The beginning of the end

Last week the Institute of Medicine released their report Dying in America and it received a fair amount of press.  I’ll be honest- I waited a bit to write about it not to revive any furor, but because I was processing some of my own experiences as a critical care surgeon who is frequently involved in end-of-life discussions.  When I am working in the burn unit, where I spend the preponderance of my clinical time, it is rare for us to be able to send patients home for their last day or days; I have been able to do this only a handful of times in my career, and it always leaves me with a mixed sense of loss and gratitude.  When I am working in the oncology ICU, a place I spend about a month out of my year, I often find myself wishing we had the opportunity to help people plan a kinder end to their story than what we are able to give them.  Unfortunately, by the time many of them get to us there is painfully little we can actually do to help them.

This leads me to where the system is coming up short, time and again, and in a way that impacts both of my areas of clinical practice.  We aren’t having the right conversations at the right times.  As a medical student and resident, I had no formal teaching on DNR orders, POLST forms, or communication with families about goals of care.  These are skills I had to pick up on the job, watching those around me, praying to have some good role models from whom I could adopt practices.  But, again, if I am the one having these conversations with patients in the ICU- or with their families- I’m not having it at the right time unless it’s a review of existing plans or wishes.  These are conversations that patients should be having with “their” doctor, be it a primary care physician or a specialist.  These are conversations that families should be having so no one has to guess what Aunt Ethel would want if she were in the hospital on a ventilator and requiring dialysis and a feeding tube, with little hope of recovery to her twice a week golf game and bridge club.  These are conversations so that you and I and the people we love the most can write the end of our own story in a way that makes the most sense to us, whatever that is, and have it honored.

I’m not saying all of this in the interest of saving money, though the maze of end of life care as we currently practice it in the US is a tremendous drain on healthcare dollars and hospital care days.  The hyperbole of “death panels” was a terrible straw man, when all that was really wanted was for physicians to be reimbursed for the work they do on end-of-life planning with their patients (something that is both time-consuming and sometimes emotionally draining).  Educating the next generation of physicians in palliative care and hospice, and the important roles that they play for patients, is critical.  Quite simply, this is something that we can and must do better in terms of education, quality of care delivered, and public policy.

Establishing goals of care for a patient based upon their wishes is arguably one of the most important things that we have the opportunity to do.  Here’s to hoping that the IOM report will spur us towards a system that supports doing it better than what we have now and in a way that truly honors the dignity of each of our patients.  That’s the very least that they deserve.

How did I get here?

The last two days have been consumed for our research team with a site initiation visit for a BARDA-funded project; I’ve previously alluded to my interest in platelet-rich plasma in the treatment of burns, and this project is part of that project complex.  As part of the visit, I was asked to give our visitors a tour of the burn unit, something I did proudly.  Our new burn unit that opened this past Fall provides the perfect home for our amazing team and our patients.

One of our visitors asked me how it was that I ended up in Burns, giving me the opportunity to share my story with their team.  I honestly did not start my surgical training expecting to end up in burns (nor did I start medical school anticipating being a surgeon, but that is a story for another day about “clerkship converts”).  My intention was to become a pediatric surgeon, and the key reason I came to Utah for my surgical training was to have the opportunity to work with Dr. Dale Johnson, a luminary in the field of pediatric surgery.  Over the first few years of my residency training, I realized that I still genuinely loved working with children…but I started to suspect that I would miss caring for adult patients.  I also found an interesting paradox in my clinical skills and interests:  while I loved the intellectual challenge and the decision-making demanded in the care of critically ill patients, I also found satisfaction in elegant, aesthetic-like procedures. As a young surgeon, you can see how this set of skills and interests might be confusing to manage.

My last clinical rotation of my third year consisted of three months as the “chief” in our burn unit.  I took care of children.  I took care of adults.  I worked some incredibly complicated physiologic puzzles.  I did some basic burn reconstruction, scar releases and the like.  I worked stupidly long hours (remember, dinosaur residency) and found myself eager to be there in spite of that.  I got to know Drs. Jeff Saffle and Steve Morris, men who would become my professional sponsors and practice partners, and realized that they were my people.  I found a home.

And in that home…stories that sealed the deal and changed my life.  The young man who sustained a 20-something percent burn from an electrical flash and who developed the most impressive acute lung injury I have seen someone survive- and whose ALI improved almost immediately when we excised his burn. He issued a challenge to himself and our team for him to be discharged prior to his 21st birthday, and with hard work on both sides we succeeded.  The father and two children whose home was destroyed in a propane explosion.  I have countless memories of holding the baby (who is now in junior high) upside down in my lap when I was finishing paperwork in the afternoons and evenings and Mom couldn’t be around.

In telling these stories, I was reminded- as I often am when I have a rare quiet moment to walk around our ICU- how truly privileged I am and we are to become part of these lives.  No, they don’t choose us; it’s a bit like our families, in which chance throws us together and the experience changes us all.

Burns?  I’m still not sure that I chose it.  It called me, and I keep answering.


March 7 reading round-up

With this having been a non-clinical week for me (which definitely means catching up on everything!), I figured that a little round up of what’s caught my attention in the literature would be appropriate.

Justin Dimick’s great work on composite measures for bariatric surgery performance.  This week was the inaugural #igsjc on Twitter, and participation was terrific.  Thanks for Andrew Wright for moderating, to Justin for being our “guinea pig” author, and to the amazing group of people who made this new on-line journal club get off of the ground.

This systematic review examining what practices actually work to reduce surgical adverse events.  As a critical care surgeon, I was gratified to see that there is scientific basis for our involvement in post-operative care.

Use of the Nationwide Inpatient Sample to evaluate the impact of insurance status on sepsis mortality.  Perhaps another argument for full implementation of the ACA and universal coverage?

Procalcitonin is not helpful in the diagnosis of infection in burns.

And, last but not least, as faculty we need to be good role models in how we respond to medical error.  The excellent work on professionalism from Gerry Hickson’s group at Vanderbilt continues.

In the non-surgical world, the Iditarod enters day 6 today.  In my usual fashion, I am completely obsessed with the canine athletes and their human teammates.  I’m hoping that it is finally Aliy Zirkle’s year after her 2nd place finishes in 2012 and 2013.

The doctor will see you now…

from approximately 350 miles away.

I practice a fairly uncommon specialty within general surgery (Burns) in the midst of a vast rural and frontier region (the Intermountain West).  Our patients come from a huge catchment area, one that covers about 1/11 of the land mass of the U.S.  My now-retired practice partner was visionary in his recognition of telemedicine as a potential component of our practice and got our burn center involved with Telemedicine a decade ago.  At that time, we were simply using telemedicine for acute burn consultations in the emergency departments of three different hospitals.  Our initial experience allowed us to show that we could use telemedicine to accurately evaluate patients at remote facilities, something that improved resource utilization and increased appropriate referral and transfer of patients from remote locations.

Fast-foward to now, when I have lost track of the number of facilities that are part of our telemedicine network.  In 2005, the first active year of our teleburn consult practice, we saw 12 patients.  In 2012 we had 321 teleburn patient consults.  In 2013, we broke the 500 visit mark.  We still see patients as emergency consultations, but we’ve added a Wednesday “teleburn clinic” to our schedule every week.  This allows us to continue to see our patients in Idaho, Montana, and Wyoming without the inconvenience of travel for them and their families.

Many potential limitations have been raised about the practice of telemedicine, some of which continue to be slow to resolve.  If a physician or APC is going to have a telemedicine practice, they want to be certain that their technology is HIPPA-compliant (sorry, folks, FaceTime doesn’t make the cut).    While licensing continues to provide a challenge for those of us who practice telemedicine- I now carry licenses in 4 states besides Utah strictly for our telemedicine practices- rules for delegated credentialing in telemedicine established by CMS have made that particular administrative hurdle less.  Arguments have been made that that telemedicine practices aren’t sustainable financially, and our experience indicates that simply isn’t true.  For the last 5 years, cumulative data from our center indicate that physician reimbursement occurs at similar rates for telemedicine and in-person outpatient visits.  There is also a profitability benefit to the originating site system; a sampling of 1/4 of our teleburn visits in 2010-2011 demonstrated that those visits directly resulted in $4.2 million in revenue to our institution.  An important aspect of that profitability is that our hospital absorbs all operating costs of our teleburn practice, including equipment upgrades.

Is telemedicine perfect?  Decidedly no.  I’m a tactile person, and sometimes I want to feel and manipulate an area of scar on a patient and simply can’t do that through our system.  Sometimes there are technology issues that mean I’m not able to “perfectly” visualize someone’s injury or scar.  Because of the nature and location of our practice, however, I simply can’t imagine NOT having telemedicine as a service for our patients and families.  Besides, there are a few patients in Idaho who can honestly say that they have had a middle-of-the-night telemedicine visit with a specialist in Salt Lake who was “assisted” by her cat.