Tuesday, June 27, 2006

Crushed Skull

Such a beautiful day

What could possibly go wrong?

Hmmm…. flashing lights on the freeway

Only police with bodies on the ground

Should I stop?

A physician, I say – “Are you sure?” He said…

ID cleared the air

Such a peaceful scene – mom and dad as if asleep on the front seat

I knew better

A small child, on the back seat lay still

It was “just” a rear-ender, I thought

Precious memories of my own loved ones, flooded my thoughts

Funny, not a bit of blood to be seen anywhere

A touch to his small skull made it clear –

His life would soon be over

I wonder when I’ll stop feeling, the crushed skull, probably never…

Richard Pitts, D.O.


April 26, 2006

Background to Crushed Skull

One Sunday morning about six months ago, I was driving back from seeing an old friend in LA. I drive a pickup and can see way ahead on the road. At the junction of the 605 and the 105 the traffic was jammed. I could see ahead that there was an accident at the junction of an on ramp and the 605. As I approached, I saw only a CHP car and bodies on the ground. Understandably, I have learned over the years that doc's showing up at a medical emergency when medics are on the scene aren't always welcomed and pretty much will normally drive by knowing that medics can do just about everything I can in a field situation. This was a different situation, so I stopped. Pretty chaotic scene. First was the interception by the Chippy... I identified my self as an emergency physician and was promptly asked for some ID, which I produced. After what seemed like some reluctance on his part, he announced to his partner that "This guy says he's a doc". I went to the car most damaged and although I was already to use the Hoag triage method "START", it was clear at first glance that none of these people were going to standup and move "over-here" . Some Chippy's were maintaining airways on the adults in the front. The import vehicle had been rear-ended by a van at what must have been a very high rate of speed. So much so that the rear seat back was at a 45 degree angle from the right rear to the back of the driver side seat. The child in the back appeared to have been sitting on a booster seat with belt, must have been violently launched by the impact.

On the seat lie a KO'd 4-5 y/o male child. Essentially no blood in sight on the child. He had sonorous breathing. I carefully opened his airway and maintained c-spine inline traction. His breathing improved. That was when I felt what seemed like a broken egg shell inside of a thick plastic bag. Still totally non-responsive... must have been quite a sight from the freeway. Medics finally arrived after what seemed like an eternity. First medic on the scene and I got into it a bit when he ordered me to let go of the kid and back out of the car. I identified myself and respectfully refused saying, "I'm not going to let go of his c-spine". After a bit, another appeared with a stablization device and I backed out. I heard one medic say to the other the child's pulse was 80. I think by this time the child was getting close to herniation.

Nothing more for me to do, so I washed my hands off and continued on my way. Not convinced that the medics appreciated the head injury of this child, I called the local trauma center on a hunch that a critical trauma child might wind up there. Spoke with one of the trauma nurses who said that they knew that a critical trauma was on the way. Suggested that they might want to get a peds neurosurgeon there. She was very thankful that I had called. Called back in a few days, kid was brain dead on life support. Skull was indeed crushed like an egg shell. Spoke with the trauma coordinator RN about a potential educational opportunity for the medics on scene.... She was nice and receptive. No hard feelings on my part since it was clear to me that the child had a fatal injury. But, it did stay with me for awhile. Possibly due to being outside the imaginary security of an ED. It was one of those sentient moments after writing this short poem, that I realized I could relax a bit now...

Copyright 2006

Richard Pitts, D.O.

Sunday, June 25, 2006

The American Healthcare Paradox

Healthcare: What should it cost? The American healthcare paradox

Richard Pitts, D.O.
Board Certified Emergency Medicine
Board Certified Preventive Medicine

Doctoral Student in Applied Management and Decision Sciences
Walden University

Ask an American how much he or she wants to spend for healthcare and the answer is frequently “as little as possible”. Ask the same American how many healthcare dollars he or she wants to have spent to assure health and recovery from sickness of self or loved one and the answer is frequently “Whatever it takes”. This seeming paradox sets the stage for what seems to be an irreconcilable dilemma for healthcare decision makers in the US.

Hardly a week goes by without articles appearing about the need to fix healthcare in the United States. Invariably the articles center on cost and quality. Pretty much everyone can agree on the need for the best quality of whatever healthcare they are receiving such as receiving the correct medication in the hospital or from the pharmacy, surgery performed on the correct side of the body and so on. But when the discussion turns to how much healthcare should cost in terms of actual dollars, the discussion falters. Perhaps it is because society in the United States needs to have another question answered first: “What are you buying”. For instance, if asked how much a car costs, most likely the response would be “It depends”. Are you buying a luxury car, a pickup for work, or an economy car? To be sure, the car metaphor is somewhat imperfect, or is it? People can, of their own volition choose to use public transportation. Public transportation may not go everywhere, but public transportation can get you to essential places albeit somewhat slower than with your own car.

Likewise with healthcare, before cost is determined, one has to ask, “What am I buying”. “What will be covered”? So what kind of healthcare are we talking about when discussing costs? Is it healthcare that provides basic coverage for most people? Here is a tougher question. Who should have coverage for organ transplants, a working person or a homeless person? Some might feel that this kind of discussion is unsavory. However, it seems unlikely that there will be resolution to the “healthcare cost crisis’ without tough questions being answered first.

How will the education of physicians be paid? How many Americans know how long it takes to train a physician? Currently after completing high school for a physician to gain licensure and board certification, a minimum of 11 years is required;four years of college, four years of medical school, a minimum of three years in residency training, such as family practice or internal medicine, and up to 16 years for some of the more complicated specialties such as neurosurgery, heart surgery and others. New physicians are becoming indentured servants with debt payments totaling hundreds of thousands of dollars equivalent to a house payment for 10 or more years. It is not hard to imagine that an individual who has invested the majority of his or her life in education might expect a return on his or her investment.

What role does technology play? When CT scanners made their debut in medicine, one U.S. Senator proclaimed that all of Southern California needed only 10 CT scanners. In fairness to the Senator, he simply could not have predicted the incredible advances in diagnostic and now interventional radiology that in some cases eliminates the need for hospitalization. An operation common place 30 years ago, called “exploratory”, is a relic of the past. It is almost unheard of in modern medicine for a patient to undergo a surgery without knowing nearly exactly what the diagnosis is and what needs to be done. But even more important is that now it is possible with advanced diagnostic techniques to NOT do an operation in a gravely ill patient since it is known ahead of time the extent of the disease and that operating is futile.

Although beyond the scope of this writing, two additional drivers that raise the cost of healthcare are 1) defensive medicine to attenuate the effects of a possible law suit and 2) spending healthcare dollars in the last month of life when the outcome is pretty much predetermined by the disease process in terminally ill patients. In these sad cases; How much is enough care? When should futile care stop? Some studies suggest that fully a third of all healthcare dollars are spent in the last month of life. Is society ready to answer these tough questions?

So coming full circle, what should healthcare cost in the United States? The answer is “That depends on what you are buying”. In 1960, a 50 year old patient with a suspected heart attack would be admitted to a general hospital bed since specialized units didn’t exist. This heart attack patient would have been given pain medicine some oxygen and maybe some nitroglycerin. Frequently, the next time the nurse checked on the patient he or she was found dead in bed. Perhaps the patient came in contact with about six other health care workers. Total cost? Perhaps a few hundred dollars.

Fast forward to 2006. The same patient is seen rapidly and given a number of medications that can actually stop many heart attacks in mid-stream. Or, in serious cases or in advanced facilities, the patient may be taken into a special procedure lab and have a small tube placed in a blood vessel to be threaded into a heart artery where a tiny balloon inflates to relieve a blocked artery. Perhaps a small device is inserted into the blocked heart artery, a stent that looks like a Chinese finger trap that works in reverse to push and keep open a diseased artery. While this technique may work for awhile, in some cases, the patient will have to have cardiac bypass surgery. This 50 year old patient now returns to a productive life free of chest pain and free of the fear of another heart attack. Most likely this hypothetical patient will have come in contact with a healthcare team of more than 25 people all highly skilled from the emergency paramedic team to the emergency department team to the cardiac care and special procedures team to the operating room team and more…. Cost perhaps north of $100,000.

While the debate rages on about how much healthcare should cost, the question of what kind of “healthcare car” is being purchased by the consumer needs to be answered. Only then will the question of cost be determined.

June 22, 2006