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Viewpoint: The National Panic Button: Taming ED Crowds with the Cloud

2011; Lippincott Williams & Wilkins; Volume: 33; Issue: 7 Linguagem: Inglês

10.1097/01.eem.0000399753.80405.1b

1552-3624

John Ogle,

Emergency and Acute Care Studies

Image“Centurion Eight Eight November, this is Denver Center. You are cleared to Mile High VOR. Hold east, delay indefinite, runway snow removal in progress.” That disturbing radio call from Air Traffic Control came in while I was flying through an icy Colorado cloud last winter. The hold clearance told me to fly circles pending further instruction. The oxygen tank was full, but the wings had trace accumulation, and fuel was down to quarter tanks. Fortunately, avionics delivered all needed data for an informed divert decision. Panic deferred. That trusty Cessna 210 predated sophisticated panic options, but today's aircraft have real panic buttons that de-ice, send Mayday calls, auto-level, or even deploy airframe parachutes. My wife and I are emergency physicians and aviation enthusiasts. As physicians and pilots, we admire the elegant simplicity of our complex national airspace system. In striking parallel with emergency medicine, flight operations are fun, technical, disciplined, and unpredictable. Best practices evolve with communications equipment. Glass cockpit screens impart amazing situational awareness. Today's flight data overlies moving maps with synthetic vision, air traffic, and weather feeds. Automated crash beacons identify locations and tail numbers. Multichannel messaging informs cloud-shrouded pilots, just as cloud computing will aid EPs. When patients or caregivers suspect medical problems, they face predictable communication dilemmas. Dial 911, hail a taxi, or call the PMD scheduling line? How to inform the closest ED? Location-aware smartphones can assist decision-making and independently route patients and medical data to nearby facilities. All these thoughts race through my head, especially when I'm waiting for a consultation, like I was during a recent phone call during the night shift that managed to transcend all five stages of grief in just 60 seconds. Denial: 0 Seconds The night was stormy, and the department was filling up, but it wouldn't be a black cloud night. Awaiting prompt connection to a primary medical doctor, I fidget on telephone hold. My attention drifts through the glass doors by the ambulance bay to unusually grey skies north of Denver. Severe storms had stalled regional air traffic, and colorful, cockpit-like tracking boards indicate regional EDs were backing up in sympathy. Fingers involuntarily multitask when hold music plays. Clicking through my patients, three have the same chief complaint: shortness of breath. One is a nonverbal 71-year-old nursing home patient who was tachypneic earlier; no details, no records. The second is a forgetful 60-year-old with diabetes and cancer — and a “dozen or so” unrecalled medications. The last is an intoxicated 47-year-old with epigastric pain who says “the doctors already got EKGs” during his military years, and he is not sure why, when, where, or what they showed. Panic light: Off. Personal attitude cloud: white. Anger: 25 Seconds Everyone was pleasant at first, but patients' patience, my tolerance, and family cheer deplete like airplane fuel in a holding pattern. I'm mad about frustratingly nondiagnostic EKGs and emergency medicine's perverse inability to retrieve external medical records. The registration desk has full access to credit scores and insurance data before clinicians visualize the first comparison electrocardiogram. No response from the covering PMD. The 2009 American Recovery and Reinvestment Act allocated $19 billion toward electronic health records, but pulling outside medical records is low yield. Why can't they be pushed to me? We all understand privacy concerns, but that same year, the penalty for HIPAA violations climbed from $100 to $50,000 per breach! Did someone forget that the “P” in HIPAA stands for portability? Panic light: Flickering. Personal attitude cloud: light gray. Bargaining: 35 Seconds Decision-making in emergency medicine is similar to aviation. Everything is time-limited, and professionals know when to abandon a task. As I scan for immediate, problem-focused, actionable information, an optimistic colleague reminds me that a momentary glance at a faxed EKG can trump hours of history-taking. Flying through cloudy Rocky Mountain turbulence is disorienting and challenging for amateur pilots like me. Blinded in low visibility (instrument) conditions, the bargaining begins. Information requirements deteriorate to absurd basics: Which way is up? What's my altitude? Where's the nearest mountain? How close are others? Where's the nearest landing field? Airborne fire and failure checklists are like ED code algorithms, simple and direct. Like a primary survey in ATLS, the Air Force trains pilots to become temporarily nearsighted when confronting in-flight emergencies. Flyers prioritize three crude goals: aviate, navigate, and communicate. EPs prioritize similarly: resuscitate, evaluate, and facilitate. Critical actions are common to both: Maintain airway/aircraft control; analyze the situation and take corrective action, reassessing frequently; and expedite patient disposition/attempt to land ASAP. A few more seconds, and I'm hanging up. Panic light: Yellow. Personal attitude cloud: dark gray. Depression: 45 Seconds (Seems Like 45 Minutes) Sadly, efforts to retrieve external records were futile. I consider myself a competent clinician but concede my limits. Last year while accompanying an aging family member to an unfamiliar ED, my contribution to that encounter was embarrassingly insubstantial. Adding only moral support, I shamefully could neither recite a complete medication list nor describe a baseline EKG on my relative's behalf. Imagine a nauseous and humble physician in the ultimate panic hardware: an F-15 ejection seat. On bailout, useful information is automatically broadcasted. Soon, distressed patients will use aviation-inspired panic button apps to send alerts to nearby EDs — with medical data attached. Panic light: red and steady. Personal attitude cloud: black. Acceptance: 55 Seconds (I'm Hanging Up) Acceptance speech: I will not blame patients, staff, the President, or PMDs for data stagnation. Instead, I embrace patient-centered cloud computing. When patients (or caregivers) press a panic button app on their mobile device, the encryption hardware (SIM card) signs and dispatches an upwind signal that will trigger a cascade of events. The user is privately authenticated, and proximity queries locate EDs near the user's position. Routers align patient requests with appropriate EHR(s). Servers fetch and forward current clinical snapshots. Before the ambulance rolls, customized data are assembled and launched downwind to us, arriving well ahead of the patient. Operating in clouds can be frustrating, but cloud computing enables a novel national panic button option. Patients can and will electronically push secure, filtered medical data directly to our emergency departments. Panic light: Off. Personal attitude cloud: bright (with silver lining). Comments about this article? Write to EMN at[email protected]. Dr. Ogleis an Air Force Flight Surgeon and Chief of Aerospace Medicine for the 153rd Medical Group. Balancing civilian emergency medicine practice with Air National Guard service, Colonel Ogle has served in Iraq and Afghanistan, and he is an instrument-rated FAA commercial pilot. Comments on emerging “ER push” notification strategies are welcome atwww.NationalPanicButton.com. In Brief Hispanic Americans Less Likely to Recognize Stroke Symptoms While stroke, heart disease, and other cerebrovascular diseases are the fourth leading cause of death in Hispanics, findings suggest that they are less likely to recognize the signs and symptoms of stroke. Approximately 795,000 strokes occur each year, and stroke and heart disease account for one in four deaths among Hispanic men and one in three deaths among Hispanic women, prompting the American College of Emergency Physicians to call for increased awareness in the Hispanic community. According to the Office of Minority Health, Hispanics between the ages of 35 and 64 are more likely to suffer a stroke than non-Hispanic whites. In a survey of 2,000 women about stroke, Hispanics were less aware of the signs and symptoms of stroke than Caucasians, and in a separate study of 25,426 individuals, non-Englishspeaking Hispanic Americans were less likely to identify the signs and symptoms of stroke or recognize the need for immediate medical attention, compared with those who speak English. “Stroke can occur suddenly and without warning,” said Juan Fitz, MD, an ACEP spokesperson and an assistant medical director of the emergency department at Covenant Medical Center in Lubbock, TX. Dr. Fitz rushed his own wife to an emergency department when she began experiencing the signs and symptoms of a stroke. “When my wife's face began to droop and she couldn't speak, we immediately sought medical attention which we believe helped aid in her recovery.” Emergency physicians can educate their Hispanic American patient about the six primary signs and symptoms of a stroke: Sudden numbness or weakness on one side of the face; facial Sudden. drooping numbness or weakness in an arm or leg, especially on one side of the body. Sudden confusion, trouble speaking, or trouble understanding speech. Sudden trouble seeing in one or both eyes. Sudden trouble walking, dizziness, loss of balance or coordination. Sudden severe headache with no known cause. Patients can also be taught the National Stroke Association's FAST test as a quick screening tool: Face: Ask the person to smile. Does one side of the face droop? Arms: Ask the person to raise both arms. Does one arm drift downward? Speech: Ask the person to repeat a simple sentence. Are the words slurred? Can he repeat the sentence correctly? Time: If the person shows any of these symptoms, time is important. Immediate medical attention may limit the effects of stroke. Call 9-1-1 or get to the hospital. Brain cells are dying. For more information about Hispanics and stroke, visit www.stroke.org.