An emergency physician stops at a roadside accident. He finds out he's not needed.

This blog post was carried in The Health Care Blog. THCB is the oldest, most active #hcsm blog. It features outstanding blogs and is produced by KevinMD

Although Dr. Edwin Leap posits he is not needed at these accident scenes, in my  opinion he has a skewed point of view, as an emergency physician somewhat jaundiced and perhaps naturally 'burned out' after a long successful and ongoing career in emergency medicine.

Let me tell you a story. On a long stretch of highway in a desert I happened upon a catastrophic accident involving three vehicles in the middle lane of the I-10 freeway. I was with my family, my wife and three sons (ages 10-15).   Traffic was speeding through the area at about 80-90 miles/hours. We were the first to arrive on the scene. The actual accident was visible to us as it occured.  I quickly intellectualized events and objectively decided to not stop and go on to our destination.



My  spouse who used to be a nurse confronted me and said 'Stop and see what you can do". Under threat of being divorced I complied. She, a nurse, and is a much better 'caregiver' than I could ever be. Nurses really do care, not just how to care or be a caregiver. She has a need to 'care'  As a physician I have a need to diagnose and treat (only one half the equation of a true healer).

Fortunately I listened to her.

I stopped and realized I was a 'first responder'.  From the side of the freeway I could see three bodies in the middle of the freeway. It was a dangerous situation for anyone.  I stood there on the side of the freeway waiting for a break in traffic. I immediately called 911

The EMT's arrived in less than 4 minutes. Fortunately although we were in a relatively isolated stretch of freeway a regional California  Higway Patrol Station was less than two miles away. It included as squadron of fireman/emt's.

As they arrived they cut off traffic (3 police cruisers, roar onto the freeway and get ahead of the cars coming down the road.

One proceeded ahead to the accident scene to coordinate their plan.  I was duly impressed, and glad I did not run into the freeway to help ( A dead me couldn't  do much)



There were three people on the highway.  Going from best to worst was a very pregnant (full term)  woman who was concious but drifting in and out of conciousness.  The second was an elderly gentleman who had been thrown out of a vehicle landing on the side of the road.  The third person lay in the median divider, crumpled head and neck twisted 180 degrees, large gash from front to back on the top of her skull, blood coming out her ears, nose and  mouth.  Her chest was crushed, she had no vital signs or reflexes with fixed, dilated pupils.

The police and EMT's asked if they should begin CPR.

The unfortunate lady was dead and the chances of a successful resusication were meager.  Besides the severitiy of blunt traume, a nearly open skull wound, and full cardiac arrest compounded her no chance of survival.

I instructed them to forget her and be attentive to the pregnant lady and the roadside victim. My assessment was she had a living baby, her vital signs were good...she had not yet gone into shock, and she had a live baby (  I happened to have my stethoscope in my car)  The uterus was quite tense....labor had begun.

I hailed down one of the on the scene highway patrol officers and told them to get a helicopter immediately....Again good fortune. The CHP station was about 1 minute from the accident site, and the helicopter was there.  Both sides of the freeway by now were closed down.  As the helicopter descended they asked me what hospital to take her to. There were three in the area, and having been on the staff at all three I chose the level 3 emergency department.  She was at the emergency department in about five minutes.

What did I do ? Nothing and everything.

By  the way I am an ophthalmologist for the past 25 years. I was a general medical officer in the Navy from 1969-1971 during the  height of the Vietnam conflict about the time of the 'Tet Offensive. You millenials will have to 'google' that one.

I ran a Navy MASH unit and I knew how to triage....as does Dr. Leap.  I did general practice for five years prior to specializing. This scene brought me back to that time.  While I did not physically perform I was able to triage and organize priorities which gave confidence to the first responders who do not have authority to make life and death decisions about CPR, administering oxygen. There immediate response is to treat unless told otherwise by a licensed M.D.

I think it was 'The perfect storm'......a good one with incredible timing and combination of EMTs police, and perhaps me, although I won't claim it.

Had I been five seconds earlier I would have missed it and been unable to respond at all.

I am not at all critical of Dr. Leap. He is far more qualified than I in the subject of emergency care.

No one can second guess these situations. There is no 'preferred practice pattern'..

As for me, my 3 kids were in the car.....they saw it all, and came to their own conclusions about the accident.  They were late to the birthday party, but will never forget what happened, and that I did stop to render aid.

I still don't really know what they thought at the time. None of them chose to follow in my footsteps as a physician.....their career now is computer science and engineering.

How the world changes !





An emergency physician stops at a roadside accident. He finds out he's not needed.

Health Reform: House Can Sue Administration

Implementing Health Reform: House Can Sue Administration Over ACA Cost-Sharing Reduction Payments (Sept. 10 Individual Market Update)

Following the  SCOTUS decision that the ACA meets constitutional standards, the House of Represenatives (Republican majority) continues it's course of amending or repealing 'Obamacare'

On July 30, 2014, the House voted along party lines to file a lawsuit challenging the President. Twice private counsel that it hired to bring the case resigned, but the House finally succeeded in engaging Jonathan Turley, a conservative professor at George Washington University, to file the action.

The legal situation becomes complex in regard to the constitutionality of certain portions of the Affordable Care Act.

In a Republican dominated House of Representatives another attempt is being made in regard to the legalitiy of the ACA subsidies funded out of the general treasury.  

Background

This lawsuit originated in an attempt by the House of Representatives to hold President Obama responsible for what it views as abuses of presidential power. Since 2010, the House of Representatives has been held by a substantial Republican majority. The House has been at loggerheads with the President on many issues, but in particular on health care reform. The House has voted over 50 times to repeal the President’s signature policy initiative, the ACA.

Frustrated by the difficulty of implementing an incredibly ambitious and complicated law, and by the unwillingness of Congress to help by adopting technical amendments, the administration has on a number of occasions acted unilaterally to make adjustments it believes to be necessary to implement the law. It has also interpreted the law differently than the House. The House has taken strong exception to what it perceives as actions in excess of presidential authority and in violation of the law. In 2014, the House decided to call upon the judiciary to aid it in its disputes with the President.

The Issues

The complaint, filed on November 21, 2014, focused on two issues: the decision by the administration in 2013 to delay the implementation of the employer mandate for a year, and the funding by the administration of the ACA’s CSR payments, arguably without an explicit appropriation.

The ACA offers low and moderate-income Americans premium tax credits to help make insurance affordable. These are offered through the tax system and are funded through a permanent appropriation for tax refunds. 

The CSRs are obviously not free. The ACA requires the Treasury to reimburse insurers that reduce cost sharing for eligible individuals and families as they are required to do. This reimbursement is made on a monthly basis. The House, however, claims that Congress failed to include an explicit appropriation in the ACA to cover these costs, and has not appropriated funds to cover the cost of the CSRs since the ACA was adopted. Indeed, as Judge Collyer notes, the administration requested an appropriation to cover the CSRs in 2013, which was never acted on. (The administration claims that it decided no appropriation was needed).

The Constitution provides at article 1, section 9, clause 7: “No Money shall be drawn from the Treasury, but in Consequence of Appropriations made by Law . . . .” The House claims that since no money has been appropriated for the CSR payments, they are unconstitutional.

This is not a trivial matter. If the CSR payments to insurers stopped, the insurers would still be legally required to reduce cost sharing—at a cost of $5 billion this year and $136 billion over the next ten years without reimbursement. Burdened with this cost without reimbursement through the CSR payments, many insurers would cease to offer marketplace coverage. Those that remained would have to raise rates dramatically to ensure solvency. Although much of the increase would be covered by the premium tax credits for low-income individuals, higher-income enrollees could face unsustainable increases. This could well put the marketplaces into a death spiral, where healthy people would drop coverage leaving only high cost patients behind.

Judge Collyer’s Opinion

After the filing of the case, the administration moved to dismiss the complaint for lack of standing. The plaintiffs, on the other hand, moved for a judgment in their favor on the legal issues. Judge Collyer asked the parties to first brief the motion to dismiss, and the September 9 decision addresses this motion.

Her opinion is long and very technical. She focuses on three issues:

• Does the House have standing to challenge the administration’s actions (that is, has the House been injured in a particular way by those actions)?
• Does the House have a legal basis for its claim?
• Is the House’s claim justiciable (that is, appropriate for resolution by a court)?

Judge Collyer rejects all of the administration’s responses to this argument. When money is spent without an appropriation, the House as an institution is injured in a particular way not shared by the public as a whole, or even by an individual member. The dispute is not about implementation of a law, but about the constitutional role of Congress. Although Congress has its own means of enforcing its will, this does not bar it from resorting to the courts in constitutional disputes.

The case will certainly be decided ultimately by the D.C. Circuit, perhaps by the Supreme Court. In the meantime, however, insurers that participate in the marketplaces will be subject to considerable uncertainty, and if there is anything that health insurance markets do not need now, it is uncertainty.

A win for the House would not mean that the ACA is unconstitutional, as would have been the case had the NFIB litigation succeeded; or even that the ACA would have to be amended, as would have been the case had King v. Burwell succeeded. It would merely mean that Congress would have to appropriate funding for the CSRs to function. The appropriation process is a perpetual battleground, and this year’s is shaping up to be as bad as ever. In the end, this would merely become one more appropriation for the administration and Congress to fight over, and one more reason why the fate of the ACA might turn on who is in charge of the next administration.

Summation

Even with less than 18 months left in  President  Obama's tenure in the White House, Republicans continue to chip away at the ACA. If the    Republicans maintain a majority in the House of Represenative, and re-capture  1600 Pennsylvania Avenue  it is almost certain that there will be significant changes to the ACA.

This however will create more havoc in unwinding the  gordeon know of the ACA.

The ACA is mostly about health insurance reform and several peripheral issues such as payment reform, the establishment of Affordable Care Organizations, all of which may be exclusive to themselves.   Some of the goals of the ACA are to make health care more affordable. This has yet to be determined in the short term.

Proponents of the law claim the cost savings are already significant. Others would point out that the infusion of significant public funds have allowed the ACA to work.

ONC: Rate of EHR Replacements Among Providers Up Significantly New data show that the percentage of eligible professionals and hospitals that switched electronic health record vendors quadrupled between meaningful use program years 2013 and 2014. Meanwhile, Texas has made $15.3 million in incorrect EHR incentive payments under the Medicaid meaningful use program.Health Data Management et al.

Latest Cyberattack Affects at Least 10M; UCLA Wins Data Breach Case New York-based insurer Excellus BlueCross BlueShield has disclosed a cyberattack that could have compromised the personal records of more than 10 million individuals. Meanwhile, a California judge ruled that UCLA Health is not responsible for the unapproved release of a woman's medical records. Health Data Managementet al.

HIMSS Releases Top Health IT Policy Priorities for Congress The Healthcare Information and Management Systems Society has published its annual "congressional asks," naming interoperability, cybersecurity and telehealth as the top policy priorities that lawmakers should address in the next year. Healthcare IT News,Politico's "Morning eHealth."

Researchers Build Genomic Database To Analyze Millions of Variants A team of researchers at the Broad Institute of MIT and Harvard is using data analytics to identify millions of genetic variants in the human exome, which is the 1% of the genome that codes for proteins. The researchers say such analysis could help improve diagnoses for individuals with complex conditions. The Atlantic.

What Are a Hospital’s Costs? Utah System Is Trying to Learn - The New York Times

Do you know about the accepted notion that emergency department visits are so expensive.



Recently the University of Utah Health  Center began to analyze real costs with a complex set of algorithms.The linchpin of this effort at the University of Utah Health Care is a computer program — still a work in progress — with 200 million rows of costs for items like drugs, medical devices, a doctor’s time in the operating room and each member of the staff’s time. The software also tracks such outcomes as days in the hospital and readmissions. A pulldown menu compares each doctor’s costs and outcomes with others’ in the department. The hospital has been able to calculate, for instance, the cost per minute in the emergency room (82 cents), in the surgical intensive care unit ($1.43), and in the operating room for an orthopedic surgery case ($12).



The big question is why does an emergency room visit cost hundreds or thousands of dollars An ER visit of one hour adds up to about $ 500.00/ hour.







What Are a Hospital’s Costs? Utah System Is Trying to Learn - The New York Times

A Doctor at His Daughter’s Hospital Bed - The New York Times

An all too familiar tale for me.







A Doctor at His Daughter’s Hospital Bed - The New York Times

Stanford MedX: The Continuity Coefficient

The Continuity Coefficient

The more handoffs, the more fumbles are possible

Jordan Shlain discusses the workflow of every doctor and how the experience of every patient is dependent on how information is presented, to whom it is presented to and it's temporal and spacial sequence. Healthloop has developed a Patient Continuity Engine which enables information to be packaged, in context, to all interested parties who may have inputs. The subsequent output is presented to the key decision 

Possible cancer cure being tested in human medical trials in Sydney, Melbourne

Possible cancer cure being tested in human medical trials in Sydney, Melbourne