Letting your fellow/resident work on someone despite probable futility...

[deleted697535]

Is the word “provider” also used commonly outside of the US? Say it isn’t so.

Well it is, but its assumed that all 'providers' are docs. Ive never seen a single CRNA. There is the odd PA knocking but no one mistakes their training with ours.

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[67552931811]

Well it is, but its assumed that all 'providers' are docs. Ive never seen a single CRNA. There is the odd PA knocking but no one mistakes their training with ours.

May I ask which country this is? I’m making a list of exist strategies. You can PM me if you don’t want to share publicly.

Thank you!

 

[mumixam]

It seems like I'm in the minority by being a bit repulsed by this. It seems very disrespectful to the patient and their family. The idea of doing futile chest compressions and chest tubes for my loved one so that a resident will supposedly learn something feels vulgar to me. Although, I guess the difference is that I would change my loved one's code status far before most.

Not to mention the ballooning costs and inefficiencies this causes in an already strained system, particularly in the ICU.

just my $.02

 

[Vandalia]

Not to mention the ballooning costs and inefficiencies this causes in an already strained system, particularly in the ICU.

just my $.02

I don't see much cost. The marginal cost of any supplies used would be negligible. As long as you are not injecting Alemtuzumab just to see what happens. Staffing is pretty much the same regardless of the census.

And I doubt this is taking place in situations where patients are backed up in the ED and staff are fainting from exhaustion.

 

[chocomorsel]

I don't see much cost. The marginal cost of any supplies used would be negligible. As long as you are not injecting Alemtuzumab just to see what happens. Staffing is pretty much the same regardless of the census.

And I doubt this is taking place in situations where patients are backed up in the ED and staff are fainting from exhaustion.

Everything adds up. Opening a crash cart is hundreds if not thousands of dollars. Zoll pads, chest tubes, ET tubes, IV tubing, IV drugs, needles, syringes.
All that, is not negligible. That’s the problem with this country. We have no idea how much any items cost in healthcare. And many assume it’s “negligible”.
It is not “negligible”. You may not see the cost. But someone does.

 

[Siggy]

Everything adds up. Opening a crash cart is hundreds if not thousands of dollars. Zoll pads, chest tubes, ET tubes, IV tubing, IV drugs, needles, syringes.
All that, is not negligible. That’s the problem with this country. We have no idea how much any items cost in healthcare. And many assume it’s “negligible”.
It is not “negligible”. You may not see the cost. But someone does.

1. Hospitals with residency programs get, at worst, really cheap staff and coverage by paying people with doctoral level training ~$15-20/hr when you take into account the amount of hours actually worked.

2. Hospitals with residency programs get, at best, a lot of extra pay to actually pay for training... including the costs of 'wasted supplies.'

3. If I had the choice of paying thousands of dollars here or there for futile care to assist training or pay for the person who manages the hospitals Twitter and Facebook feed... I'd rather pay for the training.

 

[Vandalia]

Everything adds up. Opening a crash cart is hundreds if not thousands of dollars. Zoll pads, chest tubes, ET tubes, IV tubing, IV drugs, needles, syringes.
All that, is not negligible. That’s the problem with this country. We have no idea how much any items cost in healthcare. And many assume it’s “negligible”.
It is not “negligible”. You may not see the cost. But someone does.

First, don't confuse the billed price with the actual price the hospital pays.

Second, as mentioned, this is included in the government reimbursement for GME. It is expected that a resident/fellow is going to use more resources than an attending physician in a community hospital.

Third, if you want to look at the global cost to the system, what is the cost of supplies for an attempted procedure on someone who will not survive, versus the cost of a couple extra days of ICU care from a procedural complication in the patient who will?

 

[chocomorsel]

First, don't confuse the billed price with the actual price the hospital pays.

Second, as mentioned, this is included in the government reimbursement for GME. It is expected that a resident/fellow is going to use more resources than an attending physician in a community hospital.

Third, if you want to look at the global cost to the system, what is the cost of supplies for an attempted procedure on someone who will not survive, versus the cost of a couple extra days of ICU care from a procedural complication in the patient who will?

Whatever cost I am looking at, there is still a cost. It is not free.

Second, yeah, the resident is going to use more resources. Some of those, if not most of those resources are in the time spent teaching them. Not necessarily tangible resources. Throwing away money on futile care for the sake of learning is still a wasteful practice. Go to a stimulation lab or a cadaver lab or pay attention or do more electives.

Thirdly, are you saying that if residents don't get to practice on dead/dying people, it's going to lead to more complications? Isn't that the whole point of residency and working with attending? Having attending guide you on how to do procedures on live patients? Not let you loose on your own to practice when you have no clue to what's going on?

Lastly, that person that you are practicing on for the sake of resident education, does he/she not have any rights and not want to be possibly violated for the sake of resident learning? Or are they just a corpse to play with? As someone else brought up, how does their family feel about it? They may not be in agreement with it and neither may the patient.

No need to be wasteful, and no need to abuse a human being and extend their suffering for the sake of "learning" and "practicing" and because we get government subsidies for it.

 

[chessknt]

1. Hospitals with residency programs get, at worst, really cheap staff and coverage by paying people with doctoral level training ~$15-20/hr when you take into account the amount of hours actually worked.

2. Hospitals with residency programs get, at best, a lot of extra pay to actually pay for training... including the costs of 'wasted supplies.'

3. If I had the choice of paying thousands of dollars here or there for futile care to assist training or pay for the person who manages the hospitals Twitter and Facebook feed... I'd rather pay for the training.

I for one am curious to know the true costs of central line kits, IVs, antibiotics, epi pushes etc etc. I know it isn't the astronomical billed cost but do you think it's socialized medicine low like $0.50 for a bag of zosyn or $4 for a central line kit? I think it is high enough where the futile crrt bicarb pushes on lactate 20 septuagenarian with baseline function of mobility cart only isn't negligible in the slightest.

 

[Siggy]

I for one am curious to know the true costs of central line kits, IVs, antibiotics, epi pushes etc etc. I know it isn't the astronomical billed cost but do you think it's socialized medicine low like $0.50 for a bag of zosyn or $4 for a central line kit? I think it is high enough where the futile crrt bicarb pushes on lactate 20 septuagenarian with baseline function of mobility cart only isn't negligible in the slightest.

I'm only saying that it's negligible when compared to all of the other waste in healthcare... and it's a waste that the hospitals themselves are reimbursed for in terms of cheap labor and higher reimbursement. Sorry, I refuse to cry for HCA's or Tenet's shareholders because a few extra kits got used and now they can't buy their second boat. If it's a University system, the amount of waste in academia across the university itself is enough of a joke in and of itself.

 

[chocomorsel]

I'm only saying that it's negligible when compared to all of the other waste in healthcare... and it's a waste that the hospitals themselves are reimbursed for in terms of cheap labor and higher reimbursement. Sorry, I refuse to cry for HCA's or Tenet's shareholders because a few extra kits got used and now they can't buy their second boat. If it's a University system, the amount of waste in academia across the university itself is enough of a joke in and of itself.

So then your solution is to continue to add to the problem. Because we are already wasting so much.
Ok.

 

[Radetzky]

Why do you assume the extent of the waste is a few pieces of kit. Many instances of futile care result in temporary survival, or delaying the inevitable. The ICU bed that this unfortunate soul ends up cared for in the few days that we delay the inevitable is damn expensive.

 

[chocomorsel]

Why do you assume the extent of the waste is a few pieces of kit. Many instances of futile care result in temporary survival, or delaying the inevitable. The ICU bed that this unfortunate soul ends up cared for in the few days that we delay the inevitable is damn expensive.

I took a dead patient to the OR once. As a senior resident many moons ago. Huge patient weighing about 200kg, saddle embolus, coded three times in ER and ICU, and the ICU attending was doing chest compressions as I pushed rescue drugs on the way to the OR. The ICU attending, my attending and I were all on the same page about this being futile care even though the surgeon kept saying, "We can crash onto bypass within 20 minutes". Liar. Instead of trying to stop the surgeon, my ICU attending (weak) went along with it because she had no spine, all the while complaining and agreeing with me. We, (I) spent all night on Bypass, roughly 8 hours, were unable to come off on seven/eight cardiac pressors/inotropes, so we switched to ECMO, the patient spent 24-48 hours on ECMO before they did an EEG that surprisingly showed no sign of activity :-0

You know what I "learned" from that whole ordeal? Not to take dead patients to the OR. Not to waste people's time, hospital resources, human product resources and that we are all meant to die someday. I called the chief of surgery towards the morning to see if he would stop this madness once the decision was made to transition to ECMO. He did not do s hit. I wish it had been our trauma surgeon. He'd have walked in in his cowboy boots and said stop this madness!! Guess trauma surgeons unlike cardiac surgeons know when to stop.

I bet that cost was "negligible" in the grand scheme of things. What's $100-200K really? Just a drop in the giant bucket of money that falls from heaven.

 

[leviathan]

Death isn't a bad outcome.

And dead people, of any age, don't care about "being coded".

Resuscitating to severe disability is my only fear -- otherwise, I have no problem "flogging" a dead person if it helps the staff, family, or trainee education.

In contrast, I have severely regretted placing a conscious person on mechanical ventilation. Ugh.

HH

People always use broken ribs to scare people about CPR. Like they're dead so it doesn't really matter , they're not feeling it.

Except when they are resuscitated and then die 5 days later in agony from pain and all the other medical issues.

 

[Siggy]

People always use broken ribs to scare people about CPR. Like they're dead so it doesn't really matter , they're not feeling it.

Except when they are resuscitated and then die 5 days later in agony from pain and all the other medical issues.

People who use the broken ribs argument don't know how to have goals of care. You're going to get a lot more bites with the "Let's make them comfortable... and you know who does that really well? Hospice. However we're still going to take care of them... it's just a different goal."

 

[Siggy]

I'm going to idly wonder how many people here are going to talk a big game about futile care, yet still start the 3rd pressor on the full code, end stage dementia patient in MODS because they can't talk the family into hospice care. I'm also willing to bet that those codes are at least 10 minutes.

 

[chessknt]

I'm going to idly wonder how many people here are going to talk a big game about futile care, yet still start the 3rd pressor on the full code, end stage dementia patient in MODS because they can't talk the family into hospice care. I'm also willing to bet that those codes are at least 10 minutes.

It's the United States of America bro. Every 85-year-old demented patient has the right to die intubated after 15-plus minutes of CPR. It's in the bill of rights didn't you read it? Plus if I succeed I get my cardiology colleagues a balloon pump or an Impella so that way they can pay off the next Tesla.

 

[VA Hopeful Dr]

I for one am curious to know the true costs of central line kits, IVs, antibiotics, epi pushes etc etc. I know it isn't the astronomical billed cost but do you think it's socialized medicine low like $0.50 for a bag of zosyn or $4 for a central line kit? I think it is high enough where the futile crrt bicarb pushes on lactate 20 septuagenarian with baseline function of mobility cart only isn't negligible in the slightest.

IV zosyn is about $7, a syringe of bicarb is about $10, epi used to be like $1/vial but there was a supply issue so it's up to around $20 an amp now.

An IV kit is around $5 and I don't think it's unfair to multiple that by 10-15 for a central line tray.