By Edwin Leap, MD–
It’s hard to explain what we do. And so maybe, it’s hard for others to sympathize with our situations. I mean, physicians, mid-levels, and nurses in emergency departments are tied to computers in often cramped work-spaces, even as they are required to be at the bedside almost constantly for the latest emergency or (in other cases) the latest bit of pseudo-emergency drama.
If you haven’t worked there, or haven’t for a long time, it could be that this lack of understanding is what leads hospital administrations to do one of the stupidest things imaginable. What is that thing? Banning food and drink from our work-spaces.
Now, this isn’t the case in my current job. But it is the case in all too many facilities. I talk to people. I hear things. And it’s usually justified with some unholy combination of infection control, Joint Commission and public health clap-trap, coalesced and refined, then circulated as a cruel policy.
When it’s enacted, clinical staff have their water bottles taken
away. Nobody is allowed to eat where they work. Dedicated, compassionate
staff members grow tired and dehydrated and hungry. (Maybe it’s a good
thing. They often don’t have time to urinate anyway, and water just
makes that happen more often.)
Mind you, the water bottles are sometimes kept in a nearby room, or on a nearby shelf. It’s an act of kindness, I guess. And the food? Well, all you have to do is take your break and go to the cafeteria or to the break room, right?
Those who come up with these rules don’t understand that a scheduled break is a great idea … that never happens. It’s an emergency department. It isn’t (technically) a production line; however, we try to impose time restrictions and through-put metrics. It isn’t “raw material in/product out.”
It’s “sick, suffering, dying, crazy human being in” and if all goes well, “somewhat better (at least no worse) human being evaluated, stabilized, saved, calmed, admitted, transferred, and sometimes pronounced dead” out of the other end of the line.
Those Herculean efforts can take anywhere from, oh, 20 minutes to 12 hours. During which time, it’s pretty hard to leave the critical patient in the understaffed department, with the “five minute to doctor” guarantee and the limitless capacity for new tragedy rolling through the door.
That setting makes it remarkably hard for breaks or even meals to happen at all.
As such, it’s nothing short of cruel and unusual for anyone to say to the staff of a modern emergency department, “you can’t have food or drink” — especially when it’s typically uttered by people who have food and drink in their offices and at their desks. People who have lunch meetings with nice meals or who have time to walk to the cafeteria or drive off-campus. And who feel so very good about protecting the staff from their deadly water bottles.
The argument, of course, is that the clinical staff work in a “patient care area.” Even when they aren’t at the bedside but are, for instance, behind a glass wall at a desk. If this is the case, then one could argue that the entire hospital (including administrative suites) is a “patient care area.”
They are afraid we’ll catch something. That it’s unsafe for us to eat or drink where we work. Of course, this is while we positively roll around in MRSA and breathe in the fine particulate sputum of septic pneumonia patients. This is while staff clean up infectious diarrhea and wear the same scrubs all day.
This is after we intubate poor immigrants who may well have tuberculosis and start central lines on HIV patients. This is after we wrestle with meth-addicts who have hepatitis C. And this concern for our “safety” occurs in places where physical security, actual security against potential violent attack, is a geriatric joke which is often tabled until the next budget cycle.
And as for our patients? Our food and drink are no danger to them. They and their families fill the exam rooms with the aroma of fried chicken, fries, and burgers, eaten at the bedside (often by the patient with abdominal pain). Their infants drag pacifiers across floors that would make an infectious disease specialist wake from bacterial nightmares in a sweat-soaked panic. In short, our food or drink are no threat to them and no threat to us.
But the absence of food and drink? That’s a problem. Because the ED is an endless maelstrom of uncontrollable events and tragedies, of things beyond our control for which we are responsible. It is a place of physical, emotional, and spiritual exhaustion where we rise to the challenge and manage (against the odds) to do so much remarkable good by virtue of our knowledge, our training, our courage, and our compassion.
In the midst of all that, a bottle of water, a cup of coffee, a glass of Diet Coke, a Styrofoam cup of iced tea is an oasis in the desert. And that sandwich, slice of pizza, cupcake, or salad is the fuel that helps make it happen.
More than that, food and drink are among the few pleasures we have time for each shift. They serve as bridges to the end of the day, small reminders of normalcy in a place where so little is normal.
Doubtless, one day someone will take away our music so that it doesn’t hurt our ears, or offend our patients. We’ll fight that battle when it comes.
But until then, depriving staff of food and drink proximate to where they work is of no health value and strikes me as just one more way of exerting control over the people actually engaged in the hard, grinding work of saving lives.
And worse, it’s just mean.
Originally published in MedPage Today
By Jeffrey E. Keller, MD, FAACP
Border detention facilities that house immigrants have been in the news recently because of their policy of not providing influenza vaccinations to their detainees, sparking high-profile protests. Why would an immigration detention facility, tasked among other things with providing comprehensive medical care to its detainees, refuse to provide them with flu vaccines?
To answer this question, it might be instructive to ask how influenza vaccinations are handled at other prisons and jails in the U.S. It depends on what type of facility you are in and how long you will be there. All prison systems I know of offer influenza vaccinations to their inmates. On the other hand, most jails (short-term detention facilities) do not have a routine flu vaccination program, though there are exceptions.
Vaccinations in Prisons
Inmates are sentenced to prison for a minimum of one year and usually longer. As a result, prison populations are stable. Almost all of the inmates in a particular prison now will still be there next year. Also, prisons are tasked with providing comprehensive medical care to their inmates. This includes influenza vaccinations, but also other recommended vaccinations and boosters. Of course, just like in the community at large, not all inmates want to be vaccinated. The percentage of prison inmates who get vaccinated depends on how vigorously the prison pushes the program.
If a prison advertises the availability of the flu vaccine and actively encourages its inmates to be vaccinated, the acceptance rate can be greater than 50% (compared to about 33% of adults in the community who get vaccinated). Most prisons have a “big push” campaign to encourage flu vaccines once a year in the fall. However, if a prison does not advertise the availability of the flu vaccine, the percentage of inmates vaccinated can be very low. It makes economic sense for prisons to actively encourage their inmates to be vaccinated. Every dollar spent on influenza vaccinations will save more than a dollar down the road trying to deal with influenza outbreaks.
Vaccinations in Jail
Influenza programs in jails are
different for several reasons. The first issue is that the inmate population in
a jail is not stable. The average length of stay in the average jail in the
U.S. is around 2-3 weeks and many are released within days. If a jail offers
influenza vaccinations in October, most of the inmates vaccinated will be gone
by November. The jail will now be filled with new, unvaccinated inmates. If you
vaccinate the November inmates, most (again) will be gone by December. So, to
be effective, influenza programs in a jail must last the length of the
influenza season — making jail influenza programs more difficult and expensive
to administer than a prison program.
As an example, remember that one
must order influenza vaccines well in advance. In order to have influenza
vaccines ready in the fall, a prison or a jail has to order them at least six
months earlier. A prison will know how many influenza doses it will need based
on its population and previous acceptance rate. But how many doses will a jail
need with inmates coming and going over the course of an entire flu season?
That can be hard to get right in a jail! It is expensive and maddening to order
too many vaccines only to throw the unused doses away at the end of the flu season.
Also, jails vary greatly by size and
sophistication of the medical services they provide. There are many small jails
in the U.S. (think 10 beds) where no medical personnel ever come to the jail
for routine medical care. If their inmates need medical attention, the deputies
have to load them into a van and take them to a clinic or ER in the community.
Such a jail is unlikely to offer influenza vaccinations to their inmates. On
the other hand, bigger jails (say, more than 1,000 beds) with a full-time medical
staff may indeed have an influenza vaccination program.
“Kicking the Can Down the Road”
The most successful jail influenza
programs that I have seen are done in cooperation with the local health
department. The health department is tasked with providing vaccinations to the
community at large, which includes jail inmates. When asked, health departments
often will come to the local jail once a month to provide influenza
vaccinations to any inmate who requests one. (This is also a good way to
provide screening for sexually transmitted diseases in asymptomatic inmates.)
Even small jails can approach their local health department about providing
immunizations to inmates, though few do.
Customs and Border Patrol reportedly
defended its policy of not providing influenza vaccinations during border detention
by saying that immigrants are only there for a few days and are expected to get
the flu vaccine later, when they are moved to a long-term facility. Where I
grew up, this was called “kicking the can down the road.” To my mind,
deferring vaccinations until later makes little medical or financial sense.
Since none of these detainees is going to be released, and since you are going
to vaccinate them later anyway (as reported), why not do it as part of their
initial medical screening?
Jeffrey E. Keller, MD, FACEP, is a
board-certified emergency physician with 25 years of experience before moving
full time into his “true calling” of correctional medicine. He now
works exclusively in jails and prisons, and blogs about correctional medicine
This post was originally published in MedPage Today.
Four physicians and two others protesting their inability to vaccinate migrant detainees at the U.S. Customs and Border Protection (CBP) headquarters here were arrested last Tuesday for failing to comply with federal orders to disperse.
They were held for about an hour, according to some of those who were arrested.
The two groups of protesters — about 60 people in total — had gathered in two driveways leading to CBP headquarters for about an hour when one of the groups received a warning from federal officials that if they stayed in the driveway, they would be arrested, said Marie DeLuca, MD, an emergency room physician from New York who was one of those arrested. Some of the members had blocked the driveway by laying down across the road while others chanted, “No more death.”
“We stayed peacefully in the driveway entrances of their building and said that if they weren’t going to let us in to vaccinate against the flu, we were going to remain. They didn’t let us. Instead they chose to arrest members in one of the two groups,” DeLuca said.
She said her hands were secured behind her back with zip ties by officials from the Department of Homeland Security (DHS) as she and the other protesters were led into a conference room and told to wait. After about an hour following the protest, they were issued tickets with a court date for “failure to comply with the lawful direction of federal police officers or other authorized individuals,” and then released, she said.
A San Diego Union-Tribune reporter posted a video of some of those doctors being arrested.
At about 2 p.m. Tuesday, DHS’s press secretary tweeted a picture of the protesters
and said, “Of course Border Patrol isn’t going to let a random group of
radical political activists show up and start injecting people with
Sen. Elizabeth Warren (D-Mass.) also tweeted a link to a video of the protesters, saying that “Children are dying in CBP custody due to the flu. Refusing to administer flu vaccines is neglectful and cruel.”
Other doctors arrested, who were part of the group Doctors For Camp Closure, included Mario Mendoza, MD, a former anesthesiologist who now lives in New York City and runs the organization Lifeundocumented.org; Hannah Janeway, MD, an emergency room physician in Los Angeles who helps run the Refugee Health Alliance; and Mathieu De Schutter, a pediatric hospitalist from San Luis Obispo, California. The non-physicians arrested were Rebecca Wollner of Jewish Action San Diego and Matthew Hom, a graduate student from Cerritos, California, who works with the group Never Again Action.
On Monday, the physicians began their three-day vigil and protest of federal immunization policies at the gate of the detention center in San Ysidro at about 11:30 a.m. They stayed until about 4:30 p.m. with no response despite repeated requests. Tuesday’s action took place nearby at the Chula Vista CBP headquarters.
DeLuca said the doctors and their supporters planned to return Wednesday to try one more time to administer the 120 influenza vaccines they brought with them for the detainees. They say it’s important for public health, not just to protect these detainees, but also everyone else they come in contact with.
Members of the groups chanted slogans and carried banners and signs
calling on federal officials to let them administer the vaccinations to
those inside. The vaccines were purchased with financial donations.
Originally published in MedPage Today.
Some healthcare professionals see blood, mangled bodies, and death every day, yet certain days are worse than others. As when, for instance, a dozen police officers are gunned down or 20 kids are killed in their elementary school in a mass shooting. Because public mass shootings happen nearly every 6 weeks in America, these tragedies are having a more frequent impact on the healthcare workforce.
Research data are sparse. One study surveyed 24 surgical residents working at Orlando Regional Medical Center in Florida in 2016. On June 12 that year, a gunman shot 49 people to death and wounded 53 others at the mass shooting at the Pulse nightclub. Three months later, rates of post-traumatic stress disorder (PTSD) and major depression were two and four times greater among the 10 residents on call that night versus the 14 off-duty residents. Though the differences didn’t reach statistical significance, assessments were revealing. A survey of the same residents 7 months after the mass shooting found that PTSD persisted in those affected in the on-call group but completely resolved in the off-call residents.
As part of an ongoing effort by MedPage Today to explore job stress and burnout among healthcare professionals, reporter Shannon Firth talked at length with physicians and nurses who shared personal experiences with mass shootings and how they affected their lives and careers.
Three Encounters With Mass Shootings
“After I Saw What I Saw, I Really Thought to Myself, ‘I Hope I’m Not Broken:'” Richard Kamin, MD (Sandy Hook school shooting, 2012)
“The Worst Night of My Professional Career:” Brian Williams, MD (Dallas police sniper attack, 2016)
“I Still Get That Pit Feeling in My Chest of, I Can’t Believe This is Happening:” Megan Duke, RN, CEN (San Bernardino terrorist attack, 2015)
MedPage Today intern Amanda D’Ambrosio assisted with reporting for these stories.
Originally published by MedPage Today.
Extending insurance coverage to immigrant children and pregnant women did not appear to influence whether they crossed state borders (known as in-migration) to acquire care, according to survey data.
Among 36,438 lawful permanent
residents with children, the average in-migration rate 1 year before public
health insurance was expanded to cover immigrants was 3.9% and 1 year after the
implementation, the rate remained essentially unchanged at 3.7%, reported Vasil
Yasenov, PhD, MA, of the Immigration Policy Lab at Stanford University in
California, and colleagues.
Similarly, among 87,418 women of
reproductive age, the in-migration rate 1 year before expansion was 2.7% and 1
year after it was 4.6%, the team wrote in JAMA Pediatrics.
“No Discernable Association” Between In-Migration and Insurance Expansion
“If an expansion of health
insurance coverage was associated with in-migration to another state, the
probability of in-migration would have increased in the treatment group
compared with the control group,” the researchers wrote. “There was
no discernable association between the in-migration from any state among the
treatment group relative to the control group and public health insurance
The authors compared the group of
immigrants with children with a control group of lawful permanent residents
without children. The proportion that migrated among immigrants without
children was slightly higher before and after expansion (4.0% and 5.9%,
respectively), but not significantly different from immigrants with children,
Yasenov and his team reported.
Meanwhile, among a control group of
post-reproductive women, the rate of in-migration was 3.5% and 3.9% in the
years before and after expansion, respectively, which was also not
significantly different than the group of women of reproductive age, the researchers
“We hope policy makers
concerned with spiraling costs and people flooding in from other states will
have the evidence they need to make a decision when thinking about extending
public healthcare benefits for legal immigrants in the U.S.,” Yasenov told
Findings Indicate Immigrants are Fleeing Violence and Corruption, Not Chasing Health Coverage
As of 2016, immigrants with children
were covered by public insurance in 31
states and pregnant immigrants were covered in 32 states. Many Democratic
candidates for the 2020 election support extending healthcare to undocumented
immigrants, a policy that has been suggested will increase the flow of
immigration within the U.S.
These null findings make sense in
the context in which most U.S. immigration takes place, wrote Jonathan Miller,
JD, of the Office of the Massachusetts Attorney General in Boston, and Elora
Mukherjee, JD, of the Immigrants’ Rights Clinic of Columbia Law School in New
York City, in an accompanying editorial.
Namely, many people coming to the
U.S. are fleeing from violence or political corruption in their home countries,
and “do not seek refuge in the [U.S.] because of potential access to
healthcare,” Miller and Mukherjee said.
“Making it easier for immigrant
communities to connect to and seek care from physicians will not radically
shift migration patterns. Instead, allowing access to the basic human right of
health care shows a common commitment to human decency for all who are in the
[U.S.],” the editorialists stated.
Immigrants Sampled Were Below 200% of Fed Poverty Thresholds
For this study, data were collected
from individuals residing in the U.S. from 1 to 6 years — but who were not
born in the U.S. and were not citizens — from the American Community Survey. Notably, the sample
was restricted to individuals who were below 200% of the federal poverty
thresholds to identify people who would qualify for public insurance if it were
extended, the authors noted. Immigrants on student visas, veterans, or those
married to U.S.-born citizens were excluded because they qualify for other
healthcare benefits, the team added.
The data were controlled for
personal characteristics like age, race/ethnicity, and marital status, as well
as things that varied by state and time such as cash assistance and economic
In total, 208,060 immigrants — mean
age of 33 years, 47% of whom were female — were included. About two-thirds
were Hispanic (63%), and the in-migration rate among the entire sample was 3%.
Overall, the likelihood that lawful
permanent residents would migrate to a state where public health insurance has
been expanded to cover immigrants was practically zero before and after
expansion was implemented (percentage change from -1.21 to 1.78), the authors
The likelihood was also close to
zero among lawful permanent-resident women of reproductive age when compared
with a control group of lawful permanent-resident post-reproductive women
(percentage change from -1.20 to 1.38).
In a model specifically looking at
whether public health insurance expansion would bring in migrants from a
neighboring state, no association was found between policy implementation and
the rates of in-migration of immigrants with children (–0.03 percentage points,
95% CI –0.5 to 0.44) or pregnant women (–0.02 percentage points, 95% CI –0.48
to 0.09), the researchers reported.
The primary limitation of the study,
they said, was the inability to account for time-varying factors that could
undermine the analysis, and it was also not possible to isolate states among
the border and determine whether there was an association between in-migration
and health policy specifically in these states. Lastly, the investigators said,
the association was not analyzed among county-level or city-level programs.
The study was funded by the Stanford Child Health Research Institute.
The authors and editorialists reported having no conflicts of interest.
Source Reference: Yasenov V, et al “Public health
insurance expansion for immigrant children and interstate migration of
low-income immigrants” JAMA Pediatrics 2019; DOI:
Source Reference: Miller J, Mukherjee E “Health care
for all must include everyone” JAMA Pediatrics 2019; DOI:
by Elizabeth Hlavinka, Staff Writer, MedPage Today
This story was originally published by MedPage Today.