Every other Emergency Room Doctor and every other Hospital in America has exhibited a combined audible sigh of relief at not being responsible for failing to diagnose the first Ebola patient in the United States. There is a common refrain - “There by the grace of G-d I and my hospital go”. There is sympathy and empathy for the Texas Health Presbyterian Hospital in Dallas and the ER staff. Nobody needs the whole nation second guessing your management. Nobody wants to feel that they have created a national crisis which has become the issue du jour in the media. There has been criticism of the care explicitly and implicitly and Jay H. Ell shudders to think of the pounding that all concerned have gone through both within and without the hospital.
There are several questions being asked and the one most central to this discourse is, “How on earth did the USA’s much vaunted medical system, ostensibly the best in the world, miss the diagnosis thereby resulting in a moribund patient and the scare of an epidemic with fifty persons at immediate risk of which at least 10 are at serious risk?” The Dallas Hospital was called to task and an article, in no lesser media mouthpiece than TIME, carried their explanation under the heading, “Dallas Hospital Scrambles to Explain Initial Release from Hospital”. Briefly, the hospital’s response was that it was a technical glitch that caused the disaster.
CONTEXT OF DALLAS HOSPITAL'S "MISTAKE"
Let us try and put this all in some context before going into detail about the care and the hospital explanation. The hospital provides the following minimal details - a patient with a temperature of 100.5 Fahrenheit, with abdominal pain and a decreased urination presented to the ER. Without stating anything else or whether any laboratory work was done they state that after assessment the patient was subsequently discharged. The hospital maintains, correctly so, that at that visit the patient’s symptoms were not severe and could be associated with many other afflictions. The hospital argues that the fact that he had come from Liberia was recorded earlier in the notes, by the nurse, but due to software malfunction the note did not get through to the doctor. The hospital has informed other hospitals that might have that problem to adjust their software.
Jay H. Ell believes the problem is far deeper than a software problem and, rather, is a manifestation of the paradigm of the current practice of medicine, medical education, the health care system itself and the values behind the endeavor of health or “sickness” care.
WHAT IS MAKING TODAY’S ER SO STRESSFUL
It is fair to say that American ER physicians and the discipline of Emergency Medicine are of the highest standard in the world. While ER physicians, in general, are dedicated professionals who view their modern day mission with commitment, dedication and professionalism, there are several circumstances that make their job definition that much more difficult.
The Patients.
The Emergency Room is everyone’s fantasy of the drama of medicine - saving lives left, right and center. The fact that the most popular TV series feature ER doctors bears witness to this fact and that is where George Clooney met the world. The Emergency Room is a tough place to work in that one treats, under time pressure, patients in extremis, exhibiting sophisticated psychomotor skills in the process. (That is what the ER doctor originally signed on for).
However, the ER is the one place in the USA where anyone has to be seen and evaluated, regardless of their ability to pay or regardless of whether they require emergent medical intervention or not. This brings a glut of non ER patients that place a strain on the doctor and the system. This includes drug addicts, chronic alcoholics and a host of social problems. It is extremely difficult to find institutions to accept these patients and they take up scarce ER space and time, sometimes lingering in the ER for days before being discharged or admitted to another facility. The other group of patients that are seen are patients, who don't qualify for the TV definition of ER patients, with minor complaints and or “undifferentiated Illness”. The latter is illness that has not as yet defined itself as a recognized disease process and is usually minor and is of the type that the Dallas Ebola patient presented with. More and more of those patients come to the ER facility as either they have insurance such as Public Aid where it is difficult to find one of the scarce Primary Care doctors or they still have no insurance, in spite of Obamacare, or they are just visitors as was the Ebola patient. Some just use the ER as their source of primary care not even bothering to establish themselves with Primary Care Physicians.
This all results in most ERs being overwhelmed and the wait to be seen can be several hours.
The Culture
Medicine is run in America on the business/industrial model. Thus the patient or what is now unashamedly called the “customer”, is always right. “Customer satisfaction” is measured in most places by a process that is wholly unscientific, akin to a market survey, where only those that wish to reply do. To add insult to injury, no score is designated as to whether care is regarded as excellent, good, satisfactory for example, rather, every ER is compared to all the others. So if your score is 95% and all your competitors are 97% then you will be ranked on the lowest percentile. Conversely if your score is 47% and all your opposition are 45% your ER will be graded on the highest percentile! This bizarre system has become entrenched to the extent that Medicare is going to base remuneration on the basis of the outcome.
While emphasis on meeting a patient’s needs is most important giving in to unreasonable demands such as prescribing narcotic drugs and antibiotics inappropriately is not and ER physicians do not even at the risk of a complaint and a bad review score. One can give empathy and non judgmental acceptance to all but to be a professional one has to maintain one’s integrity.
This business/industrial culture adds pressure to the already stressed out doctor.
Malpractice Litigation
In spite of all arguments that malpractice is based on standards of care it is initiated in nearly every instance on a bad outcome. Now in a heavy duty morbidity situation like an ER there are plenty of bad outcomes. So the ER doctor is obsessed with creating a record, doing everything possible, to defend him or herself in the event that the patient does die or something untoward occurs. Any one who maintains that litigation is not an issue in patient care is not practicing medicine and/or has never practiced outside of this country. Patients are investigated ad nauseam and the whole exercise is costly, time consuming and anxiety producing. Again it is not argued that the “customers” should not be appropriately evaluated but “covering one’s butt” should not be a factor in health care. For example, the alcoholic who is there every night as he refuses treatment is given a multi thousand dollar work up each night as he is, sooner or later, going to drop dead and nobody, but nobody, wants to face a situation where he/she has not repeated the bloods the night before because they could have changed would argue a tort lawyer smugly.
Needles to say this all adds up to more unnecessary stress that is so inbuilt into the ER doctor behavior that he/she hardly knows that he/she is consciously taking it into account when he/she types his/her list of orders.
The Electronic Record.
The computerized medical record may be boon to administrators, business offices and the government but it is a royal pain in the neck to the ER doctor who spends more time on the medical record than ever before at the expense of patient - doctor time. You are either looking into the face of the computer rather than the face of the patient at the bedside or rushing from the patient to get to the computer.
MEDICAL EDUCATION ,THE PARADIGM OF MEDICINE AND EBOLA.
While everybody emphasizes patient - centered care, only lip service is paid to it in medical education. It is considered "soft", "unscientific" and not worthy of much attention. Doctor - patient relationship theory, personality and the like at best are taught in token classes. They are not going to be questions on the Boards so who cares? The paradigm of medicine is Newtonian Physics. The key variable is disease that it is measurable and treatable by laboratory or imaging. There is no taking into account the variables of doctor, patient and what happens between them. There is no acceptance of the fact that the observer and the observed can change the doctor patient "experiment" and are crucial to outcome. Everyone will accept that if a doctor despises alcoholics the latter are going to get poor care from him/her. Similarly, they accept if the patient decides to "give up" and not fight you can stand on your head, the patient will die. Both the latter examples illustrate that the doctor and patient variables impact outcome and not only disease process. Also Newtonian physics assumes total physician control. It doesn’t take into account the variable of the patient who needn’t tell you that he has chest pain and then drop dead within a month after his/her interaction with you.
Now certain branches of Medicine have defined disease where fixed protocols can be used to treat patients and the failure to address the other variables in illness is not so glaring. The ER plainly has defined disease and undifferentiated disease presenting to it as was the case of Thomas Eric Duncan from Liberia. While the Hospital claims, as exculpatory, the fact that his symptoms were minor, that is just the time that intervention is needed to give the patient the best chance of survival from this dreaded disease. It is no good just shrugging one’s shoulders and blaming it on software.
Let us look what was in potentially in place to prevent this from happening. The patient variable, what the patent feels, thinks and believes was not considered important enough for the doctor to address. He/she is far to busy filling in screens on his/her computer. The system delegates this important function to the nurse and the nurse only. The nurse records the patient responses and then sends these to the doctor. In this crucial instance the software failed and the doctor proceeded, as he was taught, to address disease but there was none obvious. He therefore does the best he can and is obviously uncertain as he prescribes antibiotics in what appears to be a viral syndrome. (He has in been criticized for that by some or other member of the CDC who obviously doesn’t practice medicine on a daily basis).
The only way he/she could have got to an Ebola diagnosis was via the patient. Now one can argue it was the patient’s responsibility to share his non medical history, namely, that he has just come from Liberia . But as far as the patient was concerned he had discharged his responsibility by telling the nurse. In addition the patient may well be in denial. He did not want to hear that he could have Ebola and was only too happy and relieved, having informed the system where he came from, that Ebola, that was looming massively in his mind and surely, he believed. in the doctors’ mind, was not being considered.
The patient had a lot at stake, as he had come here to get married and that would have ensured his stay in this land so why would he change his reality. The American health care system has decided he needs antibiotics and Ebola is not in the picture.
So what could the doctor have done? While a provision is in place to avoid him getting involved in the so called “trivia” he is still ultimately responsible. But nothing in his training or even job definition that has defined and taught that he needs to vigorously pursue the patient variable. Certainly no check list in his endless computer record. He is rushed off his feet. There is the computer, the possible intubation, the cardiac whose oxygen stats are still low.. he better be nice to the patient because maybe he will be surveyed…..
There is something ringing a bell that this is not straight forward so he prescribes an antibiotic so what else could he do? Well he might have looked at the other variable, the patient, and see if he could have provided information that could have helped him/her in management. He/she needed to know the patient’s agenda, like why he came tonight with relatively mild symptoms and what were his fears? What he felt might be the cause of his not feeling well. He needed to have been trained to recognize if the patient is highly defended how to be able to facilitate these answers.
For all as long as medicine regards all these psychosocial variables as trivia Ebolas will happen, cardiac patients will drop dead having just had a "check up", hypertensives will not be controlled and so forth and so on.
BACK TO THE EBOLA PATIENT
So to trivialize this as a software glitch is to invite further problems in the future. To blame the ER doctor with all that he/she has to contend with in the modern ER is simplistic and unfair. To start with she/he needs a scribe. He/she should not have to look at a computer - the job is to manage patients. More valid patient satisfaction tools should be devised that reflect the professionalism of the doctor in meeting his/her patients needs so that he can feel comfortable about behaving professionally. Medical education needs to be adjusted to best help the doctor manage patients with all the variables not just the disease process.
In short one needs a paradigm shift in health care to prevent Ebolas as conventional knowledge and skill were not enough to prevent a disaster of unbelievable proportions and cost.
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