Sunday, September 20, 2009

Bungle after bungle kills woman in British public hospital

Woman bleeds to death after doctor accidentally punctures jugular while inserting a drip - and no blood is available for transfusion

A young woman died in hospital after waiting almost two hours for a blood transfusion that could have saved her. Sally Thompson, 20, bled to death after a doctor accidentally punctured her jugular vein during a bungled procedure. Despite an urgent request to the blood bank at Manchester Royal Infirmary, she died one hour and 45 minutes later, before any arrived.

Speaking after her inquest, her father John, 62, said she would still be alive if the blood had been available sooner. The retired farmer said: 'This hospital is supposed to be the cornerstone of the NHS in Manchester, but they couldn't get any blood for two hours. 'We have never had any answers about why it took so long. I feel very let down by the hospital.'

Coroner Nigel Meadows said the inability to supply the blood was a 'significant failure' and he would write to hospital bosses. If a patient needs a transfusion, blood is tested first by type and then further tests, known as crossmatching, are performed to check antibodies in the blood. But in an emergency when there is no time for crossmatching, blood of the same type as the patient's - in Miss Thompson's case O-negative, one of the most common types - can be given. The inquest was told that doctors did eventually request non-crossmatched blood, but by then it was too late.

Miss Thompson, an administration assistant for Rochdale Council, had suffered from a rare blood disorder, hemophagocytic lymphohistiocytosis (HLH), since she was eight. The condition caused her immune system to fail and doctors said she would eventually need a bone marrow transplant.

On August 22, 2005, she collapsed at home in Middleton, Manchester, and was admitted to the Royal Infirmary. Doctors stabilised her, but two days later she had a series of fits and was transferred to intensive care. The following evening, and with the fits still going on, doctors decided to start her on a course of chemotherapy. They decided to insert a tube called a central venous catheter into her jugular vein to administer the chemotherapy drugs directly into her bloodstream.

Dr Jaydeep Mandal, a critical care specialist registrar, who no longer works at the hospital, used a technique known as 'landmark' to find the blood vessel. But when the tube was inserted, it caused internal bleeding.

The inquest heard that the landmark technique, which involves mapping out the features of the neck to find the vein, was contrary to guidelines, which recommend using an ultrasound scan to find the vein. Ultrasound equipment was available.

However, Dr Mandal had used the landmark technique 300 times and consulted colleagues before it was agreed that it should be used on Miss Thompson, the inquest was told.

Her father said: 'It punctured Sally's vein and, unbeknown to them, she was bleeding into her chest cavity for almost an hour. 'When they did find out they sent an order down for blood but the bank said they were having trouble finding any crossmatched blood because of her disorder.'

Miss Thompson died before any blood arrived after having a heart attack caused by the internal bleeding.

Coroner Mr Meadows, who recorded a narrative verdict, said he would ask hospital bosses to review the procedure relating to central venous catheters. 'No crossmatched or uncrossmatched O-negative blood was supplied, despite it being requested during the resuscitation, and this was a significant failure,' Mr Meadows said. 'Blood salvage was organised but not initiated until towards the very end of attempts to resuscitate the deceased.'

A hospital spokesman said it had reviewed procedures concerning CVCs and was investigating why no blood was ever supplied for a transfusion.


Government Medicine vs. the Elderly

Rarely has the Atlantic seemed as wide as when America’s health-care debate provoked a near unanimous response from British politicians boasting of the superiority of their country’s National Health Service. Prime Minister Gordon Brown used Twitter to tell the world that the NHS can mean the difference between life and death. His wife added, “we love the NHS.” Opposition leader David Cameron tweeted back that his plans to outspend Labour showed the Conservatives were more committed to the NHS than Labour.

This outbreak of NHS jingoism was brought to an abrupt halt by the Patients Association, an independent charity. In a report, the association presented a catalogue of end-of-life cases that demonstrated, in its words, "a consistent pattern of shocking standards of care." It provided details of what it described as "appalling treatment," which could be found across the NHS.

A few days later, a group of senior doctors and health-care experts wrote to a national newspaper expressing their concern about the Liverpool Care Pathway, a palliative program being rolled out across the NHS involving the withdrawal of fluids and nourishment for patients thought to be dying. Noting that in 2007-08, 16.5% of deaths in the U.K. came after "terminal sedation," their letter concluded with the chilling observation that experienced doctors know that sometimes "when all but essential drugs are stopped, 'dying' patients get better" if they are allowed to.

The usual justification for socialized health care is to provide access to quality health care for the poor and disadvantaged. But this function can be more efficiently performed through the benefits system and the payment of refundable tax credits.

The real justification for socialized medicine is left unstated: Because health-care resources are assumed to be fixed, those resources should be prioritized for those who can benefit most from medical treatment. Thus the NHS acts as Britain's national triage service, deciding who is most likely to respond best to treatment and allocating health care accordingly.

It should therefore come as no surprise that the NHS is institutionally ageist. The elderly have fewer years left to them; why then should they get health-care resources that would benefit a younger person more? An analysis by a senior U.K.-based health-care expert earlier this decade found that in the U.S. health-care spending per capita goes up steeply for the elderly, while the U.K. didn't show the same pattern. The U.K.'s pattern of health-care spending by age had more in common with the former Soviet bloc.

A scarcity assumption similar to the British mentality underlies President Barack Obama's proposed health-care overhaul. "We spend one-and-a-half times more per person on health care than any other country, but we aren't any healthier for it," Mr. Obama claimed in his address to Congress last Wednesday, a situation that, he said, threatened America's economic competitiveness.

This assertion is seldom challenged. Yet what makes health care different from spending on, say, information technology —or any category of consumer service —such that spending on health care is uniquely bad for the American economy? Distortions like malpractice suits that lead to higher costs or the absence of consumer price consciousness do result in a misallocation of resources. That should be an argument for tackling those distortions. But if high health-care spending otherwise reflects the preferences of millions of consumers, why the fuss?

The case for ObamaCare, as with the NHS, rests on what might be termed the "lump of health care" fallacy. But in a market-based system triggering one person's contractual rights to health care does not invalidate someone else's health policy. Instead, increased demand for health care incentivizes new drugs, new therapies and better ways of delivering health care. Government-administered systems are so slow and clumsy that they turn the lump of health-care fallacy into a reality.

According to the 2002 Wanless report, used by Tony Blair's government to justify a large tax hike to fund the higher spending, the NHS is late to adopt and slow to diffuse new technology. Still, NHS spending more than doubled to £103 billion in 2009-10 from £40 billion in 1999-2000, equivalent to an average growth rate of over 7% a year after inflation.

In 1965, economist (and future Nobel laureate) James Buchanan observed of the 17-year old NHS that "hospital facilities are overcrowded, and long delays in securing treatment, save for strictly emergency cases, are universally noted." Forty-four years later, matters are little improved. The Wanless report found that of the five countries it looked at, the U.S. was the only one to be both an early adopter and rapid diffuser of new medical techniques. It is the world's principal engine driving medical advance. If the U.S. gets health-care reform wrong, the rest of the world will suffer too.


Obamacare will hit workers in the pocket

If U.S. health reform efforts lead to higher costs for employers, employees may end up bearing the brunt, according to a new survey. Employers will not absorb higher costs, choosing instead either to reduce benefits, lower salaries or cut jobs, the survey from professional services firm Towers Perrin said on Thursday. Eighty-seven percent of employers said they were very likely or likely to cut benefits if reform leads to higher costs. Only 11 percent said they would accept lower profits. "They simply don't have money and margins today to absorb additional healthcare costs," said Dave Osterndorf, chief health actuary at Towers Perrin.

Should reform reduce benefit costs to the companies, 78 percent they were very likely or likely to retain the savings in the business.

The survey of more than 430 human resource executives at medium and large businesses taken in July was designed to gauge opinions on reform as legislative efforts were heating up.

Congress is weighing bills that would overhaul the healthcare system, which is President Barack Obama's top legislative priority. Proposals that might drive up employer costs include those that would force employers to expand their coverage, such as to part-time workers, or those that would allow healthy workers to find coverage elsewhere, leaving employers to pay for sicker, more expensive employees, Osterndorf said.

Although the ultimate outcome of reform efforts remains uncertain, nearly one in four companies in the survey are already rethinking changes in light of possible reforms. Of all the goals of health reform, cost containment was listed most frequently as an absolutely critical or high priority among the businesses in the survey, which ranged in size from roughly 1,500 to 100,000 workers.

But, Osterndorf said, employers believe that issues such as expanding access to coverage and reforming certain insurance practices have received more attention. "Employers are saying, 'These are important social issues that are being addressed, but they don't necessarily hit on the issues that we're facing as employers,'" Osterndorf said.

Of the healthcare proposals, 53 percent of employers believe research on effectiveness of treatments will help their business by influencing the quality of care.

Employers had varying responses to how they would react to proposals mandating they offer coverage to meet certain minimum standards or pay a penalty -- called "pay-or-play" mandates. Thirty-seven percent of employers would provide company-sponsored coverage that substantially exceeds the standard. But 29 percent said they would end company-sponsored health coverage and pay the assessment if the per-employee costs to the government were much lower than current costs.


Rationing By Any Other Name...

We critics of ObamaCare may have been doing ourselves a bit of a disservice over the past few months by focusing on health care “rationing.”

Yes, “rationing” best describes some of the most disconcerting effects of government run health care, and it strikes a chord with the general public. But it is rarely used by our duplicitous opponents, leaving the door open for them to argue that we are just raising a general alarm over nothing.

But rationing does not have to be called such to be rationing. So, perhaps, we should shift our focus away from language that we prefer and toward illuminating language used by our opponents when, in cloaked words, they discuss what we all know is nothing more (and unfortunately, nothing less) than cold and calculated government rationing.

Ezekiel Emanuel heads the Federal Council of Comparative Effectiveness Research, whose job it is, we are told, to save the government money. The GLG Group observes that, “The Commonwealth Fund…has estimated that establishing a Center for Comparative Effectiveness Research could save up to $634 billion between 2010 and 2020…” And just how would it do this?

Well, in sum total, “effectiveness” in this context is merely another term for rationing. Emanuel makes it clear that the “effectiveness” of a new drug, device or procedure is not measured by whether it works to heal a patient and save lives, but by whether it is effective relative to its cost. A drug, for instance, that adds half a year of life on average to cancer patients, but costs the Obama government $50,000 cost would not receive government backing. It’s all a matter of a cold and heartless cost-benefit analysis.

Astute readers may notice that in real life, Ezekiel Emanuel now actually heads an organization that has essentially the same function as his envisioned Institute for Technology and Outcomes Assessment, which we discussed last week. From this we could glean that the word “outcomes” is another buzz word used for rationing. Only those health services whose “outcomes” justify their costs are worth Big Government’s time and money. So, in short, under Obamacare, you and your loved ones are reduced to mere dollar figures

Other words occur when members of the Obama administration, or the President himself, talk about eliminating “waste” and “inefficiency” as Obama did last week and on July 22: “We also want to create an independent group of doctors and medical experts who are empowered to eliminate waste and inefficiency in Medicare on an annual basis.”

Contrary to White House denials to the effect that this board, “will not be authorized to propose or implement Medicare changes that ration care or affect benefits, eligibility or beneficiary access to care,” the CBO has recommended that the Independent Medicare Advisory Council (IMAC) have exactly those powers in order to “improve the efficiency of the health care system.” And improving “efficiency” again means weighing costs over benefits in ways that produce rationed care.

The fact is, as Gertrude Stein opined, “A rose by any other name is still a rose.” And government “rationing” by any other name is still a death warrant for the elderly and infirm.


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