Sunday, February 23, 2014

Jahi McMath: Poster Child for Medical Futility, or Scapegoat?

I periodically check for news updates on Jahi McMath, and today I found this news report that suggests that Jahi McMath is still alive, or at least that her heart is still beating, more than two months after she was declared dead on the basis of "brain death."

Based on the commentary on previous posts here and on debating this issue, I can say the following:
  1. Jahi McMath is legally dead on the basis of an incontrovertible and unequivocal diagnosis of brain death.  I have no doubts in this regard.
  2. Jahi McMath has a beating heart and thus is not considered to be dead on the basis of the intuitions and opinions of her family and some others.
You may choose #1 or #2 above.  I personally don't care how you choose.  But I'm interested in the differences in reasoning and opinions among those who choose #1 and those who choose #2.

"No! Not NARCAN!" Exclaimed the Woman Not Breathing and Being Bagged

I will begin this post with a little anecdote.  It was about ten years ago at Johns Hopkins Hospital and I responded to a "Code Blue" on the step-down unit.  There was a woman, about 30 or 40 years old with several chronic medical problems who had stopped or nearly stopped breathing.  I was at the head of the bed delivering bag-mask ventilation (bagging; using the Ambu-bag, the first responder kinda thing).  We were preparing to intubate (insert a breathing tube into the trachea) the patient when an astute co-fellow, L.R., came on the scene and inquired as to whether the patient might be overdosed on narcotics.  He said aloud "should we try some Narcan?"  (Narcan counteracts the effects of narcotics and can cause arousal of a patient overdosed on them.)  This patient who was comatose, not breathing, and unresponsive in spite of being bagged and poked and prodded by the numerous staff who responded to the emergency, suddenly awakened and exclaimed, vehemently and audibly through the bag-mask ventilation:  "Nooooo!  Not NARCAN!"  Apparently, even a near-death experience is not as fearsome or worthy of arousal as reversal of the effects of narcotic medications.

Healthcare workers will find this amusing for its irony, and I could use it as a segue to a soapbox soliloquy about the dangers of narcotics, but I've already blogged that rant.  Here,  I'm simply using it as a segue to a discussion about the use of Narcan drips in the treatment of overdosed patients.  I was taught during a toxicology rotation in my residency a clinical saw that can be summed up as "If there's an antidote, give it."  Years of experience and reflection have borne out the wisdom of this adage.  Narcan and other antidotes are often benign and as I have discussed in other posts, their benefits even in uncertain cases often outweigh their potential harms enough that they should be given.  Narcan is especially useful when available to heroin addicts, when used by first responders in the field, or when used as a "test" of whether depressed consciousness is due to the effects of narcotics (as part of the "coma cocktail").  But when the decision has been made to admit a patient for observation after an overdose with prolonged effects, the question arises:  should we start a Narcan drip?

Sunday, February 16, 2014

You Are the Hunted: Eat What You Kill Versus the Salary Model (Let Others Do the Killing, My Eats Are Free)

"It's hard to get a man to understand something when his salary depends upon his not understanding it."  - Upton Sinclair

This week, a popular NYT article describes how physicians are flocking to salaried positions in hospitals and healthcare systems in order to preserve their incomes amid reimbursement cuts, and to protect themselves against the vagaries and uncertainties of the healthcare landscape in the age of Obamacare.  For those not used to thinking about physician remuneration, I will give a brief synopsis.  There are basically two models of physician earning, and hybrids of the two.

The "Eat What You Kill" Model
Yes, this is the colloquialism commonly used to describe physician reimbursement in a pure private practice model.  An analogy to hunting for survival, you get to bill for, and keep the collections from, patient encounters that you pursue.  The harder and the more often you hunt, the greater your bounty.  Here are the problems with this model:

Saturday, February 8, 2014

Behind Closed Doors Lurk Proxy Wars: Is Visitation Really About Visitation?

I decided to rewrite this today, on January 30th, 2016, after thinking about it for almost two years.

The previous post took on the heretical task of making the case against wide open visitation in the ICU without restrictions.  I took that stance for several reasons.  First, I'm a heretic and an iconoclast, and I believe that free thinking, rationality, and good judgment and decision making require all angles of a debate to receive their due - my goal is to keep the dialogue fire stoked.  Related to this, I sensed (and still sense) an agenda - open visitation is being pushed for ideological or financial reasons (yes, the almighty dollar - patient satisfaction scores are tied to Medicare reimbursement), professional associations such as the AACN are pushing the issue, and substandard data are being touted to support this agenda.  Next, it was and is my belief that because of the agenda, nurses' (and physicians') dissenting voices are being shamed into a collective hush by The Man, as it were, and that this censorship needed redress on this blog (it got redressed in 60,000 views and over 100 comments to the original post, still visible below.)  Furthermore, this institutionalized censorship may cause pervasive Hawthorne effects in any nursing survey that is done on the topic.  Finally, it was and is my view that if open visitation is the stated goal, there may be subgoals that are driving the desire for open visitation, and satisfaction of these subgoals through other means may be superior to open visitation for making everybody happy.  That is, desire for unrestricted visitation may be the symptom of an underlying disease and treating the underlying cause (such as poor communication) may cure both the disease and its symptoms.

Even if these considerations are cogent, reasonable and rational (which does not mean that they lead to the correct conclusions), there was a significant omission from my train of thought, small hints of which were peeking through from the text.  If some physicians and nurses don't want open visitation, maybe that too is the symptom of a deeper underlying disease that likewise could be addressed in other specific ways - and it thus follows that restricted visitation is not necessarily the solution that their symptoms demand either.