026 Discussing Healthcare: Why are physicians frustrated? (Physician rant part 2)

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Capital punishment: In Oklahoma last week a prisoner was put to death by way of lethal injection. Unfortunately, there was error in the process and the prisoner didn’t die until 43 minutes after the injection. Since then there has been debate about lethal injection and capital punishment. There should be debate about capital punishment and the methods that we use to carry out an execution. However, in this case we should look at the process of how lethal injection is performed. Here are the basics about IV catheters and the drugs used in the Oklahoma case.

Intravenous catheters (IVs) are used thousands of times every day around the world. Sometimes when an IV is placed there can be problems. The IV is placed in a vein with the goal of injecting medication or fluids directly into the vein. The medication is then spread throughout the body for the desired effect. An IV can come out of the vein if the catheter is not in far enough, if someone accidentally pulls on the catheter, or if a patient moves in a certain direction. It is difficult to tell if this happens because the catheter can still be in the skin. Medications and fluids can flow into the surrounding tissues and the desired effect of the medication will not occur. There are other complications that can occur with IVs, but the point is that an IV is not perfect and problems can occur.

The medications that were used in the Oklahoma case were good medications. By report Midazolam (Versed), Vecuronium and Potassium were administered (in that order). The effects of all three drugs depend on the dose given and the individuals ability to metabolize the medication. The first drug given, midazolam, is used to sedate a patient. In large enough doses it renders a patient unconscious and removes any memory of the event. Vecuronium was given next and is a paralytic. Paralytic medications paralyze the muscles. After receiving vecuronium the patient cannot breath until the medication dissipates. Vecuronium is a long acting paralytic. It takes about 3-5 minutes to start working and lasts 30-60 minutes. Lastly, potassium was given. Potassium is needed in our bodies to help perform normal function and it is vital to keep the heart beating. There is a very fine balance of maintaining just the right amount of potassium in the body. Too much or too little will result in death. So, potassium is given in a large bolus to cause cardiac arrest.

In theory these medications should have worked without incident. Many physicians use these medications every day and they are widely accepted as safe for patient care. I use midazolam and vecuronium on a regular basis and have never had a problem with them.

SO, WHAT HAPPENED? Well, likely the medications were not given in the vein, rather they were given into the tissue around the vein. The medications then are absorbed unpredictably and the amount of medication absorbed from the tissues was less than when given directly into the vein. This created a situation where the patient had a prolonged death as a result of medication that was not put in the vein.

HOW CAN IT BE FIXED? This is currently under review by the Oklahoma government. But, there are longer IVs that can be placed where the medications can be administered into the vein more predictably. Or, the medications can be given through 2 different IVs at the same time. The likelihood that both IVs would have complications is quite small.

I have never taken part in capital punishment, nor do I know the protocols that are in place for lethal injection in Oklahoma or any other state. But, these protocols should be reviewed and adjusted to prevent events like this in the future.

MERS-CoV: Indiana has claimed the first confirmed case of MERS-CoV (Middle East Respiratory Syndrome Coronavirus) in the United States. This is a big deal as this virus has claimed the lives of many in the middle east. MERS-CoV is a virus in the coronavirus family. The most famous of the coronaviruses is the virus that causes SARS (Severe Acute Respiratory Syndrome). MERS-CoV causes a similar illness. Although the infection is not completely understood most of the confirmed infections have had pneumonia like symptoms. The patients can become quite ill and about 33% (93 of 254) of the confirmed cases have resulted in death.

All of the cases have had some connection to the middle east. The virus is believed to have originated in Saudi Arabia, as this is the location of most of the infections.  However, there have been confirmed cases in Jordan, Kuwait, Oman, Qatar, the United Arab Emirates, France, Germany, Greece, Italy, the United Kingdom, Tunisia, Egypt, Malaysia, the Philippines, and now the United States.

The origin of the virus is unknown. There have been positive tests for the virus or the virus antibody in animals, such as the camel. This has lead to the idea that this could be an animal infection that has crossed over to humans. However, more work needs to be done to figure out the origin. It is thought that there is human to human transmission, but no one knows how it is transmitted.

There is no need for hysteria about MERS-CoV, but you should be aware of the infection if you are traveling or around individuals from the middle east who have been sick recently. Pay attention to the news for ongoing updates.

Physician rant (part 2)

Mimi Zipser, MD

Mimi Zipser, MD

Mimi Zipser, MD is an emergency physician. She, like many other physicians, is frustrated with her career. She sat down with me to discuss her frustrations. This is the second half of the interview (see episodes 25 for the first half of the interview) which was based on the following writing by Dr. Zipser:

I apologize for the ensuing rant but these are thoughts weighing heavy on my mind tonight…I am saddened by the fact that my profession as a physician has seem to become a field where instead of respect for the 11 years I spent in higher education obtaining my degree, I am overshadowed by celebrities and well meaning but poorly educated parents telling me I have no idea about the true ramifications about vaccinations. I am told time and time again that a patient has diagnosed themselves via Google and doesn’t understand why I am not treating them for x,y, and z. I am told frequently that if I don’t order a certain test or imaging, that I will be sued if I miss something. I am berated by patients who tell me I am causing them harm by not refilling their narcotics for chronic pain or giving them narcotics for even a simple bladder infection or an antibiotic for their “cold”. I am overshadowed by hospital administrators judging my quality and worth as a physician based not on how accurately or well I care for a patient medically but on how high my “CUSTOMER SATISFACTION” scores are. And in that same breath they are telling me customer service is a key factor, they strip away more and more of my time away from my actual patients by placing me in front of an electronic medical record system so I can place all my own orders, spend more time charting my interaction with the patient then I actually have physical time with the patient and then spend more time answering emails about how a “Customer” was dissatisfied with their ER visit.

 I AM A PHYSICIAN. I studied hard so I could help care for others in their time of distress and need. So I can tell someone how best to treat their condition based on evidence supported medicine. So I could possibly save a life of someone I may or may not know. So I could be an empathetic bearer of bad news to the family of those that I could not save. I AM NOT a secretary, a waitress or a salesperson helping you get the shirt in the size you want. There is not a single thing wrong with any of those professions, but it is not MY profession. NOT what I went to school for. I am not in the customer service industry. My job is not to satisfy people. The customer is NOT always right in my profession because PATIENTS ARE NOT CUSTOMERS. Patients are people with illnesses and pain or injuries who seek my help because I may be able to provide them some respite from their ailments. Patients once upon a time actually listened and physicians used to garner some respect…or at least that is what my job used to be…I feel that administration and misconceptions about how the medical field should be run has tainted what used to be a truly altruistic field. I love what I do. I love my job. But it is getting harder and harder to maintain the love with the constraints and disrespect administrative and social roles have placed on my profession…again, sorry for the tirade. I don’t usually post things like this but felt like I needed to get these thoughts off my chest.

Dr. Zipser’s views are shared by many practicing physicians. Most of us are frustrated with the changes that are occurring in healthcare. There is concern that the changes are not improving medical care. Patient care is now put on the back burner as we are forced to be concerned about things like electronic medical records and patient satisfaction.

The idea of electronic medical records is great, but the reality is that the software development and user interface are not beneficial to patient care. Rather, physician and nurse charting has become onerous and complicated. This will likely work itself out in the coming years, but for now it is impeding on the physician’s ability to care for patients. In a 2012 JAMA article patient satisfaction lead to increase healthcare costs and a 26% increase in mortality (death). It seems crazy that we would continue focusing on patient satisfaction with the results of this study. If this were the results of a drug study the study would have been stopped early and the drug would never make it to the market. So, why do we continue pushing for high patient satisfaction?

Healthcare is changing…and it should. But, we need to be careful about the changes we make. Patients should be at the center of every decision that is made about healthcare. Physicians should have a hand in making decisions about how healthcare will be delivered in the future. However, it seems like the two voices that matter most are now muted. Corporations and government are now in control of our healthcare system. The profits and expenditures for these entities control most healthcare decisions and the physicians and patients are left to argue about it.

About the Author

I am Joshua Lewis, MD, the creator of Discussing Healthcare, LLC and a board certified Emergency Physician who currently practices in the Phoenix, Arizona area. I hope you will gain meaningful insight into our healthcare system through the information provided by Discussing Healthcare. Thank you for your interest and I encourage you to contribute by calling, emailing, or leaving comments on the website.

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  1. A Physician Rant – Part 2 | Doctoring, Mothering, and Faith | July 15, 2014

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