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Tuesday, February 18, 2014
By Ruth SoRelle, MPH
After years of investigation, the U.S. Department of Justice has intervened in eight false claims lawsuits in six states against Health Management Associates, Inc., signing on to allegations of payments to doctors and clinics in exchange for patient referrals and to claims that the Naples, FL, for-profit chain pressured emergency physicians and hospital administrators to admit patients to meet corporate benchmarks, regardless of medical necessity. (Read the DOJ announcement at http://1.usa.gov/1foNoIo.)
HMA’s activities have already generated considerable interest, including a segment on the CBS news program 60 Minutes that aired in December 2012. (Watch that report at http://cbsn.ws/1foNAHE.) The push to increase admissions to the hospital from the emergency department is described in several of the suits, including one filed jointly by Jacqueline Meyer, a former regional client administrator for EmCare, the firm that provided emergency physician services to many HMA hospitals, and Michael Cowling, a former HMA division vice president and CEO of Lake Norman Regional Medical Center in Mooresville, NC.
The qui tam, or whistleblower, suits were just recently unsealed, providing details of alleged wrongdoing for the first time. Many of the suits allege an illegal kickback scheme for referrals to HMA hospitals, but the Meyer-Cowling filing, among others, describes HMA practices in emergency departments, including a mandate that its hospitals increase admission rates by:
- Setting benchmarks for hospital admissions from the emergency department: 50 percent for patients 65 and older and anywhere from 16 percent to 20 percent for the overall population.
- Directing hospital administrators to monitor ED admission rates through daily, weekly, and monthly reports generated using a customized software program called Pro-MED. The plaintiffs said each emergency physician was tracked for the number and percentage of total patients admitted as well as the percentage of patients 65 and older admitted. Some hospitals also tracked physicians on a daily color-coded report card with green signifying that a physician had met the benchmark, yellow that he had almost met it, and red that he had missed the benchmark, according to the suit.
- Using Pro-MED to flag each time an ED patient met criteria for admission, measures that were programmed right into the software. “Nevertheless, HMA used the criteria in conjunction with its customized Pro-MED software to coerce physicians to admit patients, regardless of the physician’s clinical judgment about the patient’s needs,” the Meyer-Cowling suit states. Physicians could manually override such actions, but according to the suit, physicians who had override rates of 35 percent or more received “failing grades.”
- Holding daily “flash meetings” with emergency physicians “to interrogate them about so-called ‘missed’ admissions.” According to the suit, “During flash meetings, which were commonly referred to by the ER medical personnel as ‘daily inquisitions,’ hospital CEOs and their staff often overtly threatened the ER doctors and medical directors with termination if the physicians did not increase the number of patients they admitted.”
- Distributing monthly Forced Rank Reports to hospital CEOs and administrator staff, emergency department directors, and EmCare management in which all HMA hospital EDs were ranked according to inpatient admission rates.
- Directing hospital CEOs and emergency department medical directors not to place patients in observation status “even when medically warranted, but instead were to be admitted as inpatients so that HMA could recover larger fees for their care,” the suit alleges.
- Implementing a Pro-MED software program “that identified a series of diagnostic tests to be immediately performed, according to what the triage nurse had specified as the patient’s chief complaint, before the patient had been seen by a doctor.” The Meyer-Cowling suit says HMA also required emergency physicians to order “85% of the tests specified in the protocol, despite the fact that in many instances the tests were medically unnecessary.”
- Setting benchmarks for calling patients’ primary care physicians “85% of the time for patients 65 and over” and 35 percent of the time for younger patients “not to obtain a better understanding of patients’ medical needs but, rather, to ‘sell admissions’ to primary care physicians.” HMA anticipated that these physicians would defer to the emergency physician’s recommendation about hospitalization, the suit says.
- Paying bonuses at some hospitals to emergency physicians and medical directors for meeting the benchmarks for ordering tests, calling primary care physicians, and keeping admission overrides low.
The suit also charges that “EmCare actively assisted HMA in unlawfully pressuring and inducing ER medical directors and physicians to sacrifice their medical judgment and recommend the hospitalization of ER patients and the ordering of diagnostic tests, irrespective of the medical needs of the patients.”
Ms. Meyer and Mr. Cowley claim they were fired — she from EmCare and he from HMA — because they did not go along with the push to increase admissions from emergency departments. The Justice Department is still deciding whether it will join the suit Ms. Meyer filed against EmCare.
The Meyer-Cowling suit also named Gary Newsome, CEO of HMA, as a driver of the plan to inflate patient admissions, and the Justice Department joined that action as well. Mr. Newsome headed HMA from 2008 until mid-2013 when he retired to head a Mormon mission in Montevideo, Uruguay, the suit says.
The suit lists several hospitals at which those admission activities took place. One is Carlisle Regional Medical Center, a 165-bed hospital in Carlisle, PA, that HMA had owned since 2001. Carlisle offers routine specialty care, but it is not a trauma center, and had no interventional cardiac catheterization services at the time the suit was filed in July 2011.
Ms. Meyer was assigned to oversee EmCare’s contract at Carlisle in 2009. Soon after, she attended a hospital meeting that included EmCare managers and the Carlisle ED medical director, assistant medical director, and emergency physicians. According to the suit, Frank Biondolillo, DO, the executive vice president of EmCare’s southeast region, told attendees, “‘If you want to be successful at an HMA hospital, you are going to have to admit more patients.’”
The suit continues, “Dr. [Cliff] Cloonan [assistant medical director of the ED] angrily responded that Dr. Biondolillo was not going to make him break that law and that Cloonan was going to do what was right for the patient.” After the meeting, the suit notes, EmCare managers told Carlisle CEO John Kristel what had transpired. “In response, Kristel told the EmCare group to fire Dr. Cloonan because he ‘was not on board,’” the suit states. Ms. Meyer, however, advised against that, suggesting that HMA and EmCare consult their legal departments.
“It was an insidious situation,” said Dr. Cloonan, who is not part of any of the lawsuits. “It was not really suddenly awful. Had it been, a lot more people would have [jumped] ship.”
Dr. Cloonan said he was an employee of the hospital when he first came to Carlisle, and he and his fellow emergency physicians continued that way for a couple of years after HMA took over and built a new emergency department. But about the same time that the hospital introduced Pro-MED, an HMA manager said they no longer wanted to employ the physicians, suggesting that the doctors consider a provider of emergency services like EmCare or form their own group. They ended up going with EmCare.
Dr. Cloonan said it seemed the best choice at the time. Besides, he and his colleagues were dealing with other issues. “I wasn’t pleased with Pro-MED Blue,” he said. “It was clearly constructed not to adequately document what physicians did and facilitate their work but as an accounting tool to capture revenue. It also, in my view, facilitated fraud in the sense that there was a lot of automated test ordering. It took extra steps to undo what the computer was automatically doing.”
Scott Rankin, MD, who worked part-time at Carlisle during this period, told EMN that Pro-MED “generated a nice bill, but it also pushed us to order studies that maybe we would not have ordered. If a patient showed up with chest pain, nurses were mandated to hit the chest pain box, and these studies were ordered before we saw the patients. Nurses told us, ‘We have to do this.’”
Dr. Rankin said the EPs were increasingly being pressured to admit toward the end. They came out with specific numbers — 50 percent for all patients over 65 and an overall 20 percent admission rate, he said, but such numbers were not realistic for Carlisle. “I realized I was being encouraged to commit most of the fraud being described in the government-mandated program [that physicians are required to take]. I printed out a screenshot, and went out and posted it around the computers in the emergency department.”
Dr. Cloonan said he remembers the meeting with Dr. Biondolillo well. He said he pushed back at that meeting, saying, “What I just heard is that if we don’t commit fraud, we are going to get fired.”
Before a monthly meeting of the ED staff, the medical director of the emergency department told Dr. Cloonan that he had been at a meeting at HMA headquarters and was told physicians would be fired — starting with him and Dr. Cloonan — if they did not go along with the program, Dr. Cloonan told EMN. He said he told the ED medical director that he would say nothing at the monthly physician meeting, but he would resign as assistant ED director immediately. He found a job in a nearby town.
One by one, meanwhile, other long-time emergency physicians at Carlisle began to resign. Dr. Rankin said the physicians who had worked there left voluntarily. “To have to leave their community hospital was a painful decision. However, we had that option to leave. There were other places we could work,” he said. Physicians in other communities were not as lucky, he said.
Dr. Cloonan said he was angry about what he saw happening. “There’s a huge amount of ongoing fraud, waste, and abuse that is taking place within specifically government contractual elements of health care,” he said. “When HMA was talking about admitting 50 percent of patients over 65, that’s Medicare. And it’s not confined to HMA. We have created a system that is ripe for abuse. That’s part of the problem.”
Dr. Rankin said the physicians’ concern was for their patients. “We put the patient ahead of profit,” he said. “For-profit medicine does not have that sum equation.”
Robert McNamara, MD, a former president of the American Academy of Emergency Medicine, said one thing that gets lost in the narrative is the risk to patients admitted to the hospital unnecessarily. “I’m not surprised at any of it. The suits lay it out,” he said.
Craig Brummer, MD, a former medical director at Barrow Regional Medical Center and then Walton Regional Medical Center in Georgia, described in his suit against HMA the same pressures described by Ms. Meyer, Mr. Cowling, and Dr. Cloonan. He described several patients who he said were admitted to HMA hospitals without an appropriate medical reason, including:
- An elderly Medicare patient who underwent “a chest x-ray (that showed no issues), an EKG, and lab work. [The patient] was improperly admitted with a clinical impression of ‘neck pain.’ This 71-year-old patient should not have been admitted for ‘a chest pain rule out’ assessment,” the suit says.
- An 11-month-old Medicaid patient who presented to the ED with a chief complaint of fever but who was admitted even after his fever dropped to normal. “He had a temperature of 104 degrees upon presentation and looked well,” the suit notes. “The infant was given a full workup of chest x-rays and labs and all were normal, but he was given intramuscular antibiotics and admitted to the hospital. [The patient] was admitted with a temperature of 98.7 with a clinical impression of fever.”
- An 18-year-old Medicaid patient who sustained a right knee laceration. “X-rays were negative, but he was admitted for repair of the knee laceration. This patient was admitted to the hospital for repair even though his injuries did not involve an open fracture and should have been treated on an outpatient basis.”
The Justice Department’s inquiry was described in many quarters as painstaking. Stuart F. Delery, the Assistant Attorney General for the Justice Department’s Civil Division, said in a statement that “schemes such as this one can contribute significantly to the rising cost of delivering health care and create needless patient risk.”
The U.S. Attorney for the Middle District of Georgia Michael J. Moore agreed, noting in another statement that “HMA’s submission of claims to Medicare, Medicaid and TRICARE for unnecessary inpatient stays is a serious matter that threatens the integrity of our entire health care system, and the end result is that those who need health care cannot afford it.”
HMA shareholders approved a $7.6 billion sale of the company to Community Health System (CHS) in January, merging the two systems to create the for-profit hospital operator in the United States with the largest number of facilities. Hospital Corporation of America remains largest in annual revenue. (Naples News; http://bit.ly/1ifr06p.)
CHS announced preliminary financial and operating results for 2013 on Jan. 6, noting that it was reserving $101.5 million to settle claims arising from the government’s investigation into the company’s short-stay hospital admissions and investigation at the CHS hospital in Laredo, TX. Or as the New York Times reported, “Investors seem to think that DOJ investigations, qui tam suits, and allegations of serious Medicare fraud are simply a cost of doing business,” said Sheryl Skolnick, PhD, the managing director and a head of research for CRT Capital. (http://nyti.ms/1euQmx3.) CHS is also negotiating a corporate integrity agreement with the Office of the Inspector General of the U.S. Department of Health and Human Services. (Read CHS’s 2013 operating report at http://bit.ly/1eNAD8V.)
HMA refused to comment specifically on the allegations in the suits or the Justice Department’s joining in the whistleblower lawsuits. “As a matter of policy, we do not comment on pending litigation. The existence of the government’s investigation into the issues raised in the unsealed qui tam cases has been disclosed for some time in HMAs’ public SEC filings. While our legal team addresses these matters and continues to cooperate with the Department of Justice’s ongoing investigation, HMA associates and physicians who practice at our facilities are focused on providing the highest quality patient care in all of our hospitals,” MaryAnn M. Hodge, the vice president of marketing and communications for Health Management Associates, wrote in an email to EMN.
Jennifer Whitus, the marketing communications manager for EmCare, said in an email that the company cannot comment on pending litigation.
Read the Suits for Yourself
These first four lawsuits focus on the emergency department’s role in inpatient admissions.
Jacqueline Meyer, a former EmCare regional client administrator, and Michael Cowling, a former HMA vice president and CEO of Lake Norman Regional Medical Center in Mooresville, NC, allege that HMA instituted certain practices that sought higher admission rates from the emergency department and that resulted in patients being admitted to the hospital who should not have been and in false claims being submitted to federal health programs (Medicare, Medicaid, etc.).
Craig Brummer, MD, the medical director of the emergency departments of Barrow Regional Medical Center and Walton Regional Medical Center, both in Georgia, alleges that HMA and the hospitals where he worked instituted policies (including forced ranking reports to spotlight percentages of patients admitted and flash meetings about whether ED patients were or should have been admitted) that resulted in patients being admitted from the emergency department unnecessarily. He alleges that false claims were submitted to federal health programs (Medicare, Medicaid, etc.). The Department of Justice agreed and signed on to the suit.
United States of America, the States of North Carolina, Florida, Georgia, Oklahoma, Tennessee, and Texas ex rel Thomas L. Mason, MD, Steven G. Folstad, MD, and Mid-Atlantic Emergency Medical Associates v. Health Management Associates, EmCare, et al
Drs. Folstad and Mason were emergency physicians with Mid-Atlantic Emergency Medical Associates, and served as the medical directors of emergency departments at two HMA hospitals. They allege that their medical group lost its contracts to provide emergency physicians to the hospitals because they objected to HMA’s use of the Pro-MED software and other practices designed to increase patient admissions and tests they said were unnecessary.
Dr. Plantz, a longtime emergency physician whose expertise is frequently sought about quality care in the nation’s emergency departments, alleges that HMA used Pro-MED software to order tests and procedures automatically and required physicians to order unnecessary tests and to admit patients at rates that met administration-set benchmarks. He also alleges that physicians who do not adhere to HMA’s criteria are subject to firing and that HMA mandates that emergency physicians admit patients to the hospital rather than use 23-hour observation.
These four lawsuits allege improper financial relationships that resulted in improper patient referrals.
Mr. Meyer, a former agent of the Federal Bureau of Investigation who worked for HMA in its corporate compliance department in Naples, FL, alleges that “the HMA hospitals have established prohibited, non-exempt financial relationships with physicians that refer Medicare patients to their respective hospitals and such physicians referred Medicare patients to such hospitals” and that the hospitals sought and received pay for that care. He also alleges that the defendants provided kickbacks and illegal remuneration or entered into “prohibited financial relationships in violation of the anti-kickback statute and the Stark Law, which prohibits physician self-referral, for patient referrals to HMA facilities that resulted in “claims for reimbursement for services rendered to patients.” He also said they unlawfully classified some patients as inpatients when they did not meet criteria.
Mr. Williams, an accountant with 30 years of experience, was employed by HMA as its chief financial officer between April and October 2009. He alleges that the HMA and Tenet hospitals paid financial inducements to Clinica de la Mama to refer pregnant women about to deliver their babies to their facilities. Undocumented women are not eligible for regular Medicaid coverage, but the federal-state program provides emergency medical assistance that pays health care providers for emergency services to undocumented aliens, including childbirth. He alleges that the payments violated the anti-kickback statute and that the “written contract provides for payments to Clinica for ‘interpreter services.’” He said in the suit that this was “a sham agreement that was designed to conceal the underlying financial motive, which was the purchasing of Clinica referrals.”
Mr. Nurkin, the former chief executive officer of Charlotte Regional Medical Center in Punta Gorda, FL, alleges that HMA and its hospitals “knowingly induced doctors to make patient referrals and hospital admissions by intentionally and knowingly providing the doctors with improper remuneration in violation of the federal anti-kickback statute and the Stark Law. He alleges in the suit that the hospital “paid unlawful remuneration amounting to hundreds of thousands of dollars to a physician practice group in North Port, Florida” that were subsidiaries of HMA. He said the improper remuneration consisted of “free office space, staff, equipment, and direct expense payments of up to approximately $20,000 to $40,000 per month from at least 2004 through mid 2007.”
Mr. Miller was the chief executive officer at Heart of Lancaster from June 2, 2008 to May 6, 2009 and the CEO of Lancaster Regional from June 2, 2008 until January 2009 when he was also CEO of 13 physician clinics related to the hospital. Mr. Metts was the system chief financial officer and compliance officer for Lancaster Regional, Heart of Lancaster, and 13 related clinics from June 2008 until December 2008 and also the chief financial officer and compliance officer at Lancaster Regional from December 2008 until September 2009. All those facilities are in Pennsylvania.
The suit alleges that HMA “uses whole-hospital joint venture schemes to induce local physicians to refer patients to HMA facilities in violation of the anti-kickback statute.” In their suit, they also allege that the “defendants submitted or caused the submission of false claims to federal and state health programs as a result of illegal kickbacks that … [HMA] … offered and paid, and kickbacks to physicians at HMA facilities.”
* “Ex rel” is an abbreviation for the Latin phrase ex relatione, meaning “out of the narration." It is most commonly used when the government brings a cause of action at the request of a private party, but the government typically brings an ex rel action only if it shares the interest advanced by that private party.
Wednesday, December 11, 2013
By Michelle Johnston, MBBS
Heart attacks are caused by a sudden blockage of a blood vessel supplying oxygen to heart muscle, and it is nearly always caused by a new blood clot that forms on a hardened and diseased blood vessel.
It took trials and studies on 60,000 heart attack patients to work out that clot-busters prevent deaths in heart attacks, but they only worked on one type of heart attack (which is only about five percent of all heart attacks). We took the time to get it right, refining study after study, until we were sure that introducing a potentially dangerous drug had benefits that outweighed the harm.
Every type of clot-buster that was studied worked, and the earlier it was given, the better. Interestingly, the one that caused the most brain bleeding was tPA.
Studies have been done on clot-busters in stroke. Strokes are also caused by a blockage to a blood vessel in the brain, but there are important differences between strokes and heart attacks:
The cause of the blockage is never worked out about 30 percent of the time.
Two very different types of blood clots cause strokes: new blood clots (like in heart attacks) and old blood clots called embolic clots (e.g., an old blood clot that has formed in the heart and travelled to the brain where it blocked a blood vessel).
This difference between new and old blood clots is very important because clot-busters do not work on old blood clots.
How many strokes are caused by new blood clots? No one knows for sure because we can’t work out what kind of clots (or other causes) are causing the stroke. The best guess is that it is a little less than half.
“It is important to note that the efficacy of thrombolytic drugs depends on the age of the clot. Older clots have more fibrin cross-linking and are more compacted; therefore, older clots are more difficult to dissolve. For treating acute myocardial infarction, the thrombolytic drugs should ideally be given within the first 2 hours. Beyond that time, the efficacy diminishes and higher doses are generally required to achieve desired lysis.” (Cardiovascular Pharmacology Concepts
Twelve important studies have been done: 10 were negative (they showed that clot-busting did not work in stroke), and four of these had to be stopped early because of harm (they were killing people). They have only studied this in about a sixth of the number of stroke patients compared with the heart attack studies. This is a completely different situation from the heart attack studies, where it worked in every study and with every clot-busting drug they tried.
The two positive stroke studies (i.e., they suggest a statistical benefit) have been widely criticized in the medical literature because of their scientific flaws. One of these looked at giving tPA within three hours of the stroke. Interestingly, this study proved that there was no benefit in the first 24 hours, which again is different from the heart attack studies. The other study looked at giving tPA from 3 to 4.5 hours after the stroke.
This second study also contains some major errors. The biggest flaw was an imbalance in baseline stroke severity. The placebo group (those who didn’t get tPA) were sicker, with more severe stroke; the tPA group was not as sick and had much more mild strokes. Everyone understands that people with milder strokes do better than those with more severe stroke. Obviously, the study favored tPA because the tPA group had milder strokes, which will do better anyway.
This study was re-analyzed later. If tPA really worked to improve the outcomes in sudden stroke, then there should be a much larger improvement in outcome compared with the placebo group. But there was no difference.
The studies show that tPA causes brain bleeding in about six percent of patients. Brain bleeding is the other type of stroke. It is strange that some people would advocate a treatment for stroke that can cause a (worse) stroke. Brain bleeding is very severe, and almost half the people die if this happens.
Why does brain bleeding happen with a clot-buster? Doctors think of clot-busters as being like Drano, the plumbing product used to unblock pipes. You have a damaged blood vessel inside a damaged part of the brain in strokes. It’s no surprise that putting “Drano” in there sometimes dissolves through the blood vessel and bleeds into the brain.
The largest study on clot-busting in stroke was published in 2012. This again was a negative study that showed tPA did not work, and it confirmed the increase in early deaths with tPA. Interestingly, the time to give the drug from the stroke studies is completely different from the heart attack studies.
After studying 60,000 heart attack patients, every study showed that the earlier the clot-buster was given, the better. The majority of the stroke studies do not show this effect. The reason for this is unclear, but may be because the patients who get to the hospital earlier are somehow different from the ones who arrive later.
One must always remember, however, that once the blood vessel is blocked, the brain cells will be dead in about three minutes. Giving a clot-buster later shouldn’t have any effect, and this may be what we’re seeing. It’s also worth remembering that heart muscle cells and brain cells are very different.
Researchers have used meta-analysis to “prove” that clot-busting works. The simple summary of the problem with this is summed up by the phrase: garbage in, garbage out. Badly done studies when put into a meta-analysis do not magically become good studies. There is at least one review of this that concludes “there is no consistent or proven benefit
” to clot-busters in stroke. (The NNT; http://bit.ly/NNTthrombolytics
What is the problem here? Why is there controversy in the medical world? Shouldn’t it be black and white? Either tPA works, or it does not. Easy.
Sadly, it is not so easy. Statistical analysis of any medical treatment is rarely black and white. It is about the interpretation of the research. This is where the controversy has occurred here.
So why is tPA for stroke being pushed? Because we really want it to work.
How do we resolve this problem? We think that patients and society in general expect that an offered medical treatment will have passed the test of science. The test of science requires elimination of bias, healthy scientific debate, and replication to see if a study that suggested a statistical benefit can produce that result again, which would make it more believable. Time and time again in medical research, we find that when larger more decisive studies are done, the initial exciting result becomes a disappointing one: it doesn’t work. This replication has not happened for stroke, but needs to if we want to maintain our trust in medicine.
Has anyone else raised concerns about this? Recently, the British Medical Journal
published a debate and poll on this very subject. (BMJ
4 September 2013; http://bit.ly/172AnTK
.) Other experts have also expressed similar concerns. These resources from SMARTEM.org offer further reading: “Delusions of Benefit in the International Stroke Trial” (http://bit.ly/1bEhUwt
) and “The Guideline, The Science, and The Gap” (http://bit.ly/1aTVM4u).
Is there anything else that can be done if I have a stroke? We know that having your care in a stroke unit is much more powerful than any drug. And taking part in stroke research will help us answer these questions.
Dr. Johnston is a senior emergency physician at Royal Perth Hospital, an inner city trauma center in Perth, Western Australia, and runs the fellowship teaching program there. She writes for the blog Life in the Fast Lane
), where this article first appeared.
Wednesday, October 09, 2013
Good evening everyone, and thank you for coming to my talk. This is “Travels in Emergistan,” and I’m Edwin Leap.
So, a few years ago, I was at the doctor’s office, and because I don’t want to implicate this one physician of mine, I won’t say his name, but he said to me one day, “Ed, do you do any mission work?” And this guy is a fantastic man who does lots of mission work overseas with his children, and I said, “No, I don’t,” and then I left.
And then you know how you have that discussion, and after you’re done, you think, “Oh! I should have said that!” And I said I should have said, “I go to the emergency room,” but what is that? And then I thought I need to make a name for the place I go, the place you go, the place we work. So I decided to call it Emergistan, without the intent to insult any particular country, but it just seemed like an exotic-sounding name, and frankly, we go to a sort of exotic place.
So now I will share with you the flag of our noble land. It says, “The Republic of Emergistan.” I have it on my pin here. “The Republic of Emergistan,” where our motto is “Semper A Decem.” The vulture, I think is self-explanatory. Red is for blood, green is for infection, blue is for blood, and “Semper a Decem” in reference to the pain scale is, “Always a 10.”
The Emergistan as we know it really began in 1986. For those of you who know about EMTALA’s history, that’s when EMTALA came into effect, and I believe at that point, we became who we are today, the beginnings of who we are today. So let me just say a big thank you to Washington for what we deal with every day of our lives.
And we have our pledge, right? Every country has a pledge, right? “I pledge allegiance to the flag of the Republic of Emergistan. And to the chaos and hope for which it stands. And to the brave souls who work there / facing suffering, stupidity, and never-ending need with science, compassion, and cynicism. Doing the impossible in the worst of situations with pain scales, work excuses, and ridiculous regulations for all.” Amen.
If any of you are musically inclined, I’d be happy for you to write an anthem for us, and I’ll put it on the website, and we’ll publish it. I had an idea: “Emergistan, Emergistan, doing the things nobody can. Is it dumb? Is it tough? Everyone wants more drugs and stuff. Oh, yeah, this is Emergistan.” But, you know how those Marvel comics people are.
So, some of you are nurses, some of you are not emergency physicians. You may be intensivists or what else, so I want you to understand that today you’re all Emergistanis. We are all affected by Emergistan because you admit patients for Emergistan, you come down to the department, so just like John Kennedy said, “Ich bin ein Berliner!” Today, “Ich bin ein Emergistani!” We’re all one with the people of Emergistan.
But it isn’t really a place; we’re certainly not limited by locale. Every emergency department from around the country is sort of a state of mind; it doesn’t matter so much where you are. I’ve been going to Locumstan lately, as a part-time job, and I can tell you, emergency departments are the same in every place. It doesn’t matter if they’re in Indiana, it doesn’t matter if they’re in West Virginia or South Carolina or Nevada; people do the same things and they say the same things. The doctors face the same struggles, and the nurses face the same struggles, for those of you who are nurses.
The problem is when, at the end of the day, when we go home, and we talk to people about it, people don’t believe us. Have you faced this phenomenon? When you try to talk to people about what you do, you try to explain how it is, sometimes even to your family, they sort of, like, shake their heads and think that there’s something wrong with you. Your friends don’t believe it, your administrators certainly don’t believe it, and your politicians frankly could care less. Now they think you’ve taken crazy pills.
So, I was called to testify for a friend who was brought before the state medical board on some spurious charge that had to do with missing a BUN:creatinine in a hospital. So he was charged with unprofessional behavior. So the attorney who was trying to “prosecute” him, as it were, said to me, the patient came by ambulance and, “Dr. Leap, I’m well aware that patients who come by ambulance always require immediate attention for life-threatening problems.” Really? So I said, “No, sir, that’s not true.” “Well, it…” “No, sir, but it’s not.” And so had a little impasse there, as he had to reconsider his strategy.
But if you do try to explain, people call you bitter, or they call you small-minded, or they call you a liar, or they say you just need a break, you just need some time off. I’ve written some columns about this before, and people said in response, “You need to get out of medicine for a while because you just need a break,” and “You shouldn’t practice medicine.” Well, OK. They call you hateful or judgmental. And, of course, the worst thing you can do in our society today is make a judgment about something. But don’t worry, at the end of the day they’ll still call you for Zithromax because everybody has a cold now and then.
But… those who don’t believe you, you let them sit in the waiting room for just about an hour or some time. Your friends, your family, your politicians, and they will believe everything you say. I’ve been there, though. I believe you. I believe all of the stories you tell me. You could tell me the strangest story imaginable, I would believe you because I know you’re not making this up. But, as strange as it is, we have to analyze it. We’re scientists; we want to catalogue, and we want to record the phenomena we observe in Emergistan.
So, I want to think of this as a travelogue. This [lecture] is some of my notes to share with you. And you may have notes to share with me. I’d love to hear from you if you want to write to me, you want to post things on my website or blog, I’d love to hear it. So, I’m going to be talking about the biology, anthropology, culture, and customs of Emergistan.
So I guess that makes me like Jane Goodall, except the chimpanzees weren’t quite as difficult to deal with. They had hair on their bodies, they didn’t ask for drugs, or ice chips. Ice chips, what is that all about? You get this? People ask for ice chips all of the time? It’s like the most important thing in the ER. Crushing chest pain, and “Doctor, can I have some ice chips?” So, it’s a strange place, I mean there’s rich culture, a lot of diversity of thought, and ideas, and people, and half-truths, and dysfunction. But even some physical laws are a little odd in Emergistan. I mean, it’s like a parallel universe in some ways.
Time. … Time expands and contracts oddly in Emergistan. Sometimes, when you’re doing resuscitation, 20 minutes can feel like five hours. And sometimes, when you’re doing something really good for a patient for a couple of hours, they think that you’ve taken forever, right? “I’ve been here 12 hours, and nobody’s done nothing for me, or said a word to me.” Except, what actually happened was you got a CT scan, you got Morphine, you got surgical consult and labs; that was about three hours. So, somehow, there’s a disconnect in the way people receive time in the emergency department.
Also, sound waves are different. When an appendix ruptures, it makes a sound like a shotgun. Have you hear that story before? People say, “My appendix ruptured, and I swear to God, it sounded like a shotgun going off.” Really? OK. Who knew? That is not, by the way, covered in Cobb’s Diagnosis of the Acute Abdomen or Sabiston’s surgical text.
There is also electrogenitalmagnetism. Heard of this? Maybe not. I may actually get to diagnose this myself. I may get to call this, “Leap’s Electromagnetism of the Genitals” or something. So, here’s what happens: A man comes to me in the middle of the night one day with his pregnant wife in tow, and he has two rare earth magnets pinching together his scrotum, causing pressure necrosis. As you might expect, it’s a little bit difficult to remove them. People don’t want things like that yanked or pulled on.
So after some propofol, some anesthesia, and a Schrade super tool, like that, we were finally able to remove the magnets from his scrotum. He left, and never said another word, his wife went like this and shook her head. So I got this idea later, and I contacted Schrade Corporation, and said, “I’ve got a great motto for you.” And without using his name, obviously, I said, “Here’s the story. This man had magnets on his genitals, and we used your device to get them off.
‘Schrade: the tool for your tool.’” Would you believe that Schrade Corporation sent me two T-shirts and two ball caps?
Nutrition is different in Emergistan, isn’t it? Right? In Emergistan, narcotics are like nutrition. Narcotics are vitamins, right? And benzos are co-factors, and antipsychotics give you a quiet night, but when the crazy guy in 20 is … is making a lot of noise. And Tylenol? Are you kidding me? Take some Tylenol and Motrin for your pain, and I quote, “Tylenol don’t do **** for me. It’s like taking candy.”
Immunology? Different. Anyone ever heard of this one? “I’m allergic to 5 mg Lortabs, but I can take those 10s. OK.” Right? Immunology is odd. I’ve had people tell me they’re allergic to saline, to potassium, to electricity, to oxygen, to epinephrine, all the things that you wouldn’t really think an allergy should develop to, since, you know, they’re serving your body. But, hey, it’s Emergistan! Who am I to say? Maybe those things are real allergies.
Interpersonal relationships. Boundaries are for sissies. So a patient of ours came to the department one day rather intoxicated, and my partner walked in to see her, and he said, “What can I do for you?” And she said, “What do you think of these?” and lifted up her top. He walked out. We also had a patient and another patient who were being held on psych papers who managed to meet across the curtain in the fast track, and actually have sex. I don’t know what the patients’ sitter was doing during that time. I don’t want to know. By the way, points if you can name the movie [points to picture on screen]. Thank you, “Wedding Crashers,” yeah.
Relationships in Emergistan are something that’s fiery. Right? We do see violent outbursts now and then, don’t we? We see people who have come in a little crazy. A [base]ball bat to the head is just another way to say, “I love you!”
In Emergistan, let’s face it, it isn’t just people who suffer, it’s the animals. So, a man comes to me one day, and says, “Listen, now.” Now people in the South, you understand, people start sentences like this — “Now, listen” — this is what we do, it’s like, “Bless your heart.” “Now listen here; the thing is,” he’s 45 years old, he said, “The thing is, my mom and me live with her boyfriend.” OK. Right off the bat, problem. “And the other day her boyfriend had a cardiac arrest.” OK, I’m sorry. “And when he had the cardiac arrest, he rolled out of bed and crushed the Pomeranian.” Only in Emergistan.
Even had a guy run into a groundhog on a moped. How do you run into a groundhog on a moped? Right? I just had this vision of the little groundhog eating grass and [imitates moped sound] like the moped’s like 5 mph, and they keep looking at each other. Somebody had to be pretty drunk. I think it was the groundhog actually. In South Carolina, our state bird is the Carolina Wren. In Emergistan, the state animal is the Mullet. But, not the fish, right? And that’s from [points to movie picture on screen]. And that’s from? [Audience: Joe Dirt.] Thank you, OK.
Economics. Keynes? Hayeck? Marx? Reagan? Nope, just free. Now how about trauma care? Well, you know, we know a lot about trauma. But things are different in Emergistan. I have this axiom: “If you can text from the backboard, your cervical spine is probably just fine.” Right? [imitates texting] “In car wreck, please send McDonald’s.”
And professionalism varies a bit. Remember, a lot of what you learn in medical school isn’t really true in Emergistan. It might be true in the clinic, I don’t know, but in Emergistan, it’s questionable at best. Like open-ended questions, right. You don’t ever want to say, “Do you have any pain?” What are they going to say? “Absolutely, I have pain.” Or how about this one. You know, we’re not supposed to lead them. “You don’t have chest pain, do you?” I know, it’s wrong, I know, it’s wrong, but sometimes you have to do it.
Now, the other thing about Emergistan is that people are just hard to kill. I’ve known people who had terrible injuries that surprised me. In fact, some years ago, and I’ll tell you a great story. We had an individual who was playing with his pet rattlesnake — I’m not lying — he had a pet rattlesnake. It was a canebrake rattlesnake, and it was [gestures about 4” in diameter] this big around because I saw it later. OK. So he reached in at night to kiss it goodnight and pick it up, and it bit him. OK, yeah. So guess what? Guess what was tattooed on his arm — a snake. So he’s very intoxicated. He actually experienced cardiac arrest on the way to the hospital. And there were paramedics who resuscitated him. And we ended up giving him 36 vials of antivenin … 36 vials. That’s about $72,000 worth. He lived actually. These people are hard to kill.
Here’s a classic Emergistan quote. The overdose patient says, “I took 26 Klonopins, 10 bars of Xanax, 30 Lortabs (10s, not 5s, because I’m allergic), all my momma’s Neurotins, five of daddy’s Cardizems, and drank a gallon of whiskey. I ain’t staying here; I feel fine.” Great. Great. Notice also, though, the plurals. I’ve never understood that. The Xanaxes and the Lortabs thing. This is a quintessential Emergistani, and he’ll be fine. And you know how you’ll know he’s fine? The next day he’ll be doing your roof with a nail gun. Right. “Hey, Doc! I remember seeing you last night! Remember I was drunk. Remember how drunk I was?” Yeah. Yeah, I do.
In Emergistan, physiology is very different as well. There is nothing better for a gallbladder attack than a Big Mac. Right? No matter how bad the abdominal pain, there’s a Big Mac in the room. Or, maybe at our place, maybe a Bojangles or a bag of fried chicken, or something like that. KFC. And there has to be a giant Big Gulp drink. They get better. By the way, in Las Vegas, that costs $50.
In Emergistan, two beers means two beers! I mean two big beers. This is a conversation I had with a guy one time. He said, “Now, doctor, I am drunk. I’m going home to babysit my nephew and niece!” His blood alcohol level was about 500, literally 500. And that’s how he walked around. And this is for you, Larry. [Blows kiss.] Because he later died of liver failure. But, that guy, every day he was in, he was that drunk. And he was fine, well, until he wasn’t. Social tip. If you go to Emergistan and hang out with the people, just be careful because they will drink you under the table.
Now, the other thing. Disability. Regular people, like you and I, the people I assume that we hang out with, we get fired if we don’t get along with people, right? We had this discussion earlier on before the lecture that, you know, employers have certain expectations about the things you do and say. So, having a bad attitude might end your career, or certainly that job and land you in another location. However, in Emergistan, there’s a thing called “disability.”
Travel tip on economics: bad attitude or pseudo-disease equals disability check. Right? Pseudo-seizures. What is that, right? I don’t understand. I never understood that. I take Dilantin for my pseudo-seizures. I don’t understand this. I’ve had the most bizarre people tell me the most bizarre things about disability. I say, “What are you on disability for?” “Uh, honestly, I don’t remember. My daddy got me on it.” OK. Um, “What are you on disability for?” “I can’t hold a job.” That’s intriguing, OK. “What are you on disability for?” “I’m just nervous a lot.” OK. So, in Emergistan dysfunction like that is actually very much a survival advantage.
To most people, a visit to the ER is to be avoided. I mean, I’ve been to the ER myself as a patient maybe four times in my life, maybe. Twice for kidney stones, and once for getting hit in the eye or something like that. These people, it’s like an event; it’s like a social outing. Have you noticed this? Now that’s when you have the multiple people in one thing that the nebulous complaint. It’s a family outing. “Hey, you got back pain again? I’m out of my methadone. You might want to come with me. It don’t cost nothing.”
Emergistanis are resilient. As I said, they survive injuries that would kill mere mortals. But it is my contention that the people who frequent Emergistan may be a new species entirely. Emergistanis laugh in the face of Darwinian natural selection. Darwin himself was quoted as saying, “Emergistan keeps me up at night!” – Chuck.
Of course, Emergistan gives us other lessons. Like, for instance, how medical providers in Emergistan do the right thing for the sick and the vulnerable. That’s a great thing that you do. And for the people with no other recourse. Because you know, you understand, many of these people you see have no other place to go and no other option at all. So, it is a great service that you provide every day when you travel to Emergistan.
Of course, also, unlike the natives, doctors and nurses understand that you have to go back to work no matter what. So, day in and day out, you work in spite of devastating ankle sprains, sunburns, and head colds that keep your patients at home for days. “I can’t go to work. I’ve got an ankle sprain. Can you give me an excuse?” “No.” My partner walked around on a fifth metatarsal fracture at work for weeks; and he didn’t give a lot of work excuses.
We do have unique challenges. We have violence and drug-seeking and patient-satisfaction scores. Several years ago, we had a patient who was psychotic in one state, and the state police from that state graciously dropped him off at our rest area. He was brought to our hospital and nearly choked a nurse to death. That’s great. That’s Emergistan for you!
I don’t think you’ve ever had to fill out a satisfaction score, but let’s face it, satisfaction scores are a big problem for us, right? But the problem is, when you’re happy about a thing, you don’t fill out a satisfaction score, right? I bought a truck, and I never filled out a satisfaction score. I like the truck. It’s angry people who fill out satisfaction scores.
Now, when you read that, your heart rate went up just a little bit, didn’t it? Nobody’s evaluating you today; it’s OK. You can be upset; you can even criticize me if you want to. Don’t. Doctors in Emergistan are frustrated. Frankly, because of EMTALA and things like that, we do struggle, and departments struggle, and it isn’t just physicians because hospitals collect less money on the people they see for free, nurses salaries go down and everything else. It is a difficult thing. The economics of Emergistan are frustrating and bizarre.
And the government entities that oversee us, you know, like CMS and others, they believe we’re all very rich, and so do the patients. How many times have you heard this? I love this line: “I couldn’t afford to see no doctor, so I came to see you.” Awesome. Thank you. Now, there was a time in the past when people would bring you like a chicken or a pie. We had a patient who used to bring us day-old doughnuts. I was fine with that. Now they don’t even bring you a load of copper or any meth. You know, there’s some ways you could make money if people bring you little things like that. Nobody brings you gifts anymore.
We are endlessly harassed as physicians, aren’t we? To take more tests and pay more fees and get new merit badges. How many of you are frustrated with maintenance and certification? Where you have to take a test every, seems like every, what is it every week now, I think? Yeah. And then you take a bigger test every month, you take the big test once a year, and then you donate blood and, I don’t know, it’s just more and more complicated. By the way, as an aside, ABMS, do you guys know how much money ABMS brings in every year? I shouldn’t say this. Can you guess? $300 million. OK, moving on.
We’re told to see more patients, and get give more pain medications, and smile more, and sit down, and talk more, and follow every new rule that comes down the pike from every administrative body. And it’s difficult in Emergistan all the while working as data entry clerks. Does this drive you crazy? Entering data all of the time? And who’s doing the MR? Everyone’s doing the MR now, right? It’s almost inescapable now, and it’s very time-consuming. But it is part of the technological revolution in Emergistan, and we have to face it.
As far as I’m concerned, being willing to come to work in Emergistan everyday should be its own merit badge. I don’t know how much CME I need when I’m willing to come in and take care of psychotic drug addicts all of the time. I know I need CME, but still. No, the point is it’s a difficult job, and you guys deserve a great credit for what you do.
But, if there was going to be a merit badge, I would invent this one: “Physicians Tolerating Silly Draconian Situations” — PTSDS. So, students and instructors, courses are available this summer, so I’m going to make my living off of this now. I’m going to establish my own merit badge. Now, people sometimes do take me to task over my columns, and they do take you to task when you complain. But you know what, why do we complain? We complain to cope, right? It’s the way we deal with things. It’s the way we deal with it.
It’s a hard job, and it’s a scary place in Emergistan, so we say things about what we do, but at the bottom of it all, we love our jobs, and we’re proud of what we do, and we even like the crazy people we see. You find yourself bonding with them. Like, I see them in Walmart now, and they’re like “HEY!” and I’m like, “How’s it going? You out of jail? Good. Great, how are the kids?” “It’s great to see ya!” Awesome. Yeah, don’t rob me.
They become like you’re people, right? I always tell people, these are my people. All right. The sheep of my pasture. You know, we’re proud of what we do even though we’d like to hit it big in Vegas and go home and not practice because I’ll bet if most of you hit it big, you’d have a hard time quitting because it’s sort of in you now. It’s what you do. It’s how you relate to the world. Oddly enough, I thought about my kids recently, and my kids are about to start college, one’s about to start college, and I don’t know if he’ll be in medicine or not. And I sort of thought, how sad that he won’t have to experience what I experience every day. And then I thought, really? Is it sad? Because it’s what I do. It’s so much a part of my world to be the doctor in Emergistan, to see the craziness and the weirdness, that I can’t imagine my son would want to do a thing with a life that wasn’t like that. And yet, that’s a weird thing to think. So, it’s OK for them to do whatever they want to do. We all like what we do on some level, even though we wish we could have done better.
Emergistan does use a different language altogether, right? I mean, nobody recognizes the things that people say to us. “So me and my boys had just done some Ice when this dude pulls his nine and caps Rooster right through the tat just above his junk! So we called the 5-0, and Rooster was screaming for some bars, but we didn’t have none so I gave him some Special K to chill him out.” What? Well, that makes perfect sense to me, but most people don’t really get that. Most of you understand that discussion. It’s all fun and games until somebody gets shot, especially in the junk. That’s, that’s bad. I don’t ever want to have that happen.
But more than that, more than the sort of weirdness of things that people say to us, there’s this whole other side to Emergistan. There’s all this resignation, and there’s all this loss, all this cruelty that we see, and that troubles me, and I think it troubles you. That’s what makes it hard to understand what happens there.
It’s a hard place. There’s a lot of sorrow. You know, people often ask me, “What’s the worst thing you’ve ever seen?” because they want a story about a stabbing or an amputation or something. What I tell them is the worst thing I’ve ever seen is the face of someone when I tell them someone’s dead. That’s the worst thing. The loss is hard in Emergistan. We deal with it every day, right? How many times a year do you tell someone that some bad thing that has happened or is going to happen, that they’ve lost someone? That’s miserable.
And how many times do you wonder why people seem to choose incapacity? I don’t understand that either. That’s hard for us. And do you want to know why it’s hard for us? Because we’re high-functioning. And I’m not saying that arrogantly. Let’s face it. We’re in Las Vegas at a conference on resuscitation. You’re one of those people who gets stuff done. You’re a high performer. You’ve been a high performer your whole life. When you see someone who simply can’t get out of bed to go to McDonald’s to get a job, you have a hard time understanding that, right? It’s a disconnect between us and our fellow Emergistanis.
Some days, it seems like all that we see are patients with social drama and anxiety and depression, right? Have you ever seen so much anxiety in your life? It’s like anxiety is epidemic in Emergistan. That’s all people talk about. Everyone is on Xanax or Klonopin or Valium or Adapin, or all four, right? Now, I don’t know how you stay awake; I don’t know how you breathe. But then, since there is a lot of drama, we do work at a level one drama center.
Emergistan can be a sad place. A lot of people go there because they don’t know how to cope. There’s a famous pastor and writer named John Piper. You may have heard of him. And I heard John Piper talk one time on a podcast, and he said that he had gone to visit a girl in the hospital who was a cutter. And he said, “Why do you cut?” and she said, “Oh, well I like it when the doctors and nurses touch me.” Ouch. That hits home, doesn’t it? It reminds us of the pain that a lot of our patients endure in Emergistan. Notice what it says: “ugly, fat.” [Points to a picture of an arm carved with the words “ugly” and “fat.”] Somebody carved that on their own arm.
Of course, tattoos are sometimes attempts to cover up pain or a deep-seated loathing or a love of all things cat. Have you ever seen this guy on the TV? [Points to picture of man who has changed his face using plastic surgery and tattoos to make him look like a cat.] He really, he’s a real guy. I mean he’s actually, he’s actually had like nylon whiskers put in, and his teeth filed and sharpened, and surgery to pull out the lip. He’s actually trying to be a cat. [Whispers:] You’re not a cat. This guy’s got a problem. But we see those, right? See people who somehow their sense of self, their sense of self-worth is so skewed that they have to do things to mar their bodies and change their image. It’s a very odd and sad thing at times.
Some people come to Emergistan because it’s the only safe place in their world. We have a PA who had a great insight one time. He said, “I think that people come here, Ed, because it’s the only place where they have any control.” Right? They do, right? They can say, “I demand to see the patient advocate,” “I want a blanket,” “I have pain. I need to be admitted,” “I need some more pain medicine,” and, “I want a CT scan.” They have this ability to sort of push us because they know that we want to do the right thing, they know we’re afraid of lawsuits, they know now that we have satisfaction scores. So to some extent, some of that may be a reaction that there’s a lack of control in their lives.
You ever have the little kid that you treat, right? He’s in his mom’s arms, his mom’s clearly checked out, and the kid looks at you as you’re leaving the room and goes like this, like please, you’ve got to take me with you; these people are crazy. That’s what the kid is saying to you. You’ve got to take me away. But then, when your kitchen doubles as a meth lab, even Emergistan seems sane.
Emergistan is frightening for citizens and doctors because it seems like all the bad in the world ends up there, right? You ever feel like that? Like, you go to work, and you come home with a story of one more brain tumor, another PE, a cardiac arrest, and a burn, and you know, we store all of this stuff up inside us, and we sort of get this big bank account of suffering. I really do contend that maybe of the physicians have PTSD, but many of us just work through it, and we deal with it because nobody wants to talk about it. So we have this perception that because we saw it at work, it’s very likely to happen elsewhere. So we take it home to our kids and our wives, and when our kids and wives are on the road, we think that they’re going to have a car wreck. And, every time my kid has a headache, I think it’s a tumor. And every time my wife has a cough I think she has pneumonia. That’s what happens to us. And it’s the consequence of the work we do in the place we do it.
Emergistan. It gets inside of our heads. It’s scary. V-fib – God’s control+alt+delete.
No wonder everyone is anxious. People are anxious because the world is a scary place. I mean, yeah, they’re overanxious and they don’t cope well. I had a young lady one time who told me that she was just terrified of death, terrified of death. She just didn’t’ know what to do. She was crying. And I said, “Well, what do you watch on TV?” She said, “Well, the First 48, and CSI, and …” and all these murder shows. I said, “Well, you need to turn the television off, my dear. This is why you’re anxious.” But this is why the doctors are stressed because it’s very scary in the land we call our home, Emergistan.
Seriously, though, travel tip for you. The psychology of Emergistan. Remember that there is a border, and most of what you see in Emergistan is not true outside of Emergistan, OK. It’s there, but it’s not there in the same, distilled-down, concentrated amounts that you see it at work. We have to teach ourselves to leave it at the border, all right? All that baggage of pain and suffering and fear; it’s hard, but sometimes you have to learn to let it go and leave it behind because it isn’t reflective of reality once you leave Emergistan and go back into your lives.
Why is Emergistan hard for us to understand? Why is it hard for other people to understand? I mean, we get it, don’t we? We get it a little bit because we’ve worked there so long now. We understand a little bit about the guy who gets his head caved in who wants you to stitch it up so he can go get into the fight. I don’t agree with him, but I get it. I understand what he’s saying; he’s got an honor issue. I get it that people drink to cope with mental illness because they can’t go anywhere else. You know. Dave Chappelle once, he, one time said, “White kids have psychiatrists, and black kids have liquor stores.” Kind of Emergistan.
But our patient population is a lot of folks who were raised by people with no motivation and no coping skills, and people who had never heard a kind word until one of you said it to them. All right, maybe that’s why they come back all of the time. Maybe that’s why they ask for you. How many kids do you see who need simple things done? Sutures or x-rays, and they scream; they’re completely out of control because that’s what their parents do, right? That’s how everybody copes in their house; everybody screams. You take your kids to the hospital, and you can reason with them and talk to them because you reason and talk to them at home. Well, it’s hard to understand.
It’s also hard to understand because it’s a place where psychosis can seem completely normal and where suicide attempts are just what people do. Right? When you’re upset, you try to kill yourself or you think about killing yourself and tell someone or you get a pill bottle and shake it, and say, “I’m going to take these pills.” Or you cut, or whatever.
But it’s also a place where we ask crazy people to talk to the television, right? This is telepsychiatry. “I know you’re hearing voices, so what I want you to do is talk to the nice man on the TV.” “Really? He knows my name? That guy on the TV?” I’ve always wanted to say, “He’s from the FBI.” That’d be really bad.
It’s hard to understand because the lives of the people we see are so unlike our own. And so it’s all the more vital to remember this great saying, one of my favorites from the philosopher Philo of Alexandria. He said, “Be kind, for everyone you meet is fighting a great battle.” Isn’t that true? Everybody we see is fighting some great battle. It might even be about their work or their money or their drugs or their relationship or their kids or their sickness, but it is true. And we can couch it in these terms, I think it makes it easier to cope with the difficulty we see in the people we care for. You know I make fun, and we all make fun, but the truth is I really feel for the people we see, and I love them. And you’re allowed to make fun of the people you love, sort of, right? You have brothers and sisters? You make fun of them, but nobody else can? ‘Cause I’m from West Virginia, OK. Are you kidding me? Everybody makes fun of us. I make fun of us. But I won’t let anybody else do it.
Moving on. Emergistan is the place where good ideas go to die, right? You know that little law of intents and consequences? It’s so true. How about these? EMTALA, JCAHO, pain scales, time-outs, customer service, maintenance of certification, core measures. Core measures are killing us now, right? You’ve got to have everything done within, like, like you have to have the EKG done before the patient arrives, right? In the parking lot, in the car, or else you’ve missed something. We were going over this data at our hospital, and one of our partners said the place that he had been before, what they did was, they did the EKG, and then they started the registration process. It’s actually time-stamped before the registration is done in order to get around that. It’s pretty cheesy, but it worked. Raise your hand if any of these things have driven you crazy in the last month. I’m sure they have.
If you want to see how a policy really works, watch what it does 24/7/365 in our country, in Emergistan. And watch how the Joint Commission enforces it. A lot of ideas are great ideas to begin with, right? Like mandatory EMR. It’s going to make it so easy to chart everyone, and we’re going to connect to people, and we’re going to be able to store records and share records, and it’s going to be so much faster, and it really isn’t. It didn’t work out that way. Of course, that’s because the technology were using for the ER is a little bit behind what’s out there, right? Your cat can play an iPad game. Yeah, there’s an iPad game for cats. If EMR were that simple, then I think we’d be OK.
Billboards with wait times. I don’t like this. I don’t like to have people get tweets about the wait times in the ER because I think that suggests to me maybe it’s not an emergency room.
Restraining without restraints. We had a psychiatry issue in the hospital we brought with our risk manager because we’re trying to decide how to keep people. And they said, well, if you’re going to commit him then you have to really keep him. But you can’t really keep them because they’re not fully committed until they go. But you can’t let them go because they may kill themselves. But if they do go, you can’t hold them and restrain them because physically it might hurt them. If you do it that way, you’ve got to bring them back, even though you’re not keeping them. That’s pretty much how it went. Only in Emergistan can you have that conversation, and actually follow that conversation. So, what they’re saying is they have to stay, but if they leave then I have to let them go, and I have to try and get somebody to bring them back. OK, whatever.
So, what I’m saying is this: nobody believes us, but we do work in a weird place, and it is so different from most people’s experiences that it might as well be a foreign country. The Emergistanis may not always appreciate us, but we do very important work with fewer and fewer resources, and with lower and lower compensation. And I say compensation a lot. I’m not all about the money, and you aren’t either. I’m just saying that it’s one of the things that we have to deal with. There’s a great talk I heard that was given to senior residents, and it was about life at $250,000 dollars a year. And it basically said that by the time you take into account your costs of insurance and licensure, and your benefits and all of the things, what you make per month is not so much as it sounds. And it’s true. In medicine, people assume that large numbers equal large amounts of take-home cash, which isn’t necessarily true. And, we know this in Emergistan. That’s what they don’t understand about us.
But we do meet cool and very bizarre people. I will tell you this. You will never be at a loss at a cocktail party to tell a story, right? Your brother-in-law, the accountant, or whatever he does, and your friend, the lawyer, they got nothing. When you have a story to tell, you’ve always got the greatest story about, you know, amputations, the decapitations, and all of the other horrible things that you see like the tazings. Have you seen tazings lately? You know, I had a great tazing right in front of me in the ER a few weeks ago. It was wonderful. I mean, I can say that because this is what I do. It’s a beautiful thing because the guy clearly deserved it. No, he was fine, really, it was OK, it was nothing bad.
We have travel stories, and we learn all kinds of new words and skills and profanity and drugs and things like that. We make a difference; and this is what’s really key for you to understand. You make a difference. And I’ve said it before, you make a difference in lives of people that nobody else seems to care about. You know? If you’re homeless and dirty, you don’t walk into the doctor’s office most places. Right? If you have no money, you don’t for sure. That’s the upside to EMTALA. We do get to kind of take the high ground. And I think that’s a good thing on some level. I wish it were implemented better, and I wish it were funded, but we do get to take care of people who have no other recourse. It doesn’t matter if they’re immigrants or locals or whatever, we get to provide for them, and that’s a great thing. And also you get to take care of people that other doctors are frightened to see, right?
Listen, you can’t walk drunk and screaming into most places. If you walk drunk and screaming into Walmart, they’ll escort you out and the police will take you home. If you walk into the judge’s chambers in a county court house, and you cuss and you punch the guard, you will go straight to jail. And they will taze you to some principle. That’s how that works. And then after they’ve tazed you and taken you to jail, they’ll take you to Emergistan because you’ve had chest pain or you were too drunk, right? Because like the ancients used to say, “All roads lead to Rome,” right? All roads lead to where? Emergistan. Right! You can’t arrested without going to Emergistan, right? You can’t get committed without going to Emergistan. In our place, it’s hard to get direct-admitted. So if the patient has pneumonia, the doctor’s going to have to x-ray them and they’re hypoxic, and says, “Well, I’m not sure I can trust him. Just have the emergency room check him out first.” Check him out for what? Right? OK. Well, it’s fine. Ha, it’s Emergistan.
This is the guy [points to picture] that we see him all the time. You know what the great thing about this guy is? We’ve all seen this guy a lot. This guy will scream at you and threaten you, and then the next, after he’s slept it off a few hours later, nine times out of 10 he’ll say, “Hey, I am really sorry about the way I acted last night. I didn’t mean to be like that. I was just drunk. I was just mad. I’m sorry. Did I hurt anybody?” You know? Well, yeah, that’s the handcuffs, you’ll notice. By the way, if you want to make that transition happen faster, you know what to give him? To make the drunk nice? What makes drunk people nice? Food. But what drug? Droperidol. Yeah, it actually for some reason is just a mood stabilizer. I don’t know how it works, but they’ll go from calling you names to, “Pardon me, doctor. May I have a cup of water?”
Here’s the other thing. We save lives. We rescue children from abuse. We restore families. And as frustrating as it is, that is absolutely huge, right? I used to joke that we’re the mechanics of the human machine, and that’s sort of true. We do sort of fix people so that they can go back to the other things that they’re supposed to be doing. You know, people think of medicine as this highest, most important thing in the world. Medicine’s just about making sure everyone else can do the important things. We’re here to sort of get people back into the game. All right. We mustn’t think too highly of ourselves because our job is to restore people to mundane things like roofing and carpentry and mechanic work and doing teaching and all of the other things that they do. But it’s huge because we save them, we restore them.
It could be done better. It could be done with less frustration and less hassle. That’s great. I mean, I’d love to see that. That’s why I write what I write. You know, just to sort of be a gadfly, to say, “Why can’t we do this better?” And that’s what we should all be doing. We should all be saying, “Why can’t we do it better?” That doesn’t mean that it’s not an important place, that doesn’t mean that we don’t love going to Emergistan. It doesn’t mean it doesn’t matter. It doesn’t mean that we hate it. It just means that from the inside, from where we work, we see ways that it can be done better. I think that’s legitimate.
These are my kids [shows picture]: Sam, Seth, and Elijah, and Alyssa. Who may be watching right now – hey, kids, with their mother, hello, dear. I show this slide because a few years ago, my wife had been suffering from a protracted illness, and woke up in the middle of the night, and wasn’t feeling well, stood up and passed out, and was short of breath. So, that morning we took her to the hospital, and you know what she had? She had a huge saddle embolus. It was hypoxic and was tachycardic at about 140 and hypotensive and terribly ill. And my partner, who is a very good doc, Dr. David Heap, David diagnosed it, and we decided based on our location, not a big referral center, that the best thing to do was to give her peripheral tPA. And it was a scientific experiment. Her oxygen level rose steadily over 10 minutes. Her blood pressure got up, her heart rate went down, and she was completely fine. All right. So they got to keep their mom because somebody did a really good job, and that’s what you do. OK, I got to keep my wife because somebody did a great job. That’s where Emergistan matters. That’s why when you go off to Emergistan, no matter how crazy it is, it’s worth it.
So, my point is this, intrepid travelers and fellow Emergistanis: every day that you walk into that crazy emergency department, and somebody assails you with another stupid complaint, every day that you have to argue once again about Lortabs and Percocet, or why you can’t be allergic to 5s and not 10s, and every day that you say, no, I won’t give you a refill, every day that you have to tell someone bad news, every day that you have to wrestle an intoxicated person to put them on a backboard, every day that you have to fight with an administrator to do the right thing, every day that you really, really want to put your fist through the computer because the EMR is just about to drive you crazy, every day you come back to that, every day it feels like you’re holding up the world of medicine by yourself because all things seem to land in the ER, as all the other physicians stop taking calls, every day you feel like Atlas, every day you do the right thing for people who no one else will help. You are really missionaries to Emergistan.
That’s really something to be proud of. Really something to be proud of. Because, man, it is a freak show out there. You cannot make this stuff up. [Points to fetal skeleton tattooed on young woman’s abdomen.] And that is one awesome tattoo. You know. I’m not a huge fan of tattoos, but I’ve got to say, that one is cool.
This message today was brought to you by the Emergistani ministries of travel, tourism, disability, drug control, and mental health, where our motto is, “Can I get a sandwich and a work note?” Anyone here who is interested in cabinet positions in Emergistan should see me later as I am willing to accept bribes because my son starts college this fall. After all, “Ich bin ein Emergistani.” If you would like to have a pin with the Emergistani flag on it, I have some, and I have some that say, “Level one drama center” up front. So you can talk to me later. All I’m asking is a paltry dollar to help send my son to college. Come on.
So ladies and gentlemen, thank you for having me. And thank you for taking time out of this beautiful day, you know, you could be gambling right now and watching shows, and you came to hear me. I’m honored, so thank you, and have a great day. Keep up with your great work in Emergistan.
Monday, August 26, 2013
Any new therapy needs to be judged by multiple factors — efficacy, side effects, expense, ease of use, and reversibility. Most of us would not consider giving a new therapy to our patients if it is not as effective as the old therapy, and we also want know if the new therapy is safe, or at least no more dangerous than what we’re already using.
Then we want to know the relative cost because new therapies aren’t cheap. Bringing a drug to market costs a lot of money, which is passed along to those buying the medication: patients, insurance companies, and the government.
The question before us now is, does rivaroxaban for treatment of deep venous thrombosis (DVT) warrant changing our current treatment with vitamin K antagonists (VKAs)?
The main study looking at rivaroxaban treatment for DVT was by the EINSTEIN group. (N Engl J Med 2010;363:2499.) About 3,500 patients with acute symptomatic DVT were split into two groups. Group one received standard therapy with low molecular weight heparin (LMWH) and an oral vitamin K antagonist. Group two was given rivaroxaban 15 mg bid for three weeks and then 20 mg per day for the duration of therapy, either three, six, or 12 months. This trial was supported by Bayer-Schering Pharma and Ortho-McNeil, which invariably casts a shadow of doubt on the data, but it did have good representation of the different causes of DVT, including unprovoked surgery, trauma, immobilization, estrogen, cancer, and previous venous thromboembolism (VTE).
The primary efficacy outcome was recurrent venous thromboembolism. Both groups were statistically the same: 2.1 percent for rivaroxaban and 3.0 percent for standard therapy. A combined safety outcome of major bleeding and clinically relevant non-major bleeding was the same for both groups at 8.1 percent. Major bleed rates were around one percent for both groups, which was the same major bleed rate for a follow-up study looking at rivaroxaban for PE.
But what is a "major" bleed? It was defined in these trials as clinically overt bleeding with at least a 2g/dL hemoglobin drop; bleeding that led to at least a two-unit blood transfusion; intracranial or retroperitoneal or critical site bleed; or bleeding that contributed to death.
The INR was therapeutic about 50-60 percent of the time in the EINSTEIN study of rivaroxaban for VTE, as well as in a follow-up study on PE. Would rivaroxaban have looked so good if the INR were therapeutic 100 percent of the time? We’ll probably never know. A 2011 Swedish study found the INR in therapeutic range 76 percent of the time in 18,000 patients on VKAs. How would rivaroxaban have fared against this cohort? Or would they have had higher bleeding rates if more of the EINSTEIN trial VKA group had therapeutic INRs?
Rivaroxaban starts with a loading dose of 15 mg twice daily for three weeks followed by 20 mg once daily. Starting with twice-daily dosing gives better thrombus regression than starting once daily.
We have another Xa antagonist anticoagulant that we’ve been using for a long time, low molecular weight heparin. LMWH is dosed by weight, yet rivaroxaban is not. Rivaroxaban is mostly protein-bound, giving it a low volume of distribution. This means that most of the drug moves about in the vascular bed, not body tissue. Light (<50kg), average (70-80 kg), and heavy (120 kg) subjects were given rivaroxaban in a pharmacokinetics study of 48 patients with a mix of men and women. Anticoagulant effect was similar between genders. A little more anticoagulant effect was seen in the light group and a little less in the heavy group but not enough to justify dose adjustment.
Should warfarin be voted out of office? Why would we vote the incumbent out of office if the new therapy is similar to the old one on recurrent VTE and bleeding? How would you campaign against each candidate if this were politics? Unfortunately for warfarin, it has a long track record, and we can bring out its dirty laundry.
Warfarin is simultaneously a great drug and a horrible drug. It’s great because it thins the blood, and it’s horrible because it makes patients bleed. And it has variable and erratic metabolism, needs frequent monitoring, and requires patients to have dietary restrictions. The INR was therapeutic (2.0-3.0) just more than half the time and low about a quarter of the time in the 2010 EINSTEIN study. This was in a clinical trial where you would expect tight control. Warfarin is a fussy drug, and your patients will need to give themselves LMWH shots until the goal INR is reached. Self-administration or clinic administration of LMWH can be a barrier to treatment. It’s expensive, and it can get really expensive if treatment becomes prolonged.
The new drug, rivaroxaban, is no worse than the old drug in efficacy and bleeding. Is it better? It’s orally dosed, and no bridging LMWH shots are needed. It has more reliable metabolism, less drug interaction, no dietary restrictions, and no monitoring. But like any new drug, a lot of dollar signs are attached. Then there’s the problem of reversibility, which is the Achilles heel of the new anticoagulants.
The cost of LMWH and warfarin for three months is about $1,060 at my local pharmacy. LMWH is $70 a dose; five days at two doses a day is $700. Warfarin for 95 days is about $10. INR testing is $44 dollars per test. The total number of tests is going to vary, but I’ll estimate eight total tests. That’s one every other week once the INR is therapeutic and some extra tests in the beginning before it is therapeutic. Say it will cost $350 for all the INR testing in a three-month period.
That’s only the money, not the other challenges that come with warfarin: restrictive diet, frequent testing, variable metabolism. It’s no secret that warfarin is metabolized differently by different people and even in the same person depending on the circumstances.
Rivaroxaban for three months costs about $1,209. The first three weeks, or 21 days, at 15 mg bid is $450. Then 69 days of 20 mg per day at $11 a pill is $759.
The biggest concern with rivaroxaban is that its anticoagulation effects may trigger life-threatening bleeding that we cannot easily reverse. But is it really non-reversible?
What do we know about rivaroxaban reversal? A few studies give some idea on reversal, but there’s not a mountain of evidence where we can say, “Yes, we’ve got this covered.”
The rivaroxaban pharmacology basics you need to know: its half-life is five to nine hours, it cannot be dialyzed, and it is 95% protein-bound.
Most clinicians want to know if any product can reverse rivaroxaban’s anticoagulant effect. What about prothrombin complex concentrate (PCC)? The answer is, unfortunately, kind of. Possibly. Maybe.
The study most quoted about reversal of rivaroxaban looked at 12 healthy men given rivaroxaban for three days. (Circulation 2011;124:1573; study supported by Sanquin.) Rivaroxaban prolonged the prothrombin time (PT) and the endogenous thrombin potential. Patients were then given Cofact, a four-factor PCC. As an aside, four-factor PCC was just FDA-approved in the United States, but is not widely available. Back to the study: healthy male subjects, cash in their pockets (you didn’t think they’d do this for free, did you?), and they’ve been taking rivaroxaban for three days: blood is thin, clotting tests are abnormal, and in goes the PCC. What happened?
PCC immediately normalized the PT. The control reversal agent was saline which, not surprisingly, did not correct the PT. We know that when PCC works for warfarin, it works right away. It did just that in healthy subjects taking rivaroxaban: the PT was normal right away. The endogenous thrombin potential was also normalized by PCC but not by saline. Lab tests corrected. So far, so good. But what about actual bleeding? There are no human studies on this, but there are some animal data.
One study showed that rabbits given rivaroxaban and then PCC had improved lab tests, but their ears bled just as long. (Anesthesiology 2012;116:94; the authors of this study disclosed links to one or more of these companies: Bayer HealthCare, BMS, LFB, Octapharma, Pfizer, Boehringer-Ingelheim, Leo Pharma, Sanofi-Aventis, GSK, NovoNordisk, and CSL Behring.) There was possibly underdosing of PCC in this trial but no difference between the two groups.
Another study looked at mesenteric bleeding in rats given rivaroxaban followed by PCC. (J Thromb Haemost [poster] 2009;7[Suppl 2]:379; study done by Bayer Schering Pharma.) PCC at a dose of 50 units/kg almost completely normalized bleeding time while 25 units per kilogram did not. Going back to the healthy human volunteer study, 50 units/kg of PCC was the effective dose used. PCC had no effect at 25 units/kg.
So, some animal data say PCC has little effect on bleeding, and other evidence says PCC reverses bleeding. But a rat’s gut is not a human’s brain. Can we infer that the correction of bleeding in this surrogate model applies to the catastrophic brain bleed you are seeing in your resuscitation bay? Maybe, but it’s still unknown. The evidence is better for rivaroxaban than for dabigitran. Healthy subjects in this study given rivaroxaban were also given dabigatran at another time, and PCC had no effect on the clotting tests. Some animal evidence suggests that PCC may help with dabigatran-associated bleeding.
What about our old friend FEIBA, factor eight inhibitor bypassing activity? Not everyone has PCC, but many EDs have FEIBA. Some lab data in baboons and rats given rivaroxaban show that FEIBA reduced prothrombin time and bleeding time.
Recombinant and plasma derived factor Xa antidotes on the horizon, but they are still in testing. We’ll let you know more when and if they are ready for prime time.
Rivaroxaban v. VKAs
Consider these factors to help you decide whether to use rivaroxaban or VKAs in your patients with newly diagnosed DVT. The cost for three months is about the same. Efficacy is about the same. Complications are about the same. Eight percent bleed rate and one percent serious bleed rate.
Rivaroxaban is much easier to use and VKAs have the advantage for reversibility, but it’s still a question mark. Some evidence suggests that rivaroxaban is reversible by PCC, but that research is in its infancy. PCC reverses VKA INR elevation almost immediately, but may not control the bleeding.
I can’t tell you which agent to use because there is still no right answer. I prescribe rivaroxaban and VKAs using a decision tree that involves a conversation among the patient, the primary care provider, and me. I try to make it simple for my patients by breaking it down into these factors.
Dr. Orman is an emergency physician at Valley View Hospital in Glenwood Springs, CO. He produces the ERCAST podcast (www.ercast.org), and is a regular contributor to EM:RAP. He disclosed no conflicts of interest.
Thursday, August 01, 2013
This is a continuation of Dr. Walker’s Emergentology column appearing in the August issue. Read Part 1 here.
Jarone Lee, MD, is an emergency physician status-post surgical ICU fellowship at Massachusetts General who now splits his time between managing Harvard’s SICUs and staffing a community ED. Continuing my critical care series, I asked him about his career path and thoughts on emergency medicine and critical care.
Your ICU has implemented a new policy, rapidly accepting patients regardless of whether they are resuscitated or have good IV access. How does it work? Why was it implemented? How is it working?
We started a new policy here that all critically ill trauma patients who come into the ED and do not need the OR within an hour should go directly up to the ICU. They will essentially go from the ED trauma bay to the CT scanner to the SICU. We just started it in April, and as with anything that is new, it has some snags; however, I think they are minor. The major issue is that the SICU has to adapt to getting the undifferentiated patient that might not have had all his x-rays and studies.
It is a learning curve, with many folks complaining, but I think it is going to work out well in the long term. We decided to start this because we found that many of the ICU patients are boarding in the ED for hours, and unfortunately, because the ED doesn’t have the resources we have, they are not able get the full complement of what we would do in the ICU. We are studying this now, and I believe that we will see a clinically important difference in the era post-implementation of the policy.
You now do a little of both, working as an intensivist in the surgical ICUs and still seeing patients in the community ED. Do you find that your critical care training is helpful in the ED and your ED training is helpful in the SICU?
My critical care training helps my EM work and vice versa. The critical care folks and fellows here love my comfort with ultrasound as well as my understanding of how patients present. Interestingly, I've had to use a good amount of my urgent care skills in the ICU. For example, I look for corneal abrasions, suture lacerations, do bedside I+Ds. Previously, many of the intensivists would consult ophthalmology, surgery, etc., for these minor procedures.
On the other hand, at my community emergency medicine position, we are the referral hospital for a network of 11 hospitals, and we end up boarding ICU patients regularly because ICU beds are in short supply. Beyond the boarded ICU patients, I feel like I have a better handle on antibiotic choice/dosage for the MDR infections we see from nursing homes. For example, we (not just EM but all of medicine) underdose vancomycin for our sicker patients with presumed MRSA.
Were there things that you think were tougher, doing surgical over medical critical care?
I think one of the most difficult parts of doing a surgical fellowship is that I had to learn all of the different surgical procedures. This is especially true of our vascular patients with all their major vessels bypassed. I recently took care of a patient who had a bunch of bypass grafts that had to be revised and who had a STEMI immediately post-operative. Because of his rewired arteries, there were very few places for the cardiologists to catheterize the patient. They ended up having to sacrifice our only arterial line in the wrist. And if they got into trouble, we had to plan for an LVAD because his arterial wiring wouldn’t permit an intra-aortic balloon pump.
Anything you're now more patient or understanding of, from both sides of the table? We're frequently frustrated in the ED with the ICU taking so long to see a patient or accept a transfer, and I know in the ICU frequently they're frustrated with patients who aren't as adequately resuscitated or packaged up from the ED.
Yes and no. I think the ICUs should take patients. The ICU has the staffing and resources to stabilize a patient, but I've found a bit of resistance with this mentality because the ICU folks are used to the fully worked-up patient. I personally believe that not all procedures, CTs, MRIs must be done in the ED.
If they are stable enough to transfer safely, then they should go to the ICU where we have the people, equipment, and resources available to further work up the patient. However, I also see the need to triage to the ICU correctly. Critical care beds are very expensive, and as the United States looks to cost-savings, we probably shouldn't put a patient in the ICU if he could go to a telemetry or step-down floor.
Anything you'd recommend to residents who want to go into critical care?
I was lucky that I went into critical care when there was less interest. Be sure to get involved early in the ICU, either in admin or research projects. This will also help you decide if it is for you and to start building your critical care CV.
Dr. Walker is an emergency physician at Kaiser San Francisco. He is the developer and co-creator of MDCalc, a medical calculator for clinical scores, equations, and risk stratifications, and The NNT, a number-needed-to-treat tool to communicate benefit and harm.