The handle bar of the snowmobile fractured his ribs.
Nice guy. Mid-60s. Talkative and generous in his remarks.

It occurred yesterday. He thought it would heal by itself.
Didn't want to bother us. But now he was a little breathless.

His lung was punctured. His skin was full of air. It crackled and popped as I rubbed the betadine on his chest in preparation for the procedure.

I numbed his skin and ribs.
I pushed the 6-inch metal trocar into his chest.

He started to die.

"I don't feel so good," he said.
His heart beat began to slur. Slower and slower.
His skin drenched in sweat in an instant.
Flat line.

What have I done?
Did I puncture his heart?

He was lifeless.

I sucked the air out of his chest.
We gave him atropine.
We pushed fluids.

And he began to talk. He was embarassed.
He apologized for passing out.

We started to breath again.

----

My wife lies on the bed.

My unborn daughter is breech.
She is pointing the wrong way.
The obstetricians. Our friends. Will try to turn her.

We watch her tiny heart with ultrasound.
They apply slow, firm pressure.
Slow pressure to my wife's uterus.
To my daughter's body.

"I don't feel so good," my wife said.
The tiny heart began to slur.
The instant of the moment became eternity.

She began to die.

What have we done?

We paused.
Fluids. Oxygen.
My wife lay on her side.

The tiny heart began to beat again.

---

We carry with us an index of moments.
Visceral moments. Pauses in time.

We wonder.

What have we done?

I used to drink a lot of soft drinks. It started out innocently.

A Diet Pepsi here. Coca-Cola there. One at the beginning of the shift to get going. After some time, I was up to 2 or 3 per shift.

Then I moved up to the hard stuff. Diet Pepsi Max. Red Bull. I never quite made it to Monster Energy Drink or Cocaine (33 mg of caffeine per ounce) like some of the night shift zombies. However, I started to ask myself the CAGE questions and realized I had a problem. So I stopped.

I've moved on to a more mellow and elegant drink. Tea. Specifically green tea. In fact, I'm kind of a tea geek. I can talk infusion, oxidation and fermentation with the least knowledgeable tea connoisseurs.

In ditching the high caffeine crutch of soft drinks and coffee I've found that I paradoxically have more energy and think more clearly. I feel more rested.

In the fog of my theanine-induced grandeur, I have a request. 

I leave the teapot at work.
Don't use it as a neti pot.
It's not there to flush nasal passages with saline.

It's there to steep tea.

One of our scribes wore a pedometer.
She walked over 6 miles each shift.

Six miles of chasing the doctor.
Six miles of chasing the chart, the order, the nurse, the patient.

We focus on process improvement.
Reduce the number of steps.

It doesn't make sense to have the same physician take care of patients in beds 1 and 43.

You can't see bed 43 from bed 1.
There is a different nurse.
A different tech.
A different secretary.
It's a long walk. Many steps.

It's like having a barista work the same shift at 2 different Starbucks. Just across the street from each other.

"Did you hear that order for the half double decaffeinated half-caf, with a twist of lemon?"
Nope.

"Did you know they couldn't get a line or draw bloods on that patient in 43?"
Nope.

They tried to call you, but you were doing a procedure in 1. Then they did a procedure in 42. Now it's an hour later. Nothing's done.

You can't see through walls. You can't answer every phone call. You can't eyeball the treatment result of the patient in room 1 from room 43. You can't.

One of our physicians said, "I like the walk from 1 to 43. That's how I get my exercise." That's an exercise in futility.

We aim to have the nurse, the tech, the physician, the chart and the patient walk the fewest steps for each patient visit. We want each care team to control one space.

See more patients. In less time. With fewer steps.

How many Starbucks do your baristas cover in one shift?

I recently wrote about Concierge Emergency Departments. There are challenges to such a model.

Scalpel, who blogged about free-standing EDs in Texas last year, commented:

"The concept won't work unless Medicare and Medicaid are excluded because you can't balance bill."

Can we separate care from amenities? We can't balance bill on care, but can we charge for amenities? Patients visiting the ED can purchase food from the cafeteria. They can also purchase bottled water from a vending machine in our lobby. I don't believe this violates any CMS billing standards. Even though, some patients have coins for the vending machine and others do not. Do regulations prohibit charging for a private fancy chair versus a standard waiting room chair?

Those waiting in a non-private area need to receive the same level of care. Comfort scores and pain scores could be difficult to separate. How would we audit and defend the differences?

Peter from Medical Pistache commented:

"An individual may need to visit the ER once every 5 years perhaps. Few would be willing to pay a yearly subscription for services unlikely to be needed every year."

A subscription model is one model. Segmentation of services by price and per visit would provide more service options. You can get first class, business, or coach seats on a flight. Different prices and levels of service, yet all include a chair in the sky that transports you from point A to point B.

Emergency departments generate 119.2 million visits per year. That is 227 visits per minute. An extra $1 here, or $10, or $100 there could add up to significant revenue for hospitals. Service profit could be applied to help pay for the care of all patients.

Thanks to KevinMD and GruntDoc (two of my daily reads) for their referrals.

I never thought I could be a doctor. I used to faint at the sight of anything medical.

I was 13 years old. Our class was attending a birds and the bees talk. I sat with 50 other kids on the steps of a mini-amphitheater. The teacher pointed to the large plastic uterus. Tunnel-vision, weak all over... My teenage survival instincts told me to pretend to sleep on the steps. The other pre-syncopal teens with heads bowed evidently had a similar inner voice.

As an orderly in a local hospital I watched a well-intentioned nurse insert a urinary catheter. The world became a tunnel, I soaked with sweat and the chair on wheels ran away as I grappled to sit. Suddenly I was the focus of attention. Where was I?

We dissected a placenta in medical school. I hobbled in my black-out fog to the more private bathroom.

As a resident emergency physician I was peeling fruit and accidentally created a 3 mm cut in the web space of my left hand. I gently explored my dinky incision. I awoke on the kitchen floor. Then I ate the apple.

I no longer pass out at the site of anatomy, pathology and procedure. Some switch turned on (or off). Medicine moved from the emotional "passing out" section of my brain…to the logical, analytic "red blood cells have no nuclei and mitochondria is inherited from the mother" part of my brain. I forget that these things used to be gross. I have extended periods of consciousness.

Is it possible for there to be a bed for every emergency department patient? Quiet individual rooms. Entertainment kiosks. Private bathrooms. Couches for family and guests. There is demand for this level of service.

The number of patients presenting to emergency departments outnumber the beds available. Nationally, ED visits went up 32% from 1996 to 2006. ED visits in my hospital have gone up 35% since 2001. We can't build 35% bigger EDs. We can't squeeze in 35% more ED beds. We don't have the funds.

We improve processes. We see more patients in less space, in less time, with less people, and they are often satisfied.

Many patients go to the ED and never see an ED bed. They see the physician and nurse in an intake area. Blood is drawn, x-rays are ordered, and medications are given. They sit in results waiting areas for their tests and treatment to be complete. They are discharged home. Only the sickest patients get a bed.

Some patients want more service. Some would be willing to pay for that service. Others see that service as a waste of their money.

This might occur safely if we ensure that:

• The sickest patients get a bed.
• Care is not delayed for anyone.
• Although extra service may be purchased, care is equal.

For a fee, families or individuals could become members of the Concierge Emergency Department. They might want:

• A private room.
• Couches and chairs for family.
• Wireless or wired internet connections.
• Flat screen television with movies and video games.
• Food and drinks.
• The hospital's nursing and ancillary service stars.
• Member events and dinners where they get to meet the board, executives and physicians.
• Answers to outpatient questions and appointments with hospital-based preferred physicians.

Many of the tactics used by concierge primary care physicians, hotels, and frequent flier clubs may be adopted by hospitals and hospital based physicians. The fee could be paid annually or at a higher level at the time of service. A source of cash flow for hospitals.

Is it possible to separate service level from quality of care?

My 3 yo daughter tripped in the kitchen.
A quick recovery.
A stumble. Not a fall.
She shouts, "Dad, you made me trip!"

I was in the other room.

Similar statements occur at work. From adults.
From patients. From healthcare workers.
Amplifying as we get busy.

We hold admitted patients in the emergency department. All of our beds are full. The ambulances keep arriving. Paramedics with gurneys full of sick patients form a line that extends down the hall. The waiting room is packed with patients waiting to be seen. Every bed in the hospital is full. The patients are ill. The staff is fatigued.

Enter the language of the victim. The blame.

Why are they doing this to me?
Why can't I do this?
Why don't they do this?
That's what's wrong with this job, with this department, with this individual.

Reimbursement is decreasing. Costs are rising. The economy is contracting at the level of the world, country, state, county and individual. Hospitals are starved for cash flow.  This portends intensification of the above scenario.

More sick patients. Less physical resources. Less payment.

Now is the time to rise above.

How can I add value?
How can we make this work?
What am I grateful for?

It is not the time to blame others.
It is not the time to eat our own.

Look at your values.
What is your mission?
Be great.

Joint reductions are one of my favorite emergency department procedures.

The pathology is obvious to both the patient and the physician.
The treatment is clear. Put the bone back in joint.
The success of the procedure is evident. The joint is back in normal alignment.

Some joint reductions are easier than others.
Fingers are very easy.
Shoulders are not difficult, not easy, but almost always successful.
Hips can be challenging. Sometimes they refuse to get reacquainted with their joint.

Hip reductions are one of those procedures that can injure the physician. One method involves standing on the gurney and yanking the leg. This can result in a tweaked back, a pulled groin muscle, and the occasional somersault off the gurney. Not elegant.

My favorite method is less gorilla, more investment banker circa 2008. You know, leveraged. You can pull with all your might or you can think like a 3000 BC Egyptian building a pyramid.

The technique I use is called the Captain Morgan.

Use brevital (not rum) or another concoction to get the perfect level of sedation.

Adopt the stance of the pirate and use your knee as the fulcrum to lever the hip back into place.

It doesn't work 100% of the time. But nothing does. There are 300 lb athletes where the hip pops in, and there are 90 y old ladies where no procedure short of paralysis and intubation will work.

Greg Hendey, one of my mentors, gives an excellent talk on orthopedic reductions. Here is a direct link to the pdf of his lecture at the American College of Emergency Physician's Scientific Assembly. The line drawing is from that handout.

Medicare pays physicians based on Relative Value Units (RVUs). RVUs are set based on the recommendation of the American Medical Association's RVS Update Committee.

This picture represents the makeup of the specialty societies that sit on that committee.


Not many votes for Primary Care.

It is not uncommon in medicine to be told that you cannot do something because it goes against policy.

"CMS has a policy against that."
"OSHA says we can't do that there."
"DHS says that we have to have this ratio."

These statements are very powerful. They are discussion stoppers. They can be process improvement barriers.

I've found that the best defense to these statements is to ask in an inquisitive and polite manner:

"Can you show me that policy?"

Sometimes they can.

Why are you waiting?
It might be due to variability.

Assume your physician's walk-in clinic can see 10 patients each hour.

The clinic in this case is the server. It's service rate is 10 patients/hour. You, the patient, are the customer.

What affect does the arrival rate of other patients have on whether you are seen in a timely manner?

During the hour you arrive, 11 other patients also arrive to be seen. Will there be waiting at the end of that hour?


Yes. There will be waiting.
The clinic can only see 10 patients in an hour, not 12.

How about a different scenario? What happens if 7 other patients arrive during the hour you get to the clinic?

That's a total of 8 patients in one hour. Again, the clinic service rate is 10 patients per hour. Will there be waiting?

It depends.

Are the patients arriving at exactly 7.5 minutes apart (60 minutes / 8 patients)?

If so, then there will be no waiting. But how often does that occur? Isn't it more likely that patients arrive at a variable rate?

If patients arrive at a variable rate will any of the patients wait?

Yes.

Think about it.

Can the receptionist process 4 people at once?
Can the nurse care for a batch of people at once?
Can the phlebotomist draw the blood on a batch of many patients at once?
Will rooms be occupied as other patients wait to move to the next step in the process?
Will you wait to get a room?

The most efficient processes can crumble as you increase the number of customers and the variability of arrival rate. Plan for variability.

A queue is a line.

We are queueing specialists. We create lines and we wait in queue.

We wait for the:

• physician to write the order.
• clerk to enter the order.
• nurse to execute the order.
• patient to be ready to get tested.
• lab to process the order.
• physician to see the result.
• etc.

A whole series of queues. Each one dependent on the previous.
A delay at one step results in waits at later steps. Additive delays.

Every step relies on the server to process the customer.

The server can be a thing (blood analysis machine, bed, CT scanner) or it can be a person (tech, nurse, housekeeping, physician, registration clerk).

The customer can also be a thing (lab sample, dirty bed) or a person (patient, family member, nurse).

Each server can only process a specific number of customers during a specific amount of time. Additional customers wait.

Do we have the right number of servers?
Can we eliminate steps?

I've been making a mistake during some of my lectures.

I like to emotionally engage the audience. I like to make them laugh. Sometimes I tell stories as a break between content as a sort of cognitive release. Add a little spice. But am I defeating my ability to educate effectively?

Telling stories as part of a lecture can be a great way to effectively teach. However, I need to choose the stories wisely. Highly detailed tangents, while interesting, may hurt the audience's ability to learn my key points.

Cognitive load theorists believe that the brain has a limited ability to process new information at any point in time. Seductive detail is information that is interesting but not necessarily relevant to the key points. New research supports the idea that seductive detail draws cognitive processing power away from learning the main points. In fact, the more interesting the tangent, the more it impaired a deep understanding of the key points. Our brains can only process so much new material in limited time.

Am I giving too much irrelevant detail?
Does my story distract from the key points?