The Ether Way

Contemplating Quality.

"It was all those people in the cars coming the other way. It's just that they looked so lost," she says. Like they were all dead. Like a funeral procession."

 

Robert Pirsig. Zen and the Art of Motorcycle Maintenance.

I've been thinking a lot about quality lately. For two decades, I have accepted the industrial definitions of quality advanced by Deming and his disciples, and the evidence based outcomes-driven practice style that this model drives. I and my colleagues have written about limitations resulting from a slavish devotion to this model; the stifling of innovation being one  and the reliance on weak data and the devaluation of individual experience being another. While my leadership responsibilities have kept me focused on measurable outcomes as a context acceptable to all stakeholders, I observe a frustrating flatness creeping into the medical enterprise and I have come to believe that it derives from what I now call "spread-sheet medicine," and its major driver, "quantitative quality." Quantitative quality is the narrowly focused equating of quality with clinical outcomes; morbidity/mortality  and costs.

This quantitative fixation is a classical notion, best defined by the aphorism "If you can't measure it, it isn't real." Of course, that's nonsense; just ask any musicologist or art historian. Romantic tradition understands that there is non-quantitative Quality, and that it is vital to a meaningful life. Opposing the quantitative quality is this other view of Quality; the artistic or romantic view; let's call this "values quality"

I prefer to think of quantitative outcome assessment in medicine as "effectiveness" rather than Quality. It is an important component of medical quality but it is by no means the only consideration. This is not a trivial distinction. Like all discussions or disagreements, how you frame the debate defines the results. Management people say, "you can't manage what you don't measure..." They are highly motivated to limit the scope of quality to things they can "get their arms around," in order that they may discharge their fiduciary responsibilites to hospital owners and payers. The masters of industrialized health care; the money men, aren't interested in values-quality. As a US Senator once counseled me, "The marketplace won't pay for compassion." Nor in my experience, will they acknowledge the legitimacy of any intangible values; unless, of course,  it's their turn in the bed.

Clinicians, on the other hand, find the quantitative quality paradigm to be artless; or as my 17 year old would say, "it's soul-sucking." It's not that it's not important. It is. But, while being necessary, it is not sufficient. Quantitative quality may drive systems of care, but it will never inspire caring. And, as Pirsig points out, without caring there can be no true Quality. But our dislike of being managed; of being part of the "machine," is not in itself sufficient justification for seeking to modify the paradigm. We have to have a better reason than that if we expect to persuade ourselves or anybody else that it's time for deep reconsideration.

Deep Hypothermic Circulatory Arrest for Aortic Arch Surgery: A Global Brain Ischemia Situation

 Mitch Keamy reviews some pretty interesting material on aortic arch dissection. Surgery for this is a full time affair at Penn.

I am especially interested in the deep hypothermic circulatory arrest used for this because it’s a great example of survivable human brain ischemia. My colleagues in cardiac anesthesia are particularly interested in brain protection during cardiac surgery and I am interested in brain protection in all situations. So I have taken a bit of an interest in this. (Click on all figures to expand)

Some observations:

Here is the number of DHCA cases that my colleagues do annually:

 

 

 
Some pretty good program growth here.

 

 

 

 

 

Here is the distribution of time of DHCA for aortic arch repair. John Augoustides gave me this figure:

       

 

 

 

 

 

 I forgot to mention that one way to help the brain tolerate this is to provide a bit of backwards blood flow from the vena cava up thru the brain and out the carotids. This means we can sample the blood coming out of the ischemic brain.

 

Strength for the Journey

Westley: Why can't I move? Why am I up against this wall?
Fezzik: You've been mostly-dead all day.

-The Princess Bride

In some unfortunate folks, the "arch" of the aorta becomes diseased. The layers of the aorta split apart;  a separation which spreads under the pounding of blood ejected from the heart. Over time (sometimes quickly) it can result in stroke, catastrophic heart attack, or sudden bleeding into the chest as the split advances to the branching arteries leaving the aorta for their target organs. This is called an aortic arch dissection. Alternately, the aorta can weaken, bulging like the bubble of an inner tube into an aneurysm which, if it ruptures, is almost always rapidly fatal.

If the proximal arch, the segment between the heart and the blood vessels branching off to the head and brain, is involved (type 1 dissection), the treatment is urgent surgery to replace that section. If the dissection involves the aortic valve at the proximal end (close to the heart) the valve is usually replaced as well. At the distal end (away from the heart) branching blood vessels perfusing (feeding) the heart, brain and head are sometimes involved; these then, have to be disconnected, and anastamosed (connected) to the woven dacron or gortex artificial tube which is used to replace the sick aorta. In order to do this, the circulation must be stopped; no blood flow at all...

Doc in a Box

Yes that’s me! The doc in the box!! At Penn we have developed the use of a telemedicine system, marketed and sold by Visicu, to do remote monitoring and intervention of ICU patients throughout our health system in different Philadelphia  hospitals. We call it Penn eLert.  I am sitting at a console that looks like this:

 

 

 

 

From this vantage point I can control a video camera to “go into” a room with two way audio communications, see a page summarizing all the patient’s main points, follow the bedside monitor continuously, read progress notes, view chest x rays, and review labs, among other things….everything except physically examine a patient or do a procedure on a patient. Also there is a sentry system that alarms when there is a trend or overt problem indicating that something is amiss…..wow.

 

Impaired physicians-administrative issues

"Out of timber so crooked as that from which man is made nothing entirely straight can be built"
Immanuel Kant, 1784.

In the 1980's, Michael Swango, a physician trained in Illinois, was convicted of intentionally poisoning co-workers and spent five years in prison. Despite this, after his release he managed to forge documents enabling him to acquire residency positions at various academic hospitals, where he murdered an estimated 30 patients.

In 1986, Congress passed a law entitled "The National Healthcare Quality Improvement Act." (HCQIA) The main purpose of the act was to create a national database of physician incidents, the National Practitioner Data Bank (NPDB) to block the migration of incompetent and impaired physicians, like Swango, from state to state "under the radar" of institutional scrutiny.  Despite imperfections and dificulties, the HCQIA has withstood the test of time, surviving two decades essentially unchanged.

We are all well versed on its' reporting requirements; (i.e. suspensions longer than 30 days, privileges "voluntarily" relinquished under investigation, judgments or settlements greater than $5, etc). It also indemnifies physician leaders who participate in peer review from legal liability for their "good faith" efforts, From the facility/medical staff perspective, a helpful (and sometimes vexing) aspect of the law is the requirement of institutional confidentiality. The reasons for this provision are clear; it balanced out the otherwise oppressive aspects of the law for practitioners, afforded affected practitioners a semblance of privacy pending resolution of their due process appeals, and decreased the motivations of competitors and enemies to make baseless allegations for business advantage.

the common dark of all our deaths...

-On the Road, Jack Kerouac

I have been involved in surgery for thirty years, and I am amazed daily that people will willingly submit to it. There is no greater example of the triumph of hope (and trust) over fear. A wise surgical professor at Wisconsin once lectured to our class that “an operation represents the substitution of surgically induced pathology for the patient’s own pathology, in the hope that the surgical pathology will be better tolerated.”

As I write this, I know that tomorrow, I will be caring for a patient in whom a neurosurgical colleague will be placing deep brain stimulators for Parkinsonism. The patient will be somebody who has such severe, medication resistant, brain-mediated joint rigidity and muscle tremors that going out to dine is more-or-less out of the question. Most of the people so afflicted avoid being seen in public at all. He will come to us, willing to undergo brain surgery while wide awake, in the hope that we can alleviate his disability. Sometimes the results are miraculous. Sometimes not.

So called "functional" or awake, neurosurgery is performed for a variety of reasons. Usually, it is because the procedure requires the active participation of the patient in pinpointing areas of the brain; speech, motion and such. Normally, I have a cart full of drawers full of vials full of clear liquids with magical properties that allow me to modulate (and most typically abolish) my patient's perceptions, memory, and consciousness, and thus, overcome their pain and suffering during surgery. But I don't get to use them here. (Well, the liquids would be magical, except our understanding destroys the magic; "Mark Twain's experience comes to mind, in which, after he had mastered the analytical knowledge needed to pilot the Mississippi river, he had discovered the river had lost its beauty." -Zen and the Art of Motorcycle Maintenance, Pirsig. (see also Sleep and Death are brothers).