OPYS Update

OPYS Physician Services at EDPMA 2013

Andre Creese, MD Part 3 of 3

Dr. Andre Creese is the CEO of OPYS (Our Physicians Your Success).  We are discussing Asset Management in context of the Emergency Room. 

In Part 1, Dr. Creese speaks of the empathic physician, “An empathic provider communicates a plan of treatment back to the patient and family with awareness of the impact.” 

Part 2 gives us an idea of how empathy for the patient started very close to home for Dr. Creese.

Part 3 0f 3

As an EMT, Andre’ Creese had struggled to keep a patient alive.  An ER doctor, speaking over the radio, guided him well past the point of where his training ended.  Later, he visited the patient at the hospital.   “Al, the toughest part of all this for me was when he grabbed my hand… so firmly and he wouldn’t loosen his grip.  I am getting uncomfortable, trying to let go… to let him know that I was just doing what was expected of me.   His eyes, they just fixed on me.  I couldn’t look away.  The raw appreciation in his grip and watery eyes, they just wouldn’t let me go.”  Soon after, Dr. Creese changed his college major from nursing to pre-medicine. 

From his residency, 1994-1998, to his current position as CEO of OPYS, Dr. Creese, maintains that, “Great skill, great hands, and great compassion” are needed for success.  I have worked around his schedule over the past few weeks.  I would add great endurance.  And there is, of course, the physician’s need accurate and concise information to compliment great hands, great skills, and even the expression of compassion.  People and equipment/systems provide this information.  Our focus is on equipment/systems (hardware and/or software).

In that discussion, Dr. Creese states, “The ER is dependent upon the systems that can be managed in part or fully by other departments.”   These are all related to the outcome of the patient.

I ask, “What about a system like 12-lead electrocardiography, ECG, transmitted from an ambulance to the Emergency Room?” 

Dr. Creese’s verbal meter increases interval and becomes determined.  “The goal of the 12-Lead ECG transmission is to reduce the time it takes for a patient to receive treatment to reopen an artery.  It has become an essential part of pre-hospital medicine. Time is tissue!  The Standard of Care is 90 minutes door to balloon insertion to open the artery.  This time is calculated from ER door to the balloon insertion performed in the catherization lab.  Ambulance transport time is not included in the calculation.  The 90 minute standard of care should include transport time decreasing the overall time to reopen the artery.

With 12-lead ECG transmitted by trained technicians, the 90 minute goal is calculated as time from the incident scene to the catherization lab.  The patient goes from the ambulance straight to the catherization lab without further triage.  The appropriate teams are prepared to act.  Treatment time is shortened, saving heart muscle.”  This isn’t just a matter of life and death but mental capacity or other severe chronic conditions.  “Yet, hospitals can struggle with acquiring the technology.”

Essential yet struggle, those were Dr. Creese’s words.  Having experienced such a deployment, I understand the struggle.   It’s not just expense Dr. Creese implicates as part of the struggle. 

There are clinical, state policy, and operational concerns:

- A cardiologist must read the transmitted ECG to determine if the patient has suffered a heart attack and where the damage is located. Onsite or off-site cardiology must be considered

- Understanding the clinical changes and requirements during the decision making process

- State approval of who in the pre-hospital environment may perform a 12-lead ECG

- Coordinating a program for geographical response with other services requires other parties to agree, train, and prepare.

There are equipment considerations:

- Defibrillators

- Mobile Phones

- The wireless service carriers

- Hardware and software maintenance

- Connectivity from the ambulance through the continuum of data storage and retrieval

- Whether or not the system increases or decrease net revenue

And there is more, most of which are dumped heedlessly into the laps of Department Heads or Clinical Mangers to drive and coordinate.  Time and pressure ingrain detrimental assumptions at every level.  The capital committee scrutinizes the attempt then kicks it back because information is missing or some part of the coordination fell apart.  If the project is ever approved, purchased, and deployed, a project manager has already been set up not to meet the timeline requirements.

One take away in regards to context is a simple reminder about medicine.   Dr. Creese’s path reflects that medicine is often both a profession and a passion, a lifelong dream come to fruition.   This aspiration of heart may be motivated by an incident or what may best be described as a calling.  In the ER, all of this passion and skill manifests daily while dealing with the uncertainty of who, in what condition, enters into their care (hands, skill, and compassion). 

Their patients - crime victims, heart attack sufferers, infected, those tittering on the edge of whatever  concept of the afterlife held dear… they require and deserve more than “this is our process” or the easy command to “cut everything across the board” without even allowing the thought that something else is possible.  Process is important.  Expense control is important.  Sometimes… asset managers  just have to challenge every assumed limitation.  We have to figure out how to overcome and persevere in helping clinical requirements fit into the financial reality.      

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Andre Creese, MD Part 2 of 3

Andre Creese, MD is the CEO of OPYS Physician Services (OPYS –Our Physicians Your Success) which provides Medical Leadership Consulting, Medical Consulting, and Physician Staffing.  Dr. Creese is Board Certified in Emergency Medicine by the American Board of Emergency Medicine and a Fellow of the American College of Emergency Physicians.

From Part 1: In the process of figuring out how to go to college, he had a brief, life altering conversation with a friend.  After the conversation, he became an ambulance driver through a two day a week, six month course. He also became EMT certified. The environment fit him well. A desire for a more extensive role grew.  He spent a total of 7 years responding to 911 calls.  One of his “most moving cases” centered on a stabbing victim.  This case focused his vision on becoming an MD in Emergency Medicine.  

Part 2 [The links lead to Google Maps or Street View Scenes]

Andre’ and a co-worker respond to a call in Barona, outside of San Diego, California, USA.   Someone has been stabbed in the chest.  People giving first aid on the scene cannot stop the bleeding.  The location is isolated. The lights strobe and the siren blares as Andre and his partner navigate around traffic and over the narrow, winding road.   

“We see (the helicopter) fly overhead, racing to get to the scene.  It has a doctor and nurse on board.  We still need to keep our pace until we get the official word.  Eventually, the call comes over the radio to reduce our code.  We turn the lights off.”   Getting there in a hurry is still required.

 “When we arrive, they tell us, ‘You have to respond.’  The helicopter can’t make the return flight.  Policy requires the doctor and nurse to remain with it.   We are amped again.  It’s dark now.   There’s police.  There’s commotion and there’s a guy lying in a pool of blood. 

“The drive to the scene was bad enough in the fading daylight, now it’s dark and the driver will not have the assistance of another person watching the road on the drive to the hospital.  Blood loss, darkness, and the winding road, our team energy is pegged.”

Andre takes charge of the patient’s care. “The feeling is surreal – when I am one-on-one with a patient in the back of our ambulance, tossing back and forth.  And someone is dying in front of me.   The person is talking but fading slowly.  You’re trying to keep him or her awake...  I couldn’t get to the hospital fast enough.  My partner couldn’t drive any faster and I am trying to do everything I can to keep this guy alive. 

“I get on the radio with a small community hospital.  The guy is still moaning.  His radial pulse goes.  There is blood everywhere.   I am at the end of my training.

“The doc comes over the radio.   This guy is crashing again.  The doc walks me well past the end of my training.    I, finally, find a pulse in the groin area and the doctor walks me through every necessary step to keep this guy alive.   When we get to the community hospital, the patient is alive.   We roll him into the ER.  The staff is prepared and he’s immediately taken to surgery.”

Andre and his partner are left with their normal after call duties:  clean the ambulance floor and walls, restock, get their uniforms together and prepare to take the next call.  “Slowly, everything is going back to what we call normal.” 

A few days later, Andre is with another partner.  They bring a patient to the same hospital.  Andre talks to his partner about the stabbing victim.  His partner and a nurse encourage him to go see the patient.    The nurse really pushes him to go to the surgical intensive care unit.  Andre gives in.   When he gets to the intensive care unit, the environment is so different than that of the pre-hospital.

“This is a place where ambulance driver don’t go.  We just take the patient to the ER and that’s it.   The ICU is brightly lit with fluorescent lights.  The background noise with all the monitors and beeps--everything looks sterile. “

The staff directs Andre to the patient.  

“I get to the bedside and I don’t recognize the patient.  He is clean and shaven not dirty and matted with blood.  He is about the same age as me.   He has all this equipment attached and dressed in a clean white gown… nothing like I remember from that night.   

“His eyes fixate on me as I tell him the story of the ambulance.  It’s really the only thing I could think to talk about.  He really couldn’t respond verbally.  When I finish… he has a different look on his face.  He gave me a nod.  He lifted his arm a little.  He couldn’t lift it very much.  I looked down at his hand.  I took it.

“Al, the toughest part of all this for me was when he grabbed my hand… so firmly and he wouldn’t loosen his grip.  I am getting uncomfortable, trying to let go… to let him know that I was just doing what was expected of me.   His eyes, they just fixed on me.  I couldn’t look away.  The raw appreciation in his grip and watery eyes, they just wouldn’t let me go.”