Crash Cart: Talking About Near Misses; Death to “Dry Drowning”; Will NaloxBoxes Deliver OD Prevention?

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This week: Physicians openly discuss mistakes; Why the term “dry drowning” needs to go under; NaloxBox’s solution for ODs may be worth a shot. Join in as our editors discuss the week’s headlines.

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A surgical resident at University of North Carolina says physicians need to talk more openly about their mistakes, advocating for debriefings in addition to the standard M&M conferences

She says trainees often fail to realize errors aren’t usually the failure of a single person but the failing of a system of safeguards and points to the 2013 National Healthcare Quality Report, which says most health care workers believe that mistakes will be held against them. Original Article by STAT.

Jaime Hope, MD: Mistakes are a huge part of medicine as they are a huge part of being human. Medical mistakes are now the 3rd leading cause of death in US hospitals. They continue to add checks and balances in the system and into our EMRs. We get so many pop-ups, it is easy to get warning fatigue. And even those pop-ups can fail. I had a loved one who was accidentally prescribed both Eliquis and Xarelto at the same time. And the pharmacy filled and dispensed them at the same time. The warnings failed to pick the duplicated anticoagulants. Only because I was filling her pill boxes did it get noticed. She was a good compliant patient and was just “following orders”. All the checks and balances in the world aren’t enough though. We need a culture change. We are so afraid of getting berated, fired, and sued that mistakes are not openly discussed in many forums outside the M&M, which can often be punitive anyway. How can we change the culture so we can talk in an environment free of fear?

William Sullivan, DO, JD: Sure, full disclosure would be nice. The problem is with the implementation. How do we define an “error”? The possibilities are endless. Is it an “error” to delay treatment of an MI for 30 minutes? What if you’re in a single coverage ED and running a code on another patient? In this article, was the intern’s failure to diagnose compartment syndrome an error on the intern’s part? Or was it an error on the attending for not teaching the intern sufficiently about extremity burns? Or was it an error on the system for putting the intern in that position and not having an attending evaluate every patient on arrival to the hospital? “Error” is a nebulous term. Two knowledgeable observers could view the same event quite differently. Consider dueling experts in pretty much every medical malpractice lawsuit. The problem is that as soon as an event is labeled a “mistake,” someone has to be blamed for that “mistake” – even if the medical care was reasonable. Then comes the cascade of finger pointing … by senior physicians, by hospital committees, by hospital administrators, by state agencies, by federal agencies, by patients or families, by plaintiff attorneys, and by insurance companies. Is it any wonder that medical providers “fear the bad outcome”? Good on the author for debriefing the intern and turning a “near miss” into a teaching moment, but we’ll never stop the blame game in this country, and errors – when they do exist – will always be minimized.

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Though the media airs stories of it during the summer, medically speaking, there’s no such thing as “dry drowning.”

Plenty of health organizations say there’s many reasons for the term to go to the grave. Original Article by Live Science.

E. Paul DeKoning, MD, MS: While we’re at it, a few additional terms to eliminate: double (and yes, even triple) pneumonia; walking pneumonia; chronic congenital Lyme; oh, and do you actually have to die when you get electrocuted? And bloating. What is it exactly?

Jaime Hope, MD: People clearly don’t understand the process but this term sure makes for some scary and sensational headlines. It reminds me of when Natasha Richardson died of an epidural hemorrhage after a ski accident and everyone with a minor head injury thought it would happen to them. She had a severe injury and was unconscious for a period of time prior to her lucid interval. People who die after a significant water aspiration are likewise symptomatic. One cough in the pool won’t kill you a few days later. And Paul, while we are eliminating terms, I also submit calling gastroenteritis “the flu”. And if you have a (gasp!) “double ear infection”, it’s probably a virus. We love the drama of the double, though, right?

William Sullivan, DO, JD: Nice article and nice description of the events that occur with drowning. The bottom line is that whether it is wet drowning, semi-moist drowning, or dry drowning, it is treated the same way. I think that the only people who care about nomenclature are the idiots who came up with ICD-10. Because we really have to differentiate between “bathing cramps”, asphyxia due to submersion, lung edema from an external agent, anoxia due to drowning, and asphyxia due to drowning (that’s ICD code T75.1 for all you future coding buffs). Oh and don’t forget to note whether it is an initial encounter or a subsequent visit or you’ll be in big trouble. I’ll have to take a poll, but unlike the definition provided in the article, my definition (and Webster’s Dictionary definition) of drowning is death from suffocation due to liquid in the lungs. Otherwise it’s “near-drowning.” Slightly different treatment depending on the diagnosis. And Paul – add “low grade fevers” to your list. It’s a fever or it’s not a fever, dammit. It’s like calling someone “low grade pregnant” or saying a light is “low grade on.” There isn’t some magical middle ground and even if there were, it doesn’t change anything. Enough already.

E. Paul DeKoning, MD, MS: One more phrase to debunk: high tolerance for pain. Often co-presents with a fever of 98.6.

Nicholas Genes, MD, PhD: This is a good place for Dr. Amy Levine’s article on Summer’s Water Woes including “dry drowning.”

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When professionals are unavailable, Good Samaritans can save the day

That’s the thinking behind NaloxBox, an emergency medicine kit providing life-saving naloxone to bystanders in the growing number of American communities where overdosing is common. The two professors behind say the kit has “the same goal as a fire extinguisher or an automated external defibrillator—to enable anyone in the wrong place at the right time to save lives.” Original Article by Futurity.

E. Paul DeKoning, MD, MS: Sounds reasonable for certain locations “where overdoses are likely to occur.” Where is that exactly? I’ve got some ideas. “It can happen to anybody in any walk of life,” Capraro says. “Our distribution should reflect that distribution of the epidemic.” Ok, so should we place it right next to the AED at the mall?

Jaime Hope, MD: I’m on board, seems like a great idea. The question is where to place them so that they are the most impactful. There has to be some kind of data about most common locations of overdoses. Although it can happen in all walks of life, I’m guessing even the wealthy users aren’t shooting up at Tiffany’s. Let’s get this into the hands of those who can help the most.

William Sullivan, DO, JD: OK, so the sentiment is good, but until the price of Naloxone comes down, I see this as something that will come up missing quite often. The price of Evzio is $4,500 per prescription. These NaloxBoxes contain four doses of naloxone. That’s $18,000 per box at the highest markup. Supposedly the company offers bulk deals to some groups for a mere $37.50 per dose – which is still $150 worth of medicine sitting in a small easily accessible and easily removable box. How about just ditching all of the regulations and making Narcan available over the counter so anyone can purchase it at any time?

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