Doctors Glued to Computers—And Patients Left Out : The Impact of Electronic Medical Records (EMR)

In 2009 the Health Information Technology for Economic and Clinical Health Act (HITECH) was signed into law by President Obama and this law quickly changed the way medicine in the United Sates is practiced. The law was a first step in requiring all physicians to utilize electronic records. The President promised that creating and electronic record mandate for physicians would result in a national, universal electronic medical record system and improve care and communication. Ultimately, the legislation that required EMR implementation in 2009 began the process of penalizing physicians who do not use them and started a lucrative business for healthcare IT vendors such as Allscripts, EPIC, Cerner and many others. The requirements to implement EMR resulted in thousands of physician practices having to make harsh financially motivated decisions—either close the doors or sell out to larger healthcare systems.

What are the Benefits of EMR? What are the Practical Drawbacks?

Certainly, EMR systems do have their benefits—standardized documentation and portability all improve care. When a patient travels and has an illness care is improved when another hospital and provider can easily access long-term medical records. Communication between physicians of different specialties and organizations is significantly improved. However, EMR vendors have not yet created exchangeable, universal systems as Mr Obama promised they would. Each vendor creates their own platform and continues to compete with other EMR makers by creating different interfaces—Each EMR platform has its own idiosyncrasies and none is perfect. The Obama administration failed to put any mandates on EMR vendors—they were allowed to produce whatever they liked. The burden of integration has been dumped squarely in the laps of healthcare providers. In addition, EMR systems have been designed as billing tools and NOT for clinical documentation. Hospital systems are able to reduce billing and coding staff and now force physicians and other healthcare workers to perform this role as well. Because of the design focus of EMRs to capture maximal billing they are often clinically irrelevant and woefully inefficient in the clinical setting.

There is a significant learning curve for physicians and other healthcare workers when changing from one system to another. These transitions often bring operations to a crawl as productivity and efficiency decline for several weeks to months—ultimately negatively impacting patients.

How Has The EMR Requirement Affected Physicians and Patients in the Last decade?

This past week, a study published in the Annals of Internal Medicine found that physicians are spending twice as much time logging data into electronic medical patients as they are actually spending time interacting with patients. In the study, investigators observed nearly 480 hours of clinical time from the practice of 57 physicians across multiple specialties—including family medicine, internal medicine, cardiology and orthopedics. Investigators found that during a day in the office, physicians spent 27% of their time seeing patients and 49.2% of their time on the EMR or doing deskwork. In addition, these physicians also did 1-2 hours of EMR time at home during family time every single night. Ultimately the study found that for every hour physicians spend providing direct face to face patient care, they then spend TWO hours working on the EMR. Obviously, this type of scenario is unlikely to be sustainable. Physician burn-out and dissatisfaction with their job is at an all time high—more younger doctors are retiring early and looking for employment in other industries. More importantly, many patients are beginning to feel isolated and unable to develop any type of meaningful relationship with their physician.

What’s Next?

We must get back to a patient centered focus for the US healthcare system. We cannot allow a computer screen and government mandates to separate docrom patient. We must demand that physicians be given the time and space to interact with patients in a meaningful way that allows for a human connection. While documentation and EMR technology is an important part of clinical medicine, we must not allow the computer to be the focus of the clinical visit.

Here’s what I think needs to be done:

  1. Keep laptops out of a physicians hands in the exam room
  2. Require universal connectivity and easy interaction between different EMR platforms/vendors
  3. Reward physicians for quality CARE, not for quality EMR notes
  4. Make EMR interfaces more clinically relevant, easier to use, and more efficient (NOT AS BILLING TOOLS)

These are not easy goals to achieve. However, we must work diligently to make changes or patients will become more isolated and medicine will no longer be a human interaction between doctor and patient. These changes will only be possible if all of us work together—patients and doctors–to demand legislative reform.


{This blog was originally published in my column on Bold.Global on Monday September 12, 2016}

Major Insurers Bail on the ACA—Limited Choices and Patient Struggles Ahead

(This blog was originally published on September 5, 2016 on Bold.Global)

In the last several months three major players in the Obamacare exchanges have publicly  reported millions of dollars in losses and have made plans to either pull out completely (or significantly decrease participation) in the ACA insurance exchanges. Humana, United and Aetna account for the majority of the policies written under the affordable care act and will no longer be participating in open enrollment in 2017. All three insurers have cited overwhelming losses and a responsibility to their shareholders at the motivation for the change. The mass exodus of larger insurers has created a situation where nearly 1/3 of the individual counties in the United States will have only ONE choice in the exchange—effectively creating monopolies for these insurers. The insurers that remain are already asking for substantial premium increases—in some areas premiums may rise nearly 40%. In an effort to cut costs even further, those insurers that remain are negotiating contracts with healthcare systems that will accept rock bottom reimbursements. Many major healthcare systems are not able to participate in the exchanges. This has left many Obamacare participants with very narrow “in network” choices and some areas are faced with only ONE healthcare system and its affiliated physicians.   By limiting the network choices, the insurers are able to better control costs due to the fact that more expensive physicians and hospitals can be left out. When an insurer contracts with a particular hospital system and affiliated physicians, they are able to require referrals for specialists and the often offer incentives to primary care doctors for limiting costs (with no measure of quality).

What is the obvious Fallout from NO competition??

  1. Diminished Choice

As mentioned above, the remaining insurers must cut costs. The ACA exchanges have been flooded with older, sicker patients that require more care and create a higher cost burden. In order to manage these costs, insurers are negotiating contracts with single healthcare organizations in an effort to limit costs. These contracts will eliminate choice for most of those insured through the ACA. There is a shift towards HMO style plans and there are now fewer PPO (Preferred Provider Organization) options. PPOs allow patients to make choices in providers and HMOs typically have far fewer choices. In many states, there are no PPO choices—overall 15% of customers will have NO PPO to choose from. As you may expect, the profit margins for HMOs tend to be much higher for the insurers.   In 2016, HMOs represented 65% of all ACA plan choices. Non HMO plans tend to have higher premiums and are subject to more frequent and more significant premium increases as these insurers accumulate sicker, more expensive customers.

  1. Less Quality

Whenever there is a lack of competition, quality tends to suffer—no matter what the industry—and Medicine is not immune. Cost cutting measures and incentives for physicians to “do less” can result in a lower quality of care. For the most part, insurance companies are not concerned with the health of the insured—they are focused on the cost and the risk. In an ideal world, medicine would focus on prevention rather than treatment. However, many insurers do not cover important preventative tests and prescription drugs that are designed to modify risk.

  1. Increased Cost

Insurance companies are “for profit” businesses with shareholders to which they must answer. The job of the insurance executives is to maximize profits and minimize risk—Do not be fooled, insurance companies do not care about the well being of their customers. When insurance companies such as those who are taking losses in the exchanges find that their bottom line is negatively affected, they quickly raise rates, increase co-pays and raise deductibles.

  1. Less Access

As insurers limit their networks, patients will find that they have less access. When exchanges only offer one choice of hospital system and affiliated physician groups, patients will have difficulty finding a primary care doctor or may experience waiting lists to see specialists. Ultimately, patients will be separated from their long time physicians (unless they are lucky enough to find that they remain in network). Many physicians will ultimately retire or choose not to participate in the exchanges due to lower reimbursement rates—in some cases the exchanges reimburse at rates lower than Medicare and Medicaid—which are already 30% lower than private insurance rates. Major academic medical centers—such as UCLA and Northwestern for example—and countless others, are not participating in the exchanges due to reimbursement concerns. Academic centers often have cutting edge therapies and experimental protocols for cancer and other devastating diseases. Because of network and cost containment issues, those insured by the ACA will not have access to this type of care.

WHAT needs to be done?

It is clear that the ACA is NOT working. While we have millions of newly insured Americans, many of these newly insured remain effectively “uninsured” due to the inability to meet deductibles, and the limited access to care. It is vital that we insure all Americans—but we must do so in a way that preserves patient choice and helps improve quality of care—all while being fiscally responsible. We must work to better regulate insurers and make sure that the focus of care pivots to PREVENTION in the next decade. Physicians should be measured on how well they PREVENT disease as well as how well they TREAT disease with the highest quality care. We must also require individual accountability for patients. Those that make healthy lifestyle choices should be rewarded with lower premiums. Those that choose to continue high risk behaviors—smoking, poor diet, etc—should pay more.

Ultimately, Congress will have a choice in 2017. They can either bail out a broken ACA by pouring more good money after bad—OR—they can actually legislate and reform the law, making it more effective for all parties—insurers, patients and physicians.


Greed and Pharma: What is Behind the Rise in Prescription Drug Prices?



This blog was originally authored by me and published on and @BoldGlobalNews on Tuesday August 30, 2016 and is reposted here today…

Recently we have all heard about the significant price hike of the Epi Pen made by Mylan pharmaceuticals. While Mylan and CEO Heather Bresch are dominating the headlines now, other drugs are also increasing in cost. While we see a 500% increase in the cost of the Epi Pen, Ms Bresch has seen a nearly 700% increase in salary over the last few years. Mylan is definitely not alone in its greed. Last year the CEO of Turing, Martin Shkreli increased the price of an important (and relatively cheap) drug in the treatment of HIV related illness nearly 5000 percent. Price gouging is not limited to newly developed drugs–even the price of insulin has gone up nearly 300 percent. Healthcare reform has provided more Americans with access to insurance but many still cannot afford the drugs and care that they need.

So exactly why is this occurring and what can we, as healthcare consumers, do?

A new study published in the Journal of the American Medical Association this past week has shown that the average price of a drug has increased by nearly 165% in the last seven years. Buy why? Harvard researchers postulate that the most likely reason for inflated prices is the fact that government regulation allows for drug makers to have exclusivity and near monopolies over certain drugs.   Drug makers are able to do this because Medicare and Medicaid are not allowed to negotiate prices. Even though 1 in 3 Americans are insured by these two entities, federal law allows drug makers to charge (and Medicare and Medicaid) to pay whatever is asked. There is no negotiation. No other business in the world operates in this manner. If they did, they would not exist for long. Almost every other developed nation allows (and requires) their government- sponsored health care programs to negotiate drug prices as they would any other contract for goods and services. In the US we spend more money per person as a percentage of GDP than any other country in the world. Many drugs and procedures cost much more here than abroad.

The bottom line is that Americans pay more because their ability to push back is limited by an inept government and poorly organized government sponsored healthcare programs. In addition There is little or no transparency in pharma—drug makers pay each other to delay generic production and re-file for patent protection when the end of their exclusivity comes to an end—often using “new indications” as a way to continue to avoid generic competition. In addition, the pharmaceutical lobby is quite powerful and often works to stall any meaningful legislative reform in Congress.

The Pharma Response: What about Research and Development Dollars?

 When pushed, pharmaceutical companies will claim that the prices are necessary in order to fund research and development of new drugs. However, the United States seems to fund most of the R and D that happens throughout the world. In addition, many scientific breakthroughs occur at academic institutions where much of the research is funded through government dollars in the form of National Institute of Health (NIH) grants. In fact nearly half of the most important drugs that have been developed in the last 25 years have been created through publicly funded research in academic institutions. In reality, pharmaceutical companies on average reinvest only around 20% of their profits into R and D—the rest lines the pockets of their C level executives. In the case of Mylan, the technology that is utilized to create the injector of the Epi Pen was developed by the US military in 1970 when it was created in order to inject Atropine into battlefield soldiers during a chemical attack. Mylan simply acquired the technology from another player in the market.

So What Next?

The Epi Pen controversy should serve as a wake up call to us all. Over the last 10 years, the number of children with serious allergies has risen nearly 50%. Many of these children will have a dangerous life threatening reaction known as anaphylaxis and the Epi Pen may be the difference between life and death. All children should have access to these drugs—not just those whose parents have the means to provide them at an inflated cost. As healthcare consumers we must demand that our lawmakers act to prevent the greedy and despicable acts of CEOs such as Bresch, . Shkreli and others. Both Presidential candidates have vowed to allow Medicare and Medicaid to negotiate drug prices. Both have also suggested free trade of pharmaceuticals with Canada and other foreign suppliers. In addition, we must also work to reform the FDA and its expensive, tedious and incredibly lengthy regulatory process for drug approval. The answer to inflated drug prices is simple—competition and free market—we must abolish long-standing policies that allow for exclusivity and patent protection for pharma. We must promote the development of cheaper generic alternatives earlier in the life a of new drug or therapy. While name brand drugs only account for 10 percent of prescriptions in the US today, they account for nearly 75% of the cost. Something must be done in order to protect the healthcare consumer—the Patients that depend on drugs every single day—should have the ability to receive therapy without entering bankruptcy.

Mylan Follow up…

Mylan, in and effort to respond to the public outcry has reacted by developing a new patient assistance program—this too still falls far short. Those who can pay are still paying exorbitant prices. Today, Mylan has announced plans to make a generic version—albeit at a price of 300 Dollars. (remember their cost is approximately 6 dollars per unit)   While these concessions are certainly helpful they do not address the bigger issues—increasing deductibles and skyrocketing health insurance costs will not be able to continue to pay these types of inflated prices. Ultimately, the patient will suffer.





Big Brother is “Watching” the Watchman Device—More Government Intrusion into The Practice of Medicine

Note: Let me preface this blog post and remove potential bias by making it clear that I am not an Implanter of the Watchman device.

Atrial fibrillation (AF), the most common heart rhythm disorder in the world, can be complicated by stroke and many patients must take blood thinners for life. A new device, called Watchman, is an alternative treatment for patients who do not want to take blood thinners to prevent stroke.

The Watchman, recently approved by the FDA for the prevention of stroke in AF, has entered the market and is now being implanted by very highly specialized physicians (called Electrophysiolgists). Rigorous clinical trials were performed prior to FDA approval in order to evaluate the safety and efficacy of the Watchman. The Centers for Medicare and Medicaid Services (CMS) has also ruled on the device for use in Medicare patients—but with a caveat. Before being allowed to have the device implanted, patients will be required to have a second opinion—by a physician who may or may not be trained in the implantation and management of these new devices. If the patient does not get the second opinion, Medicare will not cover the cost of the device and procedure.

CMS argues that this requirement is part of a new “shared decision making” initiative—a way to ensure that a patient’s own opinions and values are taken into consideration when discussing the risks and benefits of a procedure. The government contends that the requirement is NOT about a second opinion at all….it is more about making sure that a patient makes clear informed decisions about a particular treatment.



I have always thought that a physician must develop a relationship with their patient over time in order to create a clinical “partnership.” By working with patients and engaging patients in the treatment of their own disease, a doctor can really to get to know patients, their families and their particular values. This is certainly the way I have practiced over my15 year career. So, why then, does CMS want to involve another physician, who may have no relationship with a particular patient, in the decision making process?

In my opinion, the answer is simple—money and regulation.   Increasing pre certification requirements for patients who need procedures will ultimately reduce the numbers of procedures that are performed—ultimately resulting in fewer healthcare payments from Medicare. Many patients will decide not to go through the hassle of getting a “second opinion” from a non expert and many physicians may decide to no longer pursue these treatment options due to increased administrative paperwork burden.

The Federal government continues to inappropriately insert itself into the practice of Medicine. Increasing regulation threatens to undermine the ability of doctor and patient to engage and partner in care of chronic disease. Other recent examples of government encroachment into the doctor patient relationship include requiring physicians to discuss gun ownership during an office visit—I have written on this subject extensively in the last month.

IS The ART of Medicine being Put at Risk by Washington Politicians?

When I have discussions with my patients about treatment options, I always discuss the risks of each option, the benefits, and the data that supports each approach. I try to provide every patient and family with the information that they need in order to make a good decision—a decision that fits in with their goals, their values and their stage of life. I must admit that I resent it when CMS and our government violates the sanctity of the doctor patient relationship. As a physician it is my duty to develop a relationship with my patients. Having “Big Brother” decide that I am incapable of having a meaningful discussion with my long time patients (and friends) erodes at the very fabric of the Art of Medicine. I worry that these recurrent intrusions into the exam room will only serve to further undermine my ability to care for my patients. Throughout my career—from medical school through Fellowship–my mentors have always taught me the importance of developing meaningful relationships with patients. Why now, does the government think they need to “Watch the Watchman”?



Doctors and Gun Control: Get Politics OUT of my Exam Room


Let me preface this blog by stating that I write this to stimulate discussion and debate, NOT to sway opinions…..

Today, doctors are required to spend more and more time doing administrative work—including checking off electronic boxes in the Electronic Medical Record (EMR)—the result is less quality time with patients. Now, those that are in Washington, DC think that requiring physicians to ask about guns in the home may somehow reduce gun violence and gun related deaths in the US today. For me, the answer is simply NO. Physicians should focus on the prevention, diagnosis and treatment of disease—we should advocate for our patients BUT we should not be government agents (unless we all collectively become employed by the state. In an article published this week in the Atlantic, author Olga Khazan argues that doctors have a responsibility in preventing gun related deaths. When I read the article, I was simply struck by how much controversy surrounds this issue—How do we protect patient’s privacy rights? How do we preserve our relationships with patients? Certainly, as physicians we may ask many uncomfortable questions of our patients—Sexual history, drug and alcohol use, and other sensitive subjects—BUT should we really be asking about guns? The legal implications alone of these discussions are enough to make even the most steadfast physician a little weak in the knees….

For far too long, the government has attempted to insert itself into the sacred (and privileged “Doctor-Patient” relationship. The bond between doctor and patient is like no other-honesty, confidentiality and trust are paramount to all other concerns. There is already a debate on the role physicians should play in gun control/gun safety. Our own US Surgeon General has proclaimed in the past (prior to his appointment by a Democratic President) that gun control was a top priority for his office. In Florida, there is a law that does not allow Physicians to ask about guns except is certain circumstances. Others want to require physicians to ask and document the patients answers in the EMR. I fear that allowing discussions on guns to enter an exam room may completely undermine a physicians’ relationship with his or her patient. Patients may feel uneasy about answering the questions and may also be suspicious of why they are being asked in the first place. Patients may be less likely to TRUST their physician (for fear of some repercussion) and my also be less likely to discuss other medical issues with honesty. Lack of honest dialogue between doctor and patient can result in a lack of patient engagement and, ultimately, negative clinical outcomes.

Don’t get me wrong, we MUST educate the public about the proper use and storage of firearms. Guns should never be accessible to children and any person who owns a firearm must be trained in its safety and proper use. However, the role of the physician should remain, first and foremost, as healer—We should not be required to become firearm educators, nor should we be required to document firearm possession to the government. While I do concede that there is likely a role for the discussion of guns in a Pediatrician’s office (with the parents) in order to ensure that guns are stored properly in the home, I do not think that there should be any type of discussion in Adult medicine. There has been much research in this area and much controversy remains. This past week in the Annals of Internal Medicine, researchers from Colorado found that there is a vast array of opinions among patients when it comes to physicians asking them about guns. Only 25% of patients surveyed thought that it was ALWAYS appropriate for a physician to have a discussion about guns. 34% of those studied in stated that it was NEVER appropriate for a physician to ask about gun possession or gun use. While study authors spin the data to say that nearly 2/3rds of respondents think that it is SOMETIMES ok to ask about guns, the reality is that many Americans feel that this type of interaction is not appropriate.

Sadly, there are far too many gun related deaths in the US today. We must do more to prevent criminals, those with mental illness, and others who would do us harm to possess guns. This should be the work of the community and the local, state and Federal government—NOT the work of the physician. I fear that if we begin to mandate data collection of this sort by physicians and other healthcare providers we will undermine the trust that our patients place in us every single day.




Avoiding Burnout in Medicine: Tips For Success

Medicine has become increasingly stressful for all levels of healthcare providers. Every year, nearly 400 physicians commit suicide and in a study published in the Journal of Academic Medicine, it was found that nearly 10% of final year medical students and first year residents (called Interns) reported having suicidal thoughts. Previous studies from the National Institutes of Health found that physicians were twice as likely to kill themselves as non-physicians. The statistics are staggering—suicide accounts for 26% of deaths in physicians ages 25-39 as compared to 11% of deaths in individuals of the same age in the general population. More must be done to both recognize and prevent physician depression—this all starts with working to avoid burnout.

Burnout in medicine has been defined as Physician burnout is quite common—A study in the Mayo Clinic Proceedings found that burnout rates continue to rise and most physicians are very unsatisfied with their own work-life balance.

Warning Signs of Burnout

As burnout becomes more prevalent we have been able to identify some early warning signs. Awareness of these signs may lead to early intervention and prevention of more serious burnout resulting in physicians leaving medicine entirely.

Warning signs include:

–Emotional Exhaustion

–Depersonalization and trouble connecting with patients

–Reduced accomplishment/Confidence in skills

Causes of Burnout

In order to make a difference in the lives of physicians and their families-and prevent burnout– a great deal of effort has gone into trying to determine the causes of burnout in hopes of making more of an impact early on and preventing burnout before it occurs. In order to make this happen, we will need the support of lawmakers, regulators and medical societies.

–Too many clerical tasks—Doctors now have to perform more administrative duties and metrics are now putting increasingly daunting non-clinical tasks before physicians. Most doctors go to medical school to care for patients. Patient care provides fufillment where paperwork does not. Physicians are now scribes, coders and schedulers—in addition to healers. Many doctors are left to wonder why they went to medical school—it certainly was not for a data entry job.

–Too little time to effectively work with patients—As physicians most of us went to medical school because we loved science and we cared for patients. Patients provide challenges, opportunities for relationships and a way in which we can improve the world.

–Declining salaries—Medicine takes commitment, time and money for education. Many physicians have taken on a great deal of debt and have made numerous personal sacrifices in order to train for years to provide top-notch care to the patients that they treat. As healthcare reform moves forward, physicians are caught in the middle. Salaries decline, workload and non clinical demands increase and without meaningful tort reform, frivolous malpractice claims continue to propagate. All of these factors work to diminish physician satisfaction and contribute to burnout.

–Longer work hours—With declining reimbursement, physicians are being asked to do more with less time. Documentation requirements and Electronic Medical Records have resulted in more time spent at home completing paperwork. All of this takes away from private time with family and significantly impacts happiness and life-work balance.

Consequences of burnout

–Poor patient care—When Physicians are emotionally and physically depleted as commonly seen in burnout, patient care may suffer. Distraction, lack of attention to detail and poor decision-making can be more common. In order to provide the best care, physicians must engage with their patients and develop a personal connection. If physicians have burnout, often there is no time or energy left for cultivating these important relationships.

–Depression/suicide—A staggeringly high number of physicians, when polled, have clinical signs of depression and many have contemplated suicide. Sadly, every year in the United States, over 400 physicians commit suicide. Depression can adversely affect family life and can impact a doctor’s ability to perform in the clinical setting. Sleep disturbances and fatigue are common.

–Early retirement/MD shortages—For many, the prospect of practicing medicine is no longer tenable. Many physicians are looking for other business opportunities and are leaving medicine entirely. As the pool of insured patients grows, a physician shortage looms—If we continue to lose practicing, experienced physicians due to burnout and early retirement from medicine this shortage will only become more significant. Patient access to skilled physicians is a critical part of patient engagement and improving outcomes. If more physicians leave medicine, the work load will only grow for those who remain.

What we can do about Burnout

Burnout is a real issue in medicine today. We must make efforts to address this problem before more doctors are lost. Here are a few things that I believe will help ward off Burnout:

  1. Schedule Regular time off—extended vacations (2 weeks) While it is not the typical American way to take vacation, I think that extended time away from clinical responsibilities may be important to avoiding burnout. By “unplugging” from the office and clinical demands for more than a week at a time, healthcare professionals are able to recharge and return to clinical practice more refreshed and ready for the challenges of patient care.
  2. Schedule Regular exercise—It is a fact that regular exercise is associated with lower rates of depression and other chronic disease. In general, when we exercise, we are able to turn our thoughts away from work and outside stressors and focus on the moment. Exercise also promotes a more ideal body weight and overall improved health status.
  3. Healthy diet—Along with exercise, healthy eating can help physicians avoid burnout. When we eat good healthy well balanced meals we are able to maintain a more ideal body weight. Avoiding sugars and alcohol can certainly help avoid the depression and other burnout related complications.
  4. Supportive spouse—Having a life partner or spouse who is able to listen and support the stressed physician is very important. A supportive partner can serve as a sounding board and can offer suggestions and facilitate interventions when necessary. In addition, the supportive spouse can also help identify early warning signs for burnout and suggest early intervention..

What does the future hold?

Burnout is more common that many physicians think. No healthcare provider is immune. It is essential for physicians as well as their coworkers and families to understand the signs and symptoms associated with burnout and intervene early. Burnout can have severe consequences including depression, and in severe cases—physician suicide—are completely avoidable if we begin to better understand what the root causes of burnout are. By understanding the etiology of burnout, we may be able to design a better working environment for today’s physicians. If we do not make these changes, I fear that many physicians will leave the practice of medicine within the next 5 years.

Bringing out the Best in Medicine: How the Tragedy in Orlando Provided An Opportunity for Greatness

Whenever horrific events occur, it is important that we not only take stock in the event itself but we must also look at the good that rises from the ashes. The tragedy in Orlando this week is not without heroes. Volunteers, medical personnel, first responders and blood donors have worked tirelessly to help those in need. In the wee hours of the morning on June 12, 2016 healthcare workers in Orlando received an emergency alert to attend those affected by the worst mass shooting in US history. The quick response and expert training of those at Orlando Regional Medical Center certainly saved numerous lives. Six trauma surgeons and countless other doctors, nurses, technicians and other specialists were mobilized within minutes and were ready to receive the massive number of critically ill patients that arrived all at once.

As a physician, I can only imagine what it was like to arrive at the hospital and begin to care for the large number of wounded. In my experience in dealing with medical emergencies, instinct and training allow doctors and other healthcare providers to jump in and immediately deliver care. Years of training and study allow healthcare workers to react with professionalism, precision and compassion. While all of us are human and are emotionally impacted by such a tragic event, somehow all of those who sprung into action at Orlando Regional Medical Center were able to separate their feelings from the situation and perform their jobs at a very high level. Many hospital workers, physicians, nurses and first responders came in to help—whether they were on call, on duty or on a day off. The selflessness of these medical heroes should not be lost in the tragedy. Many of those involved have been interviewed in the days following the night of trauma and all consistently said that they simply were doing what needed to be done….

While many hospitals have had “Disaster Plans” in place for years, the events of September 11th led to more widespread adoption of these plans. Since that time, hospitals all over the country have put plans in place to deal with mass casualties. Academic societies and organizations of Trauma surgeons have worked to develop best practices and have conducted large scale studies in order to determine the most effective ways to handle these types of disasters. These plans involve extensive, centralized communication systems and a way to quickly alert all essential personnel and mobilize resources.   In addition, these plans involve intensive education and training for all hospital staff. Most hospitals, once plans are in place and staff education is complete, have regular “drills”. Many institutions even have mock disasters with actors posing as critically injured casualties. These drills allow for hospital personnel—Doctors, nurses, techs, first responders and communications specialists to hone their skills and find ways to improve responses in the case of a real disaster.

In my experience at both Duke Medical Center (during my training years) as well as at the University of North Carolina Healthcare system currently, well thought out protocols and training programs are in place and staff are reminded of these plans frequently. As a Cardiology Fellow in the late 1990s at Duke University, I experienced an emergency event first hand. While I was in the Emergency Room caring for a patient with a heart condition in the early morning hours, an alert was sent out that there had been a gang related shooting in Durham and that there was an active shooter potentially inside the ER. We were instructed to get all patients onto the ground and pull everyone into the nearest closed room. I reacted by moving several patients to the floor and pulling them into a supply closet with me. Patients were frightened and understandably anxious. During this time, the ER was locked down and police begin moving through the department in order to clear the area of any threats. Fortunately, there was no active shooter found inside the ER and, after about 30minutes, we were allowed to return to normal operations. After this experience, I remained visibly shaken and it took me a long while to move past the fear I felt that night. I can only imagine what it was like for those medical professionals involved in the Orlando tragedy.

While you may not think of the importance of these issues during the time that a disaster occurs, there are a few things that seem to make a difference in the way we as healthcare workers respond. After my experience during my Cardiology Fellowship here are a few things that I believe to be essential–

  1. Centralized Communication—IN a disaster or mass casualty event, communication is critical. Effective communication allows for patients and personnel to be where they need to be at all times in order to provide the most efficient and effective life saving care.
  2. Coordinated Care—Cooperation and coordination between surgeons, nurses, administrators and other personnel is key to the successful treatment of large numbers of patients.
  3. Staff Education—Extensive education and training must take place in order to prepare staff for mass casualty events. When called upon, staff must be able to react in an organized and calm way—all of this comes from preparation over time.
  4. Drills—It is important to practice a response to a mass casualty event. Practice allows for those in charge of the disaster plan to assess response times and identify areas for improvement.

What Are Biggest Challenges in a Mass Casualty Event? What are the Initial Steps?

The heroic efforts of those in Orlando cannot be understated. These men and women should serve as an inspiration to all of us in Medicine. Each person did their job and worked through the night to help as many victims as they could. For many of us, the thought of being faced with such a large number of seriously wounded can be overwhelming.—this is the stuff of War.   However, those first responders in Orlando met the challenge head on—they worked quickly to identify and triage the most critically ill patients. Emergency personnel attempted to quickly stabilize each patient, and then decided who needed the most urgent treatment in the Operating Room. Patients were sequentially moved from the scene, to the Emergency Department, and to the OR very quickly. IN order to triage the large number of victims, , healthcare professionals are trained to use the ABCDE approach:

  1. Airway—Make sure that each patient has stable airway—if not, we must quickly establish an airway
  2. Breathing—We must make sure that every patient is breathing on his or her own. If not, we must provide an external means of providing them with oxygen.
  3. Circulation/Hemorrhage—First responders must quickly assess if the patient has a pulse and if there is major bleeding. If there is no pulse CPR is initiated. If there is an obvious hemorrhage, efforts must be made to apply pressure, field dressings and other interventions designed to stop bleeding prior to definitive treatment. In many cases, blood and fluids must be administered in order to restore blood pressure and adequate circulation.
  4. Disability—First responders must assess each victim’s level of consciousness and if they have suffered any type of neurologic or brain injury. These injuries must be quickly triaged to a neurosurgeon in cases of head trauma.
  5. Environment—In many disaster situations there are environmental exposures (chemicals, spills, etc) that may contribute to the trauma—in the case of the Orlando shooting, this was not the case.

Unfortunately, mass casualty events have become more common in the US in the last decade. Medical personnel and hospital systems are learning to better care for patients in these large-scale emergency situations. Events such as the Orlando tragedy will cause all of us in medicine to review our protocols, plans and readiness procedures so that we will be more equipped to handle emergencies when they occur. Were it not for the heroic efforts of first responders, trauma teams, doctors, nurses and other hospital personnel in Orlando, the number of casualties could have been much greater. In the coming months, those medical heroes that helped treat the massive number of wounded will need time to heal and time to process all that they have seen and experienced. Thankfully, they were prepared and ready to respond with a heroic effort on Sunday morning.

(this piece originally published on on June 14, 2016)



June 14, 2016: Doctors and medical staff that treated the victims of the Pulse nightclub shooting answer questions at a news conference at the Orlando Regional Medical Center. (AP)