Emergency Department Life In The Hospital

Should Hospital Security Officers Carry Narcan?

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

Life In The Hospital

How To Manage A Hospital Flood

Last week, we had a water line break resulting in hundreds of gallons of water running through the hospital. Fortunately, the broken pipe was on the second floor so the water didn’t have very far to travel. I learned a lot about plumbing that night and what to do when the hospital floods. Here are some of them:

Galvanic Corrosion Is Real

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.

Water Keeps Flowing After You Turn Off The Main Water Supply

Our hospital is 16 floors high. Our water break was on the second floor. In this situation, even if you shut off the main water line, all of the water that is in the pipes on the 3rd through 16th floor will drain by gravity and so there will still be an enormous volume of water in all of those pipes that will continue to flow through a leak. The solution is to get the water to drain somewhere else – we talked about developing a “CODE F” to instruct everyone in the building to flush all of the toilets.

How Much Water Does It Take To Flush A Toilet?

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.

If The Water Damages The Fire Alarm System, Call The Fire Marshall

When the fire alarms don’t work, the fire marshall will require you to place “fire spotters” throughout the building. The number of these people will depend on the size of the building but will probably be one person for every 1 or 2 floors. They can have no other responsibilities and have to be constantly patrolling for fire and smoke. They need to have radio contact with the building’s command center. You have to keep them in position until the fire marshall inspects and approves the repaired fire alarm – the inspectors in our community work 8-5 so you have to get a lot of volunteers to do 2-hour shifts if you have a 16-floor hospital.

When Elevators Get Wet, You Can’t Use Them

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.

The Medical Director’s Job Is To Ensure Patients’ Safe And Timely Care

One of the first things I did when we had our flood was to stop by the emergency department and instruct the ED physician to put our ED on divert status – that directed emergency squads to other hospitals. Without knowing how much the flood would affect patient care, it was important to stop the inflow of patients. Once our elevators were working, we went off divert status. Although the hospital medical director will be required to spend a lot of time in the hospital disaster command center, it is a good idea to get out and walk around to the nursing stations so that you know about any patients who are having clinical deterioration and you can plan for their evacuation or get additional resources to their room to hopefully head off transfer to the ICU.

There Will Be An Information Vacuum 

In a disaster situation, it is critical that you control the flow of information to the various hospital areas. If you don’t, rumors will fill in the information vacuum and staff will get anxious. At least once an hour, all night long, I made rounds to all of the nursing stations and the ED to speak with the nurses and the doctors and update them on what was going on and what we were doing about it. I estimated that I walked up and down a total of about 100 flights of stairs over the course of the night. We had many dozens of cookies from a local cookie company that we had planned on delivering 2 days later for nurse’s week – around midnight, the Chief of Internal Medicine and I delivered one box to each nursing station. Food relieves all fears. We also had specialists from the medical center’s communication department on hand all night to control external information to the press so that the messages carried on TV, the newspaper, radio, and even social media was accurate.

A Flood Is An Epidemiology Problem

A hospital flood creates all sorts of epidemiological issues. Mold can grow in wet walls and floor tiles. Affected food has to be thrown out and food preparation areas need to be cleared by infection control. Fortunately, our leak was from fresh water and not waste water so we didn’t have to worry about bacterial contamination. We had a member of the infection control team and our infectious disease physician on-site for most of the night.

Practice Makes Perfect

We have a disaster exercise (drill) twice a year at our hospital and we take these very, very seriously with involvement of all parts of the hospital. This really helped us manage our flood because everyone knew their roles (we even have labeled vests identifying each person by role) and knew how the team works together. The medical system’s Chief Medical Officer and Chief Executive Officer even came in and to give them credit, they stepped aside and let our disaster management run the show – they just quietly made suggestions to either me or our hospital’s Executive Director, who was leading the disaster management team.

You Can’t Just Turn The Water Back On

Once a plumbing leak is repaired, all of the pipes above it have to be filled with water and that takes a long time. Air locks can also develop in large portions of pipes, preventing the rest of the pipes from filling. It can take hours to fully restore water flow to the top floors after the entire building’s water supply has been drained.

May 20, 2017

Life In The Hospital

Inside The Monster There Is A Scared Little Girl

Last Saturday, I was rounding in the ICU. A patient had been admitted overnight and his wife had told the nurse that she wanted me to call her that day. She had a pretty evil reputation – she would not permit one of the nephrology fellows to go into his room and had berated all of the doctors and nurses who had seen him. She was angry all of the time and thought everyone in the hospital was an idiot. He had initially come to the emergency department at the other hospital in our medical system but there were no ICU beds there so he was transferred to our ICU. Given his wife’s attitude, I suspect that there were a lot of physicians at the other hospital who were happy he was being admitted elsewhere. This was my first time taking care of him and I had never spoken with his wife before.

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.

He and his wife were a hard-scrapple couple who lived in a rural Appalachian area of southern Ohio. Life had not been kind to either of them and so they weren’t kind to anyone else. Because of his medical problems, it was uncommon for him to stay out of the hospital for more than a month or two at a time. When he was in the hospital, he had two states of mind: either comatose from hepatic encephalopathy or mean as a snake. His wife only had one state of mind: she was always mean as a snake all.

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.

The fellow presented the patient’s case to me and then we examined him together. A little later on, we made multidisciplinary rounds in the ICU and discussed him further. But given the complexity of his illnesses and the frequency of his hospitalizations, I figured I needed to read up on his case in more detail so I went through the electronic medical record and looked over his pulmonary function tests from 5 years ago and his sleep study from 3 years ago. I reviewed his labs, x-ray & CT images, and his cardiac imaging studies. After about 15 minutes, I felt like I knew his story pretty well and so I called her.

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”.
I asked her a few more questions that I already knew the answers to. Before she could interject any comments, I asked her if she was in the medical profession because she seemed to understand his illness so well – she said: “well, no, but I’ve had to learn a lot to take care of my husband over the years” – I already knew that she worked at night as a custodian in Athens, Ohio. I told her that I was amazed that he had been able to stay out of the hospital for 3 months straight and asked her how in the world she had managed to do such a good job of taking care of him. She then started telling me with pride how she had set up friends and family to stay with him while she worked and when she wasn’t at work, she was pretty much a full-time caregiver. She would leave detailed care instructions for whoever was there when she was at work. I told her I didn’t know how she had done it and that she must not ever get any sleep.

About that time, she started weeping and told me that she was exhausted and trying to do as good of a job as she could but was overwhelmed by how sick he was and how he wasn’t the man that she knew in the past. She was frustrated because he wouldn’t take his medications like he was supposed to, he would drink more fluids that she wanted him to, and he continued to smoke. They were poor and couldn’t afford home health.

I told her what our plans were for taking care of his respiratory failure, that we were going to give him 4 hours on and 4 hours off of non-invasive ventilation. I told her that we wanted to get him back on his usual oral hepatic encephalopathy medicines but he was too confused to swallow so we were giving him what we could rectally and that his mental status seemed to be improving so we were hoping he could take oral medications the next day. By then, she had forgotten that she was supposed to be angry that he was in our ICU rather than the other hospital’s ICU, angry that none of the doctors knew how to take care of him, and angry that he wasn’t getting better as fast as she thought that he should. I told her that it was really nice speaking with her and she had been really helpful providing me with his history. I told her she should stay home and rest up that he was stable and we’d call her if his condition changed. She thanked me for talking with her and hung up.

When I looked up, the hospitalist, pulmonary fellow, and nurse were all sitting around behind me, spectators to what they had thought was going to be a thrashing of  “the head doctor”. They had been eavesdropping on me and so I told them that she had started crying about halfway into the conversation. The hospitalist shook his head, smiled, and said “I hate you”. Then he walked away, still shaking his head and chuckling.

Inside many monsters, there is a scared little child. If you talk to the monster, the monster will talk back. But if you talk to the child, sometimes, the child will talk back. And maybe that’s what they wanted all along.

May 8, 2017

Life In The Hospital

The Nine Things That Motivate Doctors

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.

#1: Improve patients’ lives.

Ask any medical school applicant why he or she wants to go into medicine and they will almost always say they want to help people. It is the same reason why some men go into priesthood and some people become fire fighters.  For some physicians, this will be a stronger motivator than for others. For example, those physicians who take care of a lot of uninsured patients and those physicians who make house calls on their house-bound patients that can’t make it into the office. Maybe the ultimate example are those physicians who volunteered to go to West Africa to take care of Ebola victims for little pay and at great risk to their own lives, for example, those physicians in Doctors Without Borders.

#2: Garner prestige.

Doctors tend to have larger egos than the average person (and I’m saying that as a doctor). They want to be publicly recognized for their accomplishments and their expertise. It is the same reason that drives actors, politicians, and professional athletes. Examples here include medical directors (such as your truly), department chairmen, and those physicians who are always volunteering to talk with reporters about the latest disease or medical treatment. Sometime prestige local – being the cardiologist who all the other cardiologists in the hospital go to with their tough cases.

#3: Job security.

There is an old saying of “What do you call the person who finishes last in his class in medical school?” The answer is “MD”. Anyone who finishes medical school is going to get a job and that job is going to pay pretty well. The lowest paid doctor in your hospital is still making a higher-than-middleclass salary. Even if a doctor loses their job, because the practice closes or because they don’t get along with the other partners, they can find another job somewhere in just days. The demand for doctors greatly exceeds the supply of doctors. However, no one wants to have to change jobs and start up all over again so knowing that their particular job is secure is a strong motivator.

#4: Make a high income.

The thing is that what constitutes a “high income” is a very relative thing. To the average penniless college student, all physicians seem to make a high income compared to him. But to the graduating medical student, the orthopedic surgeon driving a late model Ford Shelby Mustang is making a lot higher income than the pediatrician driving a 6-year-old Ford Focus. But despite that, unless the salary differential is huge, money alone is usually not the reason a physician chooses one job over another.

#5: Make the most money in the shortest amount of time.

I see this in my own specialty of pulmonary/critical care. Many of the physicians are drawn to work in the ICU where they can generate the same number of RVUs in 4 hours as they could in 8 hours in the outpatient pulmonary clinic. Although the original idea of the RVU was to find a way to equate work effort across different specialties in order to create a common medium of exchange, inevitably, some clinical activities pay a lot better per hour worked than others. So if you are a joint replacement surgeon, you are going to be financially rewarded to operate on a patients who is “bone on bone” rather than give them a trial of physical therapy and steroid injections. Similarly, if you are a cardiologist with a nuclear camera in your office, you are going to order a lot of expensive nuclear stress perfusion studies and send very few patients to the hospital for a cardiac CT that will be interpreted by a radiologist.

#6: Operational efficiency.

Doctors crave things that allow them do their job faster and better. For me, having a PAX system on the computer in my outpatient examination room that allows me to see x-ray images immediately without having to trudge over to the hospital’s radiology film library will give me back 2-3 years of my life over the span of my career. The hospital that creates operational efficiency for inpatient care will attract and hold the best clinicians. Sometimes operational efficiency is made up of the little things – the doctors at our hospital save about 20 minutes a day by having a private gated physician parking lot adjacent to the back entrance to the hospital.

#7: Charismatic and effective leaders.

We all want to align ourselves with winners. And we want to be led by those leaders who excite us for their vision of the future and their ability to make that future a reality.

#8: The drive to belong.

The reason that humans have conquered planet Earth is that they were able to develop social groups that were bound together for the betterment of life and for safety. Physicians are no different, they want to belong to a group. That group may be the team of nurses and medical assistants in the office or it might be the team of personnel in the operating room. Maybe it is the medical staff membership in general or the partners in a group practice. Physicians are like everyone else in that they are most comfortable when they are part of a group or team.

#9: The need to understand.

Doctors are curious by nature. They want to understand what causes patients to be sick. They want to solve the mystery of a patient’s illness by uncovering the diagnosis. Some people satisfy this craving by reading detective novels or by solving crossword puzzles – doctors satisfy the craving by coming to work.

No two physicians are exactly the same and what motivates one physician may not be what motivates another physician. For institutional success, you have to align the various institutional rewards with the particular motivational factor for that unique physician. You need to know and understand every physician individually.

April 15, 2017

Life In The Hospital

A Tale Of 2 Code Blues

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.

Life has changed and the 2 codes from yesterday illustrate why.

The first code was in the lobby of Talbot Hall, the drug and alcohol treatment wing of our hospital. The patient was blue as a Smurf and needed to be intubated while he was lying on the floor of the lobby because of hypoxemia and respiratory depression. He had walked into the building to see if he could get alcohol detox. It turned out that his blood alcohol level was 0.4, five-times the legal definition of intoxication. He is now getting detoxed in our ICU.

The second code was in the lobby of the main hospital building. A young woman was found by a friend semi-conscious in the bathroom of a local Wendy’s restaurant and so she packed her up in her car and drove to the hospital where she helped get her to the information desk. There, the woman collapsed so the information desk attendant called a code blue. Like the first patient, she was also cyanotic. The team started ambu-bag ventilation. Years of drug abuse had withered away all of her veins and so as the code team was preparing to place an intraosseous needle in her bone, they tried one last sternal rub to wake her up. She took a couple of breaths and so they were able to get her to the ER where she was given Narcan to reverse her heroin/fentanyl overdose. She was later discharged back to the streets.

These two patients reminded me of the first time I had to manage a code. I was a fourth year medical student in a private hospital in Columbus doing an internal medicine rotation with one of the other medical students. We were standing in line for lunch in the cafeteria when the man standing behind us dropped dead. We checked for a pulse (which he didn’t have) and one of us did chest compressions while the other did mouth-to-mouth resuscitation. The lady at the cash register called the operator who announced a code blue to the cafeteria. I looked up as I was doing CPR and saw several of the attending physicians that I knew grab their lunch trays and leave the dining area. Finally, one intern showed up and the three of us ran the code for 20 minutes in the cafeteria before pronouncing the patient dead. No other physicians came.

Code blues in public areas of the hospital are often treated as less-emergent because frequently they are non-emergent. But these codes can sometime be the real thing. Currently, an average of one person in Central Ohio dies every day due to a drug overdose – usually a combination of heroin and fentanyl. Drug and alcohol overdose patients often make their way into public areas of the hospital before they stop breathing. So now days, when a code is called to the hospital lobby, it epitomizes that cardinal rule of medicine:

You just don’t know until you know.

March 23, 2017

Life In The Hospital

Run, Hide, Fight

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.

Partly as a response to that event and partly in response to our JCAHO site visit last summer, the hospital began plans for active shooter drills. There has been a rash of shootings in hospitals: January 2015 Brigham and Women’s Hospital in Boston, March 2016, East Jefferson General Hospital in New Orleans, July 2016 Benjamin Franklin Hospital in Berlin. Each of these three resulted in the shooting death of a physician.

The key to surviving any threat is preparation and situational awareness. On a subway station in a foreign country? Preparation is moving your wallet from your back pocket to your front pocket and situational awareness is looking at the people in front and behind you. Driving on the highway where there have been wrong-way driver fatalities? Preparation is planning whether to pull off into the left or right berm and situational awareness is looking ahead to the next exit ramp for headlights coming toward you.

Our hospital’s active shooter training is all about preparation and situational awareness. The University has prepared short videos on the OSU website, all staff have to do a CBL module (Computer Based Learning module), we have “table top” discussions with a target participation by 60% of all employees and 100% of employees in vulnerable areas (e.g., the emergency department), and this spring, we will be holding a hospital-wide active shooter drill.

Last week, I attended one of the table top discussions. We watched a series of short videos produced by the Ohio State University Police Department about “Run, Hide, Fight” and then discussion was lead by one of our hospital security officers. It was pretty enlightening and I’m better prepared because of it. Here’s what Run, Hide, Fight is all about:

Run. This is your best option. Have an escape route in mind – ever since the Colorado theater shooting, the first thing I do when going to a movie is to check where the exits are and then find a seat that gives me clear access to it. Leave your belongings behind – a purse, backpack, or computer can only slow you down. Spread out – 5 people running in a group is an easier and more inviting target for someone with a gun than 5 people running in different directions. Don’t freeze up – it is a natural reaction to stop to try to sort out what is going on; resist that temptation and sort things out while you are running. Keep your hands visible – when police arrive, you need to be sure that you are not mistaken for the shooter. Get out of the way – when police arrive, lie down with your hands out and palms up or move to the side so they have a clear view of the assailant behind you.

Hide. If you can’t run, this is your second best option. Get into a room and close the door. Turn off the lights. Turn your cell phone to vibrate. Don’t talk. Don’t huddle together with other people. Barricade the door – in a hospital room, move a patient bed to the door and lock the wheels on the bed.

Fight. Your choice of last resort. If you have to fight, there are no rules. Kick, bite, scratch and do anything to subdue the assailant. Throw things. Improvise weapons – a fire extinguisher, a chair, an IV pole.

In the hospital, we do fire drills, code blue drills, tornado drills, and now, we are doing active shooter drills. Run, Hide, Fight can save your life.

February 11, 2017

Life In The Hospital

Guilty Until Proven Innocent

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 can report that they suspect a physician is under the influence of alcohol or drugs at work: another physician, a nurse, a patient, a family member, anyone. When that happens, the medical director has to immediately sequester the physician and remain with the physician until the lab director can do testing with a forensic breathalyzer or do urine drug testing, depending on the substance allegedly consumed.

This is a priority that takes priority over other priorities and means that I had to drop what I was doing and go to the hospital to meet the physician in a conference room and keep him under direct visual contact until testing could be completed. As it happened, the lab director was in a hospital in a different county doing an administrative review so it was going to take 2 hours before he arrived. It was a Friday afternoon and I had patients that had driven in from all over Ohio and West Virginia to see me – my office staff had to tell them that I was not able to see them due to a hospital administrative emergency and send them home to be rescheduled.

Around 5:00, the breathalyzer arrived and the results were completely negative. It turns out that he had french onion soup for lunch and just had “onion-breath”. He went back to the nursing units to round on his patients and I got on the phone to apologize to my outpatients who had to drive back to their home towns without seeing the doctor.

This isn’t the first time that this has happened and I’m sure it won’t be the last time. The 2 most recent episodes were triggered by patients who called the hospital’s administrative offices to report that their attending hospitalists were intoxicated in the hospital. In both cases, the physicians were immediately removed from patient care duties and emergent cross-coverage was arranged until the physicians could be breathalyzer and urine tested – in both cases the results were completely negative. In investigating, we found out that in both cases, the patients were demanding opioid pain medications and the hospitalists suspected them of drug seeking opioid abuse. When the hospitalists would not prescribe Percocet, the patients retaliated by reporting the physicians being under the influence. Its a cunning strategy: a drug-seeking patient who gets the reputation of making a doctor’s life miserable if they don’t prescribe narcotics tends to get what he/she wants the next time since the physicians don’t want to have to be sequestered for a couple hours pending drug or alcohol testing. During those 2 hours, some other hospitalist has to cover twice their normal number of patients and at the end of the day, the sequestered hospitalist ends up working 2 hours past their normal shift just to get their work done.

On the other hand, we have had times when physicians have been at work under the influence and so we just can’t take any chances. In order to maintain the integrity of our profession, we have to take each allegation with the highest level of seriousness and we have to immediately remove the physician from patient care responsibilities until we complete the testing. It is unfortunate that some patients with knowledge of this policy take advantage of it in order to get what they want – usually narcotic medications. In this sense, the accused physician is guilty until proven innocent.

January 17, 2017

Life In The Hospital

The Nuns Versus Blue Cross

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.

When the Sisters of the Poor worked with Ransom to draw up the initial architectural plans for their new hospital tower, the Sisters wanted to do something really innovative, namely, make all of the rooms private. Up until that time, the industry standard was semi-private hospital rooms. These were rooms with 2 patients, generally separated by a pull-back curtain. Hospitals contained mostly semi-private rooms with a few “VIP rooms” that were private for only one occupant. Part of the reason for the semi-private rooms was that insurance companies would only pay for a semi-private room since a private room was considered an unnecessary luxury at the time.

But the Sisters really, really wanted to have all private rooms. In that sense, they were innovative and quite forward-thinking. The problem was, when they went to Blue Cross with their plans, the insurance company said that it would not pay for private rooms, only semi-private rooms as was their standard practice for inpatient coverage throughout the country.

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.

Now, we have circular nursing units that have about 30 patient rooms per floor, each room being half the size of a normal semi-private room at other hospitals. Since 1969, a lot has changed in healthcare and now, the industry standard has moved from semi-private to private rooms. Hospitals are scrambling to convert their old 2 patient rooms into 1 patient rooms. Furthermore, hospital rooms now require more monitoring and medical equipment that takes up space.

Also, our patients are bigger than they used to be. In 1960, the average American man weighed 166 pounds but by 2010, the average man weighed 196 pounds. In 1960, the average American woman weighed 140 pounds but by 2010, the average woman weighed 166 pounds. That means that in the past 4 decades, the average man in the United States weighs about 30 pounds more and the average woman weighs 26 pounds more. Bigger people means bigger beds, bigger chairs, and tighter spaces in the rooms designed for the smaller patients of the 1960’s.

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.

The nuns were way ahead of their time in demanding that hospitals be made of private patient rooms. But now, 40 years later, there are new demands in hospital rooms and in the future, hospital room construction will require even larger rooms to accommodate even larger American patients, more medical & monitoring equipment, and family members whose expectation is to stay overnight with patients. Additionally, as we have more emphasis on eliminating hospital-acquired infections and utilizing contact/airborne/respiratory/enteric isolation precautions, semi-private rooms will become a curiosity of history and private rooms will be the only kind of U.S. hospital patient rooms.

For me, I have my eyes set on constructing a new patient care tower with 325 sq ft rooms. Now, if I could just find $70 million…

January 7, 2017

Life In The Hospital

The 6 Words

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.

Being a hospital medical director is a lot like being a hotel manager. When I first get up in the morning, I check the hospital census to see how many open beds we are starting the day with. I usually start my day by rounding in the hospital. First, the physician lounge to catch any doctors who are pre-rounding on their patients on the computer over a cup of coffee. Then through one or two of the nursing stations to get the pulse of inpatient care for the day. Next, the cardiovascular cath lab to see what what the morning’s invasive procedure schedule is looking like and how any emergency STEMI catheterization cases from the night before went (STEMI = ST-Elevation Myocardial Infarction). Then down to the OR to see which surgeons are operating that day and how many post-op patients are anticipated to need to be admitted (and thus require an inpatient bed). The ICU comes next and I’ll check in with the ICU hospitalist to see how many ICU beds we have and whether there were any patient care issues overnight. I have my cell phone set to get a text page with every STEMI and Code Blue (cardiopulmonary arrest) 24 hours a day so in the ICU, I’ll check in to find out how any STEMI patients or Code patients did overnight. After the ICU, I go to the ER to see how many open ER beds we have, how many are being occupied by patients that need to be admitted or that are being held for psychiatric care. Next is the endoscopy suite to see how many cases are on the schedule and which gastroenterologists or surgeons are doing procedures that day. Last, it is upstairs to the Education Suite to check in with the residents to be sure that their service census is reasonably full and that they are getting a good educational experience in our hospital.

At each stop, I use the 6 words.

Some leaders think that a leadership position is all about them. Its not – its all about the people that you are leading. As an example, a few years ago we were interviewing candidates for the Division Director for my division, Pulmonary and Critical Care Medicine. One of the candidates who came through for an interview visit asked whether as Division Director, he would be able to add his name to all of the manuscripts submitted for publication from the other members of the division. You see, he thought that being the Division Director was a way to make him more famous. He didn’t realize that being a Division Director is all about making everyone else in the division famous (and he didn’t get the job).

He didn’t know the 6 words.

Being a leader for a group of 50 physicians is a lot different than being a CEO of a company. That’s because leading 50 physicians is like leading 50 CEOs. They are fiercely independent and have to be when they are the one ultimately responsible for a patient’s life or health during a surgical procedure, in the ER, in the ICU, or during an emergent cardiac catheterization. What those physicians want during their work day is know that someone has their back, that their efforts to take care of patients is recognized and valued, that their needs are being heard.

They want to hear the 6 words.

As a medical director, the doctors don’t work for me, I’m supposed to work for them. My success is defined not by my personal successes but by their personal successes. So what are the 6 words?

“Anything I Can Do For You?”

November 19, 2016

Life In The Hospital

Electronic Medical Record Translation Guide

For those of you who are new to electronic medical records, you will be learning a new language used by physicians who use electronic medical records. This quick guide will help you translate into English:

When the physician says:        The physician means:

@*#$(^*@                             Would you be so kind as to help me route this encounter?

*$@!!($##*                             I find the communication management function to be satisfyingly easy to use.

)#@@**&!                             Pardon me but could you please assist me in unburdening my inbasket with several of these fascinating communications?

*@##@#!!                              I woke up last night and was unable to fall back to sleep since I was giddy with excitement looking forward to come in to work and use the electronic medical record this morning.

*#^%@*$$                             So sorry, but I appear to have used excessive force on my return button; could I impose upon you to replace my keyboard?

/#**!!@*!                                The beautifully flowing prose that I am able to now create using the electronic medical record is like poetry and brings tears to my eyes every time I read my own progress notes.

#!**@#!?$                              While I was working on my SmartPhrases, my coffee mug has inexplicably been found to be protruding from my monitor screen.

&%@#!*!!#                            My computer seems to have fallen out of my window; might you obtain a new one for me?

!*#@!&^!**                            I dearly love this new system and I am so appreciative that I no longer have to dictate my letters.

October 27, 2016