Archive | August, 2009

Healthcare Checklist… aviation parallel

31 Aug

 

THE CHECKLIST

If something so simple can transform intensive care, what else can it do?

http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande?currentPage=all

 

This is the reality of intensive care: at any point, we are as apt to harm as we are to heal. Line infections are so common that they are considered a routine complication. I.C.U.s put five million lines into patients each year, and national statistics show that, after ten days, four per cent of those lines become infected. Line infections occur in eighty thousand people a year in the United States, and are fatal between five and twenty-eight per cent of the time, depending on how sick one is at the start. Those who survive line infections spend on average a week longer in intensive care. And this is just one of many risks. After ten days with a urinary catheter, four per cent of American I.C.U. patients develop a bladder infection. After ten days on a ventilator, six per cent develop bacterial pneumonia, resulting in death forty to fifty-five per cent of the time. All in all, about half of I.C.U. patients end up experiencing a serious complication, and, once a complication occurs, the chances of survival drop sharply.


Here, then, is the puzzle of I.C.U. care: you have a desperately sick patient, and in order to have a chance of saving him you have to make sure that a hundred and seventy-eight daily tasks are done right—despite some monitor’s alarm going off for God knows what reason, despite the patient in the next bed crashing, despite a nurse poking his head around the curtain to ask whether someone could help “get this lady’s chest open.” So how do you actually manage all this complexity? The solution that the medical profession has favored is specialization.

The B17 Boeing 299

 The plane roared down the tarmac, lifted off smoothly, and climbed sharply to three hundred feet. Then it stalled, turned on one wing, and crashed in a fiery explosion. Two of the five crew members died, including the pilot, Major Ployer P. Hill.


An investigation revealed that nothing mechanical had gone wrong. The crash had been due to “pilot error,” the report said. Substantially more complex than previous aircraft, the new plane required the pilot to attend to the four engines, a retractable landing gear, new wing flaps, electric trim tabs that needed adjustment to maintain control at different airspeeds, and constant-speed propellers whose pitch had to be regulated with hydraulic controls, among other features. While doing all this, Hill had forgotten to release a new locking mechanism on the elevator and rudder controls. 

 

They could have required Model 299 pilots to undergo more training. But it was hard to imagine having more experience and expertise than Major Hill, who had been the U.S. Army Air Corps’ chief of flight testing. Instead, they came up with an ingeniously simple approach: they created a pilot’s checklist, with step-by-step checks for takeoff, flight, landing, and taxiing. Its mere existence indicated how far aeronautics had advanced. In the early years of flight, getting an aircraft into the air might have been nerve-racking, but it was hardly complex. Using a checklist for takeoff would no more have occurred to a pilot than to a driver backing a car out of the garage. But this new plane was too complicated to be left to the memory of any pilot, however expert.

 

 

Medicine today has entered its B-17 phase. Substantial parts of what hospitals do—most notably, intensive care—are now too complex for clinicians to carry them out reliably from memory alone. I.C.U. life support has become too much medicine for one person to fly.

 

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Of course, the B17 was an amazing aircraft, but it too was replaced in time with the advent of the jet age. Take a look at what Randy Sohn jas to say. http://www.enginehistory.org/wbn/WBN02.pdf

 

Sometime around the turn of the century (in an aeronautical sense, anyway), actually in

the late forties and early fifties, the USAF was the not so proud possessor of an abysmal

flight safety record. Jets were new but piston mentalities and methods still

predominated, after all, that was what had gotten everyone through the war years and

no “deskbound Flying Safety or Ops type can tell me how to fly airplanes”! “Break left –

power off – gear, flaps and boards, first one to the club is the hottest pilot”! Sounds

great, doesn’t it? Made great movies, bar stories and – – really b-a-a-d accident records.

Attempts to make pilots realize that no one was attacking their macho in asking for a

change in techniques were met with almost universal derision. The message

transmitted was “the characteristics of the machine have radically changed”, the

message was received/perceived as “those old guys can’t contend with these jets with

their increased speeds and all”.

 

No doubt a similiar mentality exists in the healthcare world.

 

The next step from jets was automation

 

The next step from automation was crew and resource management

 

The medical world is already poking at automation and CRM, just as the airlines did even going back to WWII, but just as then, it was a rather informal deal, only embraced by a few pioneers.

 

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3X multiplier reasonable worst case #H1N1 ?

31 Aug

PR spin = fascinating, on the one hand, game plans need to be put in place, on the other, we dont need wolf crying, nor the other headaches experienced in 1976.

Typical flu season = 30,000-40,000 deaths

Predidents advisory panel presented one plausible scenario of 90,000

Some folks are freaking out on that number, thus PR spin

http://www.webmd.com/cold-and-flu/news/20090825/90-thousand-swine-flu-deaths-possible-not-likely

I wonder what the real multiplier is considering the following.

  • H1N1 has a greater affinity for the young
  • If mid October is realistic, unlike past history, fewer will have been vaccinated, due to early flu season.
  • Conspiracy theorists abound, on the left.. vaccines are evil, on the right, planning for the worst case is politically motivated to build support for healthcare reform. Both conspiracy camps willl reduce folks participation.
  • While H1N1 doesnt appear like it will morph into something worse come Oct 15, what about the spring?
3:1 sounds good from a PR pov, its reasonable enough to raise concern, but not a panic. Yet, for planning purposes, obviously there is a real multiplier the internal folks are using… I wonder what that # is.

On the Sales of dubious (High Value) Goods and Services

30 Aug

I came across this last night and went roflcopter.

Salesman must be present for use during adverse conditions, or you will not be able to detect products premium performance…. 

Must be one heck of a good salesguy.

 

Hosing up the Third Use of the Law through Media

30 Aug

Media is self-selecting, and people flock like birds of a feather to messages they want to hear. Case in point, downtrodden Christians end up far too often dwelling on the law and condemnation…

Martin Luther nailed it with his Commentary on Galations 5:8

To those that are cast down on account of their sins Christ must be introduced as a Savior and Gift, and not as an example. But to sinners who live in a false assurance, Christ must be introduced as an example. The hard sayings of Scripture and the awful judgments of God upon sin must be impressed upon them. Defy Satan in times of despair. Say: “O cursed Satan, you choose a nice time to talk to me about doing and working when you know very well that I am in trouble over my sins. I will not listen to you. I will listen to Christ, who says that He came into the world to save sinners. This is the true Christ and there is none other. I can find plenty of examples for a holy life in Abraham, Isaiah, John the Baptist, Paul, and other saints. But they cannot forgive my sins. They cannot save me. They cannot procure for me everlasting life. Therefore I will not have you for my teacher, O Satan.”

I remember some time back, a preacher was agonizing over folks who are depressed coming away from his sermons even worse off. While the Gospel was most certainly preached in his sermon, they only heard the condemnation of the law. He did not want to short change the law by anymeans, yet if it was obscuring the Gospel to those who really needed to hear it, something needed to be done.

@pubpastor presents a similar deal with one of his early sermons here http://pubpastor.blogspot.com/2009/08/while-were-at-it-lets-talk-about.html 

In other cases, high profile preachers end up having videos go viral… and far too often, in part due to online video limitations, messages get truncated, and as such its possible only the law, or only the Gospel end up going viral.

The same could be said in using twitter. With only 140 characters, its pretty hard to fit both law and Gospel in a single tweet… so one either gets law, or gets Gospel. I was joking around with some guys, that we could code a custom app, which would require both law and Gospel be presented, before one could push submit. Or in another case, a law/Gospel linguistics tool which would analyze tweets to make sure a balance of law / Gospel existed.

Of course, there is also the issue of “to he who has ears, let them hear” and I think thats cool… but how does such play out when said ears belong to a depressed person? How do they hear the Gospel when they want to dwell on the law.


This is my idea scratch pad

30 Aug

For all the things I come across, yet may not have time to fully address in a more formal blog post. Lots of randomness to be expected.