Mr. Rondell Williams, saying goodbye, and being afraid to sleep…

Private-ED-Rooms-SJRMCWe said goodbye to Mr. Rondell Williams twice in one week. The first was at his goodbye party organized by the nurses and techs in our department. He was leaving us for a new opportunity within the hospital. He would be close by but not a day-to-day part of our department. He was excited and proud and we were excited and proud for him.

Rondell was a product of our community. Born in our hospital 32 years earlier. He had kin who also worked for our hospital. He started as a security guard at 18 and after a brief stint in the military had returned. He had been a registration clerk in our department for about eight years. Essentially a front line support person.

The second time we said goodbye was at his funeral 10 days later. He died unexpectedly and suddenly, surrounded and cared for by those he had cared for. It was a truly beautiful funeral service attended by several hundred people. Rondell had a large family and many friends.

There also were people from literally every nook and cranny of our hospital.  Nurses, techs, administrators, and physicians. The local Police and Fire Departments were also well represented. Gathered to say goodbye to this special man.

All organizations have their Rondell’s. They are vastly more important than their titles imply. They are the ones who hold us together. They define our institutions. Mr. Rondell William’s was no exception.

positive energyWhat made him so special? It was simple. He literally was an endless reserve of positive energy. It was bottomless. He distributed it freely and without reservation to everyone. To  patients, their families, EMS and Police, and especially our staff. He knew everyone’s name, and of course there were the handshakes.

Rondell cultivated a personal relationship with everyone he encountered. It came in the form of his greeting to you (Dr. Ahhh-din-aro!), and a death grip handshake with various elements of dapping (or a big hug) each specific to the individual. Ours ended with the phrase “Semper Fi”!

Then came the hook. The thing he would talk to you about. The thing you would bond over. For me it was men’s suits and shoes (“looking great Dr. Adinaro!) for others it was just as private and unique. The effect on the recipient was universal. It made your day just that much better. He was a walking confidence booster. Until he was about to leave he never told us how proud he was of us. But we knew. His care of us was intentional and much needed.

We ER folk all wear a certain amount of armor to cope with the sadness, violence and loss that we experience on a daily basis.  We all do a certain amount of whistling past the grave yard. Our humor can be somewhat ghoulish. Then we go home and try to put those feeling behind us. To forget the parts of the world that both repel and attract us.

Grief and mourning are profound and difficult things for everyone. But it feels particularly difficult for those on the front end of healthcare. There is no distance. You must mourn while you take care of others. You must grieve  while seeing others sick or dying. You must confront your own mortality.

His death sent a shock wave through the close knit staff of the Paterson ER. Those first few weeks were very difficult. The loss of one of our own gets under that armor.  Our success at coping with the normal grief we experience is varied. Some days good. Others not so much. The loss of one so close tests our coping mechanisms.

04a_t607Most nurses and doctors show some form of burnout after a few years. We blame it on the long hours, intense situations, working nights, but rarely accept exposure to death as one of the causes. For me it was trouble sleeping. More specifically of being afraid to go to sleep because I might not wake up. It started after the loss of my Sister-in-law and was intensified by the job that I love and it lasted for years. It was accompanied by intense bouts of depersonalization.

Until I wrote those words just now maybe I had told two people besides my wife about that. It is not in the DNA of physicians to talk about the effect their careers have on their mental health. I suspect the same thing is true for nurses. It is embarrassing to admit that it might not be healthy for me to be an emergency physician any more.

quality-assurance-cultureIt has now been a few months since we lost Rondell. He is far from forgotten and I think about him frequently. The department has continued on. New bonds and support systems have formed. Many, I suspect, inspired by this great man. I sleep better at night and am less afraid. Writing and talking has helped as well as drawing courage from those close by. I am still willing to chase the tail of the tiger who can bite me.

I hope these words are a comfort to others. And that Rondell’s family knows how much we loved him.

Semper Fi.


The 5-Tools of Physician Leadership in the 21st Century

moneyball posterVery rare to come upon a young man like Billy. Who can run, who can field, who can throw, who can hit and who can hit with power. Those five tools you don’t see that very often….we’re looking at a guy who is a potential superstar.” (Moneyball, 2011)

 

In the movie MoneyBall they refer to the lead character (played by Brad Pitt) as being a five tool player when he was being recruited out of high school. Being a 5-tool player mean being able to (for both average (1) and power(2) ), throw with speed and accuracy (3), field (4), and is fast with great base running skills (5). It is acknowledged that most players only have 2 or 3 of these and that a true “five tool baseball player” is rare.

All physicians are leaders. We lead clinically every day. We provide leadership as we care for patients, supervise residents and medical students, and interact with all the other allied health providers. the concept of the 5-Tools of Physician Leadership is geared to those that provide leadership to other physicians.

I believe that there are also five vital tools that Physician Leaders in the 21st Century need to have. They address the fundamental thing we need….the ability to lead change in chaotic times.  The more they hone these skills the more successful they will be. Like in baseball very few will be perfect in all five .

The tools that physician leaders need to  have are:

  • Solid and respected clinical skills (1)
  • Comprehensive communication skills (2)
  • The abilities to Create (3), Execute (4) and Sustain (5)

While the first two are hardly “new”, the emphasis on creating, initiating and sustaining change are a 21st century phenomenon.

Clinical Skills:

tt-positions-greenNo matter how much the practice of medicine changes or will change it is ultimately a conservative and somewhat insular discipline. While we practice many specialties there are commonalities: The experience of medical school and residency and the focus on patient care. Without a solid clinical base recognized either from years of clinical practice or possession of coveted knowledge it is unlikely other physicians will follow you. Furthermore the perception that you are no longer sufficiently clinical (ie swinging a hammer) can also reduce your value on clinical matters. Simply put physician leaders must stay grounded somehow in the clinical world no matter how difficult that could be time-wise.

Communication:

email picThis is perhaps the most difficult of the 5-Tools to define. It takes some courage to get up in front of your distinguished peers and tell them to do something.
It is even harder to get them to listen. We are used to communicating with each other clinically. But this is different. You have to find both universal messages that work for all physicians but also appeal to the differences within and between specialties.

Communication also requires mastering different media. In an average sized hospital it would almost be impossible to communicate only in person. Most physicians (40ish and above) can be reached reliably through emails. Very few physicians under 30 these days ever open email and prefer texting and other mobile app based venues.

Create, Execute and Sustain:

technologyMedicine is becoming more integrated, more coordinated and requires cooperation across not only specialties but also disciplines (nursing, allied health, etc). If physicians are to lead they must be able to influence the way care is provided. Physicians should be well suited for these tasks. From 3rd year of medical school on we have been creating differential diagnosis, initiating treatment plans and sustaining the attention required to complete our rigorous training.

These three tools though are separate and unique. We have all met physicians who have great complex ideas that they expound upon at every staff meeting. They have vision and passion (to create) but are unable to translate that into action or sustained results.

On the opposite end is the physician who is frequently belittled by colleagues but loved by chairs. She or he is always the first one to turn in their required paperwork, is never late with their charts, and carries forward the protocols and policies of their department (the Sustainer).

The Executor is like the shock troop of change management. Able to rally their medical staff or department and charge full force into the unknown. They are able to translate the creative ideas into action and start the ball rolling. They understand the pros and cons of the change and provide the energy to get the initial job done. Like the Creators however they frequently lose interest after a while and sustained change is threatened.

Summary:

As stated earlier it is rare to find a truly 5-Tool Physician Leader. Some of the most successful I have known only possessed 2 or 3 but were smart enough to surround themselves with others who possessed the other tools. It is important to remember that while these tools are vital to a physician leader they are not the only skills needed. Comfort with data and analytics (both Big and Little Data) along with a fundamental understanding of finances and budgeting are crucial as well.


The Anatomy of a Super ER – Part Two

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Part One of Anatomy of a Super ER started with the morning ritual of change of shift and set the scene by highlighting what Paterson ER has to offer in terms of space, staff and technology.

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Part Two will follow the action of the day highlighting the processes in place to treat a large number of patients efficiently while also ensuring that those with specialized needs get cutting edge care.

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ED blueprint

ED Treatment Areas

By 11 am all 100 treatment areas are open. Until well past midnight all these beds will be in nearly constant use. In a perfect world some beds would always be open for incoming patients. But the world is rarely perfect.

 

Beds typically will remain empty for only as long as it takes for the first patient to leave and the next patient to be moved into it. At times demand will exceed this capacity anywhere from 10-40% (11-14 patients for every 10 beds). Configuring operations to be lean and efficient are key to handling the constant demand.

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CAPACITY / DEMAND

ed-signPatients arrive to the ED by different methods but enter only one of two ways : through the waiting room or the ambulance entrance. The majority (85%)  will “walk in” and present to the triage desk in the waiting room. However, critical patients will be included in this flow of humanity. Nearly 1/4 of all heart attack and stroke patients along with a smattering of patients with gunshot wounds will “walk in”.

 

TRIAGE was created as a way to “sort” patients and then expanded to capture relevant and mandatory data. This expansion beyond the purpose of sorting has made “traditional” triage time consuming (5-10 minutes per patient) and a major bottleneck. Patients can end up waiting to complete triage even when a treatment bed is open.

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In order to meet the demands of the up to 30 patients an hour who are arriving, Paterson ER has been re-engineered to streamline care. Paterson ER has a PIVOT or abbreviated triage  that is conducted within 10 minutes of arrival.

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This brief evaluation (age, chief complaint, heart rate and pulse oximetry) gets back to the basics of sorting the patients by acuity but also goes a step further and assigns patients to specific queues. Even though it takes about a minute to complete the accuracy of acuity and location assignments are very high.

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A second part is ensuring that the patients’ needs match the workflow of the area they are sent to. This means trying to keep the patients who can remain ambulatory and upright out of beds that have average lengths of stays in the hours.

supertrack flowMost ambulatory patients are treated in our Supertrack. The physicians and nurses in this area are focused on patients who can walk and generally only need 1-2 tests/treatments. A good example would be patients with complaints of localized injuries (cuts, joint pain, wrist fractures) or limited medical complaints (moderate asthma, viral symptoms, etc). At Paterson ER this enables a 9 bed treatment area to have 15-18 patients in process. The creation of virtual beds reduces time to be seen by physicians and total length of stay. The average patient in Supertrack is in and out in under 100 minutes.

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SUPERTRACK – Similar to the concept of the Fast track where patients with noncritical complaints are sent for care with the idea of keeping them out of the Main ED and speeding their care. In the Supertrack patient are seen in private treatment areas but then moved to internal waiting areas while awaiting tests to be completed. Currently over 100 patients a day are treated and discharged from these areas.

 

mc-1119l-l1doctorrstOf course some patients need the opposite of this. They need more monitoring and time. One of these groups are elderly patients. The 20 bed SrED (Senior or Geriatric ED) cares for the majority of patients over 65 years old. While the needs of this group are tremendously variable there are some commonalities. They need more extensive examinations and history taking including a review of all medications.The probability of serious illness or injury is also much greater.

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Seniors tend to benefit from a quieter and better lighted area as well as thicker mattresses to prevent pressure injuries. The SrED staff has received special training on the care of these high-risk patients. With the help of this dedicated area the average door to doctor time for Seniors is between 15-20 minutes.

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Lives Saved While You Wait

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The majority of patients seen on this day will go home (nearly 90%). However some will arrive in critical condition and need immediate life saving interventions. For them any amount of delay can be deadly (SEE Code Black). These are the patients that emergency nurses and physicians live for. Their care is based on the single minded belief that you put yourself next to the critically ill/injured patient and treat them aggressively. The resuscitation of a critical patient is a full contact sport.

04a_t607Rarely is that team composed only of emergency department personnel. Frequently what the patient needs must be drawn from the expertise of the entire hospital (SEE trauma team). This care must be coordinated and time compressed. The immediate goals are stabilization of the ABCs (airway, breathing and Circulation) with preparation for definitive care. [That definitive care includes cardiac catheterization for patients suffering heart attacks and emergent surgery for select traumatic injuries]. As many interventions as possible are performed simultaneously. For those involved time stands still and attention narrows only to this one patient.

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tt-positions-greenTRAUMA TEAM – Several times a day a page goes out “TRAUMA ALERT ADULT ED”. This summons a large group from within the ED and across the hospital. The team is led by a board certified trauma surgeon and includes an emergency physician and resident (critical for airway management), surgical residents, ED nurses and med techs, respiratory therapists, and radiology techs (xray and CT). The activation of the trauma team also puts a CT machine on hold, blood products on standby for emergency transfusions, and alerts the OR staff of the possibility of an emergent case (one OR is always on standby).

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The transition from day to night will see the same cycle. Patients come and go. Handoffs between staff attempting to make care seamless. Towards midnight the pace of incoming patients begins to slow and areas that opened at 8 am or 11 am  are now closing down. By four am only a few patients will appear as the night team finishes up the care of their patients. 7 am is just around the corner when the day will start all over again….

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Written by:

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David Adinaro MD, M.Eng., FACEP

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professional david adinaroDr. Adinaro is the Chief Medical Information Officer and Patient Safety Officer for St. Joseph’s Healthcare System in Paterson, NJ. He remains active as an emergency physician in the Paterson ER. Dr. Adinaro can be reached via  @PatersonER .

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This publication represents the personal opinion of the author and does not reflect his employer.