So there was this horrendous story out of Olive View-UCLA where a young gentleman died after spending three hours waiting in an ER. His presenting complaint was chest pain and he died of a heart attack. He was 33.
Grunt Doc’s excellent blog asked “How in the world could this happen?” I commented that “Missing an MI does not make it wise use of resources to investigate every low-probability case.”
It started a vigorous discussion that highlights important aspects of how doctors and nurses, managers and policy-makers view health care differently.
First let me make it clear that Christopher Jones’ death is a tragedy and in no way can his death be condoned, excused or reconciled. My point is that resources are limited no matter what your product and both policymakers and health care administrators need to make difficult resource allocation decisions. In other words, no matter how you want to sugar-coat it for public consumption, rationing must occur in any industry.
We can build the best possible vehicle and make one available to every adult man and woman in the US, but that does not make it any more feasible to afford allocating of those kinds of resources to a single product of such quality. True, there are differences between a critical health care service and a vehicle, and difference in the consequence of lacking access to one or the other. But the cost of preventing this death is not a single EKG. There is a larger context in which a basic economic principle holds true and governs our lives, our jobs and our livelihoods. That we were not taught such economic truths in medical school or nursing school makes them no less true.
First, there is no way to know if Mr. Jones’ wait in the ER was appropriate or not without knowing what else was going on in that specific ER that specific night. Somewhere, a California policy-maker should be asking if the ER was overloaded and why? If it was because of chronic underfunding of public hospitals, the blame lies with the politicos and the crappy level of public debate that I have been complaining about since I started this blog. Dogmatic responses and misinformation does not help resolve the very real problems providers face in that place where the rubber meets the road. Also, ER overbooking may be due to public ignorance leading to misuse of ER resources by an unrealistic populace.
There should also be an administrator looking at the triage situation in this ER. One commenter on GruntDoc described an ER that did not have a private triage area where EKG’s could be done. This is probably unacceptable in a busy inner-city ER. Perhaps triage decisions were made that an acutely ill 80-year needed to be stabilized before the 33-year old could be seen. The moral implications of this decision go far beyond the purpose of this post, but think about it. It is not an easy, cut-and-dried decision if the resources are not there to take care of everyone all the time.
Second, I must bring up some purely clinical issues. I stand by my comment that an EKG on everyone who walks in the door with chest pain is not necessarily a wise use of resources. I have seen 20-year-old have MI’s, but this is not the classic patient. An EKG may be sufficiently sensitive in a higher probability setting, it may not be sufficient to rule anything out in a 33-year old. Risk factors and not the presence of chest pain determines the probability of heart disease. If the EKG is abnormal, the probability of a false positive is also pretty high. This is not an administrative responsibility, but a medical one; this is basic clinical epidemiology. Anyone who neglects pre- and post-test probabilities is practicing cookbook medicine and not creating value for all those health care dollars being doled out. (Yes, I am being a little sarcastic here…)
So there it is. I suspect that there were resource allocation decisions by both policy-makers and administrators that probably contributed to this death. As tragic as it is, not everyone can be saved, nor should we as a society try to save everyone. Then there appears to be a basic misunderstanding of the role of the EKG in triage contributing to the sense of outrage.
My final thought is that if physicians and nurses were left to make the resource allocation decisions, we would necessarily have an expensive solution. Providing for what our patients need is what we were trained to do, it is what we are best positioned to do, it is what we would give away the farm to do. Balancing my training as a physician and my education in policy and management is the fundamental conflict in my life. Shouldn't we all be a little concerned about the bigger picture, despite our built-in internal bias?
13 comments:
ZA-
Until we're able to accept that our health care finances are finite and that the days of "save Grandma at all cost" cannot be sustained, then, and only then will America be prepared for an honest discussion regarding the overt rationing required to sustain our nearly bankrupt healthcare system.
An EKG was not needed to save this man, a system attuned to the patient, rather than the system itself, would have saved him.
Agreed, but how to get the message out with the emotional backlash. I mean, nobody messes with grandma... with good reason.
first i would like to thank you for making the point that an EKG would not have saved this young man. you make a lot of right points about the way this county hospital is being run. an over booked under staffed er is to be blamed for his death. the miss management of Antonovich's jurisdiction has let a breakdown like this occur. the media and antonovich are hiding behind one nurse and making her the scapegoat when the reality is it could have been any nurse in this situation. something much more worrysome was wrong with this patient and an EKG or a strip would not have caught this. now an exemplary nurses reputation is being ruined and her almost 20 year career is in question. any and all county employees should express their concern to antonovichs office directly. a policy needs to be put in place that puts focus on the patient and less on what is written on paper.
Hello,
This situation is another example of the failure of the LA County Board of Health and Supervisor Mike Antonovich to provide quality medical care for the needy citizens of LA County. The triage nurse did nothing wrong. The fact is that the Olive View hospital ER is severely understaffed and under equipped. The day that this man died the Olive View Emergency room was again severely understaffed. They had traveling nurses and registry nurses on duty who are not familiar with policy and procedure-even though these policies are ineffective and corrupt. The fact is that Supervisor Mike Antonovich and the LA County Health department have no concern for the citizens of LA who depend on county health services.
The ONLY reason this is now happening is because someone leaked private information to the press, which in turn miss reported the facts in order to gain ratings.
The fact is that we do not even know if this man had a heart attack. The autopsy report has not even been completed and released.
You ask what we can do.... the answer is to flood Supervisor Mike Antonovich's office with our outrage at his shoot from the hip solution and lack of leadership in changing a corrupt system. It is quite obvious that Mr Antonovich would rather lay blame on a single front line nurse in order to placate the media. He refuses to tell the truth because he is more interested in re-election than the citizens of his extremely large district.
We need to get off our butts and scream at him for what he is doing. We need to flood his office with calls, letters, and e-mails letting him know that we know he is pulling the wool over our eyes by ruining the career of a highly accredited nurse on the front lines. He is hiding behind the skirt. We must ALL let him know that we are outraged and will not stand for this anymore.
The triage nurse is innocent. The doctors involved are innocent, and we the citizens of LA County are sick and tired of a lying County Supervisor. There is nothing wrong with telling us the truth. We CAN handle the truth. We are tired of the lies and corruption within the LA County Supervisors office.
If all concerned citizens would take just five minutes to contact his office letting him know, that we know, he is using this nurse as a scapegoat and avoiding the real issues. The politicians and County Health Care Administrators are so highly paid that they have been corrupted and can only think about their exorbitant incomes and damn the citizens whose lives literally depend on county health care.
It has come to the point that our fine nurses and doctors on the front lines are literally scared to practice medicine. We cannot let this continue. Our nurses and doctors need to be able to practice medicine in an environment where fear of frivolous litigation is not present. They need more staffing and more resources but Mike Antonovich would rather keep the status quo.
Enough is enough. WE need to change the system and not be afraid of these elected officials.
I ask that all concerned citizens contact Mike Antonovich. Contact information is on his web site and the web site for the LA County Board of Supervisors. Do NOT let this go.
I am constantly reminded of the ration argument and how ridiculously skewed our american system is in terms of resource allocation.
I shivers me to think of the tracheostomies and gastrostomies being performed on 95 year old patients because their POA insists on it. It shivers me to think of the weeks and weeks of hospital time and resources consumed to save at all costs. It shivers me to think of all the resources consumed in the post hospital 24 hour care facilities.
We were reminded that our state laws did not allow a legal ground to stand on by refusing to perform these heroic measures at the insistence of the POA. Futility does not count in our court of law.
I shiver when I think of the amount of money spent by state and federal entities that could have provided 1000's of immunizations or free health care clinics for children, that instead went into saving our end of life citizens.
How do you change the system. Bankrupcy is upon us.
Dear Anonymous,
My name is John Carlson I am the person who took Chris Jones to the hospital that day. So I have first hand knowledge of what happend and who is to blame. Chris Jones died of an untreated heart attack at a hospital emergency room, where you would think he would get care. He was complaining of severe chest pain, pain going down his left arm, shortness of breath, uncontrolable shaking of the legs. His family history is of both parents having heart desease at young ages. With all of this info I knew he was having a heart attack people in the waiting room knew he was having a heart attack, but not the nurse that checked him! Now you say quit blaming the hospital and the nurse well then why do they have this job? You say the only reason of this is because someone leaked private information....well i have news for you it was someone from the hospital staff that called the los angeles times and reported this wrongfull death...not the family. Explain how? I do agree that firing the nurse was just covering their own behinds but if I didn't perform my job up to par I would expect to be fired also..how many times does someone have to explain to you that he is having a heart attack and give you all the classic information of a heart attack before you take reasonable action to prevent that person from dying. On the drive to Olive View I told him that Verdugo Hills Hospital was only 15 minutes away but he in his owm mind must of known he couldn't make it the extra miles....too bad isn't it that he still had to sit for 3 hours plus before his heart finally gave in? Lets just hope when someone you care about has to go to the emergency room that the nurse on duty performs their job correctly and compationatly and you will not have to bury that person because of neglect of duty!
John, thank you for sharing this information. I am sure there are many more details to come. Chris' death is a tragedy and certainly one which is difficult to understand and difficult to accept.
My original purpose was to focus on big picture policy issues and some clinical facts that seemed to have been neglected in the various blog discussions.
I can only imagine how my comments and the comments of my readers can ring hollow at a difficult time for you, your friends and your family. It is not my intent to distract you from your grief or give you more stuff to fret over.
I only pray that all the information comes out in the wash and there is some closure for the family. I also hope we can learn enough to set up a system for things like this not to happen again.
I deleted an anonymous comment this morning which was potentially offensive in tone to a grieving family.
I have posted an edited version of that comment and expanded on my own thoughts.
http://executivephysician.blogspot.com/2007/11/follow-up-on-la-heart-attack.html
I have deleted yet another comment...
This is not a forum in which people vent their spleens at the expense of grieving families. I will close commentary on the entire blog rather than allow such vile comments.
PERIOD.
In response to Mr. Carlson's statement.
I am a cardiac patient fully dependent on the facilities of the County of LA. I have had three major heart attacks, I have stents in every major artery of my heart. My heart muscle has been damaged to the point that I now have to have an internal defibrillator because my heart has a habit of stopping now and then. This means that I use County facilities on a monthly basis in order to stay alive. When I had my first MI I was taken by ambulance to a private hospital as it was the closest facility and time could not be wasted to take me to the nearest county facility which was 30 minutes beyond this private facility. I told them I had no insurance. The hospital therefore only tried to stabilized me, which took two days, then they transferred me to Olive View hospital. Olive view hospital where I was taken initially from the private hospital, has a cath lab but can only use it to determine if there is a coronary artery blockage. They cannot do an angioplasty to alleviate the blockage. Why? They have NO Cardiac Doctor on staff. Therefor they air lifted me by helicopter to county USC hospital. After two months of at home recovery I felt strong enough to make calls to the LA County Board of Health to question why Olive View could not perform the life saving technique called angioplasty. I was told that they did not have the resource funds. I retorted that Olive View serves a large percentage of Northern LA County residents and that I felt it was critical they have the necessary facility and Cardiac Doctors on staff to save lives. I was referred by the Health Dept to the County supervisors office as they are the ones who allocate the funds. Their response was uncaring. They blamed it on the budget. They told me it would cost millions of dollars to equip and maintain such a facility at Olive View. With all the mismanagement throughout the County Supervisors office-from health care to schools and on-I explained to them that I felt a system wide review needed to take place. They responded that such a review in their opinion was not necessary and that, again it was a matter of a lack of funds.
Many good points have been addressed in this blog. I feel that the general consensus is that the triage nurse who was fired was not to blame. As others have stated, how can one individual cause this man to die. I know from a multitude of personal experiences as a patient at Olive View that all patient charts are reviewed by several medical professionals after the initial triage. I will also say that after literally hundreds of visits to Olive View I have always been treated with the utmost care and professionalism by all the staff. The reality here is the failure of an uncaring system headed by the LA County Supervisors. In every aspect of the Supervisors office there is failure. As I mentioned it is not only health care but our schools and all public services that are under the supervisors auspices.
In the cases of heart attack and cardiac arrest, or any other heart shocks, time sets to be the most crucial factor for the survival of the patient. Sometimes, a little knowledge regarding the immediate actions to be taken may help your near and dear ones to survive in such incidents. Keith Churchwell has extraordinarily explained the pros and cons while handling patient suffering immediate heart attack or cardiac arrest. The response a person takes to treat a victim decides the probability of his/her survival. Its been my personal experience fighting to survive against a heart attack. A quick recognization of your bodily responses may increase your chances of survival. Because of having many heart problems, I was enrolled in a concierge Healthcare program from elite health. I was attacked by a severe heart attack in a party, luckily surrounded by many people. Some of the sudden changes in my body was recognized by me and anticipated immediately. I got a very severe chest pain which was almost unbearable for more than a minute. I got the suspicion that I might be having heart attack, and immediately called my physician on the phone, and explained my condition and its severity. Because of the immediate guidance, I was directed immediately to have an aspirin which I used to carry with me as prescribed by my physician. It was quite a frightening experience for me to face such a heart attack, but somehow I managed to be calm until 911 arrived. I was immediately taken to the nearest hospital, where already my physician were present and have got everything setup according to my medical history. And it was in some matter of seconds that everything was in control. A doctor, who already have the complete knowledge of the medical history and fitness of the person, extra ordinarily ameliorate your recovery process. Hence such a concierge level program from Elite health, helped me a save my life, like many others.
Heart Failure
Damage to heart muscle from a heart attack may leave the heart unable to pump effectively. If 30 percent or more of the heart muscle in the wall of the left ventricle has been affected, it is likely the patient will develop congestive heart failure.
These patients may experience shortness of breath because of fluid in lung airways. This is caused by the fact that the heart cannot effectively pump blood forward through the body. This condition can usually be treated effectively with medications but may require cardiac bypass surgery.
The American Heart Association and other medical experts say the body likely will send one or more of these warning signals of a heart attack:
# Uncomfortable pressure, fullness, squeezing or pain in the center of the chest lasting more than a few minutes.
# Pain spreading to the shoulders, neck or arms. The pain may be mild to intense. It may feel like pressure, tightness, burning, or heavy weight. It may be located in the chest, upper abdomen, neck, jaw, or inside the arms or shoulders.
# Chest discomfort with lightheadedness, fainting, sweating, nausea or shortness of breath.
# Anxiety, nervousness and/or cold, sweaty skin.
# Paleness or pallor.
# Increased or irregular heart rate.
# Feeling of impending doom
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