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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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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Forbes Critical of Patient Satisfaction Ratings of Physicians

Forbes on January 2, 2013 published a story critical of Press Gainey and other companies that obtain patient satisfaction scores.

Please note that the following is a reprint of prior blog articles (2/19/12 and 6/8/12) written on this subject by Fauquier ENT.

Indeed, much has been made about improving patient satisfaction in the healthcare industry in the belief that greater patient satisfaction equates with better health. To this end, patients are routinely asked to complete a survey based on their impressions on the care they received at a medical office, hospital, and/or emergency room.

BUT... does greater patient satisfaction actually result in or is the result of better care???

According to a recent study... higher patient satisfaction actually resulted in:

• Greater inpatient hospitalization
• Higher overall healthcare utilization
• Higher prescription usage
• INCREASED RISK OF DEATH!

The one and only measured benefit of higher patient satisfaction scores was decreased ER use.

Why would there be an increased risk of death with higher patient satisfaction scores?

Well, if a doctor always does what the patient wants, that would tend to lead towards higher patient satisfaction... EVEN if it's the wrong thing to do.

For example... when a patient sees a doctor for a perceived sinus infection, it is not uncommon for a patient to expect to leave with an antibiotic.

Unfortunately, many sinus infections are actually viral URI for which antibiotics is the WRONG course of action.

Inappropriate antibiotics lead to drug-resistant infections which lead to deaths.

However, if a doctor resists a patient's desire for an antibiotic, that would lead to a decrease in patient satisfaction.

Such medical decisions do not apply to just antibiotics, but also tests, procedures, and hospital admissions.

This example and others may oversimplify a very complex issue, but it does suggest that one interpretation of higher patient satisfaction scores are that doctors and hospital systems may choose to do the wrong thing in order to get a better score.

And that gets into the problems with how the surveys are obtained in the first place...

The Problem With Surveys

What if I told you 100% patient satisfaction scores were due to a survey of only two people... that I personally picked?

Welcome to the big bad world of patient satisfaction scores.

Often (well... pretty much all the time), I come across an article, bulletin posting, or meeting where patient satisfaction scores are announced... but no background information to back it up. HOW many people completed the survey? HOW were the people selected? WHO administered the survey?

HOW many people completed the survey?

The number of patients who actually completed the survey is very important. Mainly, because of the variance that may occur month-to-month as well as ease in manipulating the results.

Let's assume only TWO people completed the survey. The first month, both give me a thumbs up giving me a score of 100%.

However, the following month, another TWO people completed the survey, but only one gave me a thumbs up giving me a score of 50%.

NEWSFLASH!!! "Patient satisfaction scores plummeted 50% over a 1 month period of time!"

In order for meaningful interpretation of patient satisfaction scores, enough survey results MUST be obtained, especially when comparing scores across time.

HOW were the people selected?

Let's pick on the emergency room...

If I wanted to "pad" my results, I would tend to provide surveys to patients who had simple problems and who were seen quickly.

Child with an earache? Let's seem them immediately in Fast-Track ER. [Look in the ear! There's an ear infection.] Here's some antibiotics. Can you also complete this survey?

As opposed to...

55 year old narcotic-addicted patient with fibromyalgia demanding a prescription for 500 percocet pills for his chest pain. I would probably not want this patient to fill out the survey. Neither would the patient as he would probably toss it.

Granted these are extremes, but if performance bonuses are provided to departments with the best patient satisfaction scores and the ER staff were the ones providing the surveys, one can easily manipulate the results in their favor.

WHO administered the survey?

As mentioned above, survey results can be manipulated depending on who provides or gives the survey, ESPECIALLY if money is involved based on the results of the survey.

In order for survey results to be meaningful, a third uninvolved party should be the one to administer the test.

Survey Fatigue

Now even if the survey was done dispassionately and adequate number of surveys were completed, there's still the problem of survey fatigue...

What's that?

I don't know about you all, but I get about 3-4 letters per week and at least one phone call per day asking me to complete a survey on my car, toothbrush, tater tots... etc. You name it... there's a survey for it now.

Now add how many questions are asked... Hopefully one so it's quick.

But also HOW the questions are asked (yes/no versus a scale of 1-10).

As a person completing a survey, if I had my way, there would only be one question that is a yes/no question.

The more questions there are and if they are scaled rather than yes/no, the less likely I'm going to do it.

Now add if you are sick and in pain... How likely are you going to actually complete a 50 question survey on a scale of 1-10???

Probably not...

In fact, it's probably only going to be healthy individuals who tend to give better scores giving a skewed result.

Also, given the survey fatigue I and I bet most people have, it will be a rushed completion without much thought given. The default being five stars all the way down (I may not even bother to read the questions).

A decent way to look for survey fatigue is to have 2 randomly buried questions where rather than 5 stars being the best, 1 star is the best. Surveys where everything is 4 or 5 stars INCLUDING the reversed scale questions should be thrown out.

Summary

If surveys are accurately administered with statistical power and used in such a way that financial incentives are not so tightly linked to the outcomes, than potentially all stand to benefit.

However, performed the way they are currently, whether good or bad, patient satisfaction scores can be VERY misleading if not completely wrong...

I should also add that whenever money is involved, NO test is going to be 100% accurate due to cheating that is bound to happen one way or another... even if cheating occurs by providing healthcare not due to medical reasons.

I predict that this problem is going to get MUCH worse because health insurances will soon base how much reimbursement hospitals and physicians get based on patient satisfaction scores. We are talking about millions and millions of dollars.

Just read about the "no-child left behind" from the Bush era where student test scores influenced teacher pay leading to teachers allowing cheating on tests.


Sources:
Why Rating Your Doctor Is Bad For Your Health. Forbes 1/2/13

Greater Patient Satisfaction At Expense of Better Care? Fauquier ENT 2/19/12

100% Patient Satisfaction Scores. Fauquier ENT 6/8/12

Patient satisfaction: When a doctor’s judgment risks a poor rating. JAMA 11/26/12

Reference:
The Cost of Satisfaction: A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality. Arch Intern Med. Published online February 13, 2012. doi:10.1001/archinternmed.2011.1662

Patient Satisfaction and Patient-Centered Care: Necessary but Not Equal. The Journal of the American Medical Association, July 11 (jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2012.7381)

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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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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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Greater Patient Satisfaction At Expense of Better Care?

Much has been made about improving patient satisfaction in the healthcare industry in the belief that greater patient satisfaction equates with better health. To this end, patients are routinely asked to complete a survey based on their impressions on the care they received.

BUT... does greater patient satisfaction actually result in or is the result of better care???

According to a recent study... higher patient satisfaction actually resulted in:

• Greater inpatient hospitalization
• Higher overall healthcare utilization
• Higher prescription usage
• INCREASED RISK OF DEATH!

The one and only measured benefit of higher patient satisfaction scores was decreased ER use.

Why would there be an increased risk of death with higher patient satisfaction scores?

Well, if a doctor always does what the patient wants, that would tend to lead towards higher patient satisfaction... EVEN if it's the wrong thing to do.

For example... when a patient sees a doctor for a perceived sinus infection, it is not uncommon for a patient to expect to leave with an antibiotic.

Unfortunately, many sinus infections are actually viral URI for which antibiotics is the WRONG course of action.

Inappropriate antibiotics lead to drug-resistant infections which lead to deaths. They can also cause side effects that may require additional healthcare intervention.

However, if a doctor resists a patient's desire for an antibiotic, that would lead to a decrease in patient satisfaction.

Also, the more testing and treatment that is performed, the higher the risk of downstream adverse effects. For example, a patient may desire a CT scan of the chest to rule out lung cancer even though the chest x-ray is normal. Unfortunately, the CT scan picks up a small liver nodule. Needle biopsies are performed which unfortunately resulted in excessive bleeding requiring surgical correction and several days in the hospital. In the end, it was just a benign cyst that never required any treatment.

These examples may oversimplify a very complex issue, but it does suggest that one interpretation of higher patient satisfaction scores are that doctors and hospital systems may choose to do the wrong thing in order to get a better score.

Reference:
The Cost of Satisfaction: A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality. Arch Intern Med. Published online February 13, 2012. doi:10.1001/archinternmed.2011.1662

Media:
Why Rating Your Doctor Is Bad For Your Health. Forbes 1/2/13.

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