Two days ago, I was leaving the hospital and I heard the overhead announcement “Code Blue, front entrance to the hospital”. Nine times out of ten, this is because someone slipped and fell and a panicked visitor will run into the front lobby yelling something about cardiac arrest. But as I’ve mentioned in a previous post, you just don’t know until you know and so we treat every code blue as an emergency, regardless of its location.
Our hospital’s chief of cardiology and I arrived at the same time. There was a minivan at the front entrance of the hospital and an animatedly hysterical woman standing at the side with an unconscious young man in the front seat. We asked a couple of quick questions: “Does he have diabetes?”, “Does he have seizures?”, “Did he take any street drugs?”. The answers were no, no, and he “just smoked a little weed”. I took a quick check of his forearms – no needle marks.
He had a strong pulse and was breathing regularly but the best we could do was to get him to briefly open his eyes with stimulation. His pupils were small. We managed to get him out of his car and onto a patient cart. A quick oximetry check showed his oxygen saturation was 94%. We raced him to the emergency department which meant down a hallway, up one level in an elevator, and down another hallway. While we were in route, I called to the ER and spoke to our emergency department’s medical director, who happened to be on duty that evening. As we were wheeling the guy through the hospital, I told him to have a dose of intranasal Narcan ready when we arrived.
About 7 or 8 minutes after the code blue was first called, we got him into a room in the ER. By that time, he was pretty much unresponsive. Before vital signs, blood draws, or hooking him up to a cardiac monitor, he got a dose of Narcan sprayed into his nose. About a minute later, he sat up asking what was going on. He got opioids somehow – either he was snorting heroin or injecting in some unobtrusive part of the body that wasn’t easily visible. Marijuana laced with fentanyl or carfentanil is always something that we worry about but it is probably pretty uncommon.
But from an emergency response standpoint, it was pretty clear that the guy was going to die if nothing was done. In patient care areas, we keep a “crash cart” that is stocked with all of the medications that are needed to treat a patient during a cardiorespiratory arrest. But carts are not immediately available everywhere in the hospital, for example, in the driveway in front of the entrance to the building. Panicked people don’t always know to take someone with an urgent medical condition to the hospital’s emergency room, they may not even know where the emergency room is – they just drive up to the front of the hospital and yell for help. When someone has an opioid overdose, intranasal naloxone (Narcan) is life-saving and even a couple minutes delay can mean the difference between life and death. Narcan is the drug overdose equivalent of bystander CPR for cardiac arrests. So, it behooves us to have it immediately available to hospital first responders to “code blues”.
Ohio started Project DAWN as a way of getting naloxone into people who overdose on opioids as quickly as possible. In 2016, the Columbus EMS personnel administered intranasal naloxone 2,300 times. In a 6-month pilot program, 125 Columbus police officers were given intranasal naloxone to carry – they administered it 58 times and all but one of the people survived. So if city police carry intranasal Narcan, should hospital security staff carry it also?
Our hospital is currently debating this. On the one hand, a security officer responds to every code blue and they also patrol the hospital grounds, including the parking lot, where a lot of drug overdoses arrive. On the other hand, there are a lot of security officers that would need to be trained and it would require us to buy a lot of doses of intranasal naloxone to supply them all. The other option would be our nursing supervisors – there is only one of them on duty at any given time and they also respond to all code blue calls. Because of their nursing background, they would require a lot less training in administration and would likely be a lot more comfortable administering the medication. With fewer of them, it wold require a lot fewer doses to supply them. I’m not sure what the final decision will be but it is clear that we need to make intranasal naloxone more widely available, even in the hospital.
In cities, there has to be a fire hydrant every 400 feet. There has to be a smoke detector in every bedroom of your house. There should be one fire extinguisher for every 200 square feet of building space. We go to great efforts to prevent people from dying of fires. Last year, 104 Ohioans died from fire. But last year, 4,149 Ohioans died of unintentional drug overdose. That means that in Ohio, you are 40 times more likely to die of an accidental drug overdose than from a fire. How many lives could we save if intranasal Narcan was as easily available as fire hydrants and fire extinguishers?
The simplistic answer is that you get people to stop using heroin and other opioids. But as I’ve stated in a previous post, humans have a 5,000 year history with opioids and if history teaches us anything, it is that you can’t make heroin and other opioids go away by education, legislation, or moralization.
It is time to look at intranasal Narcan the way we look at automated electronic defibrillators (AEDs). Get them to where the people are who need them.
May 26, 2017
When two types of metal are attached to each other in the presence of water, a phenomenon called “galvanic corrosion” occurs. Over time, one of the metals will erode resulting in weakness of the pipes. The threads on pipes are particularly susceptible to degradation so, over time, threaded pipe connections can fail resulting in a water line break. Several decades ago, building regulations were put in place to require connections to be made with like-metals (e.g., copper to copper) but renovations done in buildings prior to the late 1970’s sometimes had steel to copper connections and these are susceptible to galvanic corrosions.
When you turn off the main water supply to a hospital, no one can flush toilets. The solution is to pour water into the toilet manually. The magic volume of water is 5 gallons. I learned that we keep 5-gallon pails in our facilities department just for this purpose.
When elevators get wet, the electronics that run them become unreliable so the elevators have to be shut down. If all of the elevators are down, you have to have some way of getting patients from one floor to another – whether it is because they need an emergent procedure, need to be transferred to the ICU, or need to be evacuated. The solution is an emergency stair sled. These come in a variety of shapes and models but allow patients to be safely moved down stairwells. Our regional trauma organization keeps a stash of them and a trailer full of them can be brought to the hospital to have on hand, just in case one or more patients need to be moved. Elevator companies are just like hospitals – they have workers on-call 24-hours a day for emergency maintenance. We had crews from two different companies working on our elevators and they were running in less than 8 hours.
Medically, he was a disaster. He had end-stage kidney disease and was on permanent dialysis. He had advanced cirrhosis from years of drinking and frequently developed hepatic encephalopathy from the build up of toxins in his bloodstream because his liver couldn’t clear them. He had congestive heart failure which, combined with his liver and kidney failure, made keeping his fluid balance in check difficult, particularly because he would not comply with his sodium and fluid restrictions. He had severe emphysema and was on 5 liters of home oxygen around the clock. Despite that, he continued to smoke and the combination of a burning cigarette plus high flow oxygen had resulted in a flame that had recently caused burns to his nose and sinuses. Looking at him in the ICU, he was morbidly obese with yellow eyes and skin that peeling off. If you opened a textbook of internal medicine, he had something from every chapter.
So, when I walked into the ICU and the nurse told me that the wife was expecting a call from “the head doctor”, the nurse looked at me with pity. The hospitalist in the ICU also told me that the wife was angry about his respiratory status and wanted a call from the pulmonologist that day. I figured there was no way I was going to get out of the phone call since I was both the pulmonologist and “the head doctor” that Saturday. The pulmonary fellow told me to be prepared to be chewed out.
When she answered the phone, she had a voice that had been worn to gravel by thousands of packs of cigarettes over the decades. She had one of those wary, Appalachian accents that conjure up images of a mobile home permanently parked off a dirt road deep in hills close to the Ohio River. I quickly introduced myself and then before she had a chance to say anything, I told her this was my first time seeing him and that I had gone through his chart but I had some questions about his medical history that maybe should could help me with. I think I caught her off-guard and so she just said, “OK, go ahead”. So, while I was looking at his sleep study, I said I was a little confused because when I was watching him sleep, his oxygen level dropped but he didn’t appear to have apnea. I asked her whether he had ever had a sleep study to investigate it and she told me that “yes, he had a sleep study a few years ago and was told he needed oxygen but didn’t need CPAP”. Then I told her that in looking at his chest CT, I thought he might have some emphysema and asked her whether he has COPD – I was staring at his previous pulmonary function tests, so I already knew the answer as she started to say, “yes, we found out 5 years ago that he has COPD”.
Doctors are unique animals in that the things that motivate them don’t necessarily motivate other people and moreover, they aren’t always motivated by the same things that motivate everyone else. So to make your hospital work, you have to know what makes them tick. Here are the 9 things that motivate doctors.
Yesterday, we had two codes in our hospital’s lobbies. I get a page for every code blue that occurs at our hospital; it allows me to keep my finger on the pulse of the hospital. Code blue is the designation we give for a cardiopulmonary arrest. When a code occurs on a nursing unit, it is usually the real thing because the nursing staff are the ones calling it and they are very good at initial assessment of a patient’s condition. On the other hand, in public areas, the codes are often called by non-clinical hospital staff who are not skilled in patient assessment and so in the past, most of the code blues that occur in the lobby or the parking lot, or ambulatory clinic locations were for situations like a patient falling or fainting. Therefore, codes in those locations were seen by many physicians and nurses as being less urgent and would often be ignored by physicians who were not a designated member of the code team.
The text message on my phone read: “Buckeye Alert: Active Shooter on campus. Run Hide Fight. Watts Hall. 19th and College”. It was a deranged student who went on a stabbing spree on the Ohio State University campus, injuring 13 people before being shot to death by OSU police last November. My son lives in a dormitory about 500 feet away from the event. He was working out in the gym and when all of the students and staff got the text message, they went into a back room and barricaded the door to prevent entrance.
A couple of weeks ago, I got one of those calls that you dread as a medical director. I was in the office seeing pulmonary patients and one of the hospital supervisors paged me to tell me that a nurse covering patients on one of the hospital floors smelled alcohol on the breath of one of the doctors. She then asked one of the other nurses if she also smelled alcohol and the second nurse said yes, she also smelled alcohol.
Anyone who has been to our hospital recognizes it right away. It is circular. If you are driving from the east into Columbus on interstate 70, it rises up in front of you like a giant cylinder on the horizon. Each nursing unit is round and the patient rooms are all on the outside, like slices of a gigantic pie.
OSU East’s tower had a (nearly identical) twin sister building in Columbus, the Christopher Inn which was designed by African-American architect, Leon Ransom and was built by the Elford building company in 1963. For 25 years, it was Columbus’s premier downtown hotel and local famed jazz musician, Bob Allen and his trio played in the bar nightly. On our wedding night in 1983, my wife and I stayed at the Christopher Inn and I vividly remember the two of us walking down the curved stairs to the bar with her wedding dress flowing down the stairs behind her with Bob Allen playing a jazz song. Sadly, The Christopher Inn was demolished in 1988 – although ultramodern in the 1960’s, by 25 years later, it was dated and out of style.
Ohio State University Hospital East first opened as St. Anthony’s Hospital in 1891, built and operated by the Sisters of the Poor of St. Francis. In the 1969, St. Anthony’s Hospital opened its new tower building, also designed by Leon Ransom and constructed by the Elford company.
So, after a lot of negotiation, the Sisters struck a deal with Blue Cross. The hospital would be allowed to have all private rooms but they would have to be exactly 1/2 the size of a standard semi-private room. In exchange, Blue Cross would pay semi-private room rates for inpatients admitted to the hospital.
At the OSU Medical Center, we have several different hospital buildings. Our newest building is the new James Cancer Hospital, a beautiful 21-story building on Ohio State’s campus that opened in 2014. It has the largest private rooms at 314 sq ft. The Ross Heart Hospital (built in 2004) is the second newest building with private rooms at 302 sq ft. Before that was the original James Cancer Hospital building (now the OSU Brain and Spine hospital building) that originally opened in 1990 with private rooms that are 239 sq ft. Rhodes Hall is one of two buildings of the main University Hospital and opened in 1976 with semi-private rooms that have now largely been converted into 224 sq ft private rooms. Doan Hall is the oldest of the OSU Medical Center buildings still in operation and was built in 1951 – its semi-private rooms have been largely converted to private rooms that are 214 sq ft.
As the medical director of a hospital, my job is not to cure disease and save lives. My job is to create an environment where other doctors can cure disease and save lives. And that’s where the 6 most important words for a medical director comes in.