Health Train Express

Friday, March 13, 2020

Health Care Social Media

Dr Damian Roland (pictured), Honorary Senior Lecturer in the Department of Health Sciences, has won an international award for his research into social media and healthcare.

The consultant in pediatric emergency care at Leicester’s Hospitals has been awarded first prize in the Stanford Medicine X | Symplur Signals Research Challenge 2015 and will present his work to the Medicine X conference at Stanford University in California on Sunday 27 September 201

Doctor wins international award for social media and healthcare research — University of Leicester

The Challenge is a joint venture by Stanford University and healthcare social media analysts Symplur. The competition aims to encourage research into social media, healthcare and the benefits this can offer to patients.

Dr Roland, who is part of the SAPPHIRE (Social Science APPlied to Healthcare Improvement REsearch) group teamed up with Dr Daniel Cabrera, of Mayo Clinic College of Medicine, and Jesse Spur BN, of the Royal Brisbane and Women’s Hospital, to secure the top prize. The trio impressed judges with their research which used social media analytics to interrogate Twitter data and give credence to an online healthcare community – to the extent that it can be defined as a community of practice.

The team focused on the Free Open-Access Medical education (FOAM) community of healthcare professionals who collaborate online to share knowledge. They interrogated the Twitter #FOAMed hashtag using the Symplur Signals analytics tool.

Sir William Osler, one of the first progenitors of Social Media

Dr Roland said: “The analytics showed millions of impressions recorded over a set period and also revealed it is a community that is growing. The #FOAMed community has proved very popular and uses the power of social media. It is truly what a community of practice can be defined as. It shows that through Twitter healthcare professionals are educating each other and this is benefiting the patients they work with.”

FOAMed slide deck

Why FOAM?... Facts, Fallacies and Foibles

1. FREE OPEN ACCESS EDUCATION
2. h"p://lifeinthefastlane.com/foam/
3. h"p://www.kevinmd.com/blog/2013/03/ﬂipped-‐classroom-‐future-‐medicine.html
4. “…and to teach them this art — if they desire to learn it — WITHOUT fee and covenant” h"p://lifeinthefastlane.com/from-‐Hippocrates-‐to-‐Osler-‐to-‐foam/
5. Photo from h"ps://www.mcgill.ca/library/branches/osler/oslerbio
6. Taking the world by STORM (in a small way) Photo by JD Hancock
7. 230 EMCC blogs in 24 Countries h"p://lifeinthefastlane.com/emcc-‐blog-‐update-‐2013/
8. IT KEEPS GETTING BIGGER… >30,000 page views daily
9. Your students will leave you behind
10. FOAM = Social Media
11. FOAM = Social Media
12. FREE OPEN ACCESS EDUCATION
13. A waste of Mme?
14. Photo from smacc.net.au
15. #Hashtags #FOAMed #FOAMcc #smaccGOLD
16. #smacc2013
17. No Peer Review = Bad?
18. Image from http://rationally speaking.blogspot.com.au/2012/01/radical-‐reform-‐for-‐peer-‐review.html
19. Publish then Filter
20. Translate and disseminate knowledge
21. Source unknown
22. Flip the Classroom h"p://lifeinthefastlane.com/2009/07/web-‐20-‐for-‐emergency-‐physicians/
23. That’s just in time…
24. Tacit knowledge sharing Photo credit: Stefan
25. Nothing replaces the bedside mentor Photos of Sir William Osler from www.collecMonscanada.gc.ca
26. License Image credit: zipckr
27. Filter Failure https://litfl.com/
28. “I don’t have time not to use social media” Bertalan Mesco https://litfl.com/
29. CAVEAT EMPTOR Think rationally
30. Lobotomise, blood let, and perform EGDT!
31. A jackass in the real world will be a jackass online Photo by public energy
32. Photo by MisterSnappy
33. Photo from The Matrix
34. TO GET #FOAMed
35. https://litfl.com/
36. http://googlefoam.com
37. h"p://iteachem.net/2013/06/ten-‐Mps-‐for-‐foam-‐beginners/
38. InfoamaMca.org
39. It is up to us to save the world! The 22nd of Peter Safar’s Laws for the Navigation of Life https://litfl.com//2009/04/laws-‐for-‐the-‐navigation-‐of-‐life/ https://litfl.com//2009/04/laws-‐for-‐the-‐navigation-‐of-‐life/

Wednesday, March 11, 2020

Coronavirus: Extraordinary Decisions For Doctors - The Atlantic

Will it come to this?

One week ago, Italy had 2,502 cases of the virus, which causes the disease known as COVID-19. At that point, doctors in the country’s hospitals could still perform the most lifesaving functions by artificially ventilating patients who experienced acute breathing difficulties.

Today, Italy has 10,149 cases of coronavirus. There are now simply too many patients for each one of them to receive adequate care. Doctors and nurses are unable to tend to everybody. They lack machines to ventilate all those gasping for air.

There are now simply too many patients for each one of them to receive adequate care.
Now the Italian College of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) has published guidelines for the criteria that doctors and nurses should follow in these extraordinary circumstances. The document begins by likening the moral choices facing Italian doctors to the forms of wartime triage that are required in the field of “catastrophe medicine.” Instead of providing intensive care to all patients who need it, its authors suggest, it is becoming necessary to follow “the most widely shared criteria regarding distributive justice and the appropriate allocation of limited health resources.”

The principle they settle upon is utilitarian. “Informed by the principle of maximizing benefits for the largest number,” they suggest that “the allocation criteria need to guarantee that those patients with the highest chance of therapeutic success will retain access to intensive care.”

The authors, who are medical doctors, then deduce a set of concrete recommendations for how to manage these impossible choices, including this: “It may become necessary to establish an age limit for access to intensive care.”

Those who are too old to have a high likelihood of recovery, or who have too low a number of “life-years” left even if they should survive, will be left to die. This sounds cruel, but the alternative, the document argues, is no better. “In the case of total saturation of resources, maintaining the criterion of ‘first come, first served’ would amount to a decision to exclude late-arriving patients from access to intensive care.”

In addition to age, doctors and nurses are also told to take a patient’s overall state of health into account: “The presence of comorbidities needs to be carefully evaluated.” This is in part because early studies of the virus seem to suggest that patients with serious preexisting health conditions are significantly more likely to die. But it is also because patients in a worse state of overall health could require a greater share of scarce resources to survive: “What might be a relatively short treatment course in healthier people could be longer and more resource-consuming in the case of older or more fragile patients.”

These guidelines apply even to patients who require intensive care for reasons other than the coronavirus because they too make demands on the same scarce medical resources. As the document clarifies, “These criteria apply to all patients in intensive care, not just those infected with CoVid-19.”

But if Italy is in an impossible position, the obligation facing the United States is very clear: To arrest the crisis before the impossible becomes necessary.

This means that our political leaders, the heads of business and private associations, and every one of us needs to work together to accomplish two things: Radically expand the capacity of the country’s intensive-care units. And start engaging in extreme forms of social distancing.

The Shortages May Be Worse Than the Disease

Over the centuries, societies have shown a long history of making the effects of epidemics worse and furthering their own destruction.

Cancel everything. Now.

Coronavirus: Extraordinary Decisions For Doctors - The Atlantic:

Tuesday, March 10, 2020

COVID-19 and the Strategic National Stockpile

Federal public health officials warned Tuesday that the spread of coronavirus in the U.S. is "inevitable.

As the nation faces increased strains on its public health workforce from the COVID-19 outbreak, a new report examines the makeup of the U.S. public health workforce. This new primer describes the current public health workforce size, expectations for growth, employee demographics, job tenure, and the skill sets most in demand. This description is offered against the broader backdrop of the overall state and local government sector.

The U.S. government has a secretive, $7 billion stash of emergency medical equipment — one that it drew on to respond to the terror attacks of 9/11, to prepare for a subsequent threat of anthrax attacks in 2001, and to help thousands of homes guard against Zika with insecticide.

The outbreak of the novel coronavirus, however, marks the first potential pandemic to reach U.S. soil since the H1N1 flu of 2009, teeing up one of the biggest challenges yet for the 21-year-old store, known as the Strategic National Stockpile.

Already, the outbreak has placed a significant strain on the stores of masks, medicine, and medical equipment. The stockpile has been called on to help with efforts to repatriate and quarantine Americans flown back from China and Japan, but has come under fire for a perceived shortage of masks — and for allowing millions of masks already in its stock to pass their expiration dates.

In past disasters, the SNS has provided resources. The timeline is shown below

Today, the Strategic National Stockpile works with governmental and non-governmental partners to upgrade the ability to respond to a national public health emergency, ensuring that federal, state, and local agencies are ready to receive, and stage and distribute products.

Since its beginning, the stockpile has responded to multiple large-scale emergencies including floods, hurricanes, and influenza pandemics. It has also supported various small-scale deployments for the treatment of individuals with life-threatening infectious diseases like anthrax, smallpox, and botulism.

Still, public health officials have criticized the stockpile for, in some cases, failing to act with sufficient urgency. After officials in Washington state requested 233,000 respirator masks, the stockpile initially offered to supply less than half the amount, the Washington Post reported. An SNS spokeswoman said the state eventually received the full requested shipment.

And the store has already proven valuable in other areas, Adams said. Beyond sending masks to hard-hit states, the stockpile helped with efforts to bring Americans in China and Japan back to the U.S., supplying protective equipment for medical workers who monitored the Americans’ health during their stays on military bases. That effort largely relied on materials stored in SNS warehouses but maintained by the National Disaster Medical System, a separate emergency medical-supply distribution network.

“We were quite involved with moving matériel to support the repatriation of State Department [employees] and other Americans from China, and then a follow-on mission of doing so from Japan,” Adams said.

Adams added that the stockpile has since “transitioned into providing support to what some would call ‘hot spot areas,’ states where they’re actively managing large numbers of patients with COVID-19,” the respiratory disease caused by the coronavirus, namely by shipping respirator masks to hard-hit regions like the Seattle metropolitan area.

Coming at a bad time there are ongoing changes for the NSP which hindered a quicker response

A spreadsheet detailing the spread of Covid-19 on a cruise ship

My first physician colleague who died by suicide

There is a lot more work to be done to de-stigmatize seeking help for those struggling with mental health issues.

How many doctors commit suicide each year?

It is estimated that every year

400 physicians take their own life

Also in Audio Format

I was busy running around the ER on a particularly busy shift when my phone buzzed, and a text message from Jane’s ex-boyfriend David popped up on the screen. I was surprised since I had not talked to him in over three years; therefore, I ignored it until I had a moment to myself an hour later and finally opened the message.

The first line of his message got straight to the point.

“Hey, I just learned that our friend Jane tragically died a short while ago, and I thought you deserved to know.”

I read this line several times, hoping I had misread something, hoping this was a mistake. However, after a phone conversation with David a short while later, I learned that Jane had committed suicide.

I was not only devastated by this news, but I also felt trapped in a permanent state of melancholy for weeks. Jane had been not only my first close friend to commit suicide, but also my first colleague in medicine to do so.

To me, and everyone who knew her, she was extremely hardworking, compassionate, and brilliant. Since she always appeared happy and upbeat on the surface, people would never assume that she was actually struggling internally.

Jane was someone I strongly felt was bound to change the world and would be lauded on International Women’s Day, yet in a tragic irony, I found out about her death on International Women’s Day.

She worked tirelessly to overcome the grueling trenches of medical school and countless microaggressions as a woman of color in a surgical field in order to earn a spot in one of the most coveted surgical subspecialty residencies where she was a star.

Jane’s story is tragic; however, the reality is that her story is not unique in medicine, especially amongst trainees. Although Jane was my first physician colleague to commit suicide, she will certainly not be the last. A recent study estimated around 400 physicians commits suicide per year. Amongst medical trainees, suicide is more prevalent than it should be. The American Foundation for Suicide Prevention (AFSP) reports that 23 percent of interns (first-year residents) have suicidal thoughts. Additionally, they also report that 28 percent of residents in the U.S. experience a major depressive episode during residency compared to 7 to 8 percent of those in a similar age range in the general population.

What I have learned about Physician Suicide

My first physician colleague who died by suicide:

Friday, March 6, 2020

The Novel Corona Virus Story

Months after being shuttered following an outbreak of a new strain of coronavirus, the Wuhan wet market was torn down Tuesday.

China was less than transparent about the COVID-19 epidemic. It is difficult if not impossible to compare China's public health program compared to the United State's program.

When did Chinese officials realize there was a new viral outbreak? Even today the number of cases seems ridiculously low for a country of 1,408,526,449 people. The last reported figures for COVID-19 (as listed on the Johns Hopkins tracking and mapping tool reported 80,500 cases in mainland China.

Did we see this coming?

The reporting of case rates in the media is subject to extreme doubt as to veracity.

Given the fact that China is a huge country with a huge population and the fact that communications outside of metropolitan having poor internet access and an unknown amount of technology, it is possible that early cases were missed and under-reported. China does not allow freedom of the press and is able to suppress news it deems harmful to the ruling communist party. However, In large metropolitan communities, there is an international presence, which is free to report the unvarnished truth.

The Chinese story became public knowledge became known in the international community in January 2020. The influenza season in the United States often begins in early September. From known influenza outbreaks, we know it takes several weeks or months to realize a new viral strain has appeared. Assuming the infection took hold in September 2009 and it did not become public knowledge until mid-January 2020 there was a 3.5 month lag in China reporting. The infection rate increased during that period in an unknown fashion.

There is no factual information that the COVID-19 outbreak actually began in Wuhan, China. It may have begun in another city or even another country in Asia.

The Chinese offered the 'Wet Market" in Wuhan as ground zero for COVID 19. This is a city of 1 million people, and 80,000 cases is a paltry number to declare an epidemic for a country of 1.5 billion people.

The trust index between China and most of the rest of the world is abysmally low. We do not believe them and they do not believe us.

The World Health Organization is the only credible source for data.

The United States team of CDC and HHS are powerful teammates. Their reaction was swift and accurate (according to Secretary of HUD, Ben Carson M.D who headed up the Johns Hopkins University Department of Neurosurgery. (in a previous life) In a non-partisan interview, he gave great credit to the CDC and HHS.

In California and Washington State Governors have declared a state of emergency. If and when needed they will have the authority to shut down schools, businesses, transportation to areas that are actively infected.

If needed this would be instituted in a progressive fashion for affected areas.

China Responds to Virus Investigation Demand by Demolishing 'Ground Zero,'

Months after being shuttered following an outbreak of a new strain of coronavirus, the Wuhan wet market was torn down Tuesday, journalist Jennifer Zeng reported. China’s communist government claims the location was ground zero for the deadly outbreak now coursing around the world. Meat from exotic animals is suspected to have been contaminated by the virus, which made the jump to humans in the unsanitary conditions of the market.

World Count COVID19 March 1, 2020

After infecting market patrons, the speed and ease of modern transit guaranteed the disease would soon begin popping up all over the planet.

Not everyone is buying China’s official story, however. Arkansas Sen. Tom Cotton has hinted at a “super laboratory” in Wuhan — a reference to the high-security bio lab in the city — as a possible point of origin for the contagious disease. Arkansas Sen. Tom Cotton has hinted at a “super laboratory” in Wuhan — a reference to the high-security bio lab in the city — as a possible point of origin for the contagion. This is highly speculative at best.

The situation is also obscured by political motives. According to Sen. Marco Rubio of Florida, Russia doesn’t seem to be buying China’s claims of a random outbreak.

“American officials have noted the existence of networks of thousands of social media accounts, many reportedly Kremlin-tied, with identical posts, publishing messages claiming that the virus is meant to ‘wage economic war on China’ and propagate ‘anti-China messages,'” Rubio wrote in a Tuesday Op-Ed for the New York Post.

Iran isn’t totally convinced of the official Chinese story either, instead claiming that the virus is the result of biological warfare.

Gholam Reza Jalali, the head of Iran’s Civil Defense Organization, told Fars News Agency that the virus’ effects and the panicked media coverage mean it could be a “biological attack” meant to destabilize the economies of Iran and China.

We may never know, one thing is for certain this strain will comix with other previous COVID strains and become a new seasonal illness. Community immunity will increase and by next year there may be a vaccine.

Wuhan Fish Market (Video)

Reclaiming Death:

Those Advanced directives we are all asked about each time we are admitted to a hospital. For me, it is not at all reassuring to be asked that question. It is only slightly less than asking "Where shall we send the body ?" I always ponder a silly answer, such as 'beam me up, Scotty". The title "Advanced Directive" is a subterfuge, as well. It is one of those papers you sign at the hospital, designed to save expenses. It is a very objective thing for a very subjective circumstance. In today's world, it has been enumerated into categories, ranging from disconnecting a ventilator if you are brain dead or have little chance of surviving a fatal illness such as cancer, multiple sclerosis. It is also a good chance it will never be read if you are admitted in a coma, or unable to respond. If someone is with you there is also a good chance they do not know if you have one.

When we talk about death what we’re really talking about is life.” – Dr. Dawn Gross, host of the radio show “Dying to Talk”

“What happens when you die? That to me is the only thing really that’s of any importance.” – George Harrison

What about those patients who want to accelerate their trip from existence to the unknown, due to extreme pain, or symptom they cannot bear?

For those who are not in extremis, walking around there is another option. California’s End of Life allows doctors to prescribe life-ending drugs for terminally ill patients who must meet strict guidelines and follow lengthy procedures before taking the medicine themselves.

The law is the culmination of decades of efforts that peaked when Brittany Maynard moved from California to Oregon, where she availed herself of a similar law just before her 30th birthday in 2014. Her death sparked a national debate and an explosion of proposed state legislation.

On the surface, California’s law is the latest headline in a growing national movement towards the kinder, gentler end of life care.

Guidelines have been published to assist doctors and patients who agree on 'assisted death. There are 4 main types of euthanasia, i.e., active, passive, indirect, and physician-assisted suicide

Yet the End of Life Option Act is much more than that.

It’s another step towards overthrowing a system in which doctors — even religious leaders – tell people how to live and die.

In my opinion, it is a good thing for all concerned since the patient is making his/her desire known. It affords legal protection for all concerned especially if the family disagrees.

It’s a conflict summarized by Stanford longevity expert Dr. Walter Bortz II in his book “We Live Too Short and Die Too Long.” Dr. Bortz makes some interesting comments about longevity.

Legality:

Not all states have laws protecting physicians and/or patients from legal repercussions.

States which have formalized the process

Right to Die in Oregon

A Doctor's Perspective

The right to die in Belgium: An inside look at the world’s most liberal euthanasia law

In California, the patient must self inject the drug, California law prohibits physicians from injecting the medication. The medical records must be reviewed by two other physicians.

This all leads to a single question — how do we want to die?

Many Americans have decades to answer that question,

As a quick overview, 258 people started the end-of-life option process by speaking with two different physicians at least 15 days apart, according to the data released by the California Department of Public Health this July. Of these patients, 191 had prescriptions written for aid-in-dying drugs between June 9, 2016 and December 31, 2016. Physicians reported that 111 of the patients died following the ingestion of the drugs.

Reclaiming Death: California’s End of Life Option Act – California Health Report:

Infection Control Protects Hospital Staff From COVID-19

Wider screening criteria and enhanced anti-infection measures resulted in no coronavirus infections among healthcare workers, despite treating 42 patients with confirmed coronavirus

Hospital-related infections have been widely reported during the ongoing coronavirus outbreak, with healthcare professionals bearing a disproportionate risk. However, a proactive response in Hong Kong's public hospital system appears to have bucked this trend and successfully protected both patients and staff from SARS-CoV-2, according to a study published online today in Infection Control & Hospital Epidemiology.

The Hong Kong success story may be due to a stepped-up proactive bundle of measures that included enhanced laboratory surveillance, early airborne infection isolation, and rapid-turnaround molecular diagnostics.

Proactive Bundle

The Hong Kong success story may be due to a stepped-up proactive bundle of measures that included enhanced laboratory surveillance, early airborne infection isolation, and rapid-turnaround molecular diagnostics. Other strategies included staff forums and one-on-one discussions about infection control, employee training in protective equipment use, hand-hygiene compliance enforcement, and contact tracing for workers with unprotected exposure.

In addition, surgical masks were provided for all healthcare workers, patients, and visitors to clinical areas, a practice previously associated with reduced in-hospital transmission during influenza outbreaks, the authors note.

Hospitals also mandated the use of personal protective equipment (PPE) for aerosol-generating procedures (AGPs), such as endotracheal intubation, open suctioning, and high-flow oxygen use, as AGPs, had been linked to nosocomial transmission to healthcare workers during the 2003 SARS outbreak.

As the outbreak evolved, the Hong Kong hospitals quickly widened the epidemiologic criteria for screening, from initially including only those who had been to a wet market in Wuhan within 14 days of symptom onset, to eventually including anyone who had been to Hubei province, been in a medical facility in mainland China, or in contact with a known case.

All suspected cases were sent to an airborne infection isolation room (AIIR) or a ward with at least a meter of space between patients.

"Appropriate hospital infection control measures could prevent nosocomial transmission of SARS-CoV-2," the authors write. "Vigilance in hand hygiene practice, wearing of surgical mask in the hospital, and appropriate use of PPE in patient care, especially [when] performing AGPs, are the key infection control measures to prevent nosocomial transmission of SARS-CoV-2 even before the availability of effective antiviral agents and vaccine

Infection Control Protects Hospital Staff From COVID-19: