Editore"s Note
Tilting at Windmills

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January 3, 2008
By: Kevin Drum

SOME ADVICE ON WHERE TO HAVE YOUR NEXT HEART ATTACK....One of the lessons from Shannon Brownlee's book Overtreated is that you really ought to avoid hospitals. Today, a new report puts some meat on those bones:

People who suffer cardiac arrest are more likely to survive if they are in a casino or airport than if they are in a hospital, researchers said today.

....A new study shows that only a third of victims in hospitals survive — primarily because patients do not receive life-saving defibrillation within the recommended two minutes....For reasons that are not clear, black patients were less likely to receive the treatment within the two-minute window.

Bottom line: in airports and casinos, half of all cardiac arrest victims survive. In hospitals, only a third survive. So if you're smart, you'll have your cardiac episode in an airport, not a hospital. If you're black, you'd be super smart to do so.

Kevin Drum 11:17 AM Permalink | Trackbacks | Comments (31)

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Could it be that people in hospitals are sicker than people in casinos and airports, and therefore less likely to survive the heart attack in the first place?

It would be interesting to control the data to compare hospital *visitors* to casinos and airports, which would be a more valid comparison.

Posted by: Greg Abbott on January 3, 2008 at 11:21 AM | PERMALINK

what greg said

Posted by: stoneyforest on January 3, 2008 at 11:27 AM | PERMALINK

At least part of the apparent discrepancy arises because hospital patients are sicker to begin with, whereas those who suffer attacks in airports and casinos generally don't have underlying illnesses or symptoms, said UCLA cardiologist Gregg C. Fonarow, who was not involved in the study.

This passage pretty much echoed what I was thinking (and what Greg above mentioned.)

The key piece of data seems to be treatment in the two minute window, which doubles the survival rate among hospital-goers. And even though numbers could be biased by situational differences.

Posted by: Royko on January 3, 2008 at 11:28 AM | PERMALINK

'those', not 'though'

Posted by: Royko on January 3, 2008 at 11:29 AM | PERMALINK

Could it be that people in hospitals are sicker than people in casinos and airports...

Posted by: Greg Abbott

FWIW, this is exactly what my cardiologist -- with 30 years experience -- said when I confronted him with the news.

One would think that the study controlled for age, etc., wouldn't one?

Posted by: Econobuzz on January 3, 2008 at 11:29 AM | PERMALINK

The other factor mentioned in the article is that people who keel over in the middle of an airport or casino are likely to be noticed immediately.

Patients in hospitals may be already lying in bed in a 'non-public' room and may not get noticed as quickly. The study excluded patients hooked up to heart monitors etc.

Posted by: Buford on January 3, 2008 at 11:30 AM | PERMALINK

Sure, everyone gave him a hard time at the time, but this is all John Tanner meant when he said "minorities die first."

Posted by: shortstop on January 3, 2008 at 11:36 AM | PERMALINK

Well Duhhhh - put slot machines in every Hospital in America.

Posted by: RobertSeattle on January 3, 2008 at 11:39 AM | PERMALINK

The casino thing seems quite obvious. They need to get you back up and gambling asap.

Posted by: Ahoyhoy on January 3, 2008 at 11:48 AM | PERMALINK

Back in the early 80's when I worked in medical electronics I heard stories from BMETs at two different hospitals about being called up by a physician to fix the heart monitor because he couldn't turn the alarm off. In both cases it turned out that the patient was dead and the doctor hadn't noticed despite the annoyingly loud alarm going off.

Posted by: Stuart on January 3, 2008 at 12:04 PM | PERMALINK

Dont people die in hopitals?
Sounds dangerous to me.

Posted by: Joe on January 3, 2008 at 12:07 PM | PERMALINK

"...In both cases it turned out that the patient was dead and the doctor hadn't noticed despite the annoyingly loud alarm going off."

Sounds like an upcoming episode from "House" with the star too stoned from his pain pills to notice the difference.

Posted by: bluestatedon on January 3, 2008 at 12:10 PM | PERMALINK

Most people die in bed so stay vertical.

Posted by: Don Bacon on January 3, 2008 at 12:13 PM | PERMALINK

Glad to see there are still some numerate people around.

And anyway, the reason to avoid hospitals is opportunistic infection. Otherwise, they're a pretty good place to have a medical emergency, all other things being equal.

Posted by: bleh on January 3, 2008 at 12:14 PM | PERMALINK

Most people die in bed so stay vertical.

Yeah, I wanna die with my boots on. But in bed.

Posted by: shortstop on January 3, 2008 at 12:15 PM | PERMALINK

My wife and I have decided to spend the rest of our lives flying back and forth between Las Vegas and Atlantic City.

Posted by: Rick Howe on January 3, 2008 at 12:42 PM | PERMALINK

Well, for once, you can be too damn smart.

In the hospital when you find a pulseless patient, you call a code, and then get the crash cart, which has the defibrillator. As the code team arrives this becomes a major production.

In the casino or airport, a security guard grabs the defib pack hanging on the wall, follows the verbal instructions the machine gives for use, and hey presto! electric shock time.

Hospitals could cut their response time by hanging the defib pack in every room.

Posted by: serial catowner on January 3, 2008 at 1:13 PM | PERMALINK

Another factor is that in hospitals you have numerous sick people to treat, so the staff's attentions are divided among multiple cases, whereas in an airport or casino medical emergencies are rare, so all the emergency personnel are focused on a single case.

Posted by: Doug on January 3, 2008 at 1:15 PM | PERMALINK

Serial Catowner: My workplace has AEDs on every other floor, in every one of our very large collection of buildings.

At least two trained operators per floor -- it's saved a few lives, and I suspect we get some sort of health insurance discount off of it.

For my money, AED's are one of the best medical inventions of the last few years. I read somewhere that they're so easy to use (I'm not one of the trained operators) that they were tested by giving them to 13 year olds, who applied them correctly following just the on-box instructions about 75% of the time.

Posted by: Morat20 on January 3, 2008 at 1:17 PM | PERMALINK

Whereas I think when your heart stops - your time is up and that should be that.

Don't come anywhere me with a defibrillator or I'll use my dying breath to kick the
crap outta you.

Yeah,'no heroic measures' here. And I freakin' mean it, too.

"Society is like a stew. If you don't keep it stirred up you get a lot of scum on the top." -Edward Abbey
Posted by: MsNThrope on January 3, 2008 at 1:43 PM | PERMALINK

My department had us do the CPR/AED training and I can say that, yes, those AED machines are pretty idiotproof. They even coach you on having one person perform CPR (complete with a beat to keep you on rhythm) while the other person gets the machine ready for the shock.

(You can do it alone, but it's easier with two.)

Posted by: Mnemosyne on January 3, 2008 at 2:09 PM | PERMALINK

Whereas I think when your heart stops - your time is up and that should be that.

Um, why? AED's aren't "heroic measures", and a good chunk of heart problems are rather easily fixed.

My father's, for instance, kept trying to stop (never did quite make it!) because of a heavily clogged artery combined with a too-low dosage of anticoagulants (he's had a clotting problem since he was thirty).

It took the insertion of a stent and the adjustment of a med he's been on 30+ years, and he hasn't had a problem in 10 years. If his heart had actually fully stopped (they had the paddles out during two of his episodes before drugs managed to stabilize him), what possible difference would that have made?

I can understand not wanting to be kept alive by a machine (at least if the machine is permanent!), but your point of view seems to rule out pacemakers, revival of people whose heart stopped because they were drowning, and a huge number of other people who basically had a temporary problem.

If you're 99 and it stops because your heart is 99 years old and too old and worn out to work, that's one thing. BUt for a 20 year old who almost drowned, or a 40 year old who threw a clot, or a 33 year old with a valve malfunction that's repairable -- why should the fact that his or her heart stopped beating briefly mean they're done?

Posted by: Morat20 on January 3, 2008 at 4:53 PM | PERMALINK

While you can make out the argument that more people die in hospitals from cardiac arrests because they are sicker to begin with, isn't that also an argument that hospitals should provide faster responses to cardiac arrests, instead of slower, as apparently they do? Given that hospitals should simply expect cardiac arrests on a frequent and emergency basis, shouldn't they arrange things so that they would be faster on the draw? Isn't that kind of the job of hospitals?

Posted by: frankly0 on January 3, 2008 at 5:01 PM | PERMALINK

The point from my previous post is that, from the standpoint of efficiency of process, you'd expect that hospitals would, on average, be faster, rather than slower, than an airport, because cardiac arrests are precisely the sort of event that they are responsible for handling.

If you think of a hospital as a health cure/treatment "factory", one of the first things you'd try to correct is slow response to cardiac arrests. Doing so is inherent to their very mission.

It's really as if they refuse to take the organizational, production challenges of fulfilling their mission seriously. It's as though they're run like an old-style American auto manufacturer, gladly churning out junk product because nobody's holding their feet to the fire.

Posted by: frankly0 on January 3, 2008 at 5:13 PM | PERMALINK

Maybe we'd be better off letting Walmart run our hospitals. At least they really, really understand logistics.

Some MDs, I think, would best be suited as greeters in any case.

Posted by: frankly0 on January 3, 2008 at 5:16 PM | PERMALINK

If you're comparing people who are just visiting the hospital vs. people just visiting airports and casinos then it might have some statistical relevance, but as noted in the article and in comments above, most of the people who have heart attacks in the hospital were very sick people before their hearts stopped. How many had cardiac arrests due to their underlying illnesses or trauma? How many were in the hospital recovering from a previous heart attack? How many had "do not resuscitate" orders? Airports and casinos are filled with a randomized sampling of relatively healthy people while hospitals are concentrators of the ill and infirm. Evidence of that is in the article which states that 750,000 people have heart attacks each year in the hospital while 250,000 have heart attacks outside the hospital. I don't doubt that hospitals need to improve their response times, but this study seems more interested in making headlines than advancing science.

Posted by: anon on January 3, 2008 at 6:01 PM | PERMALINK

This seems like as good a place as any to bring up the excellent New Yorker article about hospital ICUs in the Dec. 10 issue. In a nutshell, it's been discovered that following a simple checklist when inserting tubes into ICU patients reduces infection rates by 66%--a huge deal when secondary infections are what generally kill ICU patients.

The upshot, though, is that doctors and hospitals are resisting the checklist because, basically, there's no big pharmaceutical company behind it. It's not sexy or expensive, so no one cares.

Posted by: Rob Mac on January 3, 2008 at 7:09 PM | PERMALINK

Rob Mac, I would argue that the resistance comes from a different place. As a general rule, hospitalists (doctors who only practice in hospitals, and do not see patients in an outside practice) and nursing and allied professional staff (lab, imaging services, etc) don't give a fig about big pharma, other than to snort with derision when the subject of those pigs-at-the-trough comes up.

Instead, I would lay the blame at the feet of corporate, for-profit health care (like HCA, owned by the Frist family) and what that has done to staffing.

Let me give a first-person, anecdotal example. HCA bought the ailing Health Midwest system in and around Kansas City, taking over on - you can't make this stuff up - April Fool's Day - 2003.

The first thing they did was start cutting staff. Not only do they cut staff, they do it in a really sleazy way. They institute new rules and regs that are designed to get rid of the employees that cost the most - the ones with the most seniority and time on job. The ones who know the job the best.

I was a second shift supervisor in one of their labs. Because Blood Bank is long periods of boredom punctuated by brief bursts of chaos, the blood banker tends to manage the phlebotomy crew on second (the phlebotomy crew usually has their own managment for third shift, when the "morning run" takes place, and on first shift when the outpatient lab is open). Within a year, all of my old-timers were gone. I had a crew that had been to the Community College phlebotomy program, with less experience among them than any one of the employees who had simply become disgusted and moved on.

Call me an old softie, but I tend to think that you need to keep a few of the old timers around - especially for the dialysis and ICU patients that don't have lines, have lousy veins, and must be stuck - multiple times a day. Shortly after my crew changed, I started getting three or four incident reports a week, where in the past, I had gotten one a month, maybe, and it usually turned out that my employee was right, and then I nailed the nurse, and took great pleasure in doing so. They made damn sure if they were writing up one of mine, they were on solid ground, because I would tear them asunder if they caused my people undue grief. Suddenly, the IR's were for infected sites, or wrong-arm draws, or arterial punctures - all serious transgressions. In addition, our "contaminated" rate on blood cultures went through the roof. Instead of one a month, we were getting four and five a week. This, too, is a big damned deal. You can't start an antibiotic treatment regimen without knowing what you are trying to kill - is the septic infection gram positive, or gram negative, just for starters.

Then, when I would float over to micro to read cultures on the weekends, I started noticing that the incidence of MRSA and C-Diff was ticking up. So I started going outside the lab and walking around. I noticed that I didn't recognize any of the environmental services staff. All the senior staff was gone. The straw that broke the camels back and sent me to the state was the weekend afternoon that I verified three critical care newborns with MRSA from the NICU of one of the satellite hospitals.

Staff matters. And so does experience. Adding levels, like the checklist you mentioned is resisted by staff, not because we don't care; but because they are already stretched too thin and can't get everything done.

And this is why I avoid the health care threads. I blather on and on, and still only scratch the surface. All it does is make me mad.

Posted by: Blue Girl, Red State (aka G.C.) on January 3, 2008 at 8:07 PM | PERMALINK

The upshot, though, is that doctors and hospitals are resisting the checklist because, basically, there's no big pharmaceutical company behind it. It's not sexy or expensive, so no one cares

Did you read the article? That's not what it said at all. Doctors and nurses initially resisted the idea of filling out yet another piece of paper, because this is a fairly new study and they haven't yet been convinced that it will help. However, once they tried it, they appear to have adopted the practice. I think that as soon as they are convinced that this is a) efficacious and b) workable, the practice will be happily embraced. Not being an intensivist, it's absolutely the first time that I've heard of the practice. I'm trying to think how we could apply something ilke this to primary care. It is a cool idea, but it will take some time for it to disseminate.

Posted by: J Bean on January 3, 2008 at 9:11 PM | PERMALINK

Bad commentary, bad analysis on your part, as already mentioned above. Worth repeating, however: patients in hospitals who "have a heart attack" are more likely to be dying of something other than heart disease, with the final ending matter a ventricular fibrillation, or asystole. Patients who have a heart attack in an airport or casino are probably not healthy either (i mean, travelling today, and sitting at a slotmachine?). But they are less likely to already be quite sick.
Statistics can be used to prove anything. kevin, you are as drum as bush is dumb, but you both make the same mistakes.

Posted by: Chris on January 3, 2008 at 10:28 PM | PERMALINK

Is there no reading comprehension on this thread?

Here is the relevant passage, quoted from Kevin's original post:

A new study shows that only a third of victims in hospitals survive — primarily because patients do not receive life-saving defibrillation within the recommended two minutes
Do people not understand that this implies that it is NOT because people in hospitals are sicker, etc., that they die in greater numbers, but because they don't get the appropriate life-saving treatment in time.

The question is, how can that possibly be true in a well run hospital, whose whole charge is to deal with sick people, i.e., people who are more likely than others to require rapid treatment for such things as cardiac arrest?

Posted by: frankly0 on January 3, 2008 at 10:41 PM | PERMALINK
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