FTA: "As hard as the job is, diagnostic accuracy in the E.R. is high overall. But a recent systematic review of published research estimated that 5.7 percent of E.R. patients will have at least one diagnostic error and 2 percent have a setback as a result."
I feel like scrutinizing the industry for a 2-3% error on an obviously difficult problem is exactly why we pay so much in the United States for health care.
Could have died in his sleep. When I did my military service, we had a guy that passed away in his sleep (during night) due to pulmonary embolism. Shared barrack room with 5 other.
If you visit the emergency department of a lot of British hospitals, there will be large posters reminding the doctors "Could it be sepsis?" because of similar instances that occurred over here.
My wife (then girlfriend) and I were at a concert. She went to the bathroom to pee. She came back crying.
I told her she might have a UTI. It was not normal for it to hurt that badly to pee. She denied it. I bought her a UTI test, it came out positive. She was shaking. I told her we had to go to the hospital, she thought they were period cramps.
I call a teledoc. They video chat. She explains the pain shes feeling in her lower back means it’s likely a UTI, the infection has likely reached her kidneys, and we should go to the ER immediately.
In the ER we think they’re going to just give her some antibiotics and send her home. Nope. She throws up. Things go bad fast. Her heart rate is 160. She turns a color I’ve never seen a human before.
The next 3 days were so incredibly hard. But I’m so thankful to all the medical workers that were attentive to us.
Thankfully she makes a full recovery. For a week or so she was lethargic/tired but she’s fully healthy now.
A few months before I had read a story about a woman who’s boyfriend had died from a UTI because they went to a gospital, gave him some antibiotics, and he ending up dying at home because the infection was already too progressed to fight off at home.
Had the person who evaluated my girlfriend not evaluated seriously or just sent her off that could’ve been her. I’m so thankful they admitted her and took her care seriously.
It’s scary how quickly a UTI or some other benign infection can become sepsis. Take it seriously.
>In his effort to understand hospital safety and risk, he learned these oft-cited projections: more than 200,000 people will die each year from preventable medical errors. He was shocked. Conservatively, these estimates amount to at least one fatal Boeing 747 crash per week, Terblanche calculated.
This reminds me of the book The Checklist Manifesto by surgeon Atul Gawande. The book argues that aviation has achieved such a good safety record largely through the use of checklists, and Gawande describes his attempts to apply them to the field of medicine. Recommended. (Edit: I see that checklists are discussed later in the article; I would still recommend the book, as it has thoughts on how checklists can be applied more effectively.)
My son almost died in the first 24 hours of life. I said, "There's something wrong. There's something wrong." multiple times and the nurses finally told me, "YOU NEED TO CHILL OUT." I did chill out....
Next morning the pediatrician did his rounds, checked on my son, and immediately started speaking Latin, to go over our heads while rushing around and getting equipment to clear his lungs of amniotic fluid.
Reminds me of what my first engineering boss told me -- "When the people on the line say there is a problem. There is a problem."
- Lack of any low-intensity monitored recovery option. If the kid could just have been sent home to a traditional worrying mother, who'd been told to watch for certain warning signs - then he very likely would have lived.
- Critical shortages of front-line medical staff. (ER nurses especially noted here. But a dishonorable mention to the computer systems that the residents were fighting against.)
- However short our medical system might be on front-line resources to treat patients needing care - once it's lawsuit time, resources seem plentiful.
Heartbreaking story. They talk a lot about the possibility of bacterial infection but it was not consistent with the blood tests. It seems he just got unlucky (although should have had a Chest X-Ray).
Trying to reframe it in a coding analogy, there were a few abnormal logs maybe an exception or two but the coder was unable to figure it out and these exceptions happen all the time and so pushed to live anyway. Due to resource allocation issues they were pulled to a different job. Then the site crashed. Just awful.
I have found it very useful to discuss possible diagnoses and diagnostic steps with the LLM before going to the ER. Once there, I told them what my expectations were along with the rationale for it. They agreed with 80% of it.
Ultimately the ER was of no use in treatment, but the preparation did help rule out a serious diagnosis.
In my opinion, this is one of the more overlooked side effects of the covid pandemic: stretching resources in hospitals leads to lower quality care for everyone.
Sepsis is hard to spot. Whats interesting about this article is that once you get into the details of whatt happened on the patients second visit, its largely about the hospital information systems and how they got in the way.
An automated alert popped up warning that the doctors should consider Sepsis. That alert essentially then blocked progress, and the doctors ended up (essentially) ticking the 'not sepsis' box so that they could get on with their (reasonable) next step which was either ordering an x-ray or starting antibiotics. Then somehow after that, sepsis did not get re-considered.
It was Banerjee’s task to document Sam’s care, and as he began to do so, a pop-up appeared on his computer screen. Sam’s fever and heart rate had triggered an automated warning for sepsis, a potentially life-threatening condition in which the immune system has a dangerous reaction to an infection. It requires speedy intervention. To help the hospital comply with state-mandated sepsis regulations, the pop-up provides a checklist of tests and orders used to identify and treat sepsis.
Agyare had instructed Banerjee to hydrate Sam right away but to wait for the results of Sam’s lab work before ordering a chest X-ray or the strong antibiotics used to treat sepsis.
But Banerjee, a novice, got stuck. He couldn’t figure out how to navigate the template to make some but not all of the auto-populated orders. “This was my first patient that triggered the sepsis pathway,” he explained, in testimony. So he asked Connor Welsh, a third-year resident, for help.
At 8:50 p.m., Welsh showed Banerjee how. From his own computer, he clicked into a field on Sam’s chart to assert that sepsis was not likely: “Based on my evaluation,” the automated note said, “this patient does not meet clinical criteria for bacterial sepsis.” And then Welsh recorded what Banerjee said Agyare had said earlier: “Likely viral syndrome. Workup pending.” Welsh’s name appears on the note, but in his deposition he said he never interacted with Sam. Senior residents often help junior ones in this way, he said. “I signed this note based on the discussion with the provider, Dr. Banerjee, based on his evaluation and the medical management of Mr. Terblanche,” he testified.
...
Sam’s chart is 51 pages long, a catalog of billing codes and abbreviations, check-boxes and shorthand, updates and addenda. The record of the second visit contains numerous contradictions: Sam’s heart rate was documented at 126, yet Banerjee clicked the box “normal.” In one place it says Sam didn’t have a cough, while in another it says he did. The signatures of doctors who testified they never saw Sam — including one who was not in the hospital that night — accompany notes. Vital signs were ordered and not taken, as was an EKG.
> An automated alert popped up warning that the doctors should consider Sepsis. That alert essentially then blocked progress, and the doctors ended up (essentially) ticking the 'not sepsis' box so that they could get on with their (reasonable) next step which was either ordering an x-ray or starting antibiotics.
Man, I feel like I've been trying in vain to fight pop-ups for my whole software development career. Now we have an example where, at worst a pop-up got someone killed, and at best it was part of the chain of events that got someone killed. I don't know what it is that draws product designers to keep reaching for that horrible UX pattern, but it's got to be stopped. Nobody reads these things so a popup is the worst place to put important information that the user needs to read!
I think a lot of pop-up usage comes from company lawyers trying to cover butts: "Well, regulation says that users need to be informed of XYZ, so just stick a pop-up there. Then we can tell the regulator 'Hey at least we did our part to inform the user.'"
Just to be precise. The sepsis alarm was not blocking x-ray or antibiotics but rather suggesting them.
“””
Agyare had instructed Banerjee to hydrate Sam right away but to wait for the results of Sam’s lab work before ordering a chest X-ray or the strong antibiotics used to treat sepsis.
“””
> The signatures of doctors who testified they never saw Sam — including one who was not in the hospital that night — accompany notes.
I'd bet 10 to 1 this is due to residents or fellows copy-pasting prior notes forward. An extremely common albeit rarely problematic practice that is nevertheless lazy and underpoliced.
What? It's simple enough that it's taught to EMTs with ~160 hours of education (I'm a paramedic and EMS instructor and evaluator):
Temperature <96.8 or >100.4
Heart rate >90
Respiratory rate >20
WBC count > 12000
Add confirmed or suspected source of infection. Simplified, each additional match increases the suspicion.
The issue, as described later, is not that it's hard to spot, or the SIRS criteria tool didn't flag it, it's that the doctor didn't do their job or document correctly.
"VS were ordered and not taken"? What kind of ER is this?
My most recent septic patient had literally zero SIRS criteria, and I strongly did not suspect a bacterial source of infection. Isolated hypotension, nothing else. Said she felt great and asked to go home
To date she's grown out GPCs on 8/10 blood cultures.
Sepsis actually is hard.
Also, it sounds like a bacterial source was not suspected in this case (and was validated by the cultures being negative and the autopsy), so AFAICT this was not sepsis.
> Also, it sounds like a bacterial source was not suspected in this case (and was validated by the cultures being negative and the autopsy), so AFAICT this was not sepsis.
Am confused by this. Sepsis can be a response to bacterial, viral, or fungal infection, no?
Let's do a chronological analysis of some prior definitions of sepsis.
The first one, from the 1990s, utilized an elevated white blood cell count plus three clinical variables (temperature, heart rate, and respiratory rate). This definition is very broad; statistically speaking, it's very sensitive but has low specificity.
The most recent definition describes sepsis as 'life-threatening organ dysfunction caused by a dysregulated host response to infection.' Septic shock is defined as a subset of sepsis in patients who have a vasopressor requirement and a lactate level greater than 2 mmol/L.
Scores such as NEWS, SOFA, and qSOFA exist, but they primarily assess disease severity and prognosis for patients who are already in a hospital setting.
It is very important to always maintain a high degree of suspicion for sepsis, but it seems to me that few clinicians would have had a strong suspicion of it in this case...
You're right, and I should be more specific - what I referred to was things like SIRS, SOFA, and qSOFA (which was being introduced at the BLS level around here in 2022) for "suspicion scores".
But even then:
> but it seems to me that few clinicians would have had a strong suspicion of it in this case...
Tachycardic, febrile and with a suspected infection?
The issue here seemed to me to be two-fold, misdiagnosis of a viral infection versus bacterial, but in the setting of treating for a bacterial infection to then be consciously overlooking multiple markers for sepsis?
Hard disagree. The information system and its popup was vital information that the attending failed to act on. This anecdote serves as an example of user error and incompetence. And I’m a huge hater of popups.
Everything is optimized for corporations to make more money, to avoid liability and maximize the billable dollars. Doctors want to move meat as quick as possible, most consultations are a couple of minutes! Every doctor has to be part of this rat race because of how the system is designed!
"More than 200,000 people will die each year from preventable medical errors. He was shocked. Conservatively, these estimates amount to at least one fatal Boeing 747 crash per week."
"Doctors talk about electronic medical records as an unpleasant and frustrating chore. They object to how the charts have evolved to prioritize billing and liability defense over clinical care. And they regard the symphony of well-meaning alerts and pop-ups as a distraction at best."
"The check boxes and templates can aid efficiency, several doctors told me, but they also may distract physicians from the patients right in front of them."
I don't know a single doctor who wants this. Insurance companies want this. Don't blame healthcare workers for the hellish scenarios they are forced to work under.
Recently I got really, really sick. I was running a fever and bedridden for nearly a month straight. It got so bad one day that I ended up in two urgent cares and then they sent me onwards to the ER.
They were constantly taking my blood, constantly running tests, and in the end they basically just shrugged and said it was seemingly some random virus they didn't have a test for, nothing they could do. I heard some doctors talking outside my room about how unusual it was for me to be sick for as long as I had been, and they just seemed to brush it off and one said something like "well he's still fairly young, he'll probably get through it eventually."
They never figured out what it was, never were able to do anything to help me, just kind of shrugged, kept me overnight for more observation and then kicked me out the second the sun came out. My body and mind were absolutely shattered, especially after being woken up every 30min all night long for more blood draws, and I was told I could at least eat breakfast before I left, but they ended up reneging on this and kicking me out before breakfast time.
This was at a major hospital, a well ranked one, in a major city. The experience really opened my eyes.
I feel like the urge to fight, sue, and demand answers is the direct result of the constructive maliciousness of the medical environment, as orchestrated by the beancounters and provider/insurance bureaucracy. Let's say doctors had the bandwidth to not cut patient discussions short, not expect patients to need an adversarial "advocate", take the time to entertain unlikely hypotheses, monitor/admit for good faith investigative reasons rather than purely on liability rubric [0], etc. Then, when the doctors failed, you would feel that the failing was of a human group that earnestly did everything they could have. But the way the medical system has been whittled down into some bare bones bureaucratic assembly line, it makes it feel like every such failure is a willful and deliberate goal of the system. Why is the medical industry primarily focused on cost optimization through tightening the screws when they aren't even able to get the right answers?
[0] Like seriously I wish I could have given this kid one of the many weeks of observation that hospitals have given my paid-by-Medicare family members. The beds are available, they're just full of elderly people who had some acute problem but the hospital won't readily discharge them due to chronic medical conditions (plus they're messed up after being starved for a day in the ER).
We all want to uphold a system that limits medical school seats and won't create reliable immigration pathways for doctors to arrive here with just so doctors can maintain a specific salary. Then we'll go blame PE and consolidation and insurance or whatever.
If doctors don't have enough time, then there aren't enough doctors. Our population is aging rapidly and the need is increasing despite population growth metrics. If there are more doctors, they will need to need to spread further into regions where they're in demand.
This is a problem that we as voters should start to act upon.
Beyond the case itself, I'd hazard a sad guess that the only reason this made news is because the victim's father was a lawyer who wasn't forced to simply take the hospital president's platitude at face value (and who had the time, money, and energy to put his normal career on pause and enroll in a master's program just to investigate the issue). If that were my family, it would be "that's terrible" but no actual action, because my parents wouldn't be able to do anything about it, nor would I if something like this ever happened to my own future kids.
The ED is specifically attuned to these presentations but the sepsis alerts and algorithms in place are horrendous and will fire off even for this with viral illnesses and syndromes.
Sepsis alerts are meant to find bacteremia in patients who present with a set of vital signs and laboratory findings indicative of it and even those definitions are not readily agreed upon.
The ED is highly accurate with its diagnosis and treatments despite everything that has been said.
Trying to find a zebra in the hoof beats of horses when the number of patients quickly outstrips your department’s capabilities is a fools errand because if the workup require will overwhelm throughout to the point that the delay in care will put other patients at risk.
There is a fine line between doing enough and doing too much that will grind your department to a halt and then have your waiting room backing up.
Unfortunately for this patient, his occult condition didn’t manifest itself within his two ED visits and we don’t have prognostic capabilities to tell who will and won’t decompensate. We all make value judgements and treat the patients in front of us
> Trying to find a zebra in the hoof beats of horses when the number of patients quickly outstrips your department’s capabilities is a fools errand because if the workup require will overwhelm throughout to the point that the delay in care will put other patients at risk.
This is where that I hope (as a non-physician) that AI, used carefully, should actually be able to help. A well-designed ML system should have a decent chance at distinguishing a zebra from a horse because it has read absolutely everything, has perfect recall of that corpus, and has some ability to contextualize the knowledge it has to the situation at hand. I suspect that a good proportion of ER doctors already have those characteristics, but surely not all of them do, and surely not consistently.
An AI-assisted system will still false-positive, because the computer is still just a tool, tools are never perfect and designers of safety systems tend to err on the side of false positives. However, a thoughtful pop-up that displays when the situation really may warrant it is surely more helpful to a physician that one that cries wolf to you constantly?
My optimism assumes that there's fundamentally enough information available to make the diagnosis, however. If you're actually saying that finding the zebra would require gathering so much more information for each patient that it would lower overall outcomes for all patients, then I guess we're stuck.
There’s a thread about how emergency physicians are paid. It varies from group to group:
Physicians can be salaried and receive benefits from their group or hospital
Physicians can be 100% productivity based meaning that they will only get paid by the amount of patients they treat but they receive no other benefits from the group or hospital
In between these two groups, there is a wide variety of compensation Packages that are complicated to discuss in this comment.
Nonetheless, the overwriting factor for all emergency physicians is that we triage patients, not only after triage, but internally as well, including those patients at reside within the treatment rooms and those outside in the waiting room.
The question is, can we see less patients and spend more time with them and the answer is yes but to the detriment of the entire department and possibly not seeing a patient who is sick and who hasn’t been seen yet. Do you have to be able to tell who you can spend five minutes with and who needs 30 minutes.
Through put his king, but quality is queen, so there’s always a trade-off between seeing patients fast enough and to see enough patients through your shift, but to also how they were with all to determine which patients will require more time and more due diligence.
Every shift is a pull and push between these two dichotomies and it’s never easy and there are multiple decisions that have to be made.
71 comments
[ 4.4 ms ] story [ 106 ms ] threadI feel like scrutinizing the industry for a 2-3% error on an obviously difficult problem is exactly why we pay so much in the United States for health care.
I told her she might have a UTI. It was not normal for it to hurt that badly to pee. She denied it. I bought her a UTI test, it came out positive. She was shaking. I told her we had to go to the hospital, she thought they were period cramps.
I call a teledoc. They video chat. She explains the pain shes feeling in her lower back means it’s likely a UTI, the infection has likely reached her kidneys, and we should go to the ER immediately.
In the ER we think they’re going to just give her some antibiotics and send her home. Nope. She throws up. Things go bad fast. Her heart rate is 160. She turns a color I’ve never seen a human before.
The next 3 days were so incredibly hard. But I’m so thankful to all the medical workers that were attentive to us.
Thankfully she makes a full recovery. For a week or so she was lethargic/tired but she’s fully healthy now.
A few months before I had read a story about a woman who’s boyfriend had died from a UTI because they went to a gospital, gave him some antibiotics, and he ending up dying at home because the infection was already too progressed to fight off at home.
Had the person who evaluated my girlfriend not evaluated seriously or just sent her off that could’ve been her. I’m so thankful they admitted her and took her care seriously.
It’s scary how quickly a UTI or some other benign infection can become sepsis. Take it seriously.
This reminds me of the book The Checklist Manifesto by surgeon Atul Gawande. The book argues that aviation has achieved such a good safety record largely through the use of checklists, and Gawande describes his attempts to apply them to the field of medicine. Recommended. (Edit: I see that checklists are discussed later in the article; I would still recommend the book, as it has thoughts on how checklists can be applied more effectively.)
I'm like that and it sucks, I now bring my wife to medical appointments so she can complain for me while I downplay everything.
Next morning the pediatrician did his rounds, checked on my son, and immediately started speaking Latin, to go over our heads while rushing around and getting equipment to clear his lungs of amniotic fluid.
Reminds me of what my first engineering boss told me -- "When the people on the line say there is a problem. There is a problem."
- Lack of any low-intensity monitored recovery option. If the kid could just have been sent home to a traditional worrying mother, who'd been told to watch for certain warning signs - then he very likely would have lived.
- Critical shortages of front-line medical staff. (ER nurses especially noted here. But a dishonorable mention to the computer systems that the residents were fighting against.)
- However short our medical system might be on front-line resources to treat patients needing care - once it's lawsuit time, resources seem plentiful.
Trying to reframe it in a coding analogy, there were a few abnormal logs maybe an exception or two but the coder was unable to figure it out and these exceptions happen all the time and so pushed to live anyway. Due to resource allocation issues they were pulled to a different job. Then the site crashed. Just awful.
It is astounding how much more you can learn about your diagnosis from an LLM.
Ultimately the ER was of no use in treatment, but the preparation did help rule out a serious diagnosis.
An automated alert popped up warning that the doctors should consider Sepsis. That alert essentially then blocked progress, and the doctors ended up (essentially) ticking the 'not sepsis' box so that they could get on with their (reasonable) next step which was either ordering an x-ray or starting antibiotics. Then somehow after that, sepsis did not get re-considered.
https://archive.is/tJePt#selection-1465.0-1491.52
It was Banerjee’s task to document Sam’s care, and as he began to do so, a pop-up appeared on his computer screen. Sam’s fever and heart rate had triggered an automated warning for sepsis, a potentially life-threatening condition in which the immune system has a dangerous reaction to an infection. It requires speedy intervention. To help the hospital comply with state-mandated sepsis regulations, the pop-up provides a checklist of tests and orders used to identify and treat sepsis.
Agyare had instructed Banerjee to hydrate Sam right away but to wait for the results of Sam’s lab work before ordering a chest X-ray or the strong antibiotics used to treat sepsis.
But Banerjee, a novice, got stuck. He couldn’t figure out how to navigate the template to make some but not all of the auto-populated orders. “This was my first patient that triggered the sepsis pathway,” he explained, in testimony. So he asked Connor Welsh, a third-year resident, for help.
At 8:50 p.m., Welsh showed Banerjee how. From his own computer, he clicked into a field on Sam’s chart to assert that sepsis was not likely: “Based on my evaluation,” the automated note said, “this patient does not meet clinical criteria for bacterial sepsis.” And then Welsh recorded what Banerjee said Agyare had said earlier: “Likely viral syndrome. Workup pending.” Welsh’s name appears on the note, but in his deposition he said he never interacted with Sam. Senior residents often help junior ones in this way, he said. “I signed this note based on the discussion with the provider, Dr. Banerjee, based on his evaluation and the medical management of Mr. Terblanche,” he testified.
...
Sam’s chart is 51 pages long, a catalog of billing codes and abbreviations, check-boxes and shorthand, updates and addenda. The record of the second visit contains numerous contradictions: Sam’s heart rate was documented at 126, yet Banerjee clicked the box “normal.” In one place it says Sam didn’t have a cough, while in another it says he did. The signatures of doctors who testified they never saw Sam — including one who was not in the hospital that night — accompany notes. Vital signs were ordered and not taken, as was an EKG.
Man, I feel like I've been trying in vain to fight pop-ups for my whole software development career. Now we have an example where, at worst a pop-up got someone killed, and at best it was part of the chain of events that got someone killed. I don't know what it is that draws product designers to keep reaching for that horrible UX pattern, but it's got to be stopped. Nobody reads these things so a popup is the worst place to put important information that the user needs to read!
I think a lot of pop-up usage comes from company lawyers trying to cover butts: "Well, regulation says that users need to be informed of XYZ, so just stick a pop-up there. Then we can tell the regulator 'Hey at least we did our part to inform the user.'"
“”” Agyare had instructed Banerjee to hydrate Sam right away but to wait for the results of Sam’s lab work before ordering a chest X-ray or the strong antibiotics used to treat sepsis. “””
I'd bet 10 to 1 this is due to residents or fellows copy-pasting prior notes forward. An extremely common albeit rarely problematic practice that is nevertheless lazy and underpoliced.
What? It's simple enough that it's taught to EMTs with ~160 hours of education (I'm a paramedic and EMS instructor and evaluator):
Temperature <96.8 or >100.4
Heart rate >90
Respiratory rate >20
WBC count > 12000
Add confirmed or suspected source of infection. Simplified, each additional match increases the suspicion.
The issue, as described later, is not that it's hard to spot, or the SIRS criteria tool didn't flag it, it's that the doctor didn't do their job or document correctly.
"VS were ordered and not taken"? What kind of ER is this?
Am confused by this. Sepsis can be a response to bacterial, viral, or fungal infection, no?
Let's do a chronological analysis of some prior definitions of sepsis.
The first one, from the 1990s, utilized an elevated white blood cell count plus three clinical variables (temperature, heart rate, and respiratory rate). This definition is very broad; statistically speaking, it's very sensitive but has low specificity.
The most recent definition describes sepsis as 'life-threatening organ dysfunction caused by a dysregulated host response to infection.' Septic shock is defined as a subset of sepsis in patients who have a vasopressor requirement and a lactate level greater than 2 mmol/L.
Scores such as NEWS, SOFA, and qSOFA exist, but they primarily assess disease severity and prognosis for patients who are already in a hospital setting.
It is very important to always maintain a high degree of suspicion for sepsis, but it seems to me that few clinicians would have had a strong suspicion of it in this case...
But even then:
> but it seems to me that few clinicians would have had a strong suspicion of it in this case...
Tachycardic, febrile and with a suspected infection?
The issue here seemed to me to be two-fold, misdiagnosis of a viral infection versus bacterial, but in the setting of treating for a bacterial infection to then be consciously overlooking multiple markers for sepsis?
"More than 200,000 people will die each year from preventable medical errors. He was shocked. Conservatively, these estimates amount to at least one fatal Boeing 747 crash per week."
"Doctors talk about electronic medical records as an unpleasant and frustrating chore. They object to how the charts have evolved to prioritize billing and liability defense over clinical care. And they regard the symphony of well-meaning alerts and pop-ups as a distraction at best."
"The check boxes and templates can aid efficiency, several doctors told me, but they also may distract physicians from the patients right in front of them."
I don't know a single doctor who wants this. Insurance companies want this. Don't blame healthcare workers for the hellish scenarios they are forced to work under.
They were constantly taking my blood, constantly running tests, and in the end they basically just shrugged and said it was seemingly some random virus they didn't have a test for, nothing they could do. I heard some doctors talking outside my room about how unusual it was for me to be sick for as long as I had been, and they just seemed to brush it off and one said something like "well he's still fairly young, he'll probably get through it eventually."
They never figured out what it was, never were able to do anything to help me, just kind of shrugged, kept me overnight for more observation and then kicked me out the second the sun came out. My body and mind were absolutely shattered, especially after being woken up every 30min all night long for more blood draws, and I was told I could at least eat breakfast before I left, but they ended up reneging on this and kicking me out before breakfast time.
This was at a major hospital, a well ranked one, in a major city. The experience really opened my eyes.
[0] Like seriously I wish I could have given this kid one of the many weeks of observation that hospitals have given my paid-by-Medicare family members. The beds are available, they're just full of elderly people who had some acute problem but the hospital won't readily discharge them due to chronic medical conditions (plus they're messed up after being starved for a day in the ER).
The autopsy found pulmonary hemorrhage, enlarged heart, enlarged liver, damaged kidney.
If doctors don't have enough time, then there aren't enough doctors. Our population is aging rapidly and the need is increasing despite population growth metrics. If there are more doctors, they will need to need to spread further into regions where they're in demand.
This is a problem that we as voters should start to act upon.
Sepsis alerts are meant to find bacteremia in patients who present with a set of vital signs and laboratory findings indicative of it and even those definitions are not readily agreed upon.
The ED is highly accurate with its diagnosis and treatments despite everything that has been said.
Trying to find a zebra in the hoof beats of horses when the number of patients quickly outstrips your department’s capabilities is a fools errand because if the workup require will overwhelm throughout to the point that the delay in care will put other patients at risk.
There is a fine line between doing enough and doing too much that will grind your department to a halt and then have your waiting room backing up.
Unfortunately for this patient, his occult condition didn’t manifest itself within his two ED visits and we don’t have prognostic capabilities to tell who will and won’t decompensate. We all make value judgements and treat the patients in front of us
This is where that I hope (as a non-physician) that AI, used carefully, should actually be able to help. A well-designed ML system should have a decent chance at distinguishing a zebra from a horse because it has read absolutely everything, has perfect recall of that corpus, and has some ability to contextualize the knowledge it has to the situation at hand. I suspect that a good proportion of ER doctors already have those characteristics, but surely not all of them do, and surely not consistently.
An AI-assisted system will still false-positive, because the computer is still just a tool, tools are never perfect and designers of safety systems tend to err on the side of false positives. However, a thoughtful pop-up that displays when the situation really may warrant it is surely more helpful to a physician that one that cries wolf to you constantly?
My optimism assumes that there's fundamentally enough information available to make the diagnosis, however. If you're actually saying that finding the zebra would require gathering so much more information for each patient that it would lower overall outcomes for all patients, then I guess we're stuck.
Physicians can be salaried and receive benefits from their group or hospital
Physicians can be 100% productivity based meaning that they will only get paid by the amount of patients they treat but they receive no other benefits from the group or hospital
In between these two groups, there is a wide variety of compensation Packages that are complicated to discuss in this comment.
Nonetheless, the overwriting factor for all emergency physicians is that we triage patients, not only after triage, but internally as well, including those patients at reside within the treatment rooms and those outside in the waiting room.
The question is, can we see less patients and spend more time with them and the answer is yes but to the detriment of the entire department and possibly not seeing a patient who is sick and who hasn’t been seen yet. Do you have to be able to tell who you can spend five minutes with and who needs 30 minutes.
Through put his king, but quality is queen, so there’s always a trade-off between seeing patients fast enough and to see enough patients through your shift, but to also how they were with all to determine which patients will require more time and more due diligence.
Every shift is a pull and push between these two dichotomies and it’s never easy and there are multiple decisions that have to be made.