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First posted on Venture Valkyrie on 01/23/2013

Lisa Suennen, The Venture Valkyrie

One of my particular side interests is American Presidential history.  I am fascinated by what makes these leaders tick and how their personal make-up drives their decision-making, and thus history. A good Presidential biography chock full of detailed psychological analysis and put into the context of the history of the times can be better than the best fiction.

I just finished reading a book called Destiny of the Republic: A Tale of Madness, Medicine and the Murder of a President by Candice Millard.  What was particularly fascinating about it, aside from the manner in which Presidential elections were conducted in the 1800s and the partisan melodrama that would give today’s party leaders a run for their money, was the intersection of Garfield’s fate with the changing face of medicine at the time.  This was particularly notable because the same medical mistakes that led to the death of President Garfield are very much in the news today.

President Garfield was elected in 1881; just 4 months later an assassin shot Garfield, who was on his way to catch a train.  The assassin, who was clearly delusional and, were the citizenry not so enraged, would probably have been convicted of insanity instead of hung for murder, put two bullets into Garfield at close range.

Joseph Lister

Joseph Lister

Meanwhile, just a few years earlier in 1867, Joseph Lister had introduced the medical world to his concept of anti-septic surgery.  The result of this discovery led to a dramatic drop in sepsis-related deaths in Europe and his practices were widely adopted on the Continent, reducing the post-surgical death rate from an estimated 45% to 15%.  However, American doctors, skeptical that there could be such a thing as invisible germs, were still denying the legitimacy of Lister’s ideas.  Too time-consuming, too complicated, not necessary for expert physicians—those were the kinds of reactions that the American medical establishment had to Lister’s ideas.

Because of this, the doctors that showed up at the site of Garfield’s shooting took the measure of sticking their dirty fingers right into the wounds to try to find the bullets in Garfield’s body which, as it turns out, were themselves not fatally placed.  In fact, when Garfield died two months after the shooting, the autopsy clearly demonstrated that the bullet wounds were themselves minor compared to the massive septic infection that was introduced by doctors’ unsterilized hands and probes.  Had Lister’s sterile procedures been used and the signs of infection recognized as they mounted instead of denied by the doctors who treated him, Garfield would likely have lived out his term.  One anecdote in the story described a very junior physician on the team who felt he knew what was going on yet was reluctant to take on the more experienced senior physicians, even though his own assessment was correct.

Andrew Cuomo, Sepsis Crusader

Andrew Cuomo, Sepsis Crusader

It was a great book on many levels, but I found it particularly interesting in light of New York Governor Andrew Cuomo’s impending announcement in his State of the State Message this week “that every hospital in New York must adopt aggressive procedures for identifying sepsis in patients, including the use of a countdown clock to begin treatment within an hour of spotting it.”

According to a New York Times article on the coming announcement, Governor Cuomo has noted that “experts have been calling for action on sepsis for more than a decade, and that simple screening tools used by Kaiser Permanente in California, and Intermountain Healthcare in Utah, two hospital chains, had drastically reduced sepsis mortality rates.”  And yet, despite data demonstrating that evidence-based guidelines endorsed by key critical medical associations could reduce death from sepsis by up to 40%, most hospitals are not adhering to them.  According to the NY State Health Commissioner, the new requirement could save 5,000 to 8,000 New Yorkers from death annually and produce significant cost-reductions by eliminating costly medical errors.  On a national level, about 750,000 people per year get sepsis and up to half of these people die from it.  Over $17 billion a year is spent to treat sepsis in the U.S. yet we are getting a very poor return on that investment.

The NY Times article goes on to point out that the National Quality Forum, a consortium of health care experts that provides guidance to hospitals and the Medicare system on best practices, has recommended that all US hospitals follow these sepsis identification and treatment guidelines.  Yet, despite clear evidence that these guidelines have saved thousands of lives in a variety of programs, “no other state has taken regulatory action to require that such guidelines be used.”  Of course, you would hope that it wouldn’t take state or federal action for hospitals to do the right thing here, but it looks like it may.  Whether you are or aren’t a proponent of government activism in your normal political life, you will probably be a fan of this particular action if you or anyone you love ends up in the hospital.

Sepsis: "Invisible" but very real

Sepsis: “Invisible” but very real

In a related NY Times article, Dr. Mitchell M. Levy, a professor at Brown University School of Medicine and a lead author of a paper on the latest sepsis treatment guidelines to be published simultaneously next month in the United States in the Journal of Critical Care Medicine, and in Europe in Intensive Care Medicine, said of sepsis, “It’s the most common killer in intensive care units,” Dr. Levy said. “It kills more people thanbreast cancer, lung cancer and stroke combined.”   Wow.  You would think that saving more lives than the number that die from breast cancer, lung cancer and stroke combined would make it pretty much of a no-brainer to adopt these sepsis guidelines.

So what has prevented the widespread adoption of modern sepsis identification and treatment guidelines?  Well, according to the experts who brought these guidelines to life, the primary barrier is resistance among doctors.  Dr. Clifford S. Deutschman, director of the sepsis research program at the Perelman School of Medicine at the University of Pennsylvania and the president of the Society of Critical Care Medicine, is quoted in the Times articles as saying, “You’re talking about a profession that has always prided itself on its autonomy,” he said. “They don’t like to be told that they’re wrong about something.” Code Red in President Garfield’s room.  It seems, as they say, the more things change the more they stay the same.

In a world where we must cut costs to save our healthcare system and where unnecessary medical errors account for literally billions of dollars in avoidable costs, one can only hope that the significantly increased financial responsibility that hospitals are beginning to bear will drive them to do the right thing here.

A few interesting facts:

  • Garfield’s doctor, who steadfastly refused to consider sepsis as the cause of Garfield’s worsening condition and would not allow other doctors to attend to him as his condition grew worse, sent the US Government a bill for the equivalent of $500,000 in today’s dollars for his “care” of the dead President.  He was paid about a quarter of this, in what must have been the nation’s first provider network rate negotiation.
  • Despite this assassination, the 2nd in less than twenty years, the President and White House remained without any security detail.  It wasn’t until the third assassination, President McKinley in 1901, that the Secret Service was assigned to guard the President.  Until that time, anyone could walk into the White House and seek an audience with the President and neither he nor the building had any formal security measures.
  • For you Lincoln buffs, Robert Todd Lincoln, son of Abraham Lincoln and a Garfield cabinet member, was present at Garfield’s assassination as well as at that of his father.  Oddly enough, he was also with President McKinley at his assassination.  Note to self: don’t hang out with Robert Todd Lincoln.
  • Candice Millard also wrote The River of Doubt, my favorite presidential biography.  It is about Theodore Roosevelt’s ill-fated trip to explore the Amazon River after he lost his last Presidential election.  Highly recommended.