Each of us experience a tragedy like in Boston through their own prism. Sadness, anger, loss are universal. But I also see people who STOOD AND DELIVERED. They are MY PEOPLE: First Responders, EMTs, Paramedics, Emergency nurses and physicians, and Trauma teams. Patients and families are suffering less today because of their dedication.
I am incredibly proud of my Boston colleagues who exemplify our motto: ANYONE, ANYTHING, ANYTIME.
“Unit 8-1 to central we’ve been involved in a Signal 350 (MVA) with injuries. Need help.”
These were the first coherent words I spoke into the police radio. Moments earlier I had been thrown from the back of our ambulance into the front when we were struck head-on by an out-of-control car. I landed across the front passenger seat with my head where legs would normally be.
As I write about the events of December 16, 1988, that beautiful, cold, Friday morning seems remote yet still emotional and raw. The story now comes out of me in rote fashion. I was a volunteer EMT, riding in the patient compartment as we took a 76 year old woman to the hospital after a motor vehicle crash. She was boarded and collared and I was unrestrained moving around the back of the ambulance as we began to climb a steep hill toward our destination hospital. I remember my driver saying something about a car coming towards us. I remember seeing the car just before we hit (or maybe I don’t and just think I should). Maybe I was knocked unconscious or just stunned.
Now the absurd, almost funny moments flash by….wiggling my fingers and toes and deciding it was safe to move because I wasn’t paralyzed. Making that broadcast on the police radio. Flipping myself over into a seated position on the floor and watching as my knee moved one way and my hip another. Wondering why a broken femur did not hurt more. Handing my partner a fire extinguisher because he had the sense to realize the engine was on fire. Instructing a good Samaritan to hold my broken leg straight while I slid/climbed out of the side door. Visions of my friends and colleagues standing over me while I babbled. The irony of being put back into an ambulance (now as a patient) just after one tried to kill me.
Fortunately I don’t remember the car. I should since I was lying only a short distance away when they used a front end loader to pull our ambulance off of it. I should remember the moans and screams that must have come from some of its five occupants. But fortunately I don’t.
While I was young (2nd from left in picture) they were even younger. They were on their way back from the mall after some Christmas shopping. Two were pronounced dead at the trauma center but likely died at impact. The other three with multi-trauma. My patient was ok, as was my partner.
This day would begin a series of firsts for me. First fracture. First narcotics. First surgery (and second and third and fourth). First Christmas in a hospital bed. First corneal abrasion. First urinary retention. First foley catheter. First seizure. First lumbar puncture. First deposition. First re-learning to walk. First feeling of mortality.
It is humbling to be a patient. There is a process of assimilation into this new role and it is not gentle. You go from independent to totally dependent. You control almost nothing but crave any little amount of it. You live by other people’s schedules.
You also know that when the nurse is caring for you or the doctor is discussing things with you that there is a bond. That you are sharing something important. You know these quiet one-on-one moments are intimate and sacred to you both.
It is, of course, hard to isolate what I learned from these events. We are the sum of our experiences not solely shaped by occasional epiphanies. But I do think this horrible experience brought some good to my practice of medicine. It gave me role models to live up to and keeps me aware of the sacred spaces into which I am invited. I know what was important to me as a patient and try to provide the same:
Writing is cathartic. This post is based on very personal material covering one of the worst and yet one of the proudest days of my life.
Though a great deal of time has passed I remain grateful to everyone that cared for me that day and through my recovery. I am also honored by my patients now who place the same confidence in me that I did in my caregivers back then.
David
“You don’t know what you don’t know.”
Our department’s ED Quality Assurance (EDQA) committee will celebrate its 4th anniversary this September. By that time over 1,100 cases will have been reviewed by the roughly 10 individuals who make up this committee. Cases are obtained using both screening criteria (ED mortalities, return visits resulting in admissions) and open referrals from inside and outside the department.
While most referrals are internal, many come from other hospital departments, private attendings, and patients\families. EDQA is our major tool for barriers to providing optimal care and improving patient and staff safety.
The composition of the committee is key. It includes both ED nurses and physicians (including leadership) along with a representative from the hospital’s quality department. When appropriate, representatives from other departments also attend. Commonly this includes psych emergency services, trauma, EMS, and neurology.
The actual case reviews center around a structured questionnaire that guides discussion and is completed for each case. The focus is on determining whether the care and clinical decision making were appropriate. The committee is asked to judge whether an adverse outcome occurred and to identify any documentation, patient care, or systemic (including cultural ) issues.
Most of the review is based on the ED electronic medical record (physician and nursing notes, lab results). At the conclusion of each case the committee provides a rating (0-6) of the ED portion of care. Zero represents no individual provider concerns while a six denotes grave concerns related to avoidable severe morbidity or mortality.
The majority of charts reviewed receive a rating of zero. For the rest, most are rated in the minor to moderate range (1-3) . Severe concerns (4-6) are rare. When adverse outcomes or care\documentation issues are identified rapid feedback is also provided (usually electronically). The main goal is to educate and achieve future risk reduction rather than to be punitive.
Just as importantly many system issues (human, computer, non-ED, and cultural) that act as barriers to optimal care are identified. The knowledge of these gaps and barriers is used to further reduce risk and improve the reliability of our systems (See Swiss Cheese Model). Participation of ED leadership in EDQA (See Collaborative Leadership in the ED) is an essential element for success.
Other benefits of EDQA include:
Throughout the Spring I will be writing on the lessons we have learned in EDQA. I will be covering aggregate data on the cases reviewed; where typical gaps exist in complex systems such as the emergency department; how we can put lessons learned to work; and tips for providing better and safer care. For those excited to get started I am providing a set of lecture slides from two years ago (The Sharp End).
David
“Ebony and Ivory go together in perfect harmony.”
Most of my previous posts have looked at the sharp end where care in our emergency department takes place. I have not spent much time talking about the blunt end of our department – where the decisions that affect care are formulated. In our department the heart of that process is the EMERGENCY DEPARTMENT EXECUTIVE COMMITTEE (ED Exec for short).
This is a process that my friend and chairman Mark Rosenberg introduced about five years ago. It was both simple and radical. Get ALL of ED leadership in the same room, at the same time, every week, and talk about problems, solutions. There already existed a friendly relationship between nurses and physicians and leadership was no different. But in reality most of the time docs talked to docs and nurses to nurses.
In ED Exec our department’s physician leadership (chair, chiefs of services, residency director) and nursing leadership (director, manager, educators, clinical specialists) discuss and plan everything related to the department. Frequently representatives of outside departments (EMS, psych services, radiology) are invited to discuss relevant issues. The effect of these meetings is cohesive policy supported by all the department’s leaders that can then be implemented in unison. Our department secretary also attends these meetings. The presence of this long-time, non-clinical member of the department has added a vital perspective.
I know that this collective leadership, while sounding so simple, is a rare entity in modern health care. Successes are shared by the team as a whole while inevitable obstacles are tackled without finger pointing between nurses and physicians. Information may still stream down two different pathways to the rest of the department but the messages are consistent. This expectation of cooperation extends throughout all departmental efforts and initiatives. Successful programs like EDQA (see EDQA Post) are a direct off-shoot of this collaborative approach.
This effects were immediate but it took time to truly feel natural. My recollections of the first year of these meetings are:
Today there is still strain and conflict but it tends to be over ideas and not along practice lines. Communication within this group continues outside of the weekly meetings and sets a good example for others in our department. This collaborative style focused on getting-things-done remains the single most important thing I have learned about leadership.
David
As promised the Spring will bring two exciting series. One on EDQA and the other on Geriatric Emergency Medicine. Both will be episodic but I will be mixing them up rather than just present them in solid blocks.
“Change is hard”
So now our choices for lower risk chest pain are numerous and require additional skill sets. The simple stay or go has been replaced by:
We developed LOW RISK CHEST PAIN GUIDELINES to optimize flow and reduce admissions for diagnostic evaluation only. For the docs this requires a deeper knowledge of the extended evaluation of chest pain along with how to interpret diagnostic tests previously little used by them (calcium scoring, exercise and cardiolyte stress tests).
Also as some patients stay longer (for ED Observation lasting 16+ hours) the nurses will have to adapt to different set of patient needs and care coordination (including daily meds).
The percent of patients admitted to the hospital from our ED was already on the decline (See below). This is a reasonable step forward in that trend. Will this have the desired effect of safely reducing admissions?
Will this lead to additional guidelines targeting other types of previously admitted conditions?
Will my head explode just thinking about this? Stay tuned. 🙂
David
Anatomy of a Super ER 