William Mallon, M.D.Funny how something deemed so dangerous, and so preposterous by the politics of our day, seems to me to be exactly what is needed in health care reformand especially in Emergency Medicine. On a specialty by specialty basis, we need to identify what is futile care and decisions need to be made about what “we” as a society are going to pay for with “our” taxes. I am not talking about tense and complicated ethical issues that would tie up a panel of experts. I am talking about easy “stuff” we (in EM) can agree on (or “stuff” that science says does not work 99.9% of the time but is still being done).

At the risk of being ridiculed, I volunteer to be on the Emergency Medicine Death Panel! I relish the opportunity to establish some futility and idiocy standards. We need to declare what is clearly dead already, what will certainly be dead in a few moments, and identify elements of the system which we would all be comfortable seeing dead. We should be experts on death, after all when people are dying where do they go?  Death is an important player in EM and yet shockingly, we habitually/traditionally/culturally fail to recognize death and make ridiculous statements about it.

TAKE THIS ONE: (regarding hypothermia) “You can’t be dead until you are warm and dead”. Really? Try your local cemetery or morgue, everyone in there is cold and dead. Is there no common sense available anywhere?

OR THIS ONE: In Los Angeles the “dead in the field criteria” for 20+ years were as follows: Decapitation, Incineration, Lividity or Rigor Mortis, and finally,organs belonging inside body cavities are not inside the body.Unbelievably, we couldn’t expand it more than this, forcing EMS transport of untold numbers of corpses by red and white hearses (AKA ambulances).  There are 12,000 ambulance crashes annually pointing out that “lights and sirens” are not toys.

OR THIS: How did “the heart too good to die” (the ACLS V-fib concept) become Amiodarone, Epinephrine, mixed with broken ribs and plastic in your airway (well 75% were in the airway anyway) in time proximity to your last heart beat?  This is ridiculous death-based medical consumerism that a death panel could deal with harshly.

Even internists are called “fleas” because that pest is usually the last to leave a corpse, implying correctly that there is way too much end of life care, and not enough end of life caring. In the USA we are 37th in WHO outcomes (between the health care powerhouses of Slovenia and Costa Rica) despite spending much more than all 36 countries in front of us! I think a death panel is the quickest way to improve economically in this equation.

Let me propose an initial agenda for the death panel and posit some recommendations simultaneously. Now, I am not suggesting that I do this “panel” alone, in fact, hopefully there will be some thoughtful academic geeks, some researchers with epidemiology and health care economics knowledge, some “pit docs”, some EMS experts, even a philosopher from our world would be welcome on the panel. These people would no doubt soften my views, mitigate my positions, and make more rational suggestions and offer different solutions. However, the very reason I want to be on the panel is to start the discussion aggressively so that after the softening, mitigating, and a reasonable panel process that we actually get something done that matters.

SO HERE GOES:

1. Any paramedic who transports a patient code III to a hospital after intubation, defibrillation, and failed ACLS drugs (with CPR in progress) will be immediately demoted to EMT or fired. (Hint, we call that patient DEAD, and the vehicles that transport dead things follow all traffic rules).

2. Any Emergency Physician or Trauma Surgeon who performs a thoracotomy on a blunt traumatic full arrest will be taxed $10,000 per event with funds going back into the general Medicare fund. If they hung banked blood, the tax will be $20,000, and if anyone got a needlestick while mutilating the corpse, the tax will be $30,000. Our surgeons cracked some poor soul with blunt head trauma the other day (epistaxis, loose teeth, in PEA arrest)……..really! This policy would end that behavior. That particular thoracotomy delayed the head CT he really needed after pulses were restored with a medical resuscitation!

3. If you want to use a helicopter for urban medical transports, you should have to glide in to the helipad (AKA auto-rotation). The helipad should have both a morgue and Fire Department nearby for convenience. That way, helicopter enthusiasts can begin to recognize how expensive and dangerous this transport modality is.  In Iceland, while talking to their EMS people, I was told that their pilots do not need much in terms of retirement planning because “they fly ‘till they die”.  Really.

Is Helicopter Transport Really Worth the Risk?

4. Any code without ROSC (return of spontaneous circulation) run for more than 45 minutes will be fined $1000/minute thereafter, just because of the embarrassment caused by an EP who can’t recognize death!

5. Any Big Pharma employee making over $5,000,000/year (that’s near the federal poverty level for most CEO/CFO types) will have their income flat taxed at 80%. The same goes for any HMO CEO/CFO, employee or consultant. Failure to comply would be considered a capital crime punishable by death.

These little changes would return hundreds of millions of dollars (if not billions) to the health care system and would dramatically reduce health care expenditures. Bring on the death panels! I am already dressed in black and eager to participate!