“OK,” I said slowly. “Do you want to tell me about it?”
“Uh, well, sir, uh, I think HM3 (hospital corpsman third class) Woods should tell you about it himself. He was there.”
“OK, then,” I said, preparing myself for something worse than a ‘little situation.’ Alvin “Bubba” Woods was a big, muscular Mississippi boy who loved to hunt and fish. He had gone through field medical school, the required training for all Navy corpsmen, before being assigned to a Marine Corps unit. He ‘knew the book’, as they say of anyone who scored well on the exams. But he was not one to think much outside of the box, medically that is. He could talk endlessly about novel ways to catch fish, but when it came to medicine, he pretty much stuck to the ABCs. But he was a great shot with an M16 and could take about anyone in martial arts, so the Marines felt he was a real asset to the unit.
“Would you like to put Petty Officer Woods on the phone?” I said.
“Uh, yes sir,” he squeaked. I heard a loud crash as he fumbled the receiver in the pass to Woods.
“This is HM3 Woods,” the voice was slow, deep, and had a thick, backwoods accent.
“Petty Officer Woods,” I started slowly as if speaking to one of my children. “Would you like to tell me what happened last night?”
“We-ell sir, it was like this,” he began. “I was in my rack on the first deck, just minding my own business, when I heard a big ‘thunk’ follered by a bunch a hollerin’ up on the second deck.” I knew this was going to be one of those tall tales, because no one, and I mean no one, minded their own business in those barracks.
“And?”
“We-ell, Ah ran up to the second deck.”
“OK, Woods, you ran up to the second deck. What did you find?” I was getting impatient.
“We-ell, Whiney was just layin’ there on the floor.” Lance Corporal Billy White had such a bad reputation for complaining that he had been nicknamed ‘Whiney’. “It looked to me like he had fallen out of the rack.”
“Was he unconscious?” I asked.
“No, he was just real drunk.”
I was dumbfounded. Was I getting a call about a drunk Marine who fell out of bed? “So what happened?” I asked getting more impatient by the minute.
“We-ell, he wanted to get back in bed, but I told ‘em to keep him real still while I went and got the back board.”
“Did you see if he had any injuries? Did he hit his head? Was he bleeding?”
“Naw, I didn’t see anythang, at least not at first, but I wasn’t gonna to take eeny chances.”
“What do you mean ‘not at first’?”
“We-ell, by the time ah got back with the back board, C-collar and first aid kit, he was kinda bloody from the fight they had holdin’ him down…so he wouldn’t hurt his neck or back or anythang.”
“So they beat him up trying to keep him from being injured. That makes a lot of sense.”
“Sir, he was pretty pissed off by the time I got him taped to the board and started two Ah-Vees.”
“You boarded, collared, and started two IVs on someone who fell out of bed?”
“Yes, sir, and we gave him oxygen too,” he said proudly. “But then it kinda got out-a-hand.”
It sounded to me like it had already gotten out of hand. “What do you mean?” I asked cautiously.
“When I was startin’ the second ah-vee, Whiney bit me on the arm.” I let out a loud exhalation. “He wouldn’t let go,” he protested. “He was like a pit bull.”
“So what happened then?”
“Corporal Gonzalez kicked him in the head until he let go. And then Corporal Jones threw Corporal Gonzalez through the window.”
“What?” I almost yelled. “He threw him through a second floor window?”
“Naw, he didn’t go all the way through. When the MPs arrived they put us all in cuffs until the helicopter arrived.”
“Don’t tell me you called a helo for this?”
“I jest told Private Witherspoon to call an amblance for a trauma case. He came back and said that they were sending a helicopter because we had to go to a trauma center.” How I had slept through this night I’ll never know.
“Where is Lance Corporal White now?” I wanted to get to the bottom of this.
“They said he might be a ‘danger to others’,” he said, apparently quoting the doctor.
“But Woods, all Marines are a ‘danger to others.’ We train them to be.”
“I talked to Whiney after he got his tubes out and he was real sorry for bitin’ me. Are they gonna to keep him from goin’ over with us?” he said sympathetically.
I was absentmindedly rubbing my newly buzzed head as I pondered how many zillions of dollars just got wasted on this case.
I related the whole story to my wife by phone later in the day, ranting that this was a perfect example of medical overkill. She knew better than to try to reason with me. Finally, after a silence that I understood to mean ‘move on’, I said, “You wouldn’t believe all the cool gear that I’ve been issued.”
“Really,” she said blandly.
“Yeah, they even issued a bayonet with my M16.”
“You’ve got to be kidding,” she said. “They issued you a rifle?”
“Yeah, and a bayonet,” I said proudly. “And a pistol.”
“Oh my gosh, talk about overkill.” She was incredulous. “Do they really expect you to shoot a rifle at someone. I knew we were stretched thin, but…Are you going to get poked with your own bayonet?” I could tell she was making fun of me.
“Very funny. You don’t ‘poke’ somebody with a bayonet. I also have this very cool body armor. It looks like I could diffuse a bomb.”
“Do me a favor, will you? Don’t.”
“It weighs over 30 pounds,” I continued, ignoring her jab. “With plates in front and back that will stop an AK47 round.”
“What do you need that for? You are a 56-year-old doctor. I hope they don’t think…”
“It even has this little apron like thing that hangs down to protect my privates.”
“Like I said what do you need that for? I thought your privates were supposed to protect you.”
“Very cute.” I smiled into the phone and felt the first pangs of homesickness. This was going to be a long deployment.
**************
26 Comments
dont forget adap.. everybody gets adap referral.. and the event was surely traumatic to the patient, and well any traumatic event can scar a person.. and head injuries.. can’t say enough about all the follow-up and years of re-evaluation this will surely generate =-)
Very good work Dr Henry. You are entirely correct.
Other big costs you left out:
The cost of health insurance company profits – including the costs to individual providers of having to get the paperwork done to bill the insurance companies.
The costs of overregulation. I understood, when I was chairman of my department 15 years ago, that the cost of JCAHO prep was an average of $100,000/year per hospital in the country. I suspect it is more now. Is there ANY evidence at all that being JACHO ready improves outcomes? Other quasi and actual government regs seem to push us into a costlier use of resources. I know, if I were an office doc, I wouldn’t accept medicare and medicaid due to the regs. This pushes patients toward the expensive ED, increasing costs.
Speaking of end of life care; what about dialysis on debilitated, demented, very elderly patients. I see a lot of them in my ED, frequently, and wonder at that cost.
Speaking of workforce issues; why can’t we use the out of the military corpsmen as anything but low level techs. Seems to be a GROSS waste of a trained and experienced resource.
A woman came to my ED by ambulance for 2 weeks of chapped lips. Although I work in a Level 1 Trauma Center, I would guess fully a quarter of the patients I see do not need to see any provider in any setting. A nurse over the phone would do just fine. Although not dialysis for the vegetative, the aggregate cost of this overuse has to be a more than an insignificant slice of the health care pie. But without liability reform to protect the advisor and pain at the pump (i.e. everybody paying SOMETHING), I see no end to it.
Dr. Henry, I’m very heartened by your comments which I agree with 100% However, I feel we are in an ever decreasing minority. I think I’m the only person in my department that considers cost when working up a patient. In fact, I’ve felt pressure to do more test to be on par with the majority. How do we counter this prevasive wave of wastefulness? Does anyone remember when they put the cost of lab test on Part 3 of the medical license exam, and you were penalized if you spend too much money? How do we get that mentality back!
I,too, fully agree with Dr. Henry’s comments.
I would emphasize the point about nursing roles and add that there is a very real potential for a nursing shortage crisis by 2020. Part of the problem is that nursing education seems to be unwilling to recognize this and many qualified applicants are delayed, if not refused, entry to nursing school. The average nursing faculty age is 55 (so they are close to retirement) and nurses must have at least a master’s degree in nursing to teach. Nursing education needs a reexamination.
In the meantime, we should be busy developing alternatives to nursing in hospital settings.
Another contributor to large costs is the hospital industry building new, hotel-like facilities and wanting to be everything to everyone. We have beautiful new hospital monuments that want to be Trauma Centers, Stroke Centers, Chest Pain Centers, Cancer Centers, Pediatric Centers, etc.etc. – just down the street from another place that wants the same as well.
But the problem with this is, in addition to being wasteful of money and resources, that we simply are not graduating the medical specialists to support all these tertiary centers. This is part of the reason we currently see specialty shortages on our call panels now.
In order to actually accomplish anything meaningful in curbing healthcare spending, every stakeholder has to accept something less than they are currently receiving. That is what has occurred in other countries.
And this concept is a very tough sell in America, since we have live in a society that wants more, more, more. It will take real sacrifice and real political leadership to make some of these changes.
So, I am not very optimistic.
Is this Storz the one on the TV show?
I nominate Dr Henry to be our first Medicine Czar My Friends or is that too much Hope and Change to expect?
Don’t forget to mark the Line of Duty (LOD) form with “not in the line of duty” or he’ll be able to get a VA disability for the traumatic brain injury he suffered when kicked in the head! THAT would be adding insult to the piling on injury it has already cost us!
They would never stand for this sort of thing in the ARMY!
“NIght Shift” is always a HIT even if I only have time to scan the rest of the paper, I pause to read your latest “insight.” Thank you very much.
What I am not getting from this study is the delivery of the tap vs saline. Was one set of wounds irrigated with a 19ga catheter (or Zerowet Shield) and 60cc syringe with saline (what I have been led to believe as the standard of care) and the other held under running tap water? Or were they both irrigated the same way but with different mediums?
Dr Henry, you bring up many of the same ideas that make me frustrated every day I come to work. I spent 20 years in manufacturing prior to my medicine career and if any hospital I have ever worked in were trying to compete in business in the real business world, it would shut it’s doors within a month. Nurses answering phones, cleaning floors, making beds???? While we have a 8-10 hour wait because we have such a staff shortage! In our state EMTs and paramedics are not allowed to work in any medical capacity in any hospital because the nursing powers that be have made sure through legislation that no one will take their jobs away from them. It is a broken system.
One important issue you overlooked in your cost saving discussions was the utilization of physician assistants. You mentioned that physician’s are not always needed in pediatrics. Well they are not always needed to see every patient in the emergency department, in the pediatric office, in the FP office, etc. They are well utilized in many areas and are a great benefit to the whole system.
I agree with much of what you say doc.
I also echo the important role PA’s can play in this economic crisis. I have been practicing Emergency Medicine as a PA for several years. I studied health economics and work in management of the ED. Plenty of data to show the effectiveness of having PAs on staff.
My support for EMS is anecdotal. I have been a paramedic for sometime. I have had numerous saves for cases of cardiac arrest, anaphylaxis, drug overdose, etc.. I am confident these patients would not of survived anything above a 5 minutes basic life support transport to an ED. I could write books on all the stories to support using ALS. I have to admit though, like you said, I do not have any data to show the economics of ALS EMS. I think this is more an issue of ethics than it is economics. Shouldnt we try to provide the best care possible? I think end of life and EMS are two very different subjects. They cost money in different ways.
I suspect the cost benefit analysis of EMS would probably reveal a loss.
Actually this story isn’t so far fetched. When I was active duty USAF on Andrews AFB, MD when my ER techs said we have a combative intoxicated pt coming from the enlisted club I always had my money on either a member of the Navy or Marines (& I was right!).
Too bad you didn’t call of us CCATT folks (Critical Care Air Transport Team). We love to take folks like these out of theater to Germany and parts further from AOR.
Keep the hit’s a comin’ and be safe, be well and come home soon. Don’t hurt yourself with that M16, nasty wounds……
Doc BG
What about limiting peg tube and feeding tube placement in nonverbal, nursing home patients. Think about how much that would save. If nothing else, it would save on ED visits for “PEG tube out”.
The whole health care argument boils down to one thing: where is the money going? We have limited resources, we are spending more on health care than any other country, and our combined results are far worse than they should be. The only way to reform the system is not evolutionary, as both political candidates would have it, but revolutionary.
The biggest source of waste is the administrative overhead. The only way to real savings in the health care system is to reduce this overhead to a much smaller amount. If that means cutting out the middle man – the health insurance companies – then that is what we must do. Or at the very least, put them on a very short leash and remove the incentive they have to get rid of the sick insured and market aggressively for the healthy population. Of course, this would create a bureaucracy of its own, but a much smaller one than what we now have.
No political candidate wants to talk about this, because there are very powerful interests that basically control health policy in this country. This view is not paranoia – just count the contributions to both parties and count the number of health care lobbyists for the health insurers and big Pharma in Washington.
The ultimate answer will have to come from the bottom up. The only thing the political parties fear more than powerful business interests are the voters!
A recent private email from a Navy friend begged me to tell him that this was fiction. Of course, I said, I learned long ago that I can be sued when I tell the truth. So, yes, the stories are ‘fiction’. Nobody could be ‘that’ boneheaded. Not my Marines. Or Army either for that matter. And the Air Force, I’m not sure the Air Force has any teeth to bite anybody. So not to worry. Now I’ve got to go to chow with ‘HM2 Woods’.
Semper fi
As most of you know, I’m currently running a Shock Trauma Platoon in Iraq. This unit has one nurse (male) and 15 corpsmen and we do just fine. I’d like a chance to run an ED stateside with corpsmen. I’d bet that it could be done for a fraction of the current ED budget without a drop in quality of care, IF a) we had protection from nuisance law suits b) we could allow people to do anything that their supervising physicians had trained them to do and c) we could render the care that was medically necessary and not what was expected to get a high customer satisfaction score.
Am I asking too much? I don’t think so. But it won’t get done unless we all speak up, locally and nationally. As we reform medicine these features must be included or we will have accomplished nothing.
This tale is not so far from the truth. As an ER Nurse and retired Navy Chief the only medical treatment I would have added to a shipmate in this condition is a foley!
I have known Dr. Henry for many years. He is an incredibly intelligent man.(He should be teaching at Notre Dame, not Michigan)
I totally agree with his comments.He speaks from learned experience.I hope to pass my comments on to him in person. Gerry Duff
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I use tap water frequently in the ED.
Send the patient to the sink. It saves physician time and decreases costs. Tap water irrigates the wound with high pressure and high volume (a typical sink supplies about 40-50 psi). We published a study with roughly 500 patients at Jacobi Medical Center in Annals of EM in a pediatric population several years ago. Patients and parents seemed very satisfied. We cultured the water at several intervals throughout the study and the tap water was essentially bactera free. For more information, see the below study in Annals of EM.
Valente JH, et al. Wound irrigation in children: saline solution or tap water? Ann Emerg Med May 2003;41:609-16.
Or see this link for a quick review here: http://findarticles.com/p/articles/mi_m3225/is_/ai_112220668
Interesting and useful discussion. You are correct that individuals need to control their own spending. I hope you don’t think that some health care “Governor” can do it better.
Also many of your assumptions are wrong. Spending money on health care does indeed contribute positively to productivity. If people aren’t healthy, they can’t work. You write as if all health care spending is a money loser.
You also err in claiming that spending 16.9% of the GDP is all waste and we should get down to 5% like Singapore and we will magically have longer life expectancy and infant mortality. The numbers for infant mortality etc are reported wrong as are life expectancy. Further, why 5%? Why not 10%?
The answer is that there IS no way for any third party to determine the “proper†amount of medical spending in an economy. The only way is for the number to reveal itself in a free market system. When third parties control spending (as they do now) they will insist on things that lowers cost like letting people die too early (whether they like it or not) or telling docs how to practice medicine “efficientlyâ€.
Dr. Henry works from two flawed assumptions:
1. That your numbers are correct (e.g. we spend too much and get worse results)
2. That some third party can fix this without hurting patients and the profession of medicine.
Keep working on the concept that individuals know best how to spend their money best Dr. Henry…you are getting close to the right answer!
David McKalip, M.D.
Chair, FMA Council on Medical Economics.
Dr. Plaster- It is always an extreme pleasure to read about your insights into medicine. As I was laughing out loud my eight y.o. was asking what was so funny. It was a little tough to explain the line “all marines are a ‘danger to others.’ We train them to be.” Stay safe, you bring pleasure to many you haven’t even met- thanks.
You really think EMS is a hoax? I really don’t see doctors like you out on the street, doing our job, putting your life in danger. I guess you can observe anything from a nice and cozy ER, or in your case, a classroom. Smarten up and show me proof that ALS doesn’t help. You say there’s no study saying it helps, so show me that it doesn’t help.
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