emergency medicine


Viewpoint: Doctors Respond To Home Births That End Up In Hospital

By Shirie Leng, M.D. and Cindy Ku, M.D.

As physicians we are concerned about a recent post on CommonHealth — “What to Expect When You’re Birthing At Home: A Hospital C-Section (Possibly)” — that focuses on planned home births that end up in the hospital.

While we respect the right of women to labor and deliver in the environment of their choosing, requiring medical intervention in childbirth is neither shameful nor a moral failing. Life-threatening complications which, 100 years ago, would have meant a death sentence for mothers and babies, are now treatable and even preventable in the modern hospital maternity ward. Suggesting that women are unduly traumatized by transfer to and treatment in a medical facility does a disservice to the obstetricians, nurses, anesthesiologists, and neonatologists who work so hard to save these lives.

Here’s an example of the kind of case that could possibly result from a home birth that goes awry. While on a routine morning on the obstetrics unit, the usual routine was interrupted by a phone call from the emergency room. A laboring mother was in distress and needed an emergency caesarean, and she was about to arrive into the trauma OR. Since caesareans are not normally performed in the emergency room trauma room, everyone dropped their plans and hurriedly prepared the trauma OR. One minute later a petite young woman on a stretcher crashed through the door along with the obstetrician. “Get the baby out of me!” she screamed, writhing and crying in agony as the team transferred her to the operating table. Between her moans and her desperate outbursts, she could barely understand the questions as the anesthesiologist tried to ascertain three things: did she have heart or lung problems, did she have allergies, and did she have any potential problems with her airway?



We had no other information to go by – no laboratory data, no history, not even her name. All we knew was the baby was in breech position (legs down, not head down) and was in distress. We had five seconds to decide how we would help to save the two lives in front of us. We told her as gently as we could (though it likely didn’t register with her at all) that she needed to breathe in oxygen for herself and her unborn child, that she would be unconscious for about an hour, and we would see her and her baby in the recovery room. Vaginal delivery is not the standard of care for breech presentations because of the significantly elevated risk of shoulder entrapment in the birth canal and stillbirth. Months after this case we all still wonder how we could have done better and what would’ve happened if she hadn’t arrived in time.

Thankfully, our team — the obstetricians, anesthesiologists, nurses and neonatologists — worked together successfully and both mother and child did well. We don’t know for sure if this case began as a home birth, but it does represent the sorts of difficulties that we medical staffs wrestle with when a home birth becomes complicated and ends up at the hospital.

Childbirth always brings with it an element of danger. While everything usually goes right, when it goes wrong it usually does so quickly and seriously. To expect the idealized experience in every case is to deny reality. In 1900, when women were having the arguably blissful natural birth experience home birthers seek, the maternal mortality rate was more than 800 deaths per 100,000 births. According to the CDC, in 1997 that number was 7 per 100,000. This statistic, an upwards of 99 percent decrease in mortality rate, was not achieved by midwives and doulas with the latest technology in birthing balls and labor tubs. It was achieved through advances in science and medicine. Continue reading

New ‘Active Shooter’ Protocol: Despite Danger, Stop The Bleeding Faster

Emergency responders comfort a woman on a stretcher who was injured in one of the blasts near the Boston Marathon finish line. (Jeremy Pavia/AP)

Emergency responders comfort a woman on a stretcher who was injured in one of the blasts near the Boston Marathon finish line. (Jeremy Pavia/AP)

In any mass attack on the public — whether gun or bomb, mall or marathon — the first priority is to stop the killing. Typically, medical care tends to be delayed until danger is past. But that is now changing, to more of an emphasis on also stopping the victims’ bleeding — faster.

In the wake of the Sandy Hook Elementary School shooting nearly a year ago, a group of medical, military and law enforcement experts, commissioned by the American College of Surgeons, convened to answer a burning question: How do you increase survival in such mass attacks?

That “Hartford Consensus” group issued its initial concept document just 10 days before the Boston Marathon bombings in April, said Dr. Lenworth Jacobs, a trauma surgeon at Hartford Hospital. The much-admired emergency response to the marathon attack only bolstered the group’s findings. Support grew, and federal authorities — Homeland Security and FEMA — adopted the Hartford-based protocols in September, he said.

‘You get that timer in your head: If there are people alive…you’ve just really got to speed things up.’

Dr. Jacobs appears on Radio Boston today, and explains what the new guidelines say. The background:

In an attack, he said, “There are three zones. There’s the hot zone, which is actually dangerous, there’s an active shooter there, and the whole concept is to suppress that threat. However, in the warm zone, which is usually pretty close to the hot zone but it’s out of the sight of the shooter, there, you want to be controlling the hemorrhage. And classically, those have been different things. Law enforcement people have gone to suppress the shooter but have not necessarily been involved in controlling the hemorrhage. Now you want to have them, and the medical and rescue service people, involved very quickly in controlling hemorrhage. And then in the cold zone, which is safe, you need to do a full assessment of that person and then transport them to hospital.

What has happened is that these have been three very separate zones with three different kinds of people in there. What we’re proposing is that those zones should be compressed. So yes, you will have a hot zone but almost overlapping is the warm zone and overlapping that is the cold zone. So that the care is done much more quickly.” Continue reading

Dangerous Play: More Kids Ingesting Magnets, Rushed To ER

Years ago, a relaxing family vacation with friends in the Berkshires was cut short by a medical emergency involving the host’s 6-year-old son and a couple of powerful magnets.  The problem? The kid blithely placed a magnet in each nostril and couldn’t remove them. A bloody nose, forceps and a frantic trip to the local emergency room followed.

The child, it turns out, is far from unique.

According to a new study, the number of children ingesting magnets, or stuffing them up their nasal passages (possibly a thwarted attempt to emulate nose-piercing) has soared: cases, amazingly, quintupled between 2002 and 2011. Not only that, this spike in magnet-related accidents is leading to more serious injuries that are more likely to involve emergency surgery, according to the report, just published online in the Annals of Emergency Medicine.

Researchers propose two possible theories driving the rapid rise in cases:

1. Smaller, stronger magnets have become more widely available (and not only in kids’ toys; it’s also those addictive Buckyballs, marketed for grownups).
2. Powerful and cool-looking magnets are being used, mostly by older children to “imitate nose, tongue, lip, or cheek piercings,” the study says.

To find out more, I contacted one of the study authors, Dr. Julie C. Brown, with the department of pediatrics at the University of Washington in Seattle. Here, lightly edited is her very thorough response via email:

jar (away for a while)/flickr

jar(away for a while)/flickr

Q: What might be driving the increase in these pediatric magnet emergencies?

A: Small, powerful magnets are increasingly ubiquitous, in numerous household objects. Rare earth magnets have only been widely available and affordable since a little after 2000, and have had increasing use since. Many companies marketed rod and ball construction sets to children around 2005, and there were a number of ingestions related to a flawed Magnetix product around that time, including a Kirkland boy who died in 2005. There have been other flawed toys around that time as well. In recent years, however, it appears that the increase is due more to products not marketed as toys. They are sold with metallic bulletin boards, as fridge magnets, as jewelry, as novelty items. Continue reading

Reality Check On Those ER Wait-Time Ads: ’19 Minutes’ Could Mean 90

By Karen Shiffman
Guest Contributor

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.

WBUR's Karen Shiffman and her injured finger. (Aayesha Siddiqui/WBUR)

Karen Shiffman and her injured finger. (Aayesha Siddiqui/WBUR)

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.

A billboard that shows the emergency room wait time at St. Elizabeth's Medical Center in Brighton, Mass. (Carey Goldberg/WBUR)

A billboard that shows the emergency room wait time at St. Elizabeth’s Medical Center in Brighton, Mass. (Carey Goldberg/WBUR)

“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. Continue reading

The Cruel Irony Of Stellar Marathon Medical Planning

By Martha Bebinger

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. Continue reading

How Long Will You Wait In The ER?

Here’s some local news you can truly use: a handy comparison of wait-times at Boston hospital emergency departments.

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:

(South End Patch)

(South End Patch)

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.

Continue reading

When The Crowded Emergency Room Turns Deadly

A crowded emergency department is associated with an increased risk of death, a new report finds. (sobriquet.net/flickr)

Crowded emergency rooms can be annoying, infuriating, scary and (if you saw the brilliant documentary, The Waiting Room, about the emergency department at Highland Hospital in Oakland, Calif.) heartbreaking. Now add this to the list: Deadly

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. Continue reading

‘Doctors Without Borders’ Opens First U.S. Clinic In Post-Sandy Queens

Residents of a flood-wrecked home in Point Pleasant Beach N.J. offer encouragement to fellow Superstorm Sandy victims. (AP Photo/Wayne Parry)

My only surprise is that this hasn’t happened before. We’re rich and developed, sure, but pockets of people can still find themselves in straits as dire as those in a Third World emergency zone.

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. Continue reading

Poison Call Centers Calculate Their Value At $1.8B A Year

(Wikimedia Commons)


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)… Continue reading

Study: Psych Patients’ ER Waits In Boston Area Average 11 Hours

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. Continue reading