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Emergency Medicine

Cancer, Emergency Medicine, Medicine and Society

An emergency medicine physician’s take on honoring your emotions

But how do you really feel? Over on, Anoop Kumar, MD, reflects on his personal and professional experiences with cancer. The emergency physician cares for people with acute complications from cancer and related treatments. In the post, Kumar describes his journey through the death of his grandmother when he was in seventh grade, the bursting of a dam of emotional supression later on, and the continued leaking of grief as he confronts his confusion, sadness and loss around the event.

Inspired by a 2010 article in The Guardian, Kumar urges readers dealing with hardship to “be positive. Or be negative. Or be confused. But whatever you are, be yourself.”

Previously: Becoming Doctors: Stanford med students reflect and share experiences through podcasts

Emergency Medicine, Health Disparities, Research, Stanford News

Insurance status might perversely affect the kind of trauma care you get: Stanford study

Insurance status might perversely affect the kind of trauma care you get: Stanford study

trauma centerGiven how much my health insurance checks eat into my income, I shouldn’t need to worry about the kind of trauma care I’d get if I were ever in a car accident (knock on wood). But should I?

A new School of Medicine study reveals that even insured patients might be at risk for getting poor trauma care for severe injuries – possibly at greater risk than uninsured patients.

Why? Simply because emergency doctors at hospitals lacking a trauma center decide to keep them there instead of sending them to a hospital with more expertise.

Ironically, insured trauma patients are admitted at non-trauma hospitals at higher rates than uninsured patients are, researchers find. Ergo, insured patients may end up missing out on critical resources that trauma centers are equipped with for severe injuries.

Our press release on the study published online today reports on the researchers’ findings from analyzing more than 4,500 nationwide reported trauma cases.

Why would non-trauma hospitals want to hold on to insured patients? One possible reason is that sometimes emergency doctors fail to recognize conditions that need extra care, lead author M. Kit Delgado, MD, suggests. Hospitals may also be used to taking care of certain severe injuries on their own.

But there might also be other reasons. As Delgado elaborates in the release:

Doctors working in the trenches most often strive to do what’s best for patients. But these findings are concerning and suggest that non-trauma centers are considering admitting some patients with life-threatening injuries based on whether or not they can be paid, when research has shown these patients fare better if transferred to a trauma center.

Delgado carried out the research when he was an emergency medicine instructor at Stanford. He is currently an emergency care research scholar at University of Pennsylvania.

Calling the finding “very disturbing,” Nancy Wang, MD, senior author – and an emergency physician herself – says researchers must call attention to such disparities in trauma care. She and colleagues previously discovered disparities in access to trauma care at California hospitals between children with and without insurance.

“I believe in health care as a right,” Wang wrote to me. “I never believed that there would be disparities in access to emergency trauma care based on insurance status.”

The authors suggest closer monitoring of emergency room encounters and splitting costs between hospitals and trauma centers as potential ways to curb such practices.

In follow-up studies, they also hope to figure out how much patients know about their options, and whether their preferences are being taken into account. As Delgado says in the press release, “People who have insurance may not realize that they could do better if they are transferred.”

Previously: Comparing the cost-effectiveness of helicopter transport and ambulances for trauma victims
Photo by Seattle Municipal Archives

Emergency Medicine, Health Costs, Research, Technology

Can sharing patient records among hospitals eliminate duplicate tests and cut costs?

566748316_7b72d5b777A recent analysis of the impact of health information exchanges, which allow health-care providers to share patient records electronically and securely, shows the systems hold promise for reducing health costs and unnecessary care in emergency departments.

For the study (subscription required), University of Michigan researchers examined information on hospital health information exchange participation and affiliation from the Health Information Management Systems Society’s annual survey as well as data the  California and Florida state emergency department databases from 2007 through 2010. Both states were early adopters of health information exchanges. According to a university release:

The findings show that the use of repeat CT scans, chest X-rays and ultrasound scans was significantly lower when patients had both their emergency visits at two unaffiliated hospitals that took part in a [health information exchange]. The data come from two large states that were among the early adopters of [health information exchanges]: California and Florida.

Patients were 59 percent less likely to have a redundant CT scan, 44 percent less likely to get a duplicate ultrasound, and 67 percent less likely to have a repeated chest X-ray when both their emergency visits were at hospitals that shared information across an [health information exchange].

More research is needed to determine the value of health information exchanges on patient care and health-care costs. But in order to conduct future analysis, said study authors, more states need to report relevant data to the Healthcare Cost and Utilization Project system  to allow researchers to view the activity of individual patients across their different medical encounters, while preserving patient privacy.

Previously: Experts brainstorm ways to safely reduce health-care costs, U.S. Olympic team switches to electronic health records and A new view of patient data: Using electronic medical records to guide treatment
Photo by Tabitha Kaylee Hawk

Cardiovascular Medicine, Emergency Medicine, Patient Care, Pediatrics, Research

New approach to resuscitation training saves more kids

New approach to resuscitation training saves more kids

Heart-2014Children whose hearts stop while they are in the hospital need fast, well-coordinated resuscitation to give them the best chance of surviving their cardiac arrest. But because pediatric cardiac arrests are (fortunately) rare, pediatric physicians, nurses and other caregivers have few opportunities to experience a real response to this life-threatening emergency. And rehearsing what to do in educational settings outside the hospital may not give responders the chance to practice for unexpected problems that can arise in real life.

To solve this problem, a team at Lucile Packard Children’s Hospital Stanford implemented a new training approach. Lynda Knight, RN, MSN, the hospital’s pediatric resuscitation program educator, wanted to make sure that every person responding to emergency “codes” broadcast through the hospital when a patient’s heart stops – from attending physicians to security guards – had regular opportunities to practice working together. Knight and Deborah Franzon, MD, led a group that staged mock “codes” to simulate cardiac arrests in many locations throughout the hospital.

After the new training was implemented, the hospital’s survival rate for cardiac arrest patients jumped from 40 percent (a figure similar to the national average for children’s hospitals) to 60 percent. The findings were published this week in Critical Care Medicine.

From our press release about the study:

One key goal of the training package was for one person to quickly assume the role of the code team leader, and for others to take on specific, pre-defined roles in the team’s response. The roles were based on American Heart Association guidelines about best practices for resuscitation.

“It’s sort of like an orchestra,” Franzon said. “Everyone has a really important part to play.” For instance, one physician or nurse stood at the code cart, distributing equipment. A social worker comforted the patient’s parents. Security guards directed unnecessary foot traffic away from the area. A nursing supervisor made sure all essential roles were filled quickly.

“With this training in place, responding to codes becomes muscle memory for the whole team,” Knight said. “That’s what’s going to save lives.”

Photo by dev null

Emergency Medicine, Stanford News, Videos

“I’m glad that we were there”: Stanford emergency-response team returns home from the Philippines

"I'm glad that we were there": Stanford emergency-response team returns home from the Philippines

Time for another (feel-good) video? The SEMPER team that’s been in the Philippines for the last few weeks made it home safely yesterday; in this piece, the group is greeted at the airport by friends and family. “We saw [about] 200 patients a day. It was very difficult – I have to tell you that,” said one of the returnees, later adding, “Our presence actually made them feel good, and they’re very grateful for that. And I’m glad that we were there.”

Previously: On the ground in post-typhoon Philippines, Post-typhoon Philippines: “It is all becoming real and sinking in”, Providing medical care to typhoon survivors in the Philippines and Stanford emergency-response team heads to the Philippines

Emergency Medicine, In the News, Pediatrics, Pregnancy, Stanford News, Women's Health

Russian doctors visit Packard Children’s Hospital for childbirth-crisis training

Russian doctors visit Packard Children's Hospital for childbirth-crisis training

operationSome believe “The Trauma of Birth” is part of the human condition even during a healthy delivery. But sometimes entry into the world comes with unexpected medical complications – for mother as well as baby. Stanford’s Center for Advanced Pediatric and Perinatal Education at Lucile Packard Children’s Hospital trains health professionals on best practices for handling childbirth emergencies. An article in the San Francisco Chronicle spotlights experiences of the first Russian visitors to the center, which has been training medical experts from all over the world since 2002.

From the piece:

The simulation room looked a lot like a hospital room, with a couple of significant differences. Behind a two-way mirror, technicians sat in a control room video-recording the doctors’ every movement on seven cameras. They manipulated the vital signs shown on the bedside monitor of the mother, who was played by a hospital employee. They controlled the pumping lungs and warm breath of the baby mannequin.

After the childbirth simulation, the four Russian doctors involved in the scenario sat before a television and watched themselves on instant replay. Cringing a bit, the obstetricians admitted that they could have worked more efficiently by splitting up, with one monitoring the woman’s vital signs and the other guiding the delivery. One of the neonatologists who assisted with the newborn remarked that she should have called for help from a colleague sooner.

One of the participating doctors, Yulia Vorontsova, a neonatologist, said with the assistance of an interpreter, “When you look at a situation from the outside, it gives you a richer experience.”

Previously: “Preparation is everything:” More on how Stanford and Packard got ready for the Asiana crash, Whiz Kids: Research looks at handling pediatric crises effectively and Improving treatment for infant respiratory distress in developing countries
Photo by phalinn

Emergency Medicine, Global Health, Patient Care, Stanford News

Providing medical care to typhoon survivors in the Philippines

Providing medical care to typhoon survivors in the Philippines

SEMPER - smallYesterday we wrote about a Stanford team who had traveled to the Philippines to provide medical assistance to survivors of Typhoon Haiyan. Members of SEMPER, each carrying an average of 160 lbs of equipment, arrived on Saturday and completed their first full day of providing medical care on Monday.

The team, pictured to the right, reports that there are “clear signs of recovery” but says the devastation from the typhoon is enormous. They’re chronicling their experiences on a blog, which you can read here.

Previously: Stanford emergency-response team heads to the Philippines
Photo courtesy of SEMPER

Emergency Medicine, Global Health, Patient Care, Stanford News, Videos

Stanford emergency-response team heads to the Philippines

Stanford emergency-response team heads to the Philippines

On Friday, several members of Stanford’s emergency-response team headed to the Philippines to provide medical assistance in the aftermath of Typhoon Haiyan. Stanford Hospital videographer Todd Holland was on the scene as the team prepared, and he captured the beginning of their journey in the video above.

Previously: New Stanford Hospital team ready to mobilize for disaster relief, Treating the injured amid the apocalypse of Haiti, Reports from Stanford medical team in Haiti and Stanford sends medical team to Haiti

Emergency Medicine, Health Disparities, Public Health, Research

Texts may help people with diabetes manage care

flipphoneWhat if a doctor’s orders were as simple as two text messages a day to keep the ER at bay? A recent study published in Annals of Emergency Medicine used an automated mobile health (mHealth) program to reach low-income inner-city patients with type 2 diabetes and engage them in their own health and disease management outside of emergency facilities.

Researchers recruited 128 participants who had sought care for diabetes at the Los Angeles County Hospital of the University of Southern California ED. The study reported that the largest safety-net hospital in the county’s public care system annually serves 170,000 patients, 70 percent of them Latino. Study participants could choose English or Spanish versions of the messages, which offered tips on healthy behavior and disease management and did not require a smartphone to receive.

From a release:

For patients who received the text messages, blood glucose levels decreased by 1.05 percent and self-reported medication adherence improved from 4.5 to 5.4 (on an eight-point scale). Effects were even larger among Spanish speakers for both medication adherence and blood glucose levels. The proportion of patients who visited the emergency department was lower in the text messaging group (35.9 percent) than in the control group (51.6 percent). Almost all (93.6 percent) patients enrolled in the program reported enjoying it and 100 percent reported that they would recommend it to family and friends.

“Our goal is to transition our patients from crisis management to long-term diabetes management,” study lead author Sanjay Arora, MD, of USC’s Keck School of Medicine, said in a release. “The absence of other health care options, reaching our patients by text message makes us partners in handling their disease and improves their quality of life.”

Previously: Help from a virtual friend goes a long way in boosting older adults’ physical activityA look at the “Wild West” of medical apps and Mobile phone app helps manage diabetes
Photo by kiwanja

Emergency Medicine, In the News, Patient Care

Patient advocacy and staff courtesy in the ER

waitingroomOne morning during a ballet class I did an extra-large backbend, fainted, flipped, fell and hit my head on the bottom of the metal barre I had been holding onto, awoke on the floor and stared at my colleagues, who hovered above. The company manager insisted I go to the emergency room. A friend who wanted to get out of her Nutcracker rehearsals that day volunteered to take me. We sat in rigid chairs and waited for seven-and-a-half hours in a seemingly not very busy ER before I was seen and told that I probably did not have a concussion. While I didn’t mind waiting all that much (I was also getting out of back-to-back runs of the Snow Scene), I wondered how the experience could have gone differently. Were symptoms missed in the time that elapsed? Should I have gone to urgent care instead, to make space for more acutely ill or injured people in the ER?

I found resonance in a recent post on by Abigail Schildcrout, MD, who describes a frustrating experience navigating the ER as the parent of a young patient. In it, the physician and mother emphasizes the need for patients to be assertive and hospital staff to be attentive, but also for both parties to be respectful of the other.

From the post:

We waited far longer than we should have for the test that determined whether a surgical emergency existed.

Yes, there are people who use emergency room resources when they’re not needed. But most of us go out of our way to avoid emergency rooms. When we’re there, it means we’re really concerned about something.

When I tell my clients and my readers to advocate for themselves and their loved ones, I know it’s hard. I know it’s a delicate balance between making sure you get what you need and not annoying people in the process. But it has to be done. And hospitals are working on seeing things from the patients’ side.

Previously: Speed it up: Two programs help reduce length of stay for emergency-room visitors and Decreasing demand on emergency department resources with “ankle hotline”
Photo by cinemich

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