the Natural Condition

Health Affairs released a report yesterday (March 10th) that outlined trends in American Emergency Department wait-times between 1997 and 2004. They considered three overlapping cases: all patients (18 and older), patients with ‘emergent’ conditions as indicated by triage staff (should be seen within 15 minutes), and patients with an eventual diagnosis of acute myocardial infarction — heart attack. On the whole, the median wait time to see an ED physician increased 36%. While wait times for ‘all patients’ and ‘emergent patients’ increased by about 40% per year (22 to 30 minutes, and 10 to 14 minutes, respectively), the change in the ‘AMI patient’ wait time dwarfed them both:

During the 7 years examined, the median wait time for patients eventually diagnosed with AMI increased by 150%, from 12 minutes in 1997 to 20 minutes in 2004. That is truly shocking news. Cardiogenic-shocking news, to be precise (pardon the pun).

In the decade from 1994 to 2004, total ED visits increased by about 18% (from 93 million to 110 million, annually). Emergency Department closures — as many as 12% during the decade — compounded the boom in visits. “Other likely contributors include inpatient bed shortages leading to bottlenecks in the ED; increasing uninsurance; population aging; shortages of staffing, space, and interpreters; and difficulties assuring non-ED follow-up care.” The sum of which totaled to a crucial deferral of care in the neediest patients. The authors of the paper raise the important point that staggering wait times, or even the misgiving of staggering wait times, will cause many prospective patients to avoid the ED altogether.¹

Wide-angle reports like this one demonstrate that all the ingenious, expensive, life-saving interventions are worthless if we do not first step back and survey the simple obstructions to keeping people healthy. We might do well to count something on this scale more often.

Reference:
(1) Waits To See An Emergency Department Physician: U.S. Trends And Predictors, 1997–2004. Health Affairs. 2008. [full text - restricted access] The full article contains many more interesting statistics about wait-time changes in sub-populations (race, gender, region, etc.).

The situation: you are by yourself, and you begin to have severe chest pain, followed by acute vertigo. You are having a heart attack, and moments later you feel like you are about to faint. With a few seconds left before you lose consciousness, what do you do?

In truth, you should dial 911 on your cell phone. But after that… cough, deeply and forecefully, about once every 1 to 3 seconds. Long derailed as a hype product of the devious “world-wide web,” improvised ‘cough CPR’ may actually have some merit, according to some cardiovascular researchers. The idea of coughing to sustain arterial pressure and to induce blood flow first appeared in the Journal of the American Medical Association in 1976¹. Therein, the authors purported that coughing during ventricular fibrillation not only kept several patients conscious for up to 39 seconds after the onset of VF, but that coughing maintained arterial pressure at almost 140mmHg, compared to only 60mmHg for traditional chest compressions. That is, they indicated that ‘cough-CPR’ could have advantages over normal CPR.

And while the American Heart Association, formally and adamantly, does not endorse the maneuver², scientists continue to demonstrate that coughing during a heart attack can actually help blood circulate. The picture below shows the EKG Read the rest of this entry »