Governmental staff have been growing at exponential rate. I wonder if the largest employer in the USA is still the government....I see and hear from a different bureaucrat every time I have contact with the local, state or federal tax office, or the local or state health dept., etc. Or is the turnover so great? I think not, once they go to work for the govt they're in for life, generally speaking. There are just too many of them and not enough of us little people actually working and generating goods and services to the world. Pithy observation for the day.
Clear Stream
Wednesday, November 12, 2014
Monday, October 13, 2014
Some truth buried elsewhere...
This Ebola thing is truly shocking. Not how infectious or deadly the virus, but the btched and slapdash platitudinous drivel flying out of the mouths of bureaucrats.
I read the CDC recommendations, and found no hard data nor details on what to do as a doctor if I suspect Ebola. So, I looked online and found a revelatory letter from Infectious Disease Week.
Here it is in its entirety. In the interest of promoting data sharing and info, the entire article, which is an annotated version of a talk given by the Emory physician in charge of their Ebola unit, for lack of a better term. Emory took on the care (successfully) of Dr. Brantly and Ms. Writebol, the medical missionaries airlifted from Liberia back in August 2014.
I read the CDC recommendations, and found no hard data nor details on what to do as a doctor if I suspect Ebola. So, I looked online and found a revelatory letter from Infectious Disease Week.
Here it is in its entirety. In the interest of promoting data sharing and info, the entire article, which is an annotated version of a talk given by the Emory physician in charge of their Ebola unit, for lack of a better term. Emory took on the care (successfully) of Dr. Brantly and Ms. Writebol, the medical missionaries airlifted from Liberia back in August 2014.
EBOLA: LESSONS LEARNED, FROM IDWEEK 2014
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A summary of the presentation at IDWeek by Dr. Bruce Ribner on caring for Ebola patients in the US [1]. Dr. Ribner led the team at Emory University that cared for two patients with Ebola virus disease (EVD) in August. In light of the recent Ebola cases in Dallas and Spain he agreed that a summary could be provided to assist ID specialists in their ongoing preparedness efforts.
Planning for the care of patients
This involves the entire institution, and needs many sections to coordinate their work. EMS services were an important coordination point for the transport of the 2 patients to Emory. On the medical staff, many types of expertise were needed for clinical management: ID, critical care, anaesthesiology and several other subspecialities. Nursing, environmental management, facilities, security and media relations were all intensively involved ahead of time so that expected roles were defined. Even so, there were times when questions arose after the patients arrived.
Clinical Care
Ebola patients in Africa have only limited clinical evaluations and essentially no laboratory testing due to the lack of any infrastructure to support this. The Emory team was able to make careful clinical evaluations over time in their 2 patients and Dr. Ribner summarized the main points as follows:
- Despite weight gains of 15-20 kg, the patients were profoundly hypovolemic due to their low serum albumin and vascular leak with third spacing. Fluid losses in their patients were 5-10 L/day.
- Electrolyte losses were significant and included profound hyponatremia, hypokalemia and hypocalcemia. At initial assessment at Emory the patients were one week into illness yet these were their first laboratory determinations. Arrhythmias were noted, and both intravenous and oral electrolyte repletion was necessary.
- Nutritional depletion was evident as well.
- Ebola virus RNA was detected in blood, urine, vomitus, stool, endotracheal suctioning and semen and on skin. It was not detected in dialysate. Environmental testing in the patient rooms had no detection of viral RNA and included many high touch surfaces such as bed rails and surfaces in the bathroom.
- Intensive 1:1 nursing care was necessary around the clock. Patients were monitored continuously and this level of nursing care allowed for rapid response to clinical changes. Nursing and other team members provided emotional support, and as the patients improved, help with self-care and physical therapy.
Experimental Interventions
While there are no approved vaccines or treatments for EVD, the WHO has noted that it is ethically acceptable to consider use of experimental agents. Categories of agents under study include candidate vaccines, whole blood and immune serum, and novel therapeutic agents (monoclonal antibodies, antivirals and RNA-based drugs). Most have not been evaluated in phase 1 human studies and are in limited supply. The Emory team engaged the FDA, CDC and pharmaceutical manufacturers in active discussions as they weighed additional interventions.
Laboratory Testing and Diagnostics
Differences in guidance for laboratory testing were noted between CDC and ASM. The CDC guidance indicates that testing can be performed in a main lab with attendant infection control and analyzer safeguards that are specified by the instrument’s manufacturer, while the ASM guidance specified that point of care (POC) instruments located very close to the patient should be used. The reality the Emory team noted was that if a specimen from one of their EVD patients spilled in the main lab, it would be closed for hours to accomplish decontamination, thus impacting function of the entire hospital. There was realistic concern that technologists would not perform testing on EVD blood. These considerations prompted the Emory team to set up a POC testing area adjacent to the patient care unit[2]. Lab testing was kept to a minimum.
Surprises in Shipping
Ebola virus is considered a category A agent which requires special packaging and shipping arrangements for clinical specimens. Despite meeting these requirements, the Emory team learned that commercial carriers refused to transport the specimens even when the carriers were licensed for Category A agents.
Staff and Environmental Safety
The hospital safety officer needed to navigate multiple regulatory requirements at the federal, state and local level. Familiarity with the regulatory documents and jurisdiction was necessary.
Personal Protective Equipment
Their staff was trained in the use of PPE that included impermeable body protection (gown, leg and shoe covers), face mask or N95, eye and face protection (goggles and face shield) and gloves. Practical considerations led them to use full body suits and PAPRs. Their decision was based on the need to work for extended periods of time using PPE, the aim of decreasing physical discomfort working in multi-component PPE and the avoidance of difficulties like fogged faceshields. The donning and doffing of PPE was always observed by another staff member, and the importance of adhering to safe removal of PPE was emphasized.
Unexpected Adventures in Waste Management
Although the CDC guidance indicates that sanitary sewers are acceptable for patient waste, the local water authority disagreed. The Emory team had to disinfect all patient liquid waste with bleach or quaternary detergents for 5 minutes before it could be flushed. The hospital’s waste disposal contractor would only pick up materials that were certified as free of Ebola virus. As a consequence, the hospital had to dedicate an autoclave and move it to process all materials used in clinical care in order for it to be accepted for disposal as regulated medical waste. By the end of the patients’ stay the autoclaved and boxed materials filled several trailers.
Media and Communications
Three key messages were used to manage the tsunami of media attention: first, that the Emory team had expertise in treating serious infectious diseases; second, that the staff and hospital were trained and prepared to care for the patients; and third, that the preparations included protection of Emory patients, staff and the community. Patient confidentiality was also underscored. For the hospital staff, multiple communications were done, using town hall meetings, email and other modes. For inpatients and all new admissions, letters were given that explained the situation and reiterated the key messages, and senior administrative leaders delivered the messages as well answered questions. No decrease in admissions or elective surgeries at the hospital was noted.
Lessons Learned
Patients with EVD can be safely cared for in developed countries with appropriate safeguards. This opportunity affords close clinical observation and experience in clinical management that could be relayed to facilities with lesser infrastructure. Communication, both internal and external, is critical to manage the situation surrounding a hospitalized EVD patient.
The Society thanks Dr. Ribner and his team for their astute observations, their compassion and their willingness to share what they have learned.
Sincerely,
Barbara E. Murray MD, FIDSA, President, IDSA
Stephen B. Calderwood MD, FIDSA, President-Elect, IDSA
Marguerite A. Neill, MD FIDSA, Chair, Rapid Communications Task Force, IDSA
Barbara E. Murray MD, FIDSA, President, IDSA
Stephen B. Calderwood MD, FIDSA, President-Elect, IDSA
Marguerite A. Neill, MD FIDSA, Chair, Rapid Communications Task Force, IDSA
Thursday, October 2, 2014
Ebola Silence
Let's review how Ebola got into the US.
Back on Sept 16, just 2 weeks ago, Obama lauded the protocols and treatments in place to handle Ebola, which "is very difficult to get and it's a rare chance that it will come"-read here.
Mr. Duncan, who lived in Liberia, helped carry his landlord's dying daughter out of the home and into a car to get her to hospital. The woman was deathly sick, and her brother, who helped also, has since died. Amid this harrowing scenario, Mr. Dunca, who holds a US visa, obviously contacted his family in Dallas and was no doubt supported in his egress from Liberia. He knew he was at risk; he quit his job with Fedex, unknown if he only purchased one-way tickets.
He flew to Brussels, waited for 7 hours to get onto a United Air flight to Washington-Dulles, waited another 3 hours to board a flight to Dallas. 4 days later he was in the emergency room of a Dallas hospital with flu-like symptoms, sent home with antibiotics. Apparently he did tell "someone" he was from Liberia because he didn't have a social security number and showed his passport as I.D. Unclear that he communicated this directly to the "health care worker" that he had come into contact with a woman who died from Ebola. I guarantee you he was seen as a black uninsured man, was turfed to a RNP or PA who may not even know where Liberia is. "Uh, a suburb out to the west of us?"
I can't wait to see the fallout from that alone.
Does any American working a front desk at any urgent care center or ER in the US know what/where or why Guinea, Sierra Leone, Liberia is important? Do they know what's involved here? I'm sure not.
But the most disturbing part of all of this is the non-response and robotic, uninvolved commentary provided by Dr. Tom Frieden, head of the CDC. Clearly, he's avoiding giving out too much info which may implicate the HIPAA laws. He won't address the fall out about the countless numbers of people who have come into contact with the infected Mr. Duncan. He won't address the apartment complex he was in, nor how the water nor treatment of sewage from that complex has been decontaminated. But aside from this, a deadly virus has gotten into the community because of the incompetence and slapdash, inept rule of law and guidelines from the top. We are told all up and down that we have fantastic protocols and contingencies in place. Bull**it. There is nothing.
I have been in practice for 14 years. I used to receive daily emails from the Health Dept. about SARS, anthrax, etc about 12 years ago. Now there is silence. There is no planning. There is no info, because they don't know what to say.
I walked into the Urgent Care next to my building yesterday to take a look around. There was s sign prominently posted that firearms were forbidden on the property. There was no info on what to do or say if you had been traveling out of west Africa and felt sick. Now, both are deadly weapons, and there is ZERO about Ebola in my towns' Urgent Care. It is not politically expedient to condemn Ebola, but yes a gun.
I can only say I can't wait for the schadenfreude I will feel when I see bureaucrats resigning. Thank god Julia Pierson, former head of the Secret Service who couldn't run a n ice cream stand if her life depended on it, has resigned. Now we just need a dozen or so more to quit and the house can be straightened up...
Back on Sept 16, just 2 weeks ago, Obama lauded the protocols and treatments in place to handle Ebola, which "is very difficult to get and it's a rare chance that it will come"-read here.
Mr. Duncan, who lived in Liberia, helped carry his landlord's dying daughter out of the home and into a car to get her to hospital. The woman was deathly sick, and her brother, who helped also, has since died. Amid this harrowing scenario, Mr. Dunca, who holds a US visa, obviously contacted his family in Dallas and was no doubt supported in his egress from Liberia. He knew he was at risk; he quit his job with Fedex, unknown if he only purchased one-way tickets.
He flew to Brussels, waited for 7 hours to get onto a United Air flight to Washington-Dulles, waited another 3 hours to board a flight to Dallas. 4 days later he was in the emergency room of a Dallas hospital with flu-like symptoms, sent home with antibiotics. Apparently he did tell "someone" he was from Liberia because he didn't have a social security number and showed his passport as I.D. Unclear that he communicated this directly to the "health care worker" that he had come into contact with a woman who died from Ebola. I guarantee you he was seen as a black uninsured man, was turfed to a RNP or PA who may not even know where Liberia is. "Uh, a suburb out to the west of us?"
I can't wait to see the fallout from that alone.
Does any American working a front desk at any urgent care center or ER in the US know what/where or why Guinea, Sierra Leone, Liberia is important? Do they know what's involved here? I'm sure not.
But the most disturbing part of all of this is the non-response and robotic, uninvolved commentary provided by Dr. Tom Frieden, head of the CDC. Clearly, he's avoiding giving out too much info which may implicate the HIPAA laws. He won't address the fall out about the countless numbers of people who have come into contact with the infected Mr. Duncan. He won't address the apartment complex he was in, nor how the water nor treatment of sewage from that complex has been decontaminated. But aside from this, a deadly virus has gotten into the community because of the incompetence and slapdash, inept rule of law and guidelines from the top. We are told all up and down that we have fantastic protocols and contingencies in place. Bull**it. There is nothing.
I have been in practice for 14 years. I used to receive daily emails from the Health Dept. about SARS, anthrax, etc about 12 years ago. Now there is silence. There is no planning. There is no info, because they don't know what to say.
I walked into the Urgent Care next to my building yesterday to take a look around. There was s sign prominently posted that firearms were forbidden on the property. There was no info on what to do or say if you had been traveling out of west Africa and felt sick. Now, both are deadly weapons, and there is ZERO about Ebola in my towns' Urgent Care. It is not politically expedient to condemn Ebola, but yes a gun.
I can only say I can't wait for the schadenfreude I will feel when I see bureaucrats resigning. Thank god Julia Pierson, former head of the Secret Service who couldn't run a n ice cream stand if her life depended on it, has resigned. Now we just need a dozen or so more to quit and the house can be straightened up...
Tuesday, September 23, 2014
How to lose friends and win enemies
And here we have a couple of nice neat bullet-shaped packages given out by a self anointed nerd antisocial MD PhD who has developed drscore.com, a website where doctors are scored and rated by patients and/or peers. These are tips to APPEAR more empathic. Not to actually become empathic, heaven forbid. You just have to look like it...sick sad world...
Does this guy think everybody is a 5 year old with such superficial (and creepy) observations such as "the doctor cares about me because I used the hand sanitizer". Most people are too sick, tired, dazed to notice. Also, hand sanitizer tends to be 99% alcohol and is highly flammable, thus not recommended if you're goig to use heat generating devices on a patient. Old fashioned soap and water first and ALWAYS you knob!!!!
- If there’s no parking for the patient when they arrive for their appointment, they think you don’t care about them. So you’ve got to have a good parking situation.
- If the staff is rude when the patient calls to make an appointment, they think you don’t care about them.
Other ways of interacting with patients that convey empathy:
- I schedule a lot of patients per unit time so I run to the door of the room and when I get there, I stop. I open the door really slowly so patients will think, “Oh, he’s in no hurry,” which is part of being perceived as caring.
- I make a big deal of using the alcohol on the wall to cleanse my hands, because when they get in the car and drive home and they’re listening to a spot on National Public Radio talking about doctors who don’t wash their hands, I want them to remember that, “Dr. Feldman used that alcohol and protected me because he’s a caring doctor.”
- I try to sit down, look patients in the eye, shake hands and introduce myself to everybody in the room.
- I try to connect with patients and establish rapport
Does this guy think everybody is a 5 year old with such superficial (and creepy) observations such as "the doctor cares about me because I used the hand sanitizer". Most people are too sick, tired, dazed to notice. Also, hand sanitizer tends to be 99% alcohol and is highly flammable, thus not recommended if you're goig to use heat generating devices on a patient. Old fashioned soap and water first and ALWAYS you knob!!!!
Data mining is nothing new. It's become a forced issue in medicine because data is seen as the gateway to everything--patient volumes, scheduling, payments, procedures, the daily flow of work.
Doctors have time-limited board certifications. In essence this is a good thing, to ensure that physicians maintain high standards and excellence in their fields by continually self-education and training, because medicine is an ever changing and advancing beast that requires life long study. I became board certified in 1998 and then I re-certified with additional at-home independent study and testing--which was quite lengthy--in 2008. However, in the past 5 years or so, Maintenance of Certification, or MOC, has become linked with endless self assessments on patient safety, patient communication, peer review, and patient/customer surveys which must be filled out and then analyzed by a third party in order for the physician to maintain board certification.
Sort of how you get online surveys from hotels or stores after you purchase something? The same thing is happening in medicine. How happy or glowing would a survey be from a patient who had to go on water only for 48hrs due to pancreatitis? Or a patient with cognitive dysfunction post-stroke? Silly rabbit, tricks are for kids. It doesn't matter. Give the patient a lollipop or a small token of gratitude and they'll be happy to fill out a survey.
The patient, or the peer/colleague filling out surveys, isn't asked about the correct diagnosis or treatment. The surveys' content hinges around the customer service experience-- the "pleasingness" of office decor, the friendliness and responsiveness of staff, the accessibility of parking, the phone call to the office to make the initial appointment, and even whether the electronic health record meshes well with the colleague's electronic health record, or inter-operability of electronic technology.
I recently filled out a survey for a colleague wishing to maintain board certification. I kept a copy for my records. The survey asked me to rate the friendliness of the office staff, how well was I able to get referrals from the doctors, the overall ease and convenience for patients to see that doctor--i.e. location, parking, payment policies (!). How the fudge is this relevant to the medical service provided? What about doctors in downtown New York or Miami, where there is zero parking? How about doctors that don't participate in any 3rd party payors, are they to be penalized for going cash only? BY THE AMERICAN BOARDS OF SPECIALTIES???
Silly rabbit, we have fallen down the hole.
Doctors have time-limited board certifications. In essence this is a good thing, to ensure that physicians maintain high standards and excellence in their fields by continually self-education and training, because medicine is an ever changing and advancing beast that requires life long study. I became board certified in 1998 and then I re-certified with additional at-home independent study and testing--which was quite lengthy--in 2008. However, in the past 5 years or so, Maintenance of Certification, or MOC, has become linked with endless self assessments on patient safety, patient communication, peer review, and patient/customer surveys which must be filled out and then analyzed by a third party in order for the physician to maintain board certification.
Sort of how you get online surveys from hotels or stores after you purchase something? The same thing is happening in medicine. How happy or glowing would a survey be from a patient who had to go on water only for 48hrs due to pancreatitis? Or a patient with cognitive dysfunction post-stroke? Silly rabbit, tricks are for kids. It doesn't matter. Give the patient a lollipop or a small token of gratitude and they'll be happy to fill out a survey.
The patient, or the peer/colleague filling out surveys, isn't asked about the correct diagnosis or treatment. The surveys' content hinges around the customer service experience-- the "pleasingness" of office decor, the friendliness and responsiveness of staff, the accessibility of parking, the phone call to the office to make the initial appointment, and even whether the electronic health record meshes well with the colleague's electronic health record, or inter-operability of electronic technology.
I recently filled out a survey for a colleague wishing to maintain board certification. I kept a copy for my records. The survey asked me to rate the friendliness of the office staff, how well was I able to get referrals from the doctors, the overall ease and convenience for patients to see that doctor--i.e. location, parking, payment policies (!). How the fudge is this relevant to the medical service provided? What about doctors in downtown New York or Miami, where there is zero parking? How about doctors that don't participate in any 3rd party payors, are they to be penalized for going cash only? BY THE AMERICAN BOARDS OF SPECIALTIES???
Silly rabbit, we have fallen down the hole.
Thursday, April 10, 2014
Jihad on doctors
CMS has released the Medicare payments made to doctors in 2012. This will be an annual update henceforth. We're talking the name, address, billed charges, and paid amounts to over 800,000 US physicians on a government website. The reason is to help "track fraud and provide clarity on physician charges". Already lots of media noise has been made about the lone ophthalmologist posting millions of earnings, some doctor injecting every old retiree in south Florida with macular degeneration and getting paid $21 million--at some point, aren't there any brakes on the payouts? And if there aren't any brakes, and the work is being legitimately performed, who are they to "out" this doctor in this fashion?
Oh, the Sherman anti trust act muzzles how we can discuss fees, but then this is posted publicly?
Is there any HIPPA protections for the physician? Of course not.
In return, here's what I want:
1. The name, address, and W-2 or 1099 earnings of every government employee, "civil servant", politician, etc. posted as a searchable icon on the .gov server.
2. The name, address and amount of federal subsidy given to healthcare.gov subsidy recipients. I must know what the patient I'm treating got from the feds, and how much. If they must know what I got, then it's a 2-way street.
3. The actual federal pay-out given to all the banks, with the breakdown of how federal monies have been distributed to all the government contracts, corporations and CIA informants.
It's the attack on doctors to blackmail and destroy us so they can put RNP's and PA's in charge of patient care. I will be filled with schadenfreude after I'm filled with rage.
Oh, the Sherman anti trust act muzzles how we can discuss fees, but then this is posted publicly?
Is there any HIPPA protections for the physician? Of course not.
In return, here's what I want:
1. The name, address, and W-2 or 1099 earnings of every government employee, "civil servant", politician, etc. posted as a searchable icon on the .gov server.
2. The name, address and amount of federal subsidy given to healthcare.gov subsidy recipients. I must know what the patient I'm treating got from the feds, and how much. If they must know what I got, then it's a 2-way street.
3. The actual federal pay-out given to all the banks, with the breakdown of how federal monies have been distributed to all the government contracts, corporations and CIA informants.
It's the attack on doctors to blackmail and destroy us so they can put RNP's and PA's in charge of patient care. I will be filled with schadenfreude after I'm filled with rage.
Monday, March 3, 2014
Check the box
Franz Kafka wrote about the horrors of bureaucracy nearly 100 years ago. I remember as a student reading his works and getting totally depressed. The world can't possibly be so bad, so corrupt, so full of hateful, lazy people.
He was right. It is.
I was urged to "join in" and get a free software program so that I can partake of an idiotic scheme called meaningful use. The Medicare people have decided that having physicians enter the data for them is much better than them having to pore over data that already exists. And gee, we don't have to pay them for this work, we can dock 2-5% from their pay, in increments over the next 5 years so they won't notice, if they DON'T do it.
The free programs seem all nice, but they're free because they depend on doctors becoming their product, and then you get targeted advertising so they can pay for the scheme. Then later on, they will start charging you for their services.
I'm sick of being victimized and assaulted.
So I'm saying no to this and I'm choosing to be a doctor and care for patients.
I don't have all the time in the world to jump through every artificial hoop. I'm a human being, with a family, with physical and emotional needs, with pressures, with foibles. I'm not perfect. But I won't compromise where I know my talent lies, and I won't cut time away from being a caring compassionate doctor to click through the program to check a bunch of boxes that mean nothing to me.
A patient got married, I sent flowers. A patient's husband died, I hand wrote a letter of condolences. This must continue, or the fabric of humanity will disappear, and it'll become the Paleolithic.
I recently saw a colleague that I hadn't seen in 2 years. He has gained about 50 lbs, gone grey, and was running around his office with a laptop to enter the data and the assistant to room and gather the patients up. I felt so sorry for him. He's imploding. This man went to Harvard, Yale, is a talented surgeon...it doesn't matter. The box must be checked or his livelihood and his family are threatened.
Then I have to witness the brazen bureaucrat telling me what to do. YOU WORK FOR ME.
Read here for some acid producing stuff.
I'm off to fight the man.
He was right. It is.
I was urged to "join in" and get a free software program so that I can partake of an idiotic scheme called meaningful use. The Medicare people have decided that having physicians enter the data for them is much better than them having to pore over data that already exists. And gee, we don't have to pay them for this work, we can dock 2-5% from their pay, in increments over the next 5 years so they won't notice, if they DON'T do it.
The free programs seem all nice, but they're free because they depend on doctors becoming their product, and then you get targeted advertising so they can pay for the scheme. Then later on, they will start charging you for their services.
I'm sick of being victimized and assaulted.
So I'm saying no to this and I'm choosing to be a doctor and care for patients.
I don't have all the time in the world to jump through every artificial hoop. I'm a human being, with a family, with physical and emotional needs, with pressures, with foibles. I'm not perfect. But I won't compromise where I know my talent lies, and I won't cut time away from being a caring compassionate doctor to click through the program to check a bunch of boxes that mean nothing to me.
A patient got married, I sent flowers. A patient's husband died, I hand wrote a letter of condolences. This must continue, or the fabric of humanity will disappear, and it'll become the Paleolithic.
I recently saw a colleague that I hadn't seen in 2 years. He has gained about 50 lbs, gone grey, and was running around his office with a laptop to enter the data and the assistant to room and gather the patients up. I felt so sorry for him. He's imploding. This man went to Harvard, Yale, is a talented surgeon...it doesn't matter. The box must be checked or his livelihood and his family are threatened.
Then I have to witness the brazen bureaucrat telling me what to do. YOU WORK FOR ME.
Read here for some acid producing stuff.
I'm off to fight the man.
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