Life-Saving Emergency Trach Performed in Restaurant

On Sept 23, 2013, a physician performed a life-saving emergency tracheotomy in a restaurant on a patron who was choking on a piece of meat. [link]

While eating dinner at The Mark Restaurant in California, Dr. Royce Johnson, an infectious disease doctor affiliated with UCLA, performed this procedure on Pauline Larwood, a female supervisor and a community college trustee.

Dr. Johnson saved this woman's life using a pocket knife and the hollow cylinder of a pen after a Heimlich maneuver failed to work.

Interestingly, Dr. Thomas Frieden, director of the CDC, who was also present in the restaurant assisted in the care by monitoring Larwood’s pulse during the incident.

Also present in the restaurant witnessing the emergency procedure were:

• Francis Collins, MD (director of NIH)
• Farming and business moguls Lynda and Stewart Resnick
• Rep. Kevin McCarthy, R-Bakersfield
• Assemblywoman Shannon Grove, R-Bakersfield
• State senator Jean Fuller, R-Bakersfield

Although typically surgeons are the individuals trained to perform tracheotomies, bravo to Dr. Johnson who took the initiative in spite of the fact that he probably has never performed one.

I should also add that though media reports state that an emergency tracheostomy was performed, it is probably more likely that an emergency cricothyroidotomy was performed instead which is easier and less "bloody."

Source:
Dramatic dinner rescue involves knife, UCLA doctor and CDC chief. The Bakersfield Californian 9/24/13

CALIF. DOCTOR SAVES CHOKING DINER WITH KNIFE. The Associated Press 9/25/13

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Death From a Severe Nosebleed

Image by RIs from Wikipedia

Attila the Hun was one of the most feared enemies of the Roman Empire. Ruler of the Huns from the year 434 until his death in 452, his empire stretched from Ural River to the Rhine River and from the Danube River to the Baltic Sea.

Although there are numerous theories as to how he died, the conventional account is that he died from a severe nosebleed on his wedding night.

Some may scoff that only people in historical times die from nosebleeds... but it unfortunately still even happens in the present.

Yes... a life-threatening nosebleed can be fatal whether a historical figure like Attila or a modern day individual. And I am talking in people who are otherwise completely healthy (no hemophilia, ITP, Osler-Weber-Rendu, etc).

Indeed, a Seattle lawyer died from a nosebleed in 2008.

Two British individuals died from a nosebleed in 2008 and in 2011.

And those are just the ones that are reported in the media.

It is estimated that in 1999, 4 out of 2.4 million deaths in the United States was due to a nosebleed [link].

Fatal nosebleeds in a normal healthy individual are almost always due to an arterial bleed, notably the sphenopalatine artery located in the back of the nose. Other less common fatal nosebleeds may be attributable to the ethmoid arteries located in the top of the nasal cavity.

Treatment of such life-threathening nosebleeds depends on the situation, but may include:

• Nasal packing
• Embolization
• Surgical

Cautery as shown in the video below is rarely successful.

Sources:
Man died after suffering two-hour nose bleed. Mirror News 11/24/11

Man Dies From Severe Nosebleed. ABC News 12/2/11

Woman sues hospital after her husband dies of nosebleed. KOMONews 5/4/13

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Scam Tracheostomy in Hospital Leading to Arrests

Image from Wikipedia

A Chicago hospital owner and a few doctors were arrested in a horrific scandal involving deliberately over-sedating patients thereby ensuring a patient will not be able to come off the breathing machine leading to the excuse needed to perform a tracheostomy [link]. All done in the name for greater profits.

This scandal is particularly notable given it has come right at the heels of a New York Times story which reported that hospitals often profit from surgical errors, though in this criminal case, it was deliberate rather than unintentional errors.

Tracheostomy is typically performed whenever a patient is on a breathing machine for a prolonged period of time and there is a low likelihood of recovery.

However, prior to tracheostomy consideration, sedation is turned off so that the patient is allowed to wake up and try to breath on their own. If able to breath on their own with machine assistance, the breathing tube may be removed thereby avoiding a tracheostomy.

However, according to the lawsuit, the hospital and physician colluded to over-sedate patients thereby ensuring the patient is "ventilator-dependent" for which a tracheostomy is (erroneously) "justified".

Furthermore, patients who have undergone tracheostomy were intentionally made to stay in the hospital longer than required ("28 days") in order to earn as much money as possible in insurance reimbursements for the hospital.  [link: paragraphs 123-142]

According to media reports, this scam has so far involved 28 patients... 5 who ultimately died within 2 weeks. The most recent unnecessary tracheostomy was performed on March 1, 2013.

Because of the trach and subsequent prolonged hospitalizations, the hospital received up to $160,000 for each patient from Medicare and Medicaid.

There's more... there was a massive kickback scheme whereby the hospital paid doctors to refer cases to the hospital (clear violation of Stark Laws), doctors ordered unnecessary ER visits, and fraudulently referred patients to nursing homes and ambulance services which the hospital had a relationship with.

This awful scam was brought to light by hospital workers (administrators, physicians, and nurses) who secretly worked with the FBI and other federal investigators.

Sources:
Feds raid Sacred Heart Hospital, arrest owner and doctors. Chicago Sun-Times 4/16/13.

United States of America Criminal Case Record. 4/15/13

Hospitals Profit From Surgical Errors, Study Finds. New York Times 4/16/13

Relationship Between Occurrence of Surgical Complications and Hospital Finances. JAMA. 2013;309(15):1599-1606. doi:10.1001/jama.2013.2773.

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ER Doc Found Negligent in Bell's Palsy Case

This case is not quite what you might think...

Here's the background... The Wisconsin State Supreme Court  found an ER physician negligent for failing to offer a carotid ultrasound for a patient who presented with an isolated facial paralysis (patient did not exhibit paralysis anywhere else in the body) and upheld a $2 million jury award to the patient in 2008. Not only that, the Wisconsin Medical Board reprimanded the ER physician and fined her $300. [link]

Hmmmm... After all, it is not considered routine nor standard of care to obtain a carotid ultrasound for an isolated facial paralysis known as Bell's palsy. I should also mention that the ER physician was NOT found negligent in the diagnosis of Bell's palsy.

Well, here's the other part of the story... The patient did have a CT scan of the brain in the ER which was normal. A diagnosis of Bell's palsy was appropriately made by the ER physician and the patient sent home. Eleven days later, the patient suffered a stroke with irreversible damage. A stroke workup at that time revealed a carotid artery with 95% obstruction.

For those uninitiated, paralysis due to a blocked carotid artery would cause lack of blood flow to one entire half of the brain resulting in not only facial paralysis, but also paralysis of half the body too. Furthermore, a stroke causing facial paralysis would have forehead sparing (more on this).

The court's feeling was that the patient should have been offered a carotid ultrasound at the time of the initial ER visit for Bell's palsy... in essence, the court was stating a stroke workup should have been offered/done for a Bell's Palsy. I should also mention that most ER's do not have carotid ultrasound capabilities outside of business hours.

To reiterate, a carotid ultrasound is NOT a test that a physician would or should normally order for a Bell's Palsy workup. By the court stating a carotid ultrasound should have been performed, it has turned a medical condition of Bell's palsy which is not a stroke concern into a diagnosis of possible stroke.

Does that now mean that whenever a patient presents with a Bell's palsy, a stroke protocol should also be pursued which would include:

1) Stroke rapid response by the ER
2) Hospital admission
3) Stroke workup which would include:
  • Carotid ultrasound
  • MRI Head
  • Cardiac workup for arrhythmias (atrial fibrillation which can cause embolic stroke)
  • Pulmonary and vascular workup for deep venous thrombosis (can also cause embolic stroke)
etc, etc, etc

Medically speaking, Bell's palsy is NOT a stroke nor a concern for possible stroke nor increased risk of stroke. Bell's palsy is an isolated inflammation of the facial nerve that has nothing to do with the brain.

ER physicians have a hard enough job as it is now, but to be responsible for pursuing workups for totally unrelated diagnosis separate from the main presenting concern should be cause for concern.

Perhaps there is more to this case that was absent from what has been reported in the media...

Source:
State board reprimands doctor who was found negligent by high court. Wisconsin State Journal 3/21/13

Health Sense: How much should doctor tell you? Wisconsin State Journal 7/9/12

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Celebrity Actors Who Have Received a Trach (Catherine Zeta Jones Included)

Image Taken From www.TopScarCream.com

Tracheostomy (also known as trach) is when a hole is made in the midline neck directly into a person's windpipe (watch video). Although many people may shy away from this deforming procedure, it can be life-saving.

On that note, here is a short list of famous celebrity actors who have undergone an emergency trach for one reason or another:

Catherine Zeta-Jones
Apparently, when she was a child, she had an emergency trach done. She still has a 1.5 inch scar from this procedure which she elected to not have removed [link].

Gary Coleman
He was hospitalized for 3 months due to complications from thyroid surgery for which he underwent an emergency trach [link].

Watch video of thyroid surgery.

Elizabeth Taylor
In spring of 1961, she developed a case of pneumonia which led to an emergency trach [link].

Christopher Reeve
Of the original Superman fame, he became paralyzed from the neck down after a horse-riding accident. A tracheostomy was required for him to breath due to ventilator dependence. [link]

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Is Patient Abandonment in the Operating Room Ever Justified?

I ask this question mainly because there WAS an ENT who WAS sued for NOT abandoning his patient in the operating room [link]. No way to verify, but additional details can be found in this facebook post.

Imagine this hypothetical scenario (as details from original case are not available)...

You are an ENT surgeon in a rural community hospital performing a fairly difficult but elective sinus surgery on a 12 years old child with cystic fibrosis with extensive pan-sinus nasal polypoid disease. Given the extensive nasal polypoid disease, a fair amount of bleeding is occurring which was not unanticipated.

Suddenly, you get a phone call from the emergency room regarding a patient with progressive difficulty breathing suspected to have epiglottitis.

What do you do if you are the only ENT in the hospital?

Do you "abandon" the 12 years old child in the operating room, still bleeding, still under general anesthesia and attend to the ER patient who himself might die without an emergency tracheostomy? Doing an evaluation to determine how critical the ER patient may take anywhere from 15 - 60 minutes including the tracheostomy itself. Keep in mind that 99% of the time, a tracheostomy is NOT necessary.

And, if a tracheostomy WAS needed, you are now performing two different surgeries in two different rooms simultaneously which must break some rule somewhere... perhaps JCAHO?

Or, would you finish the surgical case first, and than proceed to see the ER patient?

What if you are the only ENT available in the region let alone the hospital? No fellow ENT colleagues to call upon for help. General surgery is "unavailable" or not comfortable with performing tracheostomies especially given ENT performs all tracheostomies in the hospital?

Patient abandonment is defined as:

• Failing to transfer a patient to an appropriate level of care
• Failing to respond to calls from a hospital regarding a patient
• Refusing to care for a patient after arranging the patient's admission
• Failing to treat a patient until new coverage is arranged

Proving patient abandonment includes:

• Your doctor had a duty to treat you - a duty was created when the physician-patient relationship was established
• You had a reasonable expectation that your doctor would treat you
• Your doctor failed to treat you although he or she was obligated to do so
• You suffered injury as a result

Well, according to one lawsuit, it seems that the ENT was required to abandon his patient in the operating room and attend to the ER patient. The lawsuit stemmed from the fact that the ENT did not abandon his patient in the operating room and the ER patient did die as a result of not being attended to quickly and competent emergency tracheostomy performed. Of course, the settled lawsuit also blamed the hospital, general surgery, and anesthesiology.

However, abandoning a patient on the operating room table is also tantamount to medical malpractice according to the very definition of patient abandonment.

And, I would not be surprised if the patient on the operating room table would have sued the ENT if he DID leave the operating room in the middle of surgery to attend to another patient for a long period of time (and even starting another operation without ever finishing the abandoned patient's surgery first).

What to do?

I have no answer...

Doing an emergency tracheostomy is HARD, even for someone who has performed hundreds of elective tracheostomies. I know... I've done perhaps a half-dozen emergency trachs in my career so far. In this particular lawsuit, I found it incredible that a hospitalist (not a surgeon) was the one who finally attempted the emergency tracheostomy (albeit unsuccessfully).

Do you consider the patient you are CURRENTLY caring for has a higher priority than a patient you have never met, even if possible life-threatening illness is involved? (Keep in mind that when called for an airway problem, that 99% of the time, an emergency tracheostomy is not needed.)

OR, do you prioritize the patient you have never met given the possible life-and-death circumstances involved, even if 99% of the time, no surgical airway is required.

What would YOU do? What should you do? Feel free to comment below!

The way I see it, the ENT would have been sued no matter what decision was made. It would have been a lose-lose and lose proposition.

By deciding to stay with his current patient, the ENT was sued by the ER patient's family. If the ENT left his current patient on the operating room table, the ENT would have been sued for abandonment. If the ENT did abandon the current patient and the ER patient still died in spite of an emergency tracheostomy, the ENT would probably be sued for wrongful death by the ER patient's family AND the patient he abandoned on the operating room table.

Source:

Hospital settles wrongful death lawsuit. Curry Coastal Pilot 10/31/12

ADDENDUM 12/5/12:
Information obtained from an anonymous source reported that the ENT who was sued ultimately had charges dismissed with prejudice. It was maintained from the beginning that the ENT's obligation was to the patient on the table and that there was no doctor-patient relationship with the deceased.

I also find it interesting that the hospital where the lawsuit occurred, now does not even have ENT coverage at all. I guess that's what happens when a lawsuit occurs when there's only solo specialist coverage. I'm predicting that this hospital will have a very difficult time to recruit another ENT to work there given this case even though the ENT was ultimately found blameless.

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Problem with Medical Protocols (and Lawsuits Because of Them)

Over the past decade working in hospitals, I've seen the proliferation of "established procedures and protocols" for literally everything under the sun...

• Chest Pain Protocol
• Discharge Protocol
• Pneumonia Protocol
• Stroke Protocol
etc, etc, etc

Protocols are essentially standing orders that are supposed to be implemented whenever a given medical situation occurs. It is supposed to follow best evidence-based practices and make it easy for healthcare personnel know what to do without thinking to hard (akin to a checklist a pilot performs before flying to ensure they did not forget something).

The problem with protocols are that it can be made so detailed as to become worthlessly bloated. To use an analogy, take the protocol, "Going Shopping Protocol."

Protocol A (Simple):
1) Make grocery list
2) Drive to supermarket
3) Pickup and purchase items on grocery list
4) Come back home

Protocol B (Detailed):
1) Pickup #2 pencil
2) Sharpen pencil to appropriate point using pencil sharpener model 15-231
3) Test pencil to ensure proper writing ability
4) Obtain 3x4 inch index card
5) Write shopping item #1 on index card using pencil (from steps #1-3)
etc, etc, etc

Now when dealing with something as complex as medicine, protocols can be a godsend or hopeless depending on how it is written and who uses it.

And, that's where protocols become problematic.

Make a protocol too detailed, and it becomes bloated to the point of being useless, especially when dealing with time-sensitive medical problems.

Take for example something as simple as "Chest Pain Protocol." Orders for EKG, aspirin, IV fluids, sublingual nitroglycerin, and morphine seem obvious (assumption being heart attack), but what if we are dealing with a 10 years old child who got punched in the stomach by a bully? What about a stabbing into the chest?

Does that mean there needs to be multiple branch-points explicitly addressed in the protocol to handle every single possible scenario of chest pain under the sun at any age for every possible scenario?

Clearly, the answer is "NO"!

So protocols are made with several assumptions:

1)  A general level of medical competence of healthcare professionals
2 ) Healthcare professionals are already familiar with a given protocol and knows when to appropriately activate it
3) Protocols are deliberately made to be not too specific as it is understood that there is variability in the care of patients. Protocols can not and should not be applied cookie cutter to every patient as there are nuances that the protocol leaves to the judgement of the doctor.

Unfortunately, by making protocols to generalized, it does open up the possibility of lawsuits.

Take an ongoing case in Georgia where the medical director of an emergency room is being sued for professional negligence in the death of a woman from a heart attack... because of a chest pain protocol he wrote. Note that this medical director NEVER provided any direct medical care, did not have an established patient-physician relationship, and was not even in the hospital when the woman came into the ER. [link]

So is the solution to avoid having any protocols in place to avoid lawsuits? Sorry... NOT having a protocol in place can also be subject to a lawsuit. In 2000, a hospital was sued for either failing to follow established anesthesia procedures or protocols or failing to have any established procedures or protocols in place. [link]

So what to do?

Well, getting sued is a risk that is inherent to the medical field, especially whenever there is a bad outcome.

As such, the default action taken by physicians and hospital administrators are to minimize or spread the risk. How?

• Have as many different physicians write-up a given protocol that is signed off by everybody (spreading the risk)
• Avoid positions of responsibility (default scapegoat for lawsuits)
• Involve many physicians in the care of a patient (spreading or transferring the risk)
• Have protocols, but do not depend on them (clinical judgement trumps protocol).
• Have MANY documented training sessions on how protocols are to be used and discuss weaknesses and strengths of them

References:
UPSON COUNTY HOSP., INC. v. HEAD 540 S.E.2d 626 (2000) 246 Ga. App. 386 UPSON COUNTY HOSPITAL, INC. v. HEAD. No. A00A1601. Court of Appeals of Georgia. October 13, 2000.

Gaulden v. Green, No. A12A1872 (Ga. Ct. App. Oct. 30, 2012)

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Financial Issues with Emergency Room Specialist Care

Imagine this scenario... A young child is playing in the yard when her pet dog bites her face. Bleeding, the child is rushed to the emergency room and the emergency room doctor offers to suture up the child's face.

The next question a parent will probably ask (or demand) is the desire for a plastic surgeon to suture the face instead of the emergency room doctor.

As such, the plastic surgeon is called in and sutures up the face beautifully.

The child and family goes home and that's when the financial nightmare begins...

The plastic surgeon bills the family for $2,000 for services rendered in the emergency room. The plastic surgeon does NOT participate with their health insurance plan and being a non-participating provider, the bill for care provided is directly sent to the child's family.

Here is a New York Times article describing this situation.

Outrageous?

Unfortunately, it is not unusual... and there are lawsuits now pending among insurance companies, specialist physicians, as well as even against patients regarding who pays the medical bills.

Here is an article portraying a hand surgeon who has sued numerous patients regarding just this scenario. Most specialists will either write-off or accept any amount after being sent to collection.

Background

If a patient has a medical problem, a call to the medical office is made to see the doctor. However, before the appointment is made, both the patient and office checks to ensure the visit will be covered by insurance. If not, a call to a different medical office is made until one that participates with the patient's insurance is found. However, if the patient decides to see a physician who does NOT participate with his health insurance company, he will be responsible for the entire bill (the office visit will not be covered by insurance).

The same is true for outside specialists called into the emergency room. These outside medical specialists participate only with certain insurances. As such, if they perform services on a patient whose health insurance does not cover that particular medical specialist, the patient will get the entire bill.

Emergency room care IS covered by insurance... because it is an "emergency," but services performed ONLY by the emergency room staff applies. NOT services by outside specialists called in.

What to Do?

So what is a patient to do in order to avoid a surprising large bill?

Ideally, have all services performed by emergency room staff and avoid services by outside specialists. If it is not life-threatening (like a facial dog-bite... ugly, but not life-threatening), have the emergency room doctor do all he can. Than follow-up as an outpatient with a specialist who participates with your health insurance plan.

If an outside specialist MUST be called in, ask whether this specialist participates with your health insurance plan. If not, ask how much the specialist will charge for services rendered. Be aware, if the outside specialist actually comes into the hospital, a consultation fee will be charged (typically around $100-$200). If a procedure is performed, a procedure charge will be present (hundreds to thousands of dollars).

A patient can request whether there is a different doctor who can be contacted should the specialist on-call not participate with his/her health insurance plan. However, be aware that typically only ONE doctor per specialty is on-call to the emergency room at any given time and as such, an alternative doctor may not be available.

Once you are aware of the charges, you as the patient needs to decide whether to proceed with specialist care or not.

Be aware that the insurance coverage issues also applies for specialist consultations during a hospitalization and not just in the emergency room.

Bottom Line

Simply going to the emergency room does not mean all medical services will be covered by insurance, especially services provided by a medical specialist.

If specialist care is required in the emergency room, just ask whether the specialist participates with your health insurance plan, because if not, be aware that you directly will get a bill.

That's just how the medical system is set up currently.

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How Does Nasal Packing Stop Nosebleeds?

It is not unusual for an ENT or an Emergency Room physician to see a patient with a very bad nosebleed... the kind that can potentially be life-threatening given how much active bleeding is occurring.

In these situations, nasal packing is the fastest and best way of stopping the nosebleed.

For any type of active bleeding, direct pressure tamponades the bleeding thereby stopping it... whether it be a stab wound to the leg or a bad nosebleed. In essence, direct pressure exerts a certain amount of pressure that exceeds the blood pressure preventing blood flow. The corollary being if the amount of direct pressure being exerted is LESS than the blood pressure, bleeding will still occur.

With nasal packing, pressure is exerted by the packing material and pressed against whatever the bleeding source is within the nose.

My personal favorite packing material is called the rapid rhino made by Arthrocare (I have no financial ties to the company). It is in essence a balloon covered by a bio-compatible self-lubricating fabric. This device is inserted into the nose in a deflated state. 

Once fully inserted into the nose, it is than inflated using a standard syringe. Enough air is inflated into the device such that the pressure exerted by the balloon exceeds the blood pressure of the vessels within the nose.

The key point here is that enough pressure must be exerted by the balloon device. If the patient's blood pressure exceeds the balloon pressure, bleeding will still occur and MORE air must be pushed in. As such, in patients with high blood pressure, more air must be inflated into the balloon device to stop a nosebleed compared to a patient with low blood pressure.

So, here is what it looks like to insert a rapid rhino nasal packing.

Step 1: After hydrating the fabric, the nasal packing is placed at entrance of nose.

Step 2: Nasal packing is fully inserted into the nasal cavity.

Step 3: The nasal packing balloon is than inflated with enough air pressure to stop the nosebleed.

Obviously, blood pressure must also be controlled and the nasal packing can be removed in about 3 days for patients not taking any blood thinners or anti-coagulants (coumadin, plavix, ticlid, pradaxa, aspirin, ibuprofen, etc). For those on such medications, packing may need to be kept in place longer.

For more information about nosebleeds.

Watch a video regarding how cauterization can stop nosebleeds.

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