Archive for April, 2011

Week in Review (April 23 – 29, 2011): The Eye Opener Health and Law Blog

Saturday, April 30th, 2011

From the Editor:

Last week was a busy but productive week for our firm’s blawgers – 6 posts – and we actually practiced law a lot! My personal thanks to our writers for taking the time to post some important pieces on health, safety, medicine and law. To our readers, my continued and sincere thanks as well. While it’s great to pull-out our soapbox and write about stuff we do and are passionate about, it’s incredibly rewarding to have you, our readers, take the time to read what we write. To those who left comments, a special thanks. We really enjoy interacting with you!

Now on to the business at hand. What did we write about that you may find interesting? Here you go.

My Pet Peeves About the New Age Mediation Process

Having been inspired by a fellow blawger from New York, Scott Greenfield, who chided legal bloggers (thus the name “blawgers”) for simply rehashing news and not taking a stand on issues, I wrote a piece called Mediation of Lawsuits: The 5 Top Things that Tick Me Off!

Having recently been through a number of mediations that were enough to pull your hair out because of the silliness that people engage in when they claim they are mediating to get cases resolved, I decided that it was time to take a stand and post a personal rant. While perhaps best understood by lawyers, claims adjusters and mediators, this blawg was not intended just for them. I’ve seen what impact foolish approaches and conduct by the participants to mediation can have on my clients, the injured parties. It was time to sound-off; so that’s what I did. I once again invite anyone who has been a party to a lawsuit mediation to do your own personal sound-off and tell us what it was like for you. It’s your turn to tell us just how much you enjoyed the process and what can be done to make it better. Read the horror story told in our Comments section by one of our Canada readers when she went through a domestic mediation process. Share your thoughts and stories as well.

Health Care: Who’s “Voiceless” When It Comes to Being Heard on Capitol Hill

Guess I had too much time on my hands at the beginning of this week (not really!). I couldn’t help but be inspired by a piece Jason Penn had done last week about how families were so adversely affected by the budget cuts that were made when the government shutdown was looming a few weeks ago. As I was going through my Google Reader early this past week, I came across an Op Ed by a doctor, who was complaining or at least suggesting that the president and congress need to hear more what doctors had to say about health care reform. Having read that, Jason’s piece jumped into my mind and the result was my blawg entitled Health Reform: What voice does the patient have in the debate.

The post brings to light the amount of money being spent by the healthcare industry in its lobbying efforts on health care reform. ObamaCare‘s raison d’etre is explored as well since it is ironic, if not sad, how the story behind all this money, lobbying and legislation seems to have been lost in the rhetoric. More affordable, better and available health care for our citizens? Then why were the most needy among us the victims of back room wheeling and dealing when the time came for budget cuts to save the federal government from closing its doors? I ask the question – who’s voice is being heard – but more important – who’s is not?

FDA approves use of “meningitis drug,” Menactra, for younger children

Hopefully you’ll never need to use this information, but if you do, Jason Penn reported on a condition – meningitis – that can affect not only adults and older children, but infants and toddlers as well. Meningitis is generally defined as an inflammation of the protective membranes covering the brain and spinal cord. Prior to a recent change in position by the FDA, there wasn’t a vaccine available for children under the age of 2. Now, with the FDA’s recent approval, Menactra can be used to vaccinate children from the age of 9 months to age 2.

In addition to this news release, Jason tells parents about the signs and symptoms they should be aware of to spot this condition.

The classic symptoms of meningitis are a high fever, headache and stiff neck. Detection of these symptoms, particularly headache and stiff neck are certainly difficult to detect in infants and toddlers. According to the Centers for Disease Control and Prevention, infants with meningitis may appear slow or inactive, have vomiting, be irritable, or be feeding poorly. Seizures are also a possibility.

To learn more about this important topic, read his piece Meningitis & Your Baby: Three Things to Think About.

Why are children still dying because of venetian blinds?

Sarah Keogh wrote what I believe is a very important piece for parents, grandparents or anyone who has a baby in the house. Years ago we all heard about the horror of parents finding their babies dead from strangulation when their necks became entangled in venetian blinds. Years have passed since those stories made the front page. Well, an update on just how well manufacturers and parents have been doing to avoid such tragedies was recently posted in The New York Times.

In her blawg entitled Window Blinds: Why are Children Still Dying, Sarah tells us the sad truth that these deaths and injuries still continue in our country. Find out what you as a caregiver of a young child need to realize about this product. Maybe you’ve put the cords up high and out-of-reach for your baby. Maybe you’ve taken other steps to avoid such a nightmarish event ever happening in your home and in your life. Unfortunately, many who have done so have still suffered this tragedy. Why? What is being done by manufacturers and the government to prevent these injuries and deaths ? Read Sarah’s piece for the answers and some practical advice you can take to make your home safer for your child.

Hospitals Reporting Methods for “Adverse Events”

We all know by now that if you want to look good to the public, all you have to do is “play with the numbers.” Well, it seems like hospitals have a penchant for doing just that. One of the key “numbers” that advocates of patient health and safety look at is how many “adverse events” take place in any given hospital. An “adverse event,” as you may already know, is – simply put – any harm to a patient as a result of medical care.

In his post this past week, Jason Penn compares some interesting adverse event bookkeeping by hospitals throughout our country. His blawg, The New Enron? Are Hospitals Cooking the Books?, brings to light serious flaws in the way that our medical institutions “count” the number of so-called adverse events taking place within their walls. His research for this piece reveals…

[M]edical errors occur 10 times more than previously thought.Maybe that wasn’t hard hitting enough. Let me try again. How about this: mistakes occur in one out of every three hospital admissions!

Frankly, that strikes me as an astounding and very concerning number. Are the numbers being reported reflecting this? The simple answer is no. Why not? Read Jason’s post and see what reporting systems are in place – or not in place as the case may be. We all remember Enron. Is this the medical version of “making the numbers look good” when they simply are not!

Surgeons and Booze – an Obvious Bad Combination – Who’s Protecting Us?

It doesn’t take a genius to realize that surgeons should not be under the influence when we as patients are “under the knife” What’s not so obvious is just how prevalent this may be in the operating rooms of our country (and throughout the world).

Wondering what the studies have been done by the medical profession to examine this problem? Have any idea what regulations are in place by hospitals to guard against the problem of “hungover surgeons”?

Wonder no more. Jon Stefanuca’s blog this past week, Hungover Surgeons: Watch Out! There’s Nothing Between You and Their Scalpel!,will tell you all you need to know. Jon queries: “Should hospitals regulate for patient safety?” What do you think? Share your comments.

A “Sneak Peak” of the week ahead

Some more good advice is on the way for parents of special needs children. We all know about what a wonderful aide dogs are for the blind. Mike Sanders will share what he’s learned how these canine wonders are being used for kids in need. Suffering from asthma or know someone who is? Jon Stefanuca will be sharing with  you some valuable information on this topic next week. A number of our clients or their now-deceased family members have suffered from this condition. Jon will share a story or two (without revealing protected confidential information) to bring to light just how this medical condition needs to be better recognized and treated by our health care providers before its too late. We all know what a difficult job nursing can be. That being said, Sarah Keogh will be telling us about some very concerning “trends” that are coming to light in this wonderful profession. Stay tuned for this important piece.

We’ll start next week off with a new blawg by our in-house medical specialist, Theresa Neumann. Her post on how important it can be to get a second opinion before you sign-up for a surgery, procedure or test is sitting in the queue just waiting to hit the pages of The Eye Opener – Views and Opinions from the Nash Community.

One Final Note: I wrote in last weekend’s Week In Review that we intended to post a new White Paper by Marian Hogan on a very important topic relating to Patient Controlled Analgesia (PCA). It didn’t happen – because of “my Bad.” I fouled-up and sent the wrong draft of Marian’ s piece to our graphic designer. He did a wonderful job – as usual – of getting it ready – it just wasn’t the right version. The problem is fixed, but my mistake will delay the posting of this important White Paper for another week. Public apology: Sorry, Marian! We’ll make it right soon.


Hungover Surgeons: Watch Out! There Is Nothing Between You and Their Scalpel!

Friday, April 29th, 2011

If you need surgery, you might want to ask your physician not to drink the night before the surgery. According to a recent study, surgeons are a lot more error-prone when operating after a night of drinking.  Sixteen medical student (residents) and eight surgeons participated in the study. They were each asked to perform simulated laparoscopic surgeries without any drinking the night before. Then, they were all invited out to dinner and were asked to drink alcohol as they pleased until they felt intoxicated.  The next day, each participant was asked to perform the same simulated surgeries, and the results were quite surprising.

Each medical student had made an average of 19 errors during surgery.  Their sober counterparts made an average of eight errors. On a side note, the fact that so many errors were made even without any drinking is not making me feel warm and fuzzy at all.  It can take one error, not eight or 19, to seriously injure a patient.

The licensed surgeons did not do much better. The ones who drank had about a 50 % spike in the error rate. Wow!  So, if you see your surgeon ordering yet another Brain Hemorrhage ( 1 part peach schnapps, splash of Irish cream, and a dash of Grenadine) the day before your surgery, you might want to buy him a Virgin Bloody Mary.

Just how prevalent is alcohol abuse among surgeons?

What is the practical importance of this information?  If alcohol impairs surgical performance and alcohol abuse is common among physicians, how safe are we as patients? A number of studies seem to support the conclusion that physicians are more likely to abuse alcohol than other professionals. For example, a study published in the Journal of Addiction, examined trends of alcoholism among male doctors in Scotland. Apparently, as many as 50% of the doctors found to have health problems liable to affect their professional competence were also found to have a drinking problem. According to the same study, the higher rate of liver cirrhosis among doctors suggests that doctors are at a higher risk for alcoholism.  Maybe it has something to do with the wide availability of quality scotch.

Another study published in the Journal of the American Medical Association analyzed the rate of substance abuse among U.S. physicians. Apparently, they are not that different from their Scottish counterparts.  According to this study, U.S. physicians are more likely to consume alcohol than other professionals. I guess one good piece of news for us patients is that, although physicians were as likely to have used illicit drugs in the past, illicit drug consumption was found to be less among practicing physicians. That conclusion, however, may depend on your definition of illicit drug use. According to the same study, physicians are more likely to self-medicate with various drugs that can be just as addictive and impairing as some of the illicit drugs. By the way, it appears that physicians prefer opiates and benzodiazepine tranquilizers to “self-medicate.”

With this in mind, consider the number of surgeries that a surgeon performs a week. While the number may differ depending on the specialty, location, and other factors, many perform multiple surgeries. I have personally met orthopedic surgeons, for example, who perform as many as 5-6 surgeries a day.  If you accept the proposition that surgeons like their booze and that the average surgeon operates multiple times a week, how frequently does a surgeon end operate after a night of intoxicating frivolity?

Should hospitals regulate for patient safety?

This seems to be the ultimate inquiry. Additional research may be necessary to correlate these two variables. After all, no one wants to be operated by a surgeon whose lifestyle makes him 50% more likely to make a mistake. Nevertheless, even absent such information, hospitals and surgeons should take to heart the results of the study.  It might even be prudent for hospitals to enact regulations to prohibit surgeons from drinking the night before scheduled surgeries.

I am unaware of a single hospital that has enacted such a regulation.   Are you aware of hospital regulations designed to prohibit surgeons from drinking the night before scheduled surgeries?  Do you know of any proposed legislation in this regard?  More importantly, if you advocate for such regulations, tell our readers how to get involved. Patients Against Drunk Surgeons (PADS) may be a cause worth fighting for.

 

Image from thegospelcoalition

The New Enron? Are Hospitals Cooking the Books?

Thursday, April 28th, 2011

Tax season is over. Well, it is over if you filed your return in a timely fashion. Don’t let this blog stop you from stashing away your W-2’s and 1040-G’s for safekeeping. I hope you never need them. But, if you will, indulge me for just a second and leave your calculator out. No, I don’t need you to calculate the ever-increasing cost to fill-up your gas tank. Let’s take a quick look at a few health care statistics. Before you cringe, declare that you ‘hate math!’ and click-back to Facebook, let me share this with you: medical errors occur 10 times more than previously thought. Maybe that wasn’t hard hitting enough. Let me try again. How about this: mistakes occur in one out of every three hospital admissions!

Yes, seriously.

It’s Hard To Measure Without a Yardstick

Despite all of their education and training, medical professionals make mistakes. You know it, I know it, and certainly they know it. I hope that we can also all agree that it is unrealistic to expect for our health care providers to be perfect. What is reasonable, however, is to require an accurate accounting of the mistakes that occur in a health care setting. Believe it or not, there is no uniform method for a hospital to classify, track and otherwise determine what is or is not a medical mistake. A negative outcome at Hospital X in Baltimore might be considered a mistake, and yet if the same negative outcome occurred at Hospital Y in Washington D.C., it would not be considered a mistake. How so?

I don’t want to bog you down with the myriad measures that hospitals use to come up with the numbers but suffice it to say that at any hospital in the United States, its administration could utilize the: Agency for Healthcare Research and Quality’s Patient Safety Indicators or the Utah/Missouri Adverse Event Classification technique, or an approach developed by the Harvard Medical Practice Study, or the Institute of Healthcare Improvement’s Global Trigger Tool, or they can do their own analysis of the records and score themselves (self-reporting.)

That was a mouthful. Essentially, a yardstick for measuring the safety of care in hospitals does not exist. Or, at least, a yardstick has not been agreed upon. The two most common methods used, however, are voluntary reporting and the Agency for Healthcare Research and Quality Patient Safety Indicators. And according to a recent study, those two methods are awful. Before you conclude that I am being too harsh, let’s take a look.

The Good, the Bad, and the Ugly

The study, conducted by David C. Classen, and published in journal Health Affairs, utilized the Institute for Healthcare Improvement’s Global Trigger Tool. The Global Trigger Tool uses specific methods for reviewing medical charts. Patient charts are analyzed methodically, analyzing discharge codes, discharge summaries, medications, lab results, operation records, nursing notes, and physician progress notes to determine whether or not a “trigger” exists. A notation of a trigger leads to further investigation into whether or not an adverse event occurred. Here is how the tools stack up:

Self Reporting (Commonly Used Method #1): 4 adverse events detected

Safety Indicators (Commonly Used Method #2): 35 adverse events detected

Global Trigger Tool: 354 adverse events detected

The Global Trigger Tool is overwhelmingly more sensitive and picked-up many, many more adverse events. Overall, the Global Trigger Tool discovered that adverse events occurred in 33.2 percent of hospital admissions or 91 events per 1,000 patient days. That number is staggering.

What kind of “adverse events” are being missed? Medication errors, surgical errors, procedure related errors, infection, pressure ulcers, device failures and patient falls. All very serious and potentially injurious to a patient. The study indicates that the error detection tool being utilized by Hospital ABC in Yourtown, USA is probably woefully inadequate.

Why Accurate Error Detection Is Important

Error detection is essential to error correction. A hospital cannot identify the areas that need improvement if it is unable to identify the areas where it is falling down on the job. Failure to utilize an adequate error detection tool ensures that the same mistakes will continue to happen time and time again. I think the results certainly beg the question: why not adopt a nationwide standard? The Global Trigger Tool or another sensitive measuring matrix strikes me as a reasonable place to begin.

Certainly, there is a financial aspect to this discussion. Extensive chart reviews and lengthy inquiries into negative outcomes are costly and time intensive. Also, what motivation, besides error prevention, does a hospital have to discover its errors? As I wrote about here before, when errors are discovered, hospitals are penalized. If a hospital’s main concern is its bottom line and not patient safety, why not continue to “self-report” or use the Agency for Healthcare Research and Quality Patient Safety Indicators and leave the adverse events undetected?  Makes sense if you want to avoid the penalties…

It doesn’t say “leave a response” down below for nothing. Feel free to let us know YOUR thoughts.

QUESTION: Have you ever had a negative outcome at a hospital? Where you told that a mistake was made or were you told otherwise?

 

UPDATE: Window Blinds: Why are children still dying?

Wednesday, April 27th, 2011

UPDATE – October 20, 2011:

A few months ago, this blog highlighted the issue of dangerous window treatments. In the original article, I discussed how difficult it was for parents to know whether the window treatments in their home were safe and the relatively small cost it would take for manufacturers to make kids safer. So the unfortunate reality is that despite the ongoing safety concerns and injuries and even deaths due to window blind cords, manufacturers persist in making and selling dangerous blinds and shades that have cords that are accessible to children. This week, the Consumer Product Safety Commission has announced another recall of so-called Roman shades and roll-up blinds. These products have cords that allow a child to become strangled if they get their neck caught between the cord and the fabric or if the child accidentally wraps the cord around their neck. While the recall says that injuries have not yet been reported based on this product, these products are of the same type as many where injuries and deaths have been previously reported. It leaves me to wonder at what point the government or some external force will provide enough pressure on the manufacturers to stop creating and marketing dangerous blinds to the public? As my original post explained the cost savings in manufacturing blinds this way is not extreme, but the costs are huge to families when children are hurt. Furthermore, these products are being sold, at least in this case, at discount stores to families who are likely buying what blinds they can afford without any knowledge of the potential danger.

 

Photo: www.flickr.com/photos/stvcr/

For several years, there have been periodic news reports about major recalls involving window blinds. Window blind manufacturers have also provided a number of different types of safety elements on their blinds. These have included breakaway plastic pieces on the bottoms of the cords and other sorts of “safer” ways to deal with the cords involved in the use of the blinds. How many of you believed that these recalls and changes meant that new blinds or blinds that had not been subject to any recalls were safe?

As a parent, I thought that I was fairly up-to-date about this issue.  I had replaced all of the Roman style blinds in one room in my home with cordless blinds before my daughter was born. I had purchased another type of cordless blind system for the playroom. In the one remaining area with older style blinds, I had carefully checked to make sure that the cords were not tied into a loop and that they were cleated-up high so that no additional cord was accessible at child-height. Then, I basically went on living my life without thinking too much more about it.

Well, a recent New York Times article changed that for me. The article details the injuries and deaths of several children. These children were all severely injured or killed by window blind cords. The disturbing part to me, however, was that many of the parents had taken what I would have considered to be major precautions. They had baby-proofed their homes. They had tied-up the extra cords. Yet still, the boys and girls mentioned were hurt or killed by either the interior cords of the blinds and/or by climbing up and getting tangled in the supposedly secured/safe blind cords.

What a disturbing wake-up call. I certainly walked around my house last night with a different idea of child safety. But, as I mentioned, I know that a cordless type of blind exists.  So, why is this not the safety standard?

The New York Times article explains:

Now, prodded by a Missouri mother whose daughter was strangled in a window blind, the Consumer Product Safety Commission has asked manufacturers to devise a way to eliminate the risks from window cords or perhaps face mandatory regulations. Critics of the industry complain that manufacturers have dragged their feet on addressing safety hazards for decades, making minor tweaks or putting the onus on parents to shorten cords or buy tie-down devices. Until recently, regulators have done little to crack down, they say.

In response to the commission’s latest push, the industry, working with a task force of regulators and consumer advocates, says it will come up with a fix by the fall.

But the negotiations have gotten off to a rocky start. Like some other regulatory battles that involve consumer safety, this one comes down to a sobering question: how much should manufacturers, and ultimately consumers, be required to pay to prevent the maiming or death of a child?

When I read this, I imagined that it came down to this question because the cost of making all window blinds cordless was prohibitive.  The article even states that “… cordless blinds are more difficult to manufacture than corded blinds and can cost considerably more in stores, by some estimates, twice as much.” However, when you examine further, it seems that the cost of cordless blinds might not really be much more and certainly not prohibitively expensive.

The article goes on to say that James G. Onder, a St. Louis lawyer who represents parents whose children have been injured or killed by blinds, “…said manufacturers have repeatedly testified in depositions that the additional cost of making a cordless blind is $1 to $2.” If this is accurate and cordless blinds can be made for $1-2 more per blind, then why are children dying?

The Consumer Product Safety Commission (CPSC) issued a press release in March 2011 that said that:

About half of the deaths of children who strangle in window cords have not been reported, according to an article in this week’s Journal of the American Medical Association and co-authored by a staff member of the U.S. Consumer Product Safety Commission (CPSC).

The study found that 49 percent of the total number of window cord strangulations in the United States were not being reported to the CPSC. The study estimates that total number from 1981 to 1995 was 359. These figures mean that nearly one child is strangling in window cords every two weeks. Almost all of these deaths (93 percent) are children three years old and under.

What does it say if window blind manufacturers are selling cordless blinds for twice as much in stores, when they only cost an additional $1 or $2 additional dollars to make? What does that say about the cost of safety? What message does that send to the parents of the child who dies approximately every 2 weeks from window cord strangulation?

If the window blind manufacturers are not going to make safer blinds of their own, should they be regulated? What about the continued marketing of a product that proclaims to have safety features but is not as safe as it can be for children? Is it worth the risk?

Meningitis & Your Baby: Three Things To Think About

Tuesday, April 26th, 2011

A quick story.  I remember opening the piece of mail. It was a quick note from a school official informing the student population that there was a suspected incidence of meningitis at another local university. The long and short of it was that if, as a residential student, I didnt want to move back home with my parents, I wanted to continue to live on campus, I would need to sign a waiver or be vaccinated.

Too many years have gone by, and  I can no longer remember what I chose, but the thought of meningitis made me think very carefully about whether I wanted to be vaccinated. At the time I didn’t know much about meningitis, but with the stern warning I received in the form of that letter, I researched and learned that the effects of bacterial meningitis (commonly caused by Neisseria meningitides) can be devastating. My choice notwithstanding, the choice of “to vaccinate or not” has recently been extended to that parents of infants and toddlers.

1. The signs of meningitis

The classic symptoms of meningitis are a high fever, headache and stiff neck. Detection of these symptoms, particularly headache and stiff neck are certainly difficult to detect in infants and toddlers. According to the Centers for Disease Control and Prevention, infants with meningitis may appear slow or inactive, have vomiting, be irritable, or be feeding poorly. Seizures are also a possibility.

2. An Ounce of Prevention: A vaccine is available

I was fortunate; I had the choice. I was a young adult, and I had access to a vaccine. Until recently, however, parents could not make a similar choice for their small children. The Food and Drug Administration (FDA) has recently approved a vaccine to prevent meningitis in babies and toddlers. Specifically, the FDA has approved the vaccine Menactra for usage in babies and toddlers. Menactra has been frequently used to vaccinate non-toddlers and non-elderly (ages 2 to 55). For now, the FDA has approved the usage of Menactra in babies as young as 9 months.

3. Is it safe to give to your child?

The FDA has ushered Menactra into the great debate of “to vaccinate or not to vaccinate.” I’ve read the literature and opinions of others on the topic. Each position has its passionate advocates. Putting the debate aside, the potential harm created by meningitis is well documented. Even though rates of meningitis are low in the United States, infants and toddlers are particularly vulnerable.  Meningitis can develop rapidly; in a matter of hours or days.  Even with proper care, the FDA says up to 15% of people who develop meningitis die from the infection. Of the people that contract meningitis, one in four will suffer complications such as brain damage or hearing loss. A scary number for any parent to consider. So, no matter what side of the debate you stand on, at least you now have a choice for your baby.

It doesn’t say “leave a response” down below for nothing. Feel free to let us know…

QUESTION:  What choice will you make?  Is vaccinating with Menactra a choice you will make?

 

Health Reform: What voice does the patient have in the debate?

Tuesday, April 26th, 2011

Recently, I came across an Op Ed entitled Health Reform Requires Listening to Doctors. The very title suggests that  physicians and the health care system in general don’t have much of a voice in the discussion of health care legislation.

The question struck me – can that really be true? If the medical profession and health care industry are crying “poor us,” as the Op Ed author would suggest, that’s rather disingenuous at best. It’s well-known in today’s world of American politics that one sure way to have a voice is to hire a lobbyist. According to the Center for Responsive Politicsover $1 billion was spent on lobbying related to health care in 2009 and 2010. Who were the big players and payers in the hiring of lobbyists?

CNN Money tells the tale of the tape:

[L]obbyists for 1,251 organizations disclosed that they worked on health care reform in 2009 and 2010, according to the center and an analysis by the Sunlight Foundation. The number of individual lobbyists who reported working on health related legislation last year hit 3,154 in 2010.

Big Pharma topped the list. The Pharmaceutical Research and Manufacturers of America spent $22 million and deployed an army of no fewer than 52 lobbyists, according to the center.

Blue Cross Blue Shield, which used 43 lobbyists, spent $21 million. The biotech company Amgen (AMGNFortune 500) employed 33 lobbyists and spent $10.2 million.

Yet another source, iWatchnews.org, reports the following:

A Center for Public Integrity analysis of Senate lobbying disclosure forms shows that more than 1,750 companies and organizations hired about 4,525 lobbyists — eight for each member of Congress — to influence health reform bills in 2009.

Among industries, 207 hospitals lined up to lobby, followed by 105 insurance companies and 85 manufacturing companies. Trade, advocacy, and professional organizations trumped them all with 745 registered groups that lobbied on health reform bills, illustrating the common Washington strategy of special interests banding together to pool money and increase their influence.

Seems like a whole lot of money was spent by the health care industry to have a voice.

This blog, however, is not intended to address issues relating to the Obama Health Care Reform (or as it is referred to in some circles as ObamaCare). I don’t claim to understand the in’s and out’s of that political football. I’ll leave that for the so-called pundits to address. What does strike me, however, is the travesty that recently played out in the setting of a threatened federal government shutdown.

Health Care Reform – the goal of the President’s Plan

What was the stated purpose and goals of the President’s health care reform? Look no further than the online posting by the White House for the answer:

Health reform makes health care more affordable, holds insurers more accountable, expands coverage to all Americans and makes our health system sustainable.

Sounds good in principle, right? Putting aside all the politics, rancor and ranting surrounding the debate over the specifics of health care reform, don’t you find it rather ironic that when recent budget cuts to avoid a government shutdown were the topic du jour, those who had very little, if any, voice were the people who desperately need can’t afford health care?

Recent Budget Cuts and Who Paid the Price

As I learned last week, when the back room deals were struck, those without a voice were the victims of political expediency.

As our own Jason Penn reported in his blog post, Budget Crisis Avoided, But What About the Babies? Can They Live With $504 Million Less in Funding?:

At the 11th hour, cuts were made, backroom deals were struck, and Washington spoke:  there will be $38 billion dollars trimmed from the federal budget.  On a positive note, federal agencies will remain operational until the end of September. Reason to cheer? Maybe. Before we break out the party hats and noise makers, let’s take a look at how healthcare fared.  The following areas are among those cut:

-         Special Supplemental Nutrition Program for Women, Infants and Children (WIC):  $504 million

-         Community Health Centers:  $600 million

-         Substance Abuse & Mental Health Services Administration:  $45 million

-         Infectious Disease prevention:  $277 million

Total:  $1.426 Billion.  Yes, billion, with a “B”!

Isn’t the answer of who does and who does not have a voice in the bigger picture of health care legislation and so-called fiscal reform self-evident. Who was there in the back rooms of our hallowed halls of Congress protecting those in need of good primary care programs? I suspect that when it’s crunch time, political expedience wins the day. Need cuts to keep a bloated beast alive and floundering? Snatch it from the ones who will be heard the least – the ones who don’t have the ability to spend over $500,000,000 a year for lobbyists so they can have their voice heard.

As Written in the Book of Isaiah the Prophet…

Apparently it’s just “politics as usual.” For all the rhetoric about making primary health care available to all Americans and improving and sustaining programs to deliver critical healthcare to those who need it the most, the voice crying in the wilderness was not loud enough. Maybe, as the Op Ed author claims, everything the medical profession and health care industry has to say is not being heard or at least being accepted. Nevertheless, they have a voice, which is more than can be said for those they claim they want to protect. How many of the enormous lobbying dollars did the medical community and health care industry spend to protect primary care programs from the budget-cutting ax? I suspect we all know the answer.

 

Image source: fromtheleft.wordpress

 

Mediation of Lawsuits: The Top 5 Things that Tick Me Off!

Monday, April 25th, 2011

Having practiced law now for almost four decades, I’ve been involved in the resolution/settlement of thousands of cases. When I was a much younger lawyer, we didn’t have formal mediation sessions. We would  just talk with the other lawyer, pick-up a phone or sit down with the claims adjuster and just worked it out. Now the in-thing is formal mediation.

For those who may not be familiar with the mediation process, in the context of our firm’s areas of practice, it is basically a formal meeting involving all parties to a legal dispute, who hire an independent person called a mediator, to try to resolve the dispute between the parties through settlement. The intent is to avoid the risk, uncertainty and expense associated with taking the dispute to trial.

There’s no doubt in my mind that a good mediation session settles some cases that might otherwise be difficult to work out. That being said, I seem to be running into some trends over the last couple of years that are – quite frankly – starting to really p**s me off!

Normally, I would keep my lawyer-rants to discussions with those in my law firm or with some lawyer pals, who share the same frustrations. Recently, however, I read a post by a legal blogger – a blawger (a lawyer who blogs), Scott H. Greenfield, who took to task legal bloggers for not taking a stand on issues. His blawg is titled Dead Lawyers Have No Enemies. I decided I would do the Lazarus thing and take a stand on an issue that’s been bugging me for some time – modern day mediation and mediators.

In no particular order, here is my list of the top 5 things about mediation that just tick me off:

1. No meaningful discussions before the mediation session

How many times now have I heard the mantra -”No, we don’t want to engage in any settlement discussions (interpretation – no first offer) until we get to mediation.” Far too many times I’m afraid. Why is this? Can’t people get the process started before mediation so that we all can make an intelligent decision as to whether formal mediation has a chance of working or whether the upcoming mediation has all the ear-markings of a waste of time and money?

Here’s the mediation scenario: The clients have to miss work or otherwise be inconvenienced to be at mediation. Many times we have to travel some distance to attend. We sit through the mandatory (but necessary for the clients) introduction by the mediator advising those new to this process who the mediator is, what his/her background is, what the process is all about, how it’s confidential and nothing said can ever be used outside the mediation session. The confidentiality form is signed and the parties go to their separate rooms.

On behalf of my clients (the party bringing the lawsuit), we make a demand. After some time passes (which varies greatly depending on the mediator), the first offer is made. Lately, more often than not, the offer is some ridiculously low-ball amount. The mediator tells you and your clients: “Don’t take it personally. They’re just trying to send a message” You fight every instinct welling-up inside you to send your own message by just walking out. After getting control of your own emotions, you try to calm your clients down. Not easy to do sometimes – for instance when (by way of a real life example) my clients just been told their dead child is worth $25,000. Of course that’s not what’s being said by the defendant’s insurer, but that’s exactly how it resonates – in this example – with the plaintiffs, who do take it personally.

There’s no doubt that when as a plaintiff’s lawyer you make a demand that’s simply ridiculous, you somewhat deserve to get low-balled in Round 1. However, when you purposely try to put a reasonable number on the table – albeit giving yourself room to negotiate, it is enraging and detrimental to the process on many levels when you get low-balled by the defense. Apparently, the defense doesn’t believe you actually tried to make a reasonable initial demand. They take a reasonable demand as a sign of weakness in the plaintiff’s case. Yet, if I were to take the other approach and start with an equally outrageous demand in Round 1, I would never hear the end of it from the other side. Sure – “reasonable” is in the eye of the beholder, but skilled advocates generally have a sense of the range it takes to be in at the end of the day to settle any given case.

My free advice: If mediators were doing their job, they would get the negotiations underway before the first formal mediation session. My suggestion: let’s get all the foreplay out of the way before the formal mediation session. If it’s going to be a waste of everyone’s time, then let’s put our efforts and money to better use and not mediate in the first place.

2. The Defense not understanding the impact of their conduct

Having been a defense lawyer before switching sides (referred to by insurance adjusters as “going to the dark side“), for years, I didn’t sit in the room with the injured party when we sent the first offer (and the second and the third and….) into the plaintiff’s room. Had I been a fly on that room’s wall, maybe I would have realized a lot earlier just what impact our “message” was going to have on that injured party, whose case we claimed we were trying to settle.

As the years went by and I saw some plaintiff lawyers packing-up their bags and heading-out with their clients as a response to our message offer, I started to get it. Call me a “slow learner,” but at least I had my epiphany.

Now that I am sitting with the injured person who brought the lawsuit, let me share a bit of advice with my colleagues on the other side. Don’t p**s off the plaintiff and in turn his/her lawyer by sending the wrong message. Does any defense lawyer or risk management person really believe the plaintiff wants to hear: “Your dead child (or replace with – your injured child, your missing leg, your paralyzed son – and every other injury that has befallen a plaintiff) is worth $25,000 or $50,000.”

Now that I’ve been sitting with these injured or grieving people for years, I get to see firsthand  just what kind of impact a low ball, “message offer” has on people. It starts the process out on the wrong foot. You – as the lawyer representing the injured person – have to try to remain calm in order to calm your client down. You try to convince them that this is just a game being played and they shouldn’t read anything into it. Well, Dear Defense Lawyer and Claims Person, it is not a game to the person who’s been injured!

Apparently many defense lawyers are relying on their bible, Mediation 101, which ostensibly tells them that when they are in the initial general session, the defense should tell the plaintiffs just how sorry they, the defense, are for the injuries and losses the plaintiffs have suffered.

Well here’s some free advice from the dark side: With the first chance you have to show that this empathy was really sincere, don’t slap the plaintiffs in the face with a low ball, message offer. It’s not a good technique!

If you, the defense, take this approach, you have completely lost all credibility, the war is on and now it will take hours of worthless and unnecessary haggling to get to where this all could have started if the parties had started out in good faith efforts to negotiate. Hopefully, Advanced Mediation Technique – 201 will be coming out soon!

3. Mediators who are nothing but high-priced messenger services

Finding a qualified mediator seems to be getting harder and harder. The good ones seem to be booked-up for months to come. Maybe that’s because they are good. Why does it seem to me that every retired judge now thinks that he or she is a qualified mediator? Sorry, Former Member of the Judiciary, but you are not all qualified. Some are; some are not.

How many times have the litigants experienced a mediator who simply walks from room to room and delivers the latest offer or the latest demand? My answer: way too many times! If I need a courier, I’ll hire a courier. They are a heck of a lot less expensive and could be equally effective.

Since so many of us “in the trenches” are searching for skilled, qualified and effective mediators, who don’t cost an arm and a leg (and dramatically increase the costs of the case), a lot of newbie mediators are among the selection pool. Well, I for one am not interested in a mediator getting his or her training-wheels on my client’s case. Can’t there be some universally accessible databank or message board or listserv in today’s digital age where litigators can freely express their views, comments and criticisms of mediators so that litigants can have a real choice of qualified, reasonably priced and effective mediators? Maybe I’ll make that my next project – in my spare time.

4. Using mediation as a “feeling out” session

I cannot tell you how many times I have gone to a mediation session where the goal seems to be that one side – usually the defense – wants to get a feel for just how much it’s going to take to get the case settled or to get a feel for the plaintiff and how they will come across to a jury if the case doesn’t settle.

Sorry, but mediation is not discovery! If the defendant’s insurer or claims person wants to gain these insights, then they should take the time, in serious cases, to attend the plaintiff’s deposition. If they can’t be there, maybe they will be interested to learn that there’s new technology called a video deposition. It’s only been around for years!

In this same vein, it fascinates me when I hear a messenger mediator tell me some of the justifications for why a low-ball offer being made is well-founded. The mediator (particularly those in the messenger class) takes as gospel so-called facts about the case from the defense and conclude they are being reasonable – or even magnanimous – when these facts are nowhere to be found in the evidence of the case being mediated!

Recently, I had a defendant and its settlement team of lawyers and adjusters, totally enamored with their causation defense (admitting in essence the caregivers had totally failed to follow acceptable standards of good medical care but claiming – “our conduct, which we recognize was awful, didn’t cause your client’s injuries”) that drove the entire negotiations toward abject failure. After hours of meaningless back-and-forth, small, incremental offers and demands, the whole mediation session fell apart.  If the mediator had truly known the real facts of the case, he would have realized that this so-called defense was in large part predicated on a defense expert’s unfounded opinion. Truth be known, that “expert” had totally failed to read our client’s subsequent care records, which disprove his baseless opinions.

Should I have told the defense where they were wrong? Or – should I save this information for cross-examination if I honestly believe the case is not going to settle and I will have to try it? Tough call – but I opted for the latter course since the negotiations were going nowhere fast anyway. I made a judgment call that the reserve put on the case by the healthcare was so low that this case would not settle no matter what they learned that day.

Mediation sessions are intended to resolve cases, not act as a session for the claim’s representative to figure out what the case is about! Just how many serious cases do these claims people have that they can’t come prepared for mediation? How in the world do they set a reserve on a case not understanding the medicine (in a medical malpractice case) of the case?

A free, albeit unsolicited message for our claims brethren: If you don’t or can’t understand the medicine before you put a value on it, learn the medicine from your defense lawyer. Isn’t that what you are in part paying for when you pay their hourly fees? Really know your file and question your defense counsel about their recommendations. Simply put – come to mediation understanding the facts and the law as best you can. Don’t see mediation as just another opportunity to spend a day out of the office.

5. Mediators who don’t, can’t or won’t challenge the positions of each side

Maybe this is a corollary to my “don’t be just a messenger,” but it holds a special place in my heart– so it makes the list. I can’t tell you how many mediators announce during the initial, joint session (where all parties and counsel are present) that they are not advocates for one side or the other. Well that’s fine; however, there comes a time when the position of one party or the other needs to be challenged by the mediator.

Messenger Mediators just listen and are often blindly impressed by the arguments of the lawyers for each side. Here’s the problem – a good mediator needs to be able to understand the validity – or lack thereof – of those arguments to be effective. If a mediator doesn’t understand the law or the facts of a case well enough to challenge either side’s position, then what purpose do they serve?

Admittedly, a mediator cannot possibly know the “facts” of a case as well as the litigants. That does not mean, however, that they should simply show-up and facilitate a settlement by trying to act as a middleman in reaching the “sweet spot” of dollars that both sides are willing to accept to reach a settlement. While this approach may work in some smaller cases, it simply does not work in more complex and higher value cases.

Some of the best mediators I have had the pleasure to work with listen to the arguments, analyze the relative strengths and weaknesses of those positions and then challenge the parties and lawyers by questioning the validity of their arguments and position. When that’s done, it is amazing how progress is made toward a resolution of the case. Simply put, good mediators cut through the posturing and puffery and expose the weaknesses of each side’s case. The only way that can happen is if the mediator has taken the time to really learn the case. In my field of medical malpractice, that may mean taking the time to read the key medical records, key depositions or whatever other “evidence” each side believes supports their respective position and using that knowledge to cut to the heart of the issues.

Sure – it may mean paying a mediator a bit more for their time, but if it gets a settlement done, isn’t it worth it? I for one would rather spend money for a mediator who can perform this type of service than one who spends hours in the mediation session just listening to a party’s specious arguments, getting a new offer or demand and then doing the shuttle diplomacy gig. Way too often, this time-consuming shuttling from one room to the other doesn’t work. The mediator’s time “in the room” would be much better spent by questioning, probing and dissecting the relative positions of each side. That – in my experience – works more often than not and gets the case settled. Every case has weaknesses for all parties involved. So – Mediators – find the weaknesses, expose them and use them to bring reality to the mediation process in order to get it done. You don’t have to be an advocate, but you do need to be pro-active.

What are your pet peeves?

This blawg rant is not intended just for lawyers or mediators. I’d love to hear from people – like clients/parties to a lawsuit, who have participated in today’s modern marvel – formal mediation sessions.

Lawyers and litigants – plaintiff and defense – what is it about mediation that you think needs to be fixed? Maybe if we all put our heads together, we can make this a more meaningful process for everyone.

Related Posts:

One More Mediation Pet Peeve, John Bratt, Miller & Zois

 

 

 


 

 

Week in Review (April 18 – 22, 2011) The Eye Opener Health and Law Blog

Saturday, April 23rd, 2011

From the Editor:

This past week, our blawgers (guess I’ll use this term now since we are legal bloggers) were busy on their keyboards once again. They covered a number of topics relating to law, medicine, health and patient safety. This week we posted a primer on aortic aneurysms and how they can present as back pain, a blog about “robot” anesthesiology, a disturbing post about how the recent threat of a federal government shutdown was averted but at a cost to those who are in dire need of healthcare, an interesting piece about laughing gas making its way back into the American medical scene for labor and delivery and finally, and a highly read piece on a not-to-often discussed topic but one of potential grave concern – shift switching by nurses and how this might impact patient safety.

Here’s our usual “quick summaries” for you to peruse, click on, read and comment:

Aneurysms – a deadly condition you need to know about!

Our in-house medical specialist, Theresa Neumann, wrote another highly educational and need-to-know piece about a condition that can present as back pain but which has deadly consequences for those who have this condition.

As Theresa’s research made us aware – “1 in every 50 males over the age of 55 have an abdominal aneurysm, this is a more common pathologic diagnosis than some others.  Men also corner the market at an 8-to-1 ratio as compared to women with abdominal aneurysms.”

As is the case with all of Theresa’s writings, we offer through her valuable information from someone who’s “been there” and “done that” in the clinical setting. Don’t miss her post entitled Aneurysms: A Potential Deadly Condition That May Present as Back Pain.

Who’s using remote control and a joy stick to put a breathing tube down your throat?

Mike Sanders brought to our attention a new practice of anesthesiologists – in Canada – that may soon be part of anesthesia management in the United States as well – using robotics to intubate patients. While you can certainly learn about the concept of intubation by reading Mike’s blog, basically, this is placing a small tube down a patient’s airway so that the anesthesiologist can control the airway and provide ventilation to a patient undergoing surgery.

Here’s an except -

Medical News Today is reporting that Dr. Thomas Hemmerling of McGill University and his team have developed a robotic system for intubation that can be operated via remote control.

For more on this fascinating new project by Dr. Hammerling and his team, read Mike’s post entitled Robot Anesthesiologists?

Government Shutdown Avoided – but who will pay the price for the “deals” that were cut?

The newest member of our blogging team, Jason Penn (fast approaching veteran blawger status) did a fascinating piece of the story-behind-the-story of the recent crisis our country faced when the federal government was on the verge of a shutdown. We all know about deals being cut in the back rooms of congress. We all know that the government avoided a shutdown this time around when the senate and house worked out a compromise that resulted in millions of dollars being earmarked for cuts in the budget.

Jason tells us what programs relating to healthcare will suffer as a result of these negotiated cuts. As some wise person once said, “why is it always those who are least represented who bear the burden of budget cuts?” Maybe it’s because they can’t afford lobbyists to protect them like those who need protection the least can.

Read Jason’s eye opening and no-punches-pulled report on just who will be the victims of the deals in his post of this past week Budget Crisis Avoided, But What About the Babies? Can They Live With $504 Million Less in Funding?

Will moms-to-be now be “laughing” their way through labor and delivery?

One of our seasoned blawgers, who every now and then is driven to report on the off-beat issues of law, medicine and healthcare, Jon Stefanuca, stepped up to the plate once again and took a swing at the return of an old-timer to the arsenal of pain relief for mothers-to-be undergoing labor and delivery – laughing gas!

As Jon’s piece in Eye Opener this past week tells us -

It appears that a number of hospitals are now considering making laughing gas available as a pain relief measure for women in labor. A hospital in San Francisco and another in Seattle have been using laughing gas in their labor and delivery units for a while. Hospitals like Dartmouth-Hitchcock Medical Center plan to offer laughing gas to laboring mothers in the immediate future.

For more about this return of laughing gas to our obstetrical units, read Jon’s piece Laughing Gas Making Its Way Back Into the Labor and Delivery Department.

Nursing and Sleep Deprivation: Is it a risk factor for patient safety?

I suspect somewhere along the line you have done “an all-nighter” – whether it was getting ready for a big test, a social event, or for some other reason. Remember how you felt as you made it through that night or the next day? Have you ever done it several nights in the same week? How about doing it a few times one week and then do the same thing the next week and the next…. Well you no doubt get the idea. You’ve been exhausted, right? Well what about nurses, who have to do this for a living?

Nurses have lives too. They have children, home responsibilities and obligations, and some form of social life. What happens when they swap shifts or are asked to do “a double”?

Sarah Keogh was back blogging this past week and wrote a fascinating (and concerning) post entitled Nurses Switching Shifts: Does a Lack of Sleep Put Patients at Risk? We invite you to read Sarah’s piece and share your comments. Are you a nurse who lives this lifestyle? What are your thoughts about nurses being allowed to work multiple shifts or back-to-back shifts in terms of patient safety? Should there be restrictions on nurses’ shifts just as there (finally) are work restrictions on doctors-in-training?

A “Sneak Peak” of the week ahead

As part of our continuing effort to “get the word out there” on issues relating to health, medicine, patient safety and the law, we post from time to time more extensive research pieces called White Papers. Well, the time has arrived for another White Paper to be posted on our website. Marian Hogan has completed her piece on a very important topic – Patient Controlled Analgesia in today’s hospital environment. She examines how some hospitals are now heavily marketing a spa-like environment so you choose them over the competition. Yet lurking in the shadows of these facilities which promote flat screen TV’s, valet parking, in-room safes and the like is a very dangerous practice: placing patients on patient-controlled-analgesia (for pain relief) without vital monitoring devices and patient safety practices. It’s at the “printer” now; we hope to have it online this week.

From our blawgers you can expect reports on a disturbing fight between manufacturers and child safety experts over – blinds! After decades of controversy, you’ll find out where the battle lines are now drawn, who’s winning and who the real losers are in this war. Wonder how healthcare safety is doing since the report To Err is Human was published by the Institute of Medicine over a decade ago? Jason Penn will be providing an updated report card, which you should not miss. Alcohol and surgery – not a good combination! Jon Stefanuca plans on posting a piece that looks deeper in the obvious problems with this potentially deadly combination.

This is just a taste of what’s to come. I better wrap-up now. I’m working on finishing the third installment on Medical Technology and Patient Safety. Oh yeah, if time permits, I might even get to post a piece I’ve been working on this past week – a lawyer’s rant about our modern day love affair with mediation practices and trends.

As always, don’t forget - subscribe to the Eye Opener and tell your friends about us too! …and… don’t forget to join our social networking communities on Facebook and Twitter.

Hope you have a great weekend!

Nurses Switching Shifts: Does a Lack of Sleep Put Patients at Risk?

Friday, April 22nd, 2011

Image from scrubsmag.com

Many of us take it as a given that if we end up in a hospital, we will be taken care of by an around-the-clock group of health care professionals. These doctors, nurses and other staff will be awake and alert to care for us and prevent any potential problems during our stay. However, how many of you have thought about how this impacts these health care professionals on their days off? I know that I had not thought too much about this issue. I had taken for granted that if I or a loved one were hospitalized that the professionals involved in their care would be at least well rested enough to avoid major medical errors.

I have read lots of different reports about all of the rule changes for doctors in training regarding how many hours they can work in a week or at one time. I had never before read a report regarding the impact of work schedules on nurses. While I knew that most nurses worked 12-hour shifts, I have to admit that I had not thought about how this impacted their own lives or patient care. That changed when I read a recent article in medicalnewstoday.com. This article discusses a study published in Public Library of Science One that was conducted “…to examine the strategies that night nurses use to adjust between day and night sleep cycles.”

What seems obvious in retrospect, but that I had never really considered before, is that nurses who work the night shift (typically 7 pm until 7 am – or “7p to 7a” as they like to call it), normally do not stay up all night in their “non-work” lives. On their days off, they often want to live a more typical life with daytime awake hours. The ramification of this is that they need to switch their sleep schedule back and forth several times throughout the week. Can you image having to do that yourself and still perform your job properly?

The medicalnewstoday.com article explains that “[a]s many as 25 percent of hospital nurses go without sleep for at least 24 hours in order to adjust to working on the night shift, which is the least effective strategy for adapting their internal, circadian clocks to a night-time schedule.”

The “First Shift” Effect

So, the first issue in this revelation is that as many as a quarter of hospital nurses are going without sleep for at least 24 hours when adjusting to working the night shift. I shudder to think of how many nurses around the country are therefore working at least their first night shift every week while on hours 12-24 of not having slept.

While others may function better than I do without sleep, I don’t think that I would ever feel comfortable being cared for by a nurse who had not slept in the prior 12 hours before starting their shift. It seems to me that this opens up the possibility for many medical errors and patient injuries.

The Circadian Clock Effect

The second issue I had was that this is also “the least effective strategy for adapting their internal, circadian clocks” – which I take to mean that if a nurse who has not slept for that first shift is not bad enough – it also does not work very well to help them be adjusted and well rested for the rest of the week.

If the concerns about the health of the public being cared for by tired nurses is not bad enough, this can also be quite damaging to the health of the nurses themselves. These selfless individuals who are caring for others are – frankly – at risk.

A number of previous studies have found that repeated incidence of circadian misalignment the condition that occurs when individuals’ sleep/wake patterns are out of sync with their biological clocks is not healthy. Jet lag is the most familiar example of this condition. Circadian misalignment has been associated with increased risk of developing cardiovascular, metabolic and gastrointestinal disorders, some types of cancer and several mental disorders.

So, these nurses are risking their own health in addition to potentially the health of their patients.

Just how important is sleep?

Just how much does sleep matter? Well, another article from medicalnewstoday.com recently looked at sleep in a very different context. It examined a study from the Journal of Clinical Sleep Medicine, which showed that “…automobile crash rates among teen drivers…” were dramatically higher in otherwise similar school districts where teens started school earlier in the morning (a difference of about 1 hours and twenty minutes). While there is no proof yet that this connection is causal, there certainly seems to be a strong connection even after adjusting for other possible factors. The article also mentions that:

Another study in the April issue of the Journal of Clinical Sleep Medicine suggests that delaying school start times by one hour could enhance students’ cognitive performance by improving their attention level and increasing their rate of performance, as well as reducing their mistakes and impulsivity. The Israeli study of 14-year-old, eighth-grade students found that the teens slept about 55 minutes longer each night and performed better on tests that require attention when their school start time was delayed by one hour.

While teens and teenage behavior can be different from that of adults (thank goodness), I still think that these studies highlight some of the key issues of sleep deprivation. Adults seem likely to also make more mistakes, lack attention and act more impulsively when functioning on less sleep.

However, a review of a study from Nursing Economics entitled “Shift Work in Nursing: Is it Really a Risk Factor for Nurses’ Health and Patients’ Safety” suggests that other factors put nurses’ health at greater risk and that shift work does not impact the number of medical errors. The study was conducted in Israel in 2003. It is important to note that this study looked at nurses working alternating 8-hour shifts and did not directly look at the issue of nurses not sleeping in order to switch between 12-hour shifts.  The investigators in the study were surprised by some of their findings:

Shift work and organizational outcomes. In the present study, we investigated the impact of sleep disturbances on shift nurses and on two organizational outcomes: errors and incidents and absenteeism from work. Based on our literature review (Morshead, 2002; Muecke, 2005; Westfall-Lake, 1997), we expected that “non-adaptive shift nurses” would report on more involvement in errors and adverse incidents as compared to “adaptive shift nurses.” We also assumed that non-adaptive nurses, who by definition have more sleep-related complaints, would have higher absenteeism rates due to illness compared to their adaptive colleagues. Neither of our hypotheses was supported by the results of this study.

Instead the study found that:

It appears that gender, age, and weight are more significant factors than shift work in determining the well-being of nurses. Moreover, nurses who were identified as being non-adaptive to shift work based on their complaints about sleep were found to work as effectively and safely as their adaptive colleagues in terms of absenteeism from work and involvement in professional errors and accidents.

What do you think? Would you want a nurse who has been up for 24 hours to be caring for you or your loved one? Should it be the nurse’s decision whether they are alert enough for work? Should rules be created for nurses just as they were for physicians in training? What about nurses who enjoy the flexibility and freedom allowed by this sort of schedule? Have you worked as a nurse? What are your experiences and feedback on whether this is a problem?

Related Post – you may want to read:

A Surgeon’s Sleep Deprivation and Elective Surgery – Not a good (or safe) combination.

The New England Journal of Medicine published a Perspective on December 30, 2010, that screams common sense and should be embraced as a starting point to implement some new patient-safety standards of practice. Place yourself in the position of a patient getting ready to undergo an elective (i.e. non-emergency) surgical procedure. You’re wheeled into the operating room for your surgery and are greeted by your surgeon in the process. Read more…


 

Laughing Gas Making Its Way Back Into The Labor And Deliver Department

Thursday, April 21st, 2011

According to a recent article published by MSNBC, laughing gas or nitrous oxide is making its way back into labor and delivery units in American hospitals. Although laughing gas has long been used as a pain relief in various countries, including Canada and the U.K., it has lost its popularity in the U.S. Well, maybe not for much longer.

It appears that a number of hospitals are now considering making laughing gas available as a pain relief measure for women in labor. A hospital in San Francisco and another in Seattle have been using laughing gas in their labor and delivery units for a while. Hospitals like Dartmouth-Hitchcock Medical Center plan to offer laughing gas to laboring mothers in the immediate future. Dartmouth-Hitchcock’s plan is currently being reviewed by the federal government, and arrangements are presently being made for the procurement of delivery equipment for laughing gas. Vanderbilt University Medical Center may begin offering laughing gas as well later this year.

History

Laughing gas is not a new pain relief method. Its use had become very common in hospitals when Joseph Thomas Clover invented the gas-ether inhaler in 1876. Particularly, its use in the labor and delivery setting had been very common before the introduction of epidural and spinal anesthesia. Because laughing gas is unable to eliminate pain to the same degree as epidural or spinal anesthesia, it simply could not compete with the more sophisticated pain relief alternatives, which entered the marker in the 30s and 40s.

What is laughing gas?

Nitrous oxide, commonly known as laughing gas or sweet air, is a chemical compound with the formula N2O. It is an oxide of nitrogen. At room temperature, it is a colorless non-flammable gas, with a slightly sweet odor and taste. It is used in surgery and dentistry for its anesthetic and analgesic effects. It is known as “laughing gas” due to the euphoric effects of inhaling it, a property that has led to its recreational use as a dissociative anesthetic.

Laughing gas as an important pain relief alternative

Although laughing gas can only take the edge off pain, it just might be an important alternative to other more conventional pain relief methods. The patient does not have to rely on an anesthesiologist to administer the gas. The patient can herself choose how much gas to administer at any time. The effects of the gas are not long-lasting. Therefore, the patient does not have to recover in a post anesthesia care unit. Importantly, there is no associated loss of sensation and motor function during the delivery process. As such, the gas does not interfere with the woman’s ability to breath and push during labor. Laughing gas is also not known to have any adverse effects on the baby in utero.

The administration of laughing gas does not require any invasive medical procedures. By contrast, consider epidural anesthesia: An epidural requires that an epidural catheter be threaded into the epidural space, which is only about 2 mm wide. Any mistake and the consequences can be catastrophic. Epidurals have been known to cause spinal cord injury secondary t0 toxicity, spinal cord infarcts, severe hypotension, paraplegia, epidural bleeding, and even death. None of these complications are associated with the use of laughing gas.

: httpv://www.youtube.com/watch?v=1TO4sOgiIeU]

According to Suzanne Serat, a nurse midwife at Dartmouth-Hitchcock Medical Center:

We have a number of people who don’t want to feel the pain of labor, and nitrous oxide would not be a good option for them. They really need an epidural, and that’s perfect for them. […] Then we have a number of people who are going to wait and see what happens, and when they’re in labor, decide they’d like something and then the only option for them is an epidural but they don’t need something that strong. So they would choose to use something in the middle, but we just don’t have anything in the middle.

Nitrous oxide may just prove to be that middle option for many women who prefer to give birth without the use of powerful and potentially dangerous analgesic/anesthetic agents. If you are an expectant mother, ask your obstetrician if nitrous oxide is a pain relief option that may be available to you during labor.

Image from cartoonstock.com

For more information about epidural anesthesia and epidural complications, you may want to read these posts too:

Having an epidural when you deliver your baby? 3 Questions to ask the doctor!

5 Questions to Ask Your Obstetrician Before You Go to the Hospital

Epidural Analgesia – What Should an Expectant Mother Consider? What are the risks?