White Coat Underground

I try not to overbook at my office. I have about 16 slots every morning for returning patients (fewer if I have new patients booked, which I usually do). I usually schedule, counting new and old patients, 12 patients every morning. If I were to cut my appointment slots down to 10 minutes instead of 15, I could really pack ‘em in, and I may have to do that some day, but with the 15 minute slots, I can usually squeeze in people who want to walk in because they’re sick. There’s only so much that can be done to control the flow; if someone has chest pain, I’m going to be running late from then on. If everyone is well, I’ll be right on time.

Influenza is the destroyer of schedules. If I have 12 slots booked, and just two people with the flu want to be seen, I’m either going to squeeze them into the middle of the schedule or tack them onto the end. Either way, I’m going to run late, and patients will feel it.

Imagine a similar phenomenon nation-wide. Primary care physicians are trying to see their new patients, physicals, blood pressure and diabetes follow ups, and everything else, and for a few months, several more patients per day need to be seen. This is what happens during a bad flu season. Wait times will go up for both the flu patients, and the diabetics, and in a short period of time, appointments will be unavailable anywhere.

Now think bigger. Think of a large hospital with, say, 100 ventilators, with usual staffing for 80 of them. While most people with the flu don’t get terribly ill, some do, and may need mechanical ventilation and ICU care. Some of those out with the flu may be nurses, respiratory techs, and doctors, but if all of them stay healthy, and the hospital can find extra staff for all 100 ICU/ventilator beds, what happens to respiratory failure patient 101?

Here’s some reading for you.

Comments

#1 Colin
October 25, 2009

Nationalize vent manufacturing.
#2 PalMD
October 25, 2009

While I assume that the comment is tongue-in-cheek, it’s important to remember that the problem is not simply a limited supply of ventilators but also the beds and staff to care for these patients. There is the additional problem of what to do with all of the “hopeless” cases that we as Americans insist on ventilating until they finish dying, esp during a pandemic.
#3 Colin
October 25, 2009

Yes it was. If only bailing out some company would fix things up…

The MN report is rather lengthy but the last table summarizes your question pretty well. I presume it becomes more challenging to ration (after all the “hopeless cases” are removed from vents) when you have to let, otherwise, healthy adults die to give the vent to a child (per the MN report).

How do you handle a pandemic when there is insufficient staff? You might be able to find staff for 100 vents but what if you can’t? You have 100 vents and 30 staff? Hope for the best?
#4 D. C. Sessions
October 25, 2009

How do you handle a pandemic when there is insufficient staff?

How do you handle any medical emergency when you have too few caregivers to go around?

It’s called triage. That’s not just the name of a station you have to get past at the ER, it’s how we assign resources in a resource-constrained emergency.

The green tags are going to be OK if they have to wait. The black tags are going to die regardless.

The red tags are the ones we can save if we throw resources at them.

Triage originated with battlefield medicine, and the principles haven’t changed. They are that most medical of oxymorons: cold-blooded compassion. In wealthy societies we’ve managed to hide from the most fundamental reality of all: we’re all going to die. Details vary.

FWIW: I’ve conducted mass-casualty training exercises. In my limited experience, primary care physicians are the worst at triage because they get too involved in trying to save everyone. No disrespect intended, it’s just not their normal environment. In fact, you have to love them for it.
#5 Donna B.
October 25, 2009

OK, I’m prepared to be excoriated by one and all… but where is it assumed that constant preparedness for pandemics is the “best” overall assurance of basic health of the populace?

I really have no problem with planning for the worst, nor do I have a problem with public health initiatives. But, I do have a problem with the idea that the health infrastructure should at all times be prepared to deal with the worst possible outcome.

Should we be “gearing up” for a probable need? No doubt. However, I suggest that it is not possible — physically, psychologically, or socialogically — to be prepared for every trauma, tragedy, or pandemic disease. I don’t come to this conclusion politically, but rather fiscally. It does not make financial sense to always be prepared for the worst.
Before you excoriate me completely, remember that preparedness for the worst is one of the hallmarks of the “paranoid militia” verbiage.

There really is a fine line between adequate and sensible… and paranoid. It is a hard line to define.
#6 Colin
October 25, 2009

DC, but is the same for a flu pandemic? A mass causality is immediate but a flu pandemic is drawn out.

Put another way: when was the last car pile-up that took months to handle? You might start with staff for 100 vents but some will get sick over time and you end up with 30. It’s not unexpected like a plane crash.
#7 PalMD
October 25, 2009

No, DC is correct. The patients keep trickling in and we have to have a plan to deal with them yesterday.

Donna, preparing means evaluating your resources, deciding how much additional “constitutive” capacity is feasible, and how to create surge capacity. Preparedness does not mean running at surge levels every day. The biggest disaster is usually the failure to prepare correctly.
#8 Donna B.
October 25, 2009

I would not argue with disaster following failure to prepare correctly… it’s just that I don’t know if it is possible to prepare correctly for the unknown, or for the unexpected.

That does not mean that I do not think we should not try — it means that I think we should not blame those who tried when they fail.

And that doesn’t mean that I expect failure! Honestly, I expect success, I just do not want it to be considered GUARANTEED.
#9 PalMD
October 25, 2009

Nothing is guaranteed, but we have known for decades that there will always be more flu pandemics. We know for decades that the big one would hit New Orleans some day. There are plenty of disasters we can prepare for but fail to. I’m happy to blame people who fail to plan properly. Those who plan well deserve praise, even if the outcome isn’t as good as would be desired, but those who fail to plan…
#10 Nomen Nescio
October 25, 2009

It does not make financial sense to always be prepared for the worst. Before you excoriate me completely, remember that preparedness for the worst is one of the hallmarks of the “paranoid militia” verbiage.

and your main argument against such people would be a purely financial one? are you sure you can’t do better than that? because if that’s the main opposing argument, then i’m joining the survivalists.

i think PalMD was hinting at an old military truism, that failing to plan is planning to fail; in a crisis situation it might be more important to know what to do with what you’ve got than to have a bunker full of extra goodies you’d never normally use. because many crises rob you, first and most, of the time to make any further plans, or to step back and reevaluate your resource allocations — so having that thinking done in advance can be half your problem solved.

okay, some extra goodies might be crucial to have stocked up and should probably be acquired ahead of a crisis. that’s why hospitals have (e.g.) emergency electrical generators which, the vast majority of the time, only see use half an hour a week for testing purposes. but there are good financial arguments for having such supplies around, and the best arguments against investing in them don’t boil down to dollars and cents.
#11 katydid13
October 27, 2009

How many of us really need to see the doctor when we have the flu? I know that we feel like we are going to die, but unless you are having issues breathing or have a super high fever what can a doctor do besides commiserate with you, tell you to take over the counter decongestants and drink lots of fluids? My mother will do that over the phone for free.

This is not to knock the skills of doctors, but unless you are early enough for anti-virals or having serious complications you just have to ride the flu out. There is not lots of heoric doctor stuff to do as far as I know.
#12 Shay
October 28, 2009

I work for the Health Dept of a large in size but not so large in population Midwest agricultural county (1200 square miles, 160K residents)*. We have been able to hold one very successful H1N1 vaccination clinic and have another planned for tomorrow.

A great deal of the credit is due to the buy-in from the biggest employers in the county including retailers, the local Red Cross and churches, the school districts, and the two non-profit (religious-based) hospitals here. We could not make this happen without their help, whether volunteers, medical staff, equipment, facilities etc.

(*I’m not a healthcare provider which is why I ask some really basic questions sometimes. I’m the – sigh – county bio-terrorism planner).
#13 Liz Ditz
October 28, 2009

Back in the summer, my local Big Hospital did some test-runs on drive-through flu/respiratory illness care:

http://stanfordhospital.org/newsEvents/newsReleases/2009/rampingupforfluseason.html

Aside from vaccination, part of the solution is to keep not-emergently-ill folk from clogging the system. OK, folks at home: what have you done to prepare for home nursing for those who do not need hospital-level support?