The value of a scribe: The patient's care was expedited

Fabio Giraldo is a Scribe with ScribeAmerica.  This is his story:

I was working a night shift in a single-coverage Emergency Room and I happened to be floor training as well. It was a busy night and the E.R. was gridlocked, and patients were starting to pile up in the waiting room. It was common for the triage nurse to place orders to get things started under the attending physician's name when the waiting room started filling up, and this night was no different. Being that the E.R. was gridlocked and we were not seeing any new patients, I took this opportunity to show the trainee how to look up X-rays on the PACS system.  I also started to explain to the trainee that it was important to monitor the waiting room results, being that the physician we were working with was the only physician on, and all of these [X-ray] studies were being ordered under his name.

As the apprentice scribe started pulling up images from patients in the waiting room, I heard him say "Wow!  This X-ray looks really weird."  I looked over to the PACS station and noticed this patient had free air under the right hemi-diaphragm, a finding that is consistent with a bowel perforation [a hole all the way through the wall of the intestine, which causes bacterial contamination of the abdominal cavity or peritonitis, a painful dangerous infection of its lining].  I immediately had my physician look at the X-ray.  He agreed and immediately called the surgeon on call, who took the patient to the Operating Room.

Approximately 30 minutes after the patient was taken to the O.R. my physician received a phone call from Radiology to notify him that one of his patients was found to have a bowel perforation on X-ray.  Because the apprentice scribe was vigilant to the orders placed in the waiting room, this patient's care was expedited and they were already in the O.R. by the time the Radiologist called the E.R.  [The prompt treatment of peritonitis can prevent complications, according to Freed's Medical Dictionary.]

Thanks to Fabio, and to Michelle Thompson of CWR & Partners for connecting us.  Read another story of how one very different medical practice has a technician serve as scribe, enabling the prompt preparation of a visit summary.

Milford Regional’s PFAC Story, as told by Beverly Swymer [Part 1]

In June of 2012, as members of the Milford Regional Medical Center’s Patient/Family Advisory Council (PFAC), we were searching for a direction to go.  Dr. Jeff Hopkins, Chief of the Emergency Department, gave a presentation to us about the care of behavioral health patients in the Emergency Department and how the volume impacted the E. R. The patients who came to the E.R. needed follow-up care but the resources for staff to refer them to were very limited. With the deinstitutionalization (of mentally ill patients), the use of antipsychotic drugs can help to control the behavior of this patient population but this often results in homelessness and the revolving door syndrome. Patients with drug addiction and/or mental health issues and subsequent problems need active intervention and follow-up care.  They are a growing number of E.R. patients, often seen on an emergent basis.  These people are devastated; they do not know where to turn, so they seek out care and support in the E. R. and often arrive in a crisis state. The staff, not being trained in psychiatric care, aim to keep the patients safe, maintain their medicine regime and actively seek out appropriate behavioral health care support…essentially custodial supportive care while in the E.R. The result was long-term stays in the E.R. (sometimes this meant many hours or even days), which was troubling. It was especially difficult to place patients who’d been violent, children and those patients who had complex medical problems in addition to their behavioral issues as well as the difficulty of placement of behavioral health patients on the weekends.

As the PFAC Co-Chair at the time, I met with Dr. Hopkins to discuss how the PFAC could realistically have an impact on this issue.  We discussed ways to educate the community about the Behavioral Health Care crisis, and to identify ways to short-circuit the crisis step by connecting the E.R. patients to community services in a more timely fashion. This was our initial approach to define the role of the PFAC Subcommittee within the hospital: to define “better care”. We on the PFAC had a couple of meetings to discuss how to accomplish this effort. By September 2012, we started meeting on a monthly basis.

I became the head of the Behavioral Health Subcommittee of the PFAC at that time because I believed the PFAC, through collaboration with other healthcare providers, could make a difference in behavioral health care in the E.R.  I felt this issue impacts us all because it impacts health care in general as well as care in the E.R.  If ten of 30 beds are occupied with behavioral health patients, especially if occupied for extended periods of time, this impacts bed availability for all other patients. The goal of the PFAC Subcommittee was to find ways to improve care with better resources in the community and thus ultimately alleviate the impact on the E.R.

Assuming responsibility as Chairperson, my role through all of this was to get this challenging endeavor on track. Monthly meetings were and continue to be held. To develop a more comprehensive approach to this issue, we reached out to others who dealt with this patient care population. For example, we invited representatives from Case Management, Social Service, Nursing and Riverside Counseling Services to join the subcommittee in an effort to improve care of the behavioral health patient. It took a real strong collaborative approach and the PFAC was part of all of those discussions. As the PFAC Subcommittee chair, I worked with the E.R. behavioral health team to incorporate everyone’s input, obtain feedback from others and evaluated how it was all working.  I, along with other members of the PFAC Subcommittee, presented the PFAC and ED Behavioral Health Program at the Health Care for All PFAC State Conference at Holy Cross, the Massachusetts Coalition for the Prevention of Medical Errors, the Juvenile Advocacy Group (JAG) Community Breakfast and at a webinar hosted by Health Care for All.

We formed a diverse group with Dr. Hopkins, Chief of the Emergency Department, community caregivers, a child psychiatrist, Riverside Emergency Services, Nursing, Case Management, Social Service and a family member who dealt first hand with the issues of trying to find care for her son in crisis, etc

We reached out to the E.R. staff for their input and perspective on Behavioral Health Care in the E.R., asking for their suggestions on how to improve care of the behavioral health patient while in the E.R. The nurses developed a list of very helpful suggestions to enhance the care of the behavioral health patient while under their care. Some creative but simple suggested improvements included: a predictable schedule, showers, attention to proper nutrition, an opportunity to take a walk, exercise, music, etc., since some of these patients were in the E.R. for days. This effort showed the staff we were willing to listen and we valued their input.

As a result of this collaborative effort between the PFAC, Emergency Department, Case Management and Community Benefits, we received a grant from the EOHHS (Executive Office of Health and Human Services). This grant enabled us to provide an educational program for the E.R. nurses interested in Behavioral Health and to provide initial funding for Behavioral Health nursing positions. The first group of behavioral health nurses became mentors for their colleagues in the E. R.  This initiative was very well received by the nursing staff.

An integrated team was developed comprising Case Management, ED front line staff, Riverside, and other mental health care workers. Patients are evaluated during daily rounds in the E.R. Therefore they all know where each patient is in their care management and what follow-up resources could be identified. At one time, for those patients on behavioral watch or at risk of suicide, we had security guards watching over them. A program was developed to train people as Patient Safety Advisors. These people are specifically trained to interact with the behavioral health care patient in the E. R. while they waited for individualized plans of care.

Next we looked into the community for resources available to provide timely care and counseling to the behavioral health patient population. Our thinking was if we could provide opportunity for timely care and support we could short circuit the need for crisis intervention in the E.R. at 3 am.  Information was presented to our PFAC Behavioral Health Subcommittee about the Interface Referral Service of the Massachusetts School of Professional Psychology (MSPP). This service provides information about services available in and around the community and guidance in how to navigate the mental health system.  I, as well as others on the team, reached out and spoke with other communities who had successfully utilized this service. This was the first time this organization would be working in a hospital broad based outreach. In February of 2013, we signed a contract with Interface. In addition to making the information about this service available in our E.R, we notified (via letter) the schools, pediatricians’ offices, Counseling Services, Youth Groups in town, Library’s Youth Department, etc., all in an effort to make the public aware of this referral service.  This was one more step in our effort to make Behavioral Health Care better and available to our community when needed.  We’re trying to meet the patients’ needs for medication, personal needs, etc., with active intervention, not just custodial care in a hospital setting with a broad-based community outreach.

Stay tuned for Part 2.  In the meantime, read a story about other innovations by Patient/Family Advisory Councils at Milford and Beth Israel Deaconess Medical Center. 

After everyone had left: Choosing an Emergency Room

The day after my daughter's Bat Mitzvah in Boston, after everyone had left, my mother asked me if I'd bring her to the Emergency Room. She'd been having pain radiate down her neck. She'd waited until then to ask because she didn't want to ruin my daughter's special day. I wanted the best care for her, and wanted her to get it quickly. She wanted to catch a train to NYC to see an old friend. I called 2 E.R.s to find out how long she'd have to wait. The shorter wait was at a very small community hospital in our suburban home town. I asked the E.R. for their FAX number, and in the car on the way, I called my mother's doctor's office in Atlanta and asked them to FAX her problem list and medication list to the E.R. in Boston.

When we got to the E.R., the problem list and medication list were already there, and they quickly got her in to see a doctor. They gave her an EKG, X-rays, and blood tests to rule out a stroke. And they arranged a specialist at a nearby Harvard teaching hospital to see her on a TV screen - a quick telemedicine consult.

They ruled out a stroke, gave her some quick education about the problem they'd discovered, so she WAS able to catch her train in time. The lessons?: Get an advocate who can put you first. Choose your E.R. Get them the critical information they need.

The stories in my book, Getting Your Best Health Care: Real-World Stories for Patient Empowerment, come from my personal experiences in my family, my professional work as a hospital consultant, and research for my blog. There are stories of famous doctors who've been patients, and what we can learn from them. There are stories about the health crises of celebrities and public figures, and what we can learn from them.

I've been working for 15 years as a consultant in helping hospitals prevent medical errors, and improve the quality of care. When my father-in-law died from a medical error in 2002, it changed me. I later began writing stories to educate and empower and warn people in Patient Safety Blog. So my interest was first professional, then very painfully personal, and then professional in a different direction, as a patient advocate.

Now my work enables people to partner with their doctors, to get the best patient-centered care.

They stopped me from saving her life: Patient partnership and E.R. treatment

Lee's story:
I live here in Arlington, Massachusetts. For several years I was dating a woman named Elizabeth. She was a Type 1 diabetic from when she was 12 years old. She hadn't taken good care with her insulin when she was young because she was angry and felt adults didn't understand her. Her mom was divorced several times during her childhood, and that added to what she rebelled against by eating sugar when she shouldn't. She also feared gaining weight if she took as much insulin as she should. Most type 1 diabetics became diabetics as children, and have inner psychological battles. There's a very private inner painful world – they could die if they don't do what they're supposed to do. Some kids rebel….

When I met her, Elizabeth's condition had advanced to the point where both of her kidneys had failed, and she had received a transplanted kidney from her mother. She had had five eye operations, and was legally blind in one eye. She had neuropathy [a nerve problem] in her feet and hands, and couldn't balance well. She was an adorable, absolutely lovely and loving person, the most amazing person I ever met.

Due to side-effects of the immunosuppressive drugs she was on to prevent rejection of her transplanted kidney, her vascular condition had degenerated to that of a typical 95-year old woman (though she was only 43). At the time of her kidney transplant, the immunosuppressive drugs used caused calcium to leach out of bones and deposit in the walls of her arteries, so she had atherosclerosis, and plaque deposits in her arteries.

During 2008 she had four minor strokes, and recovered completely from each. She also developed arterial spasm events in her brain which could give stroke-like symptoms. She'd have to go the E.R. when a brain artery spasm happened, and the spasm could be immediately relieved with Compazine.

On New Year's Eve Day last year, she called me at 6 am in the middle of one of these brain arterial spasms; I rushed to her house and drove her to the E.R.

She had been through the same situation in that E.R. four or five times before, so it was all in her records what needed to be done, including a letter with specific directions from her stroke specialist; all they had to do was give her a short I.V. [intravenous, i.e., into the vein] of Compazine. But the E.R. doctor decided to review her whole case first. So she continued retching, and her retching caused a cerebral hemorrhage. Because of the cerebral hemorrhage she was taken off Plavix in the ICU [intensive care unit]. Before she completed her recovery from the hemorrhage in the ICU, she had a severe stroke – because she'd been taken off the Plavix - and she died.

During the whole time in the E.R., I was telling the nurse, "You need to give her the Compazine! Here's a letter about that from the stroke [physician] specialist!" I asked the nurse, "Can't you just give the IV?" She said, Not without a doctor's order. The letter from the stroke specialist wasn't good enough.

So she didn't get the Compazine in time. That review by the E.R. doctor effectively killed her – because of the time he spent on it.

I knew more about her condition, much more, than the E.R. doctor because I'd read hundreds of pages of information about it. The nurse asked him to come into the room and talk to me, but he did not come in until after her hemorrhage, and by then it was too late.. Doctors assume that someone who's not an M.D. is an idiot; it's not the case. Sometimes we are better educated about a condition than the doctor.

With the computer system at that hospital, there's no way for a standing order to be placed in the system to dictate what to do during an E.R. visit with a particular problem. So someone with a recurring condition (as most stroke patients have), cannot take advantage of their stroke specialist's prior knowledge of what has to be done.

I've called every major vendor of healthcare software in the U.S. No system has a feature allowing it to hold a standing order for the E.R. If such a feature existed, Elizabeth would be alive.

Back up four months: When we learned first about the brain arterial spasm problem that Elizabeth had, and how critically she'd need Compazine, I asked if I could have a vial of Compazine and a syringe to use in an emergency. Their answer: the standard dose is by I.V. and not syringe injection. Our policy is that we don't allow people to have Compazine at home. I had specifically tried to be responsible in a way to save her life, and they stopped me, like they did later in the E.R. too.

I'd tried to save her another way, too. When we were in the car on the way to the E.R., I called ahead, and asked them to please get the Compazine ready. They answered, "No, you’re not an ambulance."

I don't want to pursue a legal case unless that is necessary to change their system. Not every doctor will be good; the guy that was on duty in the E.R. was horrible. I want a capability so a person can prevent damage from the stupidity of an inadequate doctor by acting ahead of time.

This business of preventing people who are highly responsible for their health from helping themselves and the ones they love is insane!

The hospital wouldn't let us have a Compazine for an emergency they knew would predictably occur. What do you mean, she can't have a syringe?! She gave herself insulin about four times a day!

I could be trained. I'm a very competent person. I taught at MIT and I designed medical equipment for years at Hewlett Packard. If I'd known a spasm could kill her, I'd have done whatever it took to have that Compazine at home. If I had to, I would have stolen the stuff.

Lee's Advice: If you or someone you love has a recurring condition that needs to be treated at the E.R., write a letter to the hospital urging them to put in place a standing order at the E.R. for how to treat your condition. Urge them also to put in place a policy of preparing for your arrival based on a phone call from you. If there is a treatment you should be trained to give at home, push to be trained to administer that treatment.

Please feel free to send a copy of this along with your request, and please let the writer of this blog know what response you get.


Thanks to Lee Weinstein for sharing Elizabeth's story.

Read about a near-miss in matching a patient’s home medications with hospital medications [“medication reconciliation”].

Her first one since childhood: Counselors for the uninsured

Francine Fitz, a 57-year-old Worcester widow who relied on the E.R. for routine health problems until she was diagnosed with breast cancer last year, is one of the patients helped by counselors at the UMass Memorial Medical Center. The counselor, Heather Reddick, helped her enroll in subsidized health insurance. A telemarketer paid $10 an hour, Francine could not afford her employer's health plan, she said.

The counselor also helped her find a primary care doctor, her first one since childhood. The doctor works at a UMass health center and had just opened his practice to new patients, so Francine was able to get an appointment the next day.

Now, when she feels sick, she calls her doctor first, instead of heading to the E.R.

"I have never seen a doctor who calls me at home to make sure I'm OK," she says. "He even gives my children his private cell phone number, if they have a question."

A number of medical centers have added telephone help lines, counselors and social workers in their E.R.s to answer insurance questions, enroll uninsured people, and find them a primary care doctor. UMass Memorial Medical Center has gone further, sending counselors to laundromats, barber shops, farmers' markets, and churches. Armed with BlackBerries, portable scanners and laptops, they sign people up for insurance as well as food stamps, Social Security disability coverage, and other programs.

Advice to uninsured people in the E.R.: Ask the hospital what help they can give you in addition to treating your immediate medical problem.

Read another story about the new Massachusetts health coverage law.

Thanks to Kay Lazar for the source story in today's Boston Globe.

An hour after being discharged from the Emergency Room: A family physician's conflict of interest

Question for the Ethicist:
I am a family physician. A patient I'd not seen in months passed away about an hour after being discharged from an emergency room. Her mother, also my patient, asked me to review the records and autopsy to see if she should bring a malpractice suit against the E.R. physician and the hospital. I am friends with the physician and on the hospital's board. Ought I to comply with this request?
-J.R., Connecticut

Answer:
You should not. Indeed, you cannot – not properly, not without risking charges of bias. Your attachment to your friend and your position on the hospital’s board create – or may seem to create – divided loyalties. You should recuse yourself from this task, explain to the patient's mother why you are doing so and refer her to a disinterested physician with the expertise to review the records and advise her how best to proceed.

Update:
J.R. met with the family but did not offer a medical opinion, explaining that the records offered insufficient information for him to do so. He said he believed that they would not be satisfied unless the matter were investigated further and so suggested they speak to a lawyer who would have a neutral expert review the case.

Read about another ethical issue.

Thanks to Randy Cohen for the source story in the Ethicist column in the New York Times Magazine of May 25.

An hour after being discharged from the Emergency Room: Conflict of interest on a potential malpractice suit

Dr. J.R.'s question:
I am a family physician. A patient I'd not seen in months passed away about an hour after being discharged from an emergency room. Her mother, also my patient, asked me to review the records and autopsy to see if she should bring a malpractice suit against the E.R. physician and the hospital. I am friends with the physician and on the hospital's board. Ought I comply with this request?


Ethicist Randy Cohen's answer:
You should not. Indeed, you cannot – not properly, not without risking charges of bias. Your attachment to your friend and your position on the hospital's board create – or may seem to create – divided loyalties. You should recuse yourself from this task, explain to the patient's mother why you are doing so and refer her to a disinterested physician with the expertise to review the records and advise her how best to proceed.

Update: J.R. met with the family but did not offer a medical opinion, explaining that the records provided insufficient information for him to do so. He said he believed that they would not be satisfied unless the matter were investigated further and so suggested they speak to a lawyer who would have a neutral expert review the case.


Advice to family members considering a lawsuit for a medical error: Consult a doctor or nurse who was not involved.


Thanks to Randy Cohen for the source article in the Ethicist column of the New York Times Magazine of May 25.

She told the EMTs to take her an hour away: Stroke and tPA

Dr. Diana Fite, a 52-year-old emergency medicine doctor in Houston, knew her blood pressure had been dangerously high for five years. But she convinced herself her actual blood pressure was lower and healthier. And she thought she was too young to take medicine; she would worry about high blood pressure when she got older.

Then, one morning while driving, her whole right side felt weak. She "had no strength whatever in the hand that was holding the wheel. And my right foot was dead. I could not get it off the gas pedal," she recalled. She grabbed the steering wheel with her left hand, and steered into a parking lot. Then she used her left foot to pry her right foot off the gas pedal. She called 911, and spoke with great difficulty. She told the ambulance crew to take her to a hospital an hour away, to a stroke center whose doctors had experience with diagnosing stroke and giving the medicine tPA within the essential three-hour window for it to be effective.

The tPA started to immediately dissolve the blood clot that had caused her stroke. "I had weird spasms as nerves started to work again. An arm would draw up real quick, a leg would tighten up. It hurt so bad I was crying because of the pain. But it was movement, and I knew something was going on," she said.

Now she has completely recovered. She looks back with dismay on her cavalier attitude toward high blood pressure. Now she takes three blood pressure pills, a drug to prevent blood clots and a cholesterol-lowering drug, and plans do so daily for the rest of her life.

"Boy, when you go through this, you never want to go through it again. I have been given that precious second chance. I was so blessed."

She was also blessed in being among the 3 – 4% of stroke victims who receive tPA when they should. Many victims wait too long to report their symptoms, and many hospital Emergency Room doctors don’t always diagnose stroke accurately.

Advice: Send this to your friends with high blood pressure.

Read another of our healthy heart stories, or read Gina Kolata’s source story in yesterday’s New York Times.

Why Did I Miss It?: A misdiagnosis

The Emergency Room doctor's story:

Evan McKinley (not his real name) was hiking when he felt a sharp pain in his chest. He was a forest ranger in his early forties, trim and extremely fit. He had felt discomfort in his chest for several days, but this was more severe: it hurt each time he took a breath. He decided to see a doctor in a nearby hospital’s emergency room.

The emergency room doctor noted that McKinley had never smoked or been overweight; had no family history of heart attack, stroke, or diabetes; and was under no particular stress. His family life was fine, he said, and he loved his job. His blood pressure, pulse, lungs and heart appeared normal when the doctor examined him, and an electrocardiagram (EKG), chest X-ray, and blood tests also seemed normal. The emergency room doctor concluded that McKinley must have a muscle strain, and told him not to worry about the chest pain.

The next morning, McKinley had a heart attack (an acute myocardial infarction) that could have cost him his life. The doctor later explained, “Why did I miss it? I didn’t miss it because of any egregious behavior, or negligence. I missed it because my thinking was overly influenced by how healthy this man looked, and the absence of risk factors.”

Emergency room doctors have a particularly difficult diagnostic challenge because they often have very little information on a patient’s history.

Advice to patients: Keep your personal health information with you at all times. If you have to go to the E.R. with a condition that is difficult to diagnose, it might help the doctor save your life.

Read another emergency room story. Or read the full article on this by Dr. Jerome Groopman in the New Yorker.