It was just one of those stupid things. I was cutting the stems off of flowers, not really paying attention, and somehow managed to snip my knuckle along with the stems. The blood began to spew.

I’m not one to panic. I calmly reached for some dish towels and applied pressure, then ran the gash under cold water. A red river flooded the sink. The dish towels soaked through, so I switched to bath towels. Finally, it dawned on me that the bleeding was not just going to stop and I might need some stitches.

I live right near the Longwood Medical Area, but theorized that if I went to one of the major hospitals down the street, I’d be in competition with people needing face transplants and end up waiting 12 hours. I recalled passing a billboard for Saint Elizabeth’s in Brighton advertising how quick the waiting times were in its Emergency Department — under 20 minutes, if memory served. So I wrapped my bloodied hand in Bounty and a fresh bath towel, and drove 15 minutes or so to St. E’s. The posted wait time on the billboard as I passed was 19 minutes.

At the hospital, I left my car with the valet, ran in to the emergency room, walked up to the desk and handed the receptionist my driver’s license for identification. She asked me what had happened and I told her, then I sat down in the waiting room and struck up a conversation with a very terrified 7-year-old who had just taken a tumble on the playground. We compared boo-boos.

About half an hour later, a nurse brought me in to an exam room, took my temperature and blood pressure, and asked me to unwrap my hand. After he had a look at the gash, he handed me some fresh gauze wrapping and sent me back to wait. About half an hour after that, I was taken to another exam room where another nurse looked at my wound, then gave me more gauze and some paperwork to fill out.

“What’s up with that billboard sign?” I asked her. “I thought I was going to be seen within 19 minutes.”

She rolled her eyes and said, “Tell me about it. We get that all the time. It just means that you’re going to get to the receptionist by then. Why don’t you call and tell the marketing people that it’s not true?”

Another half hour after that — so roughly 90 minutes in all after I arrived — a nurse practitioner fixed up my finger.

Everyone was nice. Everyone seemed to know what they were doing. It still was probably faster than if I’d gone to one of the hospitals down the street from my home. But that’s not why I went there. I did get good care, but it strikes me that there’s something missing here — like truth in advertising. I’m left with the feeling that they got me there under false pretenses.

Chris Murphy, spokesman for Steward Health Care System, which includes Saint E’s, responds:

The ED wait time billboard at Saint Elizabeth’s measures a patient’s “door to room” time. That means it represents the time it will take for you to register, be triaged and put in a treatment room. This is a standard measure for hospital emergency departments. The wait time is calculated with data from the hospital’s IT system and tracks patients that have registered for treatment and are in the process of being treated. It updates every fifteen minutes, but if there is a sudden influx of patients it can take some time for the system to catch up. Also, patient acuity plays a major role in treatment time. As you would imagine, doctors and other clinicians treat patients with the highest acuity first. Someone that is showing signs of a heart attack, stroke, severe physical trauma, respiratory distress etc., will be treated by a clinician before someone with a cut on their finger.

Point taken. Also, Saint Elizabeth’s is far from the only hospital to advertise brief waiting times. It has become a common hospital practice lately. Newton-Wellesley does it. Metro West. Many area hospitals include waiting times on their websites.

And perhaps for the hospitals, it makes sense to measure and advertise the “door to room” time. But for all the rest of us who live in real time, it may be good to know: Nineteen minutes doesn’t really mean 19 minutes.

Karen Shiffman is the executive producer of WBUR’s On Point with Tom Ashbrook. She would like to thank CommonHealth’s Carey Goldberg for typing this up for her.

In the medical world, the Boston Marathon has been known for years as a planned disaster, one of the largest planned mass casualties in the country.

Hundreds, sometimes thousands, of runners are treated every year by more than 1,000 doctors, nurses and other medical personnel who volunteer on race day.  Planning begins months before the marathons with doctors and nurses in charge of medical records, equipment, ambulances, water, short term triage, runner-family relations and a half dozen other specific tasks. Federal DMAT or Disaster Medical Assistance Teams are positioned along the route.  Tents at the finish line look like MASH units, with IVs dangling from dozens of cots.

“The marathon is a tremendous opportunity to test the plans that we (Boston) would use in an unplanned casualty event,” said Mary Clark, the director of emergency preparedness at the Department of Public told me in 2009 for a story on marathon medical preparations.

But suddenly, last week, what was supposed to be a test turned into the real thing.

The monumental race that has become the model for Boston’s response to a disaster was, itself, attacked. And, though no one ever intended it this way, it turned into an acclaimed validation of the city’s mass-casualty preparations.

Three spectators died at the scene: 23-year old Lu Lingzi, 29-year-old Krystal Campbell and 8 year-old Martin Richard, whose funeral was today.  But so far, all 55 patients taken to area hospitals with urgent or life-threatening injuries have survived; 15 have had amputations of one or both legs.

Praise for Boston’s medical response continues to pour in.

“Boston has set an excellent example that response efficacy and strength is built on planning and preparation. Emergency systems everywhere should aspire to be Boston strong,” says The Lancet in an editorial published online today.

Doctors, nurses and EMTs on Bolyston St. pulled off their belts or torn strips of cloth to stop the flow of blood from feet and legs. In hospitals, all available personnel ran to emergency rooms.

But in the marathon medical tent, despite careful planning and years of experience, many volunteers did not feel qualified to handle injured patients coming in off the street. Dr. Sushrut Jangi, writing in the New England Journal of Medicine, saw shredded arteries, veins, ragged tissue and muscle.

More victims followed: someone whose legs had been charred black, another man with a foot full of metal shrapnel, a third with white bone shining through the thigh. I watched in shock as the victims were rushed down the center aisle to ambulances at the far end of the tent. Many of us barely laid our hands on anyone. We had no trauma surgeons or supplies of blood products; tourniquets had already been applied; CPR had already been performed. Though some patients required bandages, sutures, and dressings, many of us watched these passing victims in a kind of idle horror, with no idea how to help.

“You try to tell yourself that is an opportunity to learn,” says Boston EMS Chief James Hooley, his voice trailing off.

Hooley says Boston had a lot of factors in its favor in addition to planning.  The marathon is run on a holiday so hospitals had more operating rooms open than they would during a regular business day.  There are six level one trauma centers within a few miles of the explosions.  Marathon planning includes police and firefighters who rushed to assist victims on Boylston St.

“It’s horrible beyond belief, but where it happened and the day it happened did lend us the best opportunity for good outcomes for people,” says Hooley. “That’s hard now for someone who’s maimed for life,” he continues, “and we have to be concerned about how we support those folks and those families going forward.”

“Boston Strong” is the rallying cry for victims and supporters recovering from the marathon bombings.  In the medical world, many doctors, nurses and EMTs are adding,”Boston Ready.”

With spiffy graphics from The South End Patch here’s a ranking of how long, on average, you’ll wait in the ER (based on new data from the Centers for Medicare and Medicaid); how long it will take before you’re admitted to the hospital and several other important measures:

At the South End’s Boston Medical Center, the average time patients spent in the emergency department before they were seen by a healthcare professional was 18 minutes, which is much quicker than the state and national averages of 40 and 30 minutes, but longer than the wait at Mass. General, which is 10 minutes.

Of those patients, the average time patients spent in the BMC emergency department before being sent home was 181 minutes, compared to the state average of 152 minutes and the national average of 140 minutes.

Finally, the average time patients spent in the BMC emergency department, before they were admitted to the hospital as an inpatient was 280 minutes, compared to the state average of 311 minutes and the national average of 277 minutes.

Waiting around for emergency care has got to be one of the more stressful activities in life. And as we’ve reported earlier in a somewhat related post, if the ER is particularly crowded, things can turn even more dangerous.

A recent report published online in the Annals of Emergency Medicine found that “patients admitted to the hospital from the emergency department during periods of high crowding died more often than similar patients admitted to the same hospital when the emergency department was less crowded.”

A new report published online in the Annals of Emergency Medicine found that “patients admitted to the hospital from the emergency department during periods of high crowding died more often than similar patients admitted to the same hospital when the emergency department was less crowded.”

A crowded ER, it turns out, was also associated with longer hospital stays and slightly higher costs, the study found.

Why might this be? The authors suggest a few reasons:

ED crowding may reduce access through prolonged waiting times or through increased time to care as a result of longer ambulance transport after diversion…A large literature has demonstrated the negative effect of ED crowding on throughput, including delays in the treatment of myocardial infarction, pneumonia, and painful conditions. Finally, output focuses on the transfer or discharge of patients from the ED. A common barrier to output is high inpatient occupancy, resulting in patients boarding in the ED while waiting for an available hospital bed. Prolonged boarding times may delay definitive testing and increase short-term mortality, length of stay, and associated costs. Continuity of care in the ED may be compromised by frequent nursing and physician shift changes, and ED priority on evaluating new patients may divert attention from ongoing care of boarded patients.

Here’s more from the news release:

“ER crowding is dangerous,” said lead study author Benjamin Sun, MD, MPP, of Oregon Health & Science University in Portland. “We looked at nearly a million admissions through emergency departments across California, a large number of patients. Crowding was associated with 5 percent greater odds of inpatient death.”

Researchers analyzed 995,379 emergency department visits resulting in admission to 187 hospitals. Daily ambulance diversion – the practice of closing an ER to ambulances because it is too crowded to accept new patients – was the measure of emergency department crowding. Admission to the hospital from the ER on days with prolonged ambulance diversion (a median of 7 hours) – or high emergency department crowding – was associated with 5 percent increased odds of dying in the hospital compared to admissions on days with low ambulance diversion (a median of 0 hours).

Patients who were admitted on days with high emergency department crowding had 0.8 percent longer hospital stays and 1 percent increased costs per admission. Periods of high emergency department crowding were associated with 300 excess inpatient deaths, 6,200 hospital days and $17 million in costs.

“Emergency department crowding is likely to become worse in the future because of the volume, complexity and acuity of emergency patients,” said Dr. Sun. “Policymakers should address ER crowding as an important public health priority.”

The study was supported by the Agency for Healthcare Research and Quality and the Emergency Medicine Foundation.

Reuters reports here:

Manhattan doctor Lucy Doyle has done stints with the global medical relief organization Doctors Without Borders in the Democratic Republic of Congo and Kenya. But her latest assignment is a real eye-opener: New York City.

In the wake of Superstorm Sandy, Doctors Without Borders has set up its first-ever medical clinic in the United States, and Doyle finds herself on the front line of disaster just miles from her day job.

“A lot of us have said it feels a lot like being in the field in a foreign country,” said Doyle, who specializes in internal medicine at New York’s Bellevue Hospital, now closed by Sandy’s damage.

A week after Sandy swept through New York City, knocking out power and public transportation for days, Doctors Without Borders established temporary emergency clinics in the Rockaways – a remote part of Queens that faces the Atlantic Ocean – to tend to residents of high-rises that still lacked power and heat and had been left isolated by the storm.

“I don’t think any of us expected to see this level of lacking access to healthcare,” said Doyle.

Read the full story for vivid descriptions of patients’ predicaments. Can it happen here? Oh, yes.

Hat-tip to On Point’s Karen Shiffman.
 

If you, like so many of us, have a little magnet on your fridge displaying the number of the Poison Control Center, you probably think of it as an emergency aid for when projectile vomiting hits — not as a money-saver.

But the American Association of Poison Control Centers – hit hard recently by federal budget cuts — has just released a calculation that the poison center system saves the country $1.8 billion a year in health costs and lost productivity.

Something to think about, in this season of drug lab scandals and tainted injections that additional investment in public health might have helped avert. The report calculates that the funding for poison control centers costs each American resident 43 cents a year. Rarely am I as happy to spend a few cents. It’s an American-Express-ad type of thing: The ability to know exactly what number to call when your toddler has just eaten a bunch of aspirin? Priceless.

From the press release:

ALEXANDRIA, VA – A report released today confirms the value of the American poison center system, indicating that poison centers save Americans more than $1.8 billion every year in medical costs and lost productivity, according to Rick Dart, M.D., Ph.D, past-president of the American Association of Poison Control Centers (AAPCC)…

The Lewin Group’s analysis included the four most commonly referenced savings metrics (savings due to avoided medical utilization, reduced hospital length of stay, in-person outreach, and reduced work-loss days).

“Even though poison centers save countless lives and more than a billion dollars each year, America’s 57 poison centers suffered a federal funding cut of 36 percent in 2011, as well as cuts in state and local funding,” Dart said. “Further reductions in funding will make it difficult for poison centers to continue to provide life-saving services. This important report shows the value poison centers bring to the nation’s health care system.”

This just in from the American College of Emergency Physicians: a study led by Massachusetts General Hospital that offers some numbers to quantify the worsening problem of psychiatric patients waiting long hours in emergency rooms — significantly longer hours than other patients.

The study included five hospitals in the greater Boston area, two academic medical centers and three community hospitals; it does not name them explicitly.

WASHINGTON—Patients having psychiatric emergencies wait 11.5 hours in the emergency department, and those who are older, uninsured or intoxicated wait even longer, according to a study published online yesterday in Annals of Emergency Medicine (“Patient and Practice-Related Determinants of Emergency Department Length of Stay for Patients with Psychiatric Illness”). Overall, these patients wait approximately 42 percent longer in the ER than other emergency patients.

“Although we did not see differences between patients who were publicly and privately insured, patients without insurance spent four more hours in the ER than these other groups,” said lead study author Anthony Weiss, MD, MBA, of Massachusetts General Hospital in Boston, Mass. “These patients are waiting the longest for care, and shrinking resources are having a disproportionate effect on these very vulnerable people.”

Researchers analyzed records for 1,092 adults with psychiatric emergencies. Patients discharged home spent an average of 8.6 hours in the emergency department, while patients admitted to a psychiatric unit within the hospital stayed 11 hours. Patients transferred to an outside unit within the local health care system stayed 12.9 hours and those transferred to a facility outside the local health care system stayed 15 hours.

Younger patients waited less than older patients: in the 18 to 39-year-old group, the average length of stay was 10.7 hours, but patients older than 60 spent 12.6 hours in the emergency department. One-third of the patients tested positive for alcohol and these patients had average stays in the emergency department of 14.5 hours.

“Between 2000 and 2007, psychiatric visits to ERs grew by 231 percent,” said Dr. Weiss. “This increase in volume, when combined with fewer resources outside the ER, have led to a real crisis for this population. Long waits for care aren’t good for anyone but they are especially harmful to patients in psychiatric distress.”

Readers, what’s your experience? Longer? Shorter? Different?

The economist, Joseph Doyle, of MIT’s Sloan School of Management found that an increase of about $4,000 per patient in hospital spending led to a 1.4 percent decrease in the mortality rate. “The high spending hospitals in areas in Florida have lower mortality in what I consider comparable patients,” he said.

It might seem intuitive that investment in emergency care yields better health outcomes, but it’s a topic of hot debate, Doyle notes. (Think Atul Gawande in The New Yorker, and his pivotal piece on McAllen, Texas, which found that greater spending in various regions of the country doesn’t necessarily lead to better health.)

Doyle said that by studying ER visits by patients in Florida from out-of-town, you can reduce substantially the confounding factor of local patient variation that might otherwise occur. In his study, published in the American Economic Journal: Applied Economics, and condensed here by the MIT News office, Doyle looked at patient discharge data from nearly 37,000 hospitalizations between 1996-2003:

Doyle analyzed the patient data by ZIP code, age and even seasonality of visit to make sure that he was studying demographically similar tourists being treated throughout Florida.

Moreover, Doyle notes, Florida has significant “variation in how areas treat patients after heart attacks. Florida looks like a microcosm of the U.S., with high-spending and low-spending areas. And the per-capita income of an area is not correlated very well with [hospital] spending.” In Fort Lauderdale, for example, hospitals spend 30 percent more on heart patients than they do in nearby, affluent West Palm Beach.

Therefore, the variation in results that Doyle found does not stem from the prior health of patients, but from the level of care itself. Specifically, the greater expenses — and benefits — in heart treatment seem to come from a broader application of intensive-care-unit (ICU) tools and having more medical personnel on hand…

Overall, a 50 percent increase in what Doyle calls a hospital’s “spending intensity” allows it to reduce mortality rates due to heart problems to about 26 percent below the mean.

Interestingly, in Miami, one of the most expensive regions in the country, some hospitals, but not all, showed better survival. “I would expect some diminishing returns on spending,” Doyle said. “Some hospitals spend money wisely and some don’t,” he added. “The trick is to figure out which is the wise spending.”

Preliminary data:
-Emergency department visits for approximately 60,000 Boston residents enrolled in Neighborhood Health Plan decreased overall by 20 percent between 2008 and 2010. More specifically, of those residents who are Commonwealth Care members the decline in ER visits fell 57 percent. This drop is striking as it demonstrates how effectively patient behavior can be impacted, particularly among those with previously limited access to the primary care system.

-Aggressive disease management programs targeting high-cost patients with chronic illnesses like diabetes improve health and keep care in lower-cost settings:
Patients enrolled in Lynn Community Health Center’s diabetes management program between 2008 and 2010 achieved a 21 percent drop in blood sugar levels. The program places intense focus on prevention screenings and self-management of the disease with the help of a team of nurse case managers and community health workers.

-Hypertensive patients receiving care at Neponset Health Center in Dorchester between 2008 and 2010, 14 percent saw an improvement in blood pressure readings. According to the US Centers for Disease Control and Prevention, as many as 29 percent of US adults have high blood pressure (an indicator of hypertension) and less than a third of them have it under control. As little as a 12 to 13 point reduction in blood pressure in the population could reduce heart attacks by 20 percent, strokes by 37 percent and deaths from all cardiovascular diseases by 25 percent. Overall, the combined cost to employers from diminished productivity as a result of three obesity-related health conditions (hypertension, heart disease and diabetes) is estimated at $1,018 per employee per year.

The piece cited this study — the first-ever comprehensive analysis of medical emergencies related to snow shoveling from 1990 to 2006 and published in the American Journal of Emergency Medicine — which found that: “U.S. hospitals treat on average about 11,500 injuries and medical emergencies a year related to shoveling snow.” Moreover, shoveling:

…places extraordinary demands on the cardiovascular system and can raise heart rates above recommended upper limits after only two minutes. Freezing temperatures also constrict peripheral blood vessels, further stressing the heart. Two-thirds of shoveling injuries occurred in men, and 15% of injuries were in children under 18 years old. More than half of injuries resulted from acute musculoskeletal exertion, 20% from slips and falls, and nearly 7% from cardiac problems, such as heart attack.

The study said most shovels contribute to injuries because of their non-ergonomic design, which hasn’t changed in over a century. Researchers recommend shovelers under 18 be supervised, people should warm up with light exercise before shoveling and sedentary individuals should consider hiring someone for the task.

I think their advice about warming up before shoveling (and considering hiring someone better fit for the task) should also apply to taking your 5-year-old sledding in blizzard conditions when not another soul is around to call 911 if necessary.