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Tuesday, May 22, 2018 at 1:29PM The Supreme Court ruled Monday (5/21/18) that companies can prohibit workers from using class-action litigation to resolve workplace disputes. In a 5-4 decision on three consolidated cases, the justices said companies can include clauses in employment contracts that require employees to use individual arbitration to resolve disputes.
Monday, April 30, 2018 at 8:00AM This past week the phrase “kiss up, kick down” was used to describe Ronny Jackson, then a nominee for the Secretary of Veterans Affairs (1). Wikipedia defines the phrase as “a neologism used to describe the situation where middle level employees in an organization are polite and flattering to superiors but abusive to subordinates” (2). Like most, I do not know Jackson and have no knowledge of the truth. However, the behavior attributed to Dr. Jackson is pervasive and harmful in medicine.
Kiss up, kick down is part of a blame culture. McLendon and Weinberg, see the flow of blame in an organization as one of the most important indicators of organization robustness and integrity (3). They argue that blame flowing upwards in a hierarchy proves that management can take responsibility for their orders and supply the resources required to do a job. However, blame flowing downwards, from management to staff, or laterally between professionals, indicate organizational failure. In a blame culture, problem-solving is replaced by blame-avoidance. Weinberg emphasizes that blame coming from the top generates "fear, malaise, errors, accidents, and passive-aggressive responses from the bottom", with those at the bottom feeling powerless and lacking emotional safety (4).
Calum Paton, Professor of Health Policy at Keele University, describes kiss up kick down as a prevalent feature of the UK National Health Service culture. He raised this point when giving evidence at the public inquiry into concerns of poor care and high mortality at Stafford Hospital in England (5). According to Paton, credit was centralized and blame devolved or transferred to a lower level. "Kiss up kick down means that your middle level people will kiss-up, they will please their masters, political or otherwise, and they will kick down to blame somebody else when things go wrong."
The VA scheduling scandal is a similar American example where management failed to provide the number of providers necessary to care for the patients. When caught, management attempted to blame the physicians (6). This is hardly surprising given that the physicians are often leaderless without anyone to speak for them. Too often physician leaders are not chosen from the best and brightest to protect the best interests of the patient and staff. Rather they are selected because they are the most compliant with management (kiss up).
Physicians near the top of a hierarchy are usually administrators peripherally involved in patient care. They may not always act with the best interests of the patient and staff but with what is best for their bosses and themselves as both the Stafford and VA examples illustrate. As such, they can be expected to “roll over on anyone” (kick down), a phrase used to describe Dr. Jackson (1). Furthermore, their practice skills may be weak or outdated making them particularly dangerous to the organization.
Physicians who put patient needs first often find themselves at odds with what is best for management. It may be time to reconsider how physician leaders are chosen. The medical staff is probably in the best position to judge which physicians are the best physician leaders rather than the obsequious leaders often chosen by management (7). If the medical staff chosen physician leader can work with management, the organization will have a dyad leadership. If not, then the physician leaders with the support of the staff can oppose those policies deemed harmful to patients or the organization.
Richard A. Robbins, MD
Editor, SWJPCC
References
Cite as: Robbins RA. Kiss up, kick down in medicine. Southwest J Pulm Crit Care. 2018;16(4):230-1. doi: https://doi.org/10.13175/swjpcc060-18 PDF
Saturday, March 31, 2018 at 8:00AM David Shulkin MD, Secretary for Veterans Affairs (VA), was finally fired by President Donald Trump ending long speculation (1). Trump nominated his personal physician, Ronny Jackson MD, to fill Shulkin’s post. The day after his firing, Shulkin criticized his firing in a NY Times op-ed claiming pro-privatization factions within the Trump administration led to his ouster (2). “They saw me as an obstacle to privatization who had to be removed,” Dr. Shulkin wrote. “That is because I am convinced that privatization is a political issue aimed at rewarding select people and companies with profits, even if it undermines care for veterans.”
Former Secretary Shulkin’s tenure at the VA has had several controversies. First, as undersecretary of Veterans Healthcare and later as secretary money appropriated to the VA to obtain private care under the Veterans Access, Choice, and Accountability Acts of 2014 and the VA Choice and Quality Employment Act of 2017 appears to have been largely squandered on administrative salaries and expenses rather than hiring healthcare providers to shorten VA wait times (3). Second, Shulkin took a trip with his wife to Europe eventually ending up at Wimbledon to watch tennis (4). The purpose of his trip was ostensibly to attend a London Summit with senior officials from the United States, the United Kingdom, Canada, Australia, and New Zealand to discuss topical issues related to veterans. Although the summit occurred over 2 1/2 days, Shulkin and his wife traveled for 11 days at the taxpayer expense including a side trip to Denmark.
“The private sector, already struggling to provide adequate access to care in many communities, is ill-prepared to handle the number and complexity of patients that would come from closing or downsizing V.A. hospitals and clinics, particularly when it involves the mental health needs of people scarred by the horrors of war,” Dr. Shulkin wrote (2). “Working with community providers to adequately ensure that veterans’ needs are met is a good practice. But privatization leading to the dismantling of the department’s extensive health care system is a terrible idea.” Going on Shulkin states that, “Unfortunately, the department [VA] has become entangled in a brutal power struggle, with some political appointees choosing to promote their agendas instead of what’s best for veterans … These individuals, who seek to privatize veteran health care as an alternative to government-run VA care, unfortunately fail to engage in realistic plans regarding who will care for the more than 9 million veterans who rely on the department for life-sustaining care.”
However, the VA for many years has engaged in a relentless expansion of administration at the expense of healthcare. In the absence of sufficient oversight, Shulkin and VA Central Office did little to curb this trend (3).
Assuming he is confirmed, what will Ronny Jackson, Shulkin’s replacement, do? It seems likely that he will do exactly what Shulkin alleges and Trump apparently wants, i.e., privatize VA healthcare. Whether Jackson will be able to bend the large VA bureaucracy towards privatization is another matter given his lack of healthcare administrative experience. Shulkin may also be right that privatization may only reward select people and companies with profits rather than improving veterans’ care. Regardless, healthcare is more expensive than not delivering healthcare, so the price will probably rise. Time will tell, but something needs to be done. To paraphrase former VA undersecretary Ken Kizer, it is time for another “Prescription for Change” at the VA.
Richard A. Robbins, MD*
Editor, SWJPCC
References
*Dr. Robbins has received compensation for providing healthcare to veterans under the VA Choice Act.
Cite as: Robbins RA. What does Shulkin's firing mean for the VA? Southwest J Pulm Crit Care. 2018;16(3):172-3. doi: https://doi.org/10.13175/swjpcc052-18 PDF
Tuesday, March 6, 2018 at 8:00PM Within the past year two tragic events, the shootings in Las Vegas and Florida have renewed the debate about guns. The politics and the money that fuels the political debate have sharply divided politicians. As tragic as these mass shootings are, deaths by suicide far outnumber the loss of live in these shootings. In 2014 suicide was the tenth most common cause of death with 42,826 lives lost (1). Half of the suicides were by firearm (21,386).
The medical profession has traditionally been reluctant to speak about politically sensitive issues such as abortion, sexuality, and guns. However, beginning early in this millennium some medical societies such as the American Academy of Pediatrics, the US Preventative Services Task Force and even the Department of Veterans Affairs were suggesting physicians ask patients about gun behavior, but a few patients complained (2-5). There were some anecdotal reports of patients feeling “pressured” to answer questions about guns (5). One grumbled that it was invasion of privacy. The National Rifle Association also viewed the medical community’s gun-related questions as discriminatory and a form of harassment. In 2011, the Republican-controlled Florida legislature, with the support of the then and still state’s Republican governor, Rick Scott, passed restrictions aimed at limiting physician inquiries about gun ownership and gun habits. Under the law, doctors could lose their licenses or risk large fines for asking patients or their families about gun ownership and gun habits. Fortunately, this law was struck down by the 11th U.S. Circuit Court of Appeals (5). The Court ruled in 10-1 decision that the law violated the First Amendment rights of doctors and did nothing to infringe on the Second Amendment right to bear arms.
Eight health professional organizations and the American Bar Association have released a call for action to reduce firearm-related injury and death in the United States (6). Specific recommendations include the following:
Our national professional societies including the American Thoracic Society, the American College of Chest Physicians and the Society of Critical Care Medicine have all endorsed this call for action to gun violence (7).
Editors of the Annals of Internal Medicine have recently urged physicians to sign a formal pledge committing to having conversations with their patients about firearms (8). The Annals campaign began in the wake of the Las Vegas shooting and gained momentum after the February 14 school shooting in Parkland, Florida. So far nearly 1000 physicians have signed the pledge (9).
People who commit firearm violence against themselves or others often have notable risk factors that bring them into contact with physicians. We in the pulmonary, critical care and sleep communities are positioned to prevent some of these deaths. Patients with chronic diseases including COPD and sleep deprivation are known to be at higher risks for suicide (10,11). By inquiring about guns during these patients’ clinic visits, we may be able to identify potential problems and prevent some deaths.
It is ironic, but hardly surprising, that Florida, a state known for a series of gun-rights laws and its “Stand Your Ground” self-defense law (5), is the site of the latest mass shooting. The shooter, Nikolas Cruz, by all descriptions could have readily been recognized as a potential threat. Perhaps if he had been identified and an intervention performed before the Florida law banning physicians from discussing guns when the he was 12, a tragedy could have been avoided. As Florida Sen. Marco Rubio recently found out, the times may be changing (12). Politicians should keep their politics out of the clinic, hospital and physician-patient relationship. Those who do not, and especially those who by their actions put our patients in peril, do so at their own political risk.
Richard A. Robbins, MD
Editor, SWJPCC
References
Cite as: Robbins RA. Guns, suicide, COPD and sleep. Southwest J Pulm Crit Care. 2018;16(3):138-40. doi: https://doi.org/10.13175/swjpcc039-18 PDF
COPD, Florida, death, deprivation, firearms, guns, politics, sleep, sleep apnea, suicide Sunday, February 25, 2018 at 8:00AM Intubation is one of, and perhaps the, highest risk procedures a critically ill patient can require, and the practice has largely been extrapolated from knowledge gained from airway management in the operating room (OR). Trouble arises when one encounters challenges with placing the tube or performing mask ventilation, termed the ‘difficult airway’. The difficult airway in the OR is relatively rare yet can be catastrophic when it is encountered unexpectedly. As a result, significant resources are devoted to developing task forces, guidelines, new devices and airway adjuncts to help manage the difficult airway and prevent avoidable complications. Outside of the OR, the difficult airway is encountered more frequently and with potentially devastating consequences. Reflexively, it is easy to blame the increased incidence on the skill of those managing airways as airway management has historically been viewed as a laryngoscopy problem--difficulty for us is the source of risk for the patient. Many facilities relegate airway management to an on-call anesthesiologist, leading to a significant variability in training and skill in airway management; and physicians skilled in life support but cannot safely put their patients on life support. Newer devices have led to a significant reduction in the difficulty with laryngoscopy, and it is becoming increasing clear to us that the terminology related to airway management outside of the OR should be reconsidered. Airway management outside of the OR commonly starts with the difficult airway because of the severely altered physiology, thus the importance of first-attempt success. Our current definition of the difficult airway lacks complete appreciation of the risks in these patients by focusing on the difficulty with laryngoscopy for the operator. For airway management of critically ill patients outside of the OR to positively impact patient outcomes, we must broaden our understanding of the risks associated with intubation.
There is no doubt that the difficulty one experiences in performing mask ventilation, laryngoscopy or tracheal intubation puts the patient at risk of untoward complications. However, limiting the focus to this traditional definition neglects the danger to the patient, which can occur in the absence of any technical difficulties. There is a strong association in the published literature between the number of intubation attempts and procedural complications (1-3), however there is also a significant risk of complications despite successful first-attempt tracheal intubation (i.e., no difficulty) (3). Thus, skillfully performing laryngoscopy and tracheal intubation that succeeds easily on the first attempt in a patient with physiologic derangements presents significant danger with airway management. This derangement may relate to a host of physiologic or pathologic issues and the resulting danger to the patient often relates to the consequences of hypoxemia or hypotension. To reduce the danger to the patient, careful attention is required to prepare the patient for induction, laryngoscopy and transition to positive pressure ventilation with emphasis on preoxygenation, maintenance of oxygenation and hemodynamic optimization.
Patients may face danger in any of the three phases of airway management: preparation and planning, implementation of the plan, or post-intubation management. Each phase presents both patient and contextual factors that accumulates and potentially compounds danger. Incomplete preparation, prolonged attempts at tracheal tube placement, disturbed physiology, an unskilled operator in a familiar environment or a skilled operator in an unfamiliar environment all contribute to different phenotypes of complications. All can lead to different phenotypes of complications. Contextual factors include issues such as provider skill, access to equipment and help, various biases and conditions that in part are defined as human factors and are well-known to influence patient outcomes. To help mitigate technical difficulty experienced by the clinician and danger to the patient, special attention must be paid to each phase of airway management.
There are three phenotypes of complications that can arise from tracheal intubation. While the incidence of complications increases with successive attempts, the etiology and opportunity to attenuate those complications differs (Figure 1).
Figure 1. Studies outside of the OR show increased complications with successive attempts, with 10-20% for first attempt, 40-60% for second attempt, etc. However, different phenotypes of complications likely contribute differently at each point during airway management and thus provide various clinical and research targets. Incomplete or inadequate preparation or planning results in avoidable intubation-related complications because of early depletion of oxygen reserve, leading to aborted attempts or adverse events earlier than expected (Green bars). Complications that occur due to difficulty with laryngoscopy, tube placement, or mask ventilation despite pre-intubation optimization and preparation increase with successive attempts (Red bars). This is the traditional “difficult airway.” Complications that occur because of altered physiology likely contribute to the majority of complications with 1 or 2 attempts. These patients are so physiologically disturbed (e.g., hypoxemic respiratory failure, RV failure, tamponade), that they are intolerant of any attempt, any apnea, or the transition to positive pressure ventilation. These are the patients that when they degenerate into cardiac arrest despite first attempt success, we tell ourselves that they were just really sick and there’s nothing we could have done.
Complications can arise from inadequate preparation such as preoxygenation, improper positioning or an incomplete plan. Other complications arise from true difficulty with laryngoscopy, tube placement, or mask ventilation despite adequate preparation. With both of these types of complications, repeated attempts can lead to airway injury and edema that can precipitate a can’t-intubate can’t oxygenate scenario, but also the risk is from an association with the depletion of oxygen reserve, hemodynamic consequences of hypoventilation, or aspiration of gastric contents leading to critical hypoxemia. It is this latter association that should be eliminated with an increased focus on danger. Some patients have physiologic challenges that increase the risk of complications with any attempt (i.e. the “physiologically” difficult airway). These disturbances can be so severe that despite optimal preparation, risk cannot be completely obviated. By better understanding the danger presented by these three phenotypes, there is potential to clinically and scientifically approach airway management in critically ill patients that we have not considered historically. To date, we have typically focused efforts on preventing complications related to difficult laryngoscopy, yet the most significant danger likely comes from incomplete preparation and unfriendly physiology.
Continuing to use the ‘difficult airway’ nomenclature in the critically ill patient risks confusion and undue variability without addressing the overall danger. For example, does anticipating difficulty and altering the plan, which then results in no difficulty being encountered during the intubation qualify as a difficult airway? Should one write a note in the chart, register the patient with a database, and send the patient a letter notifying them of the difficult airway they were predicted to have, but yet did not have? This presents a Schrödinger’s cat paradox in that the airway is both difficult and not difficult at the same time. From a research perspective, the term ‘difficult airway’ can be fraught with ambiguity or error. Studies comparing devices, techniques, or methods often focus either on the anticipated difficult airway, which is poorly predicted, deliberately exclude difficult airway patients, or isolate one aspect while ignoring the others (e.g. apneic oxygenation while ignoring preoxygenation) (4-11). Conversely, focusing on laryngoscopy-related complications ignores significant danger in airway management from incomplete preparation and difficult physiology-related complications, especially considering most patients are intubated in the first two attempts. We should refocus our energies on mitigating the danger by optimizing the pre- and peri-intubation process. Research should focus on how to best reduce complications associated with multiple attempts and disturbed physiology, and eliminate complications related to poor preparation altogether. These efforts will elevate our expertise in placing patients on life support to the level our patients deserve.
Jarrod M Mosier, MD1,2,; George Kovacs, MD3; J. Adam Law, MD4; John C Sakles, MD1
1Department of Emergency Medicine, University of Arizona. 1609 N. Warren Ave, Tucson, AZ 85724
2Division of Pulmonary, Allergy, Critical Care, and Sleep. Department of Medicine, University of Arizona. 1501 N Campbell Ave, Tucson, AZ 85721
3 Departments of Emergency Medicine, Anaesthesia, Medical Neuroscience, Dalhousie University, Halifax, NS B3H 3A7
4 Departments of Anesthesiology and Emergency Medicine, Dalhousie University, Halifax, NS B3H 3A7
References
Cite as: Mosier JM, Kovacs G, Law JA, Sakles JC. The dangerous airway: reframing airway management in the critically ill. Southwest J Pulm Crit Care. 2018;16(2):99-102. doi: https://doi.org/10.13175/swjpcc004-18 PDF