhaka, Bangladesh for acute diarrhea. They found that measurements based on a child’s mid-upper arm circumference accurately diagnosed malnutrition, but measurements based on weight were unreliable and misdiagnosed about 12-14 percent of the cases when the patient had diarrhea and dehydration.

“Because dehydration lowers a child’s weight, using weight-based assessments in children presenting with diarrhea may be misleading,” Levine said in a press release. “When children are rehydrated and returned to a stable, pre-illness weight, they may still suffer from severe acute malnutrition.”

Since poor nutrition is a common problem in areas where medical resources are limited, the best tools to diagnose malnutrition are effective and inexpensive. Tape measures are cheaper and are often easier to come by than scales, so the results of this study are especially encouraging for people who want the best and most affordable way to measure malnutrition in children. “Based on our results, clinicians and community health workers can confidently use the mid-upper arm measurement to guide nutritional supplementation for children with diarrhea,” said Levine.

Previously: Stanford physician Sanjay Basu on using data to prevent chronic disease in the developing worldMalnourished children have young guts and Seeking solutions to childhood anemia in China
Photo by European Commission DG ECHO

Emergency Medicine, Global Health, Haiti, Stanford News

A tale of two earthquakes: Stanford doctor discusses responses to the Nepal and Haiti disasters

A tale of two earthquakes: Stanford doctor discusses responses to the Nepal and Haiti disasters

boy in Nepal - 560

Nepal’s 7.8 earthquake in late April killed 8,000 people and displaced thousands more. Paul Auerbach, MD, a professor of emergency medicine at Stanford, spent about a week caring for the people of Kathmandu and recently sat down for a Q&A session with Shana Lynch of Stanford’s Graduate School of Business, where Auerbach earned a master’s degree in 1989.

Auerbach was also part of the medical response team in Haiti after the 2010 earthquake there killed hundreds of thousands. While talking with Lynch, he compares the two earthquakes and the very different medical responses they needed:

When you come in, you need to find the victims. You need to treat them. You need medical supplies. You need adequate personnel in order to manage the life- and limb-threatening injuries in the first few days. From the moment of the earthquake and forward, there’s a need for water and food. In Haiti, the supplies initially weren’t there. Everything needed to be carried in. In Kathmandu, for the most part, the supplies were available. Of course, they needed supplementation, and that happened and will continue to happen. In Kathmandu, they never were in a situation where they had nothing, which was unfortunately the situation in Port-au-Prince.

He also discusses some of the challenges of coordinating an appropriate disaster response plan:

There comes a point when you have enough people and enough supplies. At that point, you need to start storing things and sending people home.

The responses are never perfect because you discover that you need more of something and less of something else. The same holds true for people. For example, the changing nature of medical conditions following an earthquake causes you to need emergency medicine specialists early on, but then orthopedic surgeons and reconstructive surgeons later during the response.

Lynch and Auerbach’s conversation also touches on why community leaders need to plan for disasters, regardless of where they are. It’s an interesting inside look into how medical teams think about and respond to natural disasters.

Previously: “Still many unknowns”: Stanford physician reflects on post-earthquake Nepal, Day 6: Heading for home after treating Nepal earthquake victims, Day 4: Reaching beyond Kathmandu in treating Nepal earthquake victims, Day 2: “We have heard tales of miraculous survival” following Nepal earthquake, Day 1: Arriving in Nepal to aid earthquake victims and Reports from Stanford medical team in Haiti
Photo courtesy of Paul Auerbach

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