but not in Soviet Russia

Outside emergency department, you go down tubes. Inside emergency department, tubes go down you!

Reform, rationing, swine flu, and futile intensive care

Nobody knows how bad Pandemic H1N1 2009 will be when it returns to the northern hemisphere at the end of the year, but it's reasonable to prepare for the worst, especially when the experience in the southern hemisphere has been somewhat difficult:

http://www.telegraph.co.uk/health/healthnews/5887477/Swine-flu-intensive-care-beds-will-be-swamped-experts-warn.html
http://www.dailytelegraph.com.au/news/nsw-act/westmead-hospital-caring-for-25pc-of-swine-flu-patients/story-e6freuzi-1225752418671

(I am not endorsing either the Torygraph or the Daily Terror with these links)

See http://www3.interscience.wiley.com/journal/122520541/abstract for the actual article.

The United States has one of the highest number of intensive care beds per capita in the industrialised world. This may be partly definitional: most intensive care units elsewhere are 1:1, with 1:2 units being described as "high dependency", and partly due to the proliferation of subspecialised ICUs. Current bed usage is about 65%, so there is room for a 50% rise in the number of ICU beds needed without going into bed debt, although of course not all those beds are ventilator beds, and ventilators seem to be what is needed right now.

However, there is the possibility that there will not be enough ICU beds for everyone. Daniel Sokol addresses this here.

In a country with a large amount of government control and payment of healthcare, like the UK or even Australia, the decisions are hard enough to make. When money comes into the equation, it may become even harder.

If a hospital is running out of ICU beds, should it be forced to give charity care through EMTALA for the people presenting with novel H1N1 pneumonia requiring ventilation?

Will a well-insured futile-care ICU patient take priority over a young and previously healthy uninsured H1N1 pneumonia patient?

Will hospitals be able to stay afloat if, instead of filling a cardiothoracic ICU with well-insured and high-paying CABG and MVR patients, it is filled with uninsured and never-planning-to-pay H1N1 pneumonias, each consuming a course of Xigris as per the SSC guidelines, and then staying on the vents forever?

How many patients will be bankrupted by a stay in the ICU, a course of Xigris, whatever fancy new antibiotic they decide to administer, etc?

Even ignoring money/insurance issues, is H1N1 going to be the tipping point, where hospitals decide that they will not take futile care patients into the ICU anymore?

I wonder if these relatives, gung-ho to go full-code, will regret the decision -- or even put down granny -- when they need a vent and cannot get one.

Carrots and sticks

A young man presents to casualties with asthma that seems reasonably severe, with poor oxygenation despite 15mg of nebulised albuterol. He is still tight and has fairly horrible PFTs (FEV1/FVC of 44% post-albuterol) so I commence him on an albuterol infusion.

Several hours later when I discuss the need for admission, he declines and I convince him to at least allow us to wean the infusion before he walks out. He signs out AMA eventually after the infusion is weaned. He then comes to me and requests an albuterol puffer.

I mention that it is available OTC; he states that he cannot afford it. I offer to write a prescription (which reduces the cost from $11 to $5). He states that he still cannot afford it. I decline to provide him with hospital-stock albuterol. He threatens to make a complaint.

I am of the opinion that at the point at which he signs out AMA, he is no longer my patient and my duty of care is discharged. I have told him why I think he needs to remain in hospital and he accepts the risks of leaving. He makes his choices and he lives with them.

Should I have given in? or is this acceptable use of a carrot?

A crisis in confidence.

Most of the time, I'm awesome.  I diagnose, I treat, I bristle with self-assurance and my colleagues come to me for assistance.  I exude it enough that about a month into internship, my senior thought I was a year more advanced than I was, and it pays off;  I get to do procedures that my colleagues of the same level don't get to do because they're not pushy or confident enough.

Sometimes, though, I'm reminded, by myself, of how junior I actually am.   The thing that being a gunner (and I have to admit, I was a gunner to some extent) is that it doesn't prepare you for the real thing, for life at the coalface.  You know how to treat textbook presentations and complications, and you learn how to perform procedures competently by the textbook, but life's not textbook, especially not life at a hospital system that owes its suppliers 40 million dollars.

The patient (unimportant details changed for privacy) was a NESB pleasantly demented elderly person who'd fallen, hit their head, and sustained a blunt laceration to the head.  After doing the falls workup and admitting the patient to the geriatrics service, the end of my shift was coming and the lac, which was nonurgent, should be sewn up before the pt goes to the ward (don't trust geriatrics residents to do any procedures at all).

I infiltrate the would with some 2% lidocaine with adrenaline after being told that bupivicaine (my first choice) is overkill.  The would is explored and after finding that it goes down to bone with no fracture evident, I give a gram of cefazolin and wait for adequate tissue levels since I don't want to be suturing up the galea with a cutting needle and making little microfractures that can become osteomyelitic, not in a 90yo with DM, 3V CAGS and CCF anyhow.

Resus call, resuscitate resuscitate resuscitate.  Stable patient, goes to another doc.

I look for sutures.  My personal preference is for 3/0 vicryl deep, and 3/0 blue nylon at the surface.  There's 3/0 blue polypropene which is an acceptable compromise, but the only absorbable suture on the shelf is 5/0 PDS.  I spent twenty minutes searching the storeroom because the nurses are short-staffed and can't/won't help me (understandably, since they think I'm just being pedantic).

I splash some more betadine down and put down a fenestrated drape.  The patient's child -- a dentist -- moves the drape by grabbing the top surface with their hands.  The area near the fenestration's still good, so I ask for another fenestrated drape to put on top in an X pattern to have a smaller field.  The would edges are freshened into a nice lenticular pattern, they don't come together so I undermine the layer between the galea and the periosteum a little and it comes together with minimal tension.

Obviously too much tension for the 5/0.  or maybe I'm just blaming the suture for me being a clutz, but I've been awake for 17 hours at this point and I get a needlestick.

Unscrub, wash wash wash wash wash.

It's now an hour past home time.

Ask the charge sister to call theatres and get me some 3/0 vicryl.  While this is happening, see the young woman with chest pain sent in for ?PE.

Vicryl arrives.  I look at it and there's no description of the needle, but in my mind-addled state I assume that I'm looking in the wrong spot.  I don't really care anymore.

Scrub in again, irrigate some more, open the vicryl.  IT'S A VICRYL TIE.  What do they think we're doing, vascular surgery?

I unscrub, find some plain gut (a suture I have NEVER used before - I like my synthetics).  Try to work out if it's acceptable.  Decide it's not.  Try and find a reference that supports using nonabsorbables deep (I remember seeing one as a student).  Pt's child complains about how the pt is old and having back pain from the positioning required for the procedure.  On how the procedure is taking so long, and that the lignocaine has worn off (it hasn't).  On how the patient has an open wound on the head.  Never mind that the pt refused to be positioned prone (the ideal position for an occiput laceration) in the first place and I'm only doing this in the left lateral position because of that.  Never mind that I'm now two hours past the end of my shift, we're down a doctor and a nurse, the waiting room is full, and if you want me to actually apply the working hour limits and sign out to the night guy, your parent will not be sutured for another 5 hours.  Never mind that I have myself to look after here.

Anyhow, enough whining.  The crisis in confidence is that I don't know how to make do.  I don't know what's acceptable, what's not, and how to make the best of the crappy resources we're given;  when fighting for the patient to have what's proven by evidence, or at least taught in the textbooks, is more important than keeping the nursing hierarchy onside.

I used to give Hartmann's solution (lactated Ringer's) routinely to all my patients, and the nurses complained.  They like to use gelofusine (a gelatin colloid) for patients, and I don't like to do that.  I now back down, in the absence of clear harm.

It's easy to know what to do when you've been taught it.  It's hard when you just have to fumble through.  Maybe I should have done that elective in South Africa after all.

On actually blogging.

I never published any of the posts in my old blog, but it serves as a snapshot of that terrifying time that is the start of internship.  The name has changed because I'm no longer that cocksure ortho wannabe, and indeed, as the time comes to apply for jobs for next year, I don't know what to apply for.