The Mayo Clinic Approach to Healing Healthcare

The power of volunteerism and compassion among healthcare workers is evident right now more than ever before. Healthcare workers are showing us the heart of America, and after this COVID-19 crisis resolves, we as a nation will stand taller. The Mayo Clinic, one of the most revered health systems in the world, is working at the front lines of this pandemic through extensive research efforts and preparing their hospitals to accommodate a surge in patients. But Mayo Clinic’s preparedness in this situation is the result of an over 150-year history of building a culture ingrained in employees. So, what makes the Mayo Clinic a symbol of hope to the 1.2 million patients who are treated at their hospitals and clinics each year? I spoke with Dr. Leonard Berry, a distinguished professor of Marketing at Texas A&M and co-author of Management Lessons from Mayo Clinic, to learn more. Dr. Berry’s book, coauthored with Kent Seltman who served as Mayo Clinic’s first marketing director, has sold more than half a million copies worldwide, and the book has been described as “a landmark” in the healthcare field by former Administrator of the Centers for Medicare and Medicaid Services Dr. Donald Berwick. Out of the innumerable positive qualities Mayo Clinic possesses, I want to discuss three that I believe are key to their success: Mayo Clinic’s high-quality doctors, its culture of medical teamwork, and its welcoming environment.

Healthcare is not a want-service, it is a need-service. We all need healthcare, and as Dr. Berry says, “the most important consumer decision you will ever make is choosing your doctor.” Only in the medical field does a patient need to trust their healthcare provider with their most personal and intimate information. From his study of the Mayo Clinic, Dr. Berry identified characteristics of Mayo doctors that help instill such a high level of physician-trust within each of their patients. Dr. Berry found that the ideal physician embraces the following qualities:

Confidence — the physician’s assured manner generates trust
Empathy — the physician is able to genuinely understand what a patient is feeling both physically and emotionally and is able to communicate this empathy
Humane — the physician has a deep level of care for the patient and is not rushed
Personal — the physician treats the patient as an individual rather than as “just another patient”
Forthright — the physician clearly explains the situation with a patient without beating around the bush
Respectful — the physician listens to the patient’s wishes intently
Thorough — the physician explains everything and follows up with a patient’s health

Dr. Berry explains how many Mayo physicians possess most, if not all, of these qualities as do outstanding doctors elsewhere. At Mayo Clinic, doctors hold each other accountable. He says, “the currency at Mayo Clinic is clinical excellence, and employees set a very high standard for one another.”

Mayo Clinic is guided by the principle of “the needs of the patient come first,” and this is clear in its compensation structure. Mayo doctors are paid by salary. While most doctors around the country are financially incentivized to perform more medical care, this is not the case at Mayo. At Mayo, a physician never has a financial incentive to do an unneeded test or procedure—or a financial disincentive to lend a helping hand to another physician. At Mayo, medicine is a cooperative science, and multiple doctors pool their knowledge and work together to treat a single patient. Dr. Berry explains how more care is not necessarily better care, and can harm the patient while resulting in waste. Dr. Berry summarizes this by saying that “those who need to bask in the starlight of personal recognition or wealth are not a good fit at Mayo and need to work elsewhere.”

I asked Dr. Berry what gives Mayo its competitive advantage among the 6,000+ hospitals in the US, and he discussed how all their medical services are provided “under one umbrella.” Mayo Clinic houses virtually every specialty in medicine, and this is fruitful for both patients and physicians. Often, if a patient has three medical issues, they have to visit four different doctors at four different facilities. At Mayo, patients receive a highly connected, coordinated care plan.

No one wants to be at the hospital, and Mayo Clinic knows this, which is why they have created a hospital environment in which the healing begins as soon as you walk in. Their buildings emphasize natural light, mute noise, and minimize the impression of crowding, just to name a few. Keeping the noise level to a minimum is a top priority, as noise is a significant patient stressor. Dr. Berry says many may not realize that moving a portable x-ray machine near a patient room creates the same level of noise as driving a motorcycle right outside the room. For kids, Mayo has embedded animal tracks in the carpet, guiding their young patients to their rooms. They even have water fountains as low as 18 inches so that not even toddlers feel left out! As Dr. Berry says, “Mayo Clinic is really good at majoring in minors… because the little things add up.”

Whether there is a public health crisis that shakes the world or a personal health crisis that shakes your world, the Mayo Clinic will always be a symbol of hope. The compassionate culture ingrained in Mayo has created a hospital where employees want to finish the job rather than look at the clock. Stories of exceptional gentleness by Mayo employees are numerous, and each one shows us what is possible when the needs of the patient always come first. To conclude this article, I would like to share one story Dr. Berry includes in his book, describing a 91-year-old woman’s visit to the emergency room after suffering a fall. The elder woman came into the ER with her daughter, a Mayo employee, and they were seen by Dr. Luis Haro. As Dr. Haro examined her, he asked if the woman could stand up and take a few steps. As she took a few steps, she bumped into Dr. Haro. With her wit, she said, “Well, I suppose we could waltz.” To which Dr. Haro replied with “Yes, we could” before taking her into his arms and waltzing a few steps. In her letter to Mayo describing the story, the patient’s daughter says, “My mother was absolutely enchanted as she loves to dance, and I started to cry. The sight of this tiny fragile old woman being waltzed around the room by this most handsome young man was just too much… this is the caliber of doctor we have here, someone whose medical expertise is a given but whose compassion and kindness are extraordinary.”

I spoke with Dr. Leonard Berry, co-author of Management Lessons from Mayo Clinic, about what makes Mayo Clinic a phenomenal health system.

Paying for Health, not Healthcare

As healthcare spending nears $4 trillion annually, political and economic questions regarding what should be done have consumed the 2020 democratic candidates. Some candidates such as Elizabeth Warren and Bernie Sanders have called for a complete dissolution of private insurance companies in exchange for a government-run Medicare-for-all plan. I spoke with Dr. Patrick Conway, the former CEO of Blue Cross Blue Shield of North Carolina and former Chief Medical Officer for the US Centers for Medicare and Medicaid Services, about ways that we can keep our current system while reducing overall healthcare costs. Conway’s work as the Chief Medical Officer included overseeing a $1.5 billion-dollar annual budget, and after becoming the CEO of Blue Cross Blue Shield of North Carolina, he oversaw healthcare delivery for 4 million Americans. It is incredibly challenging to find the “right answer” when it comes to healthcare, and I believe it’s important to seek out numerous perspectives in an attempt to determine our options. Insurance companies are often the center of the debate around healthcare, which is why I sought to speak with Dr. Conway; however, my goal is to present more than just one perspective, all of which share the common goal of reducing healthcare costs in America.

Throughout our conversation, Dr. Conway stressed the importance of “buying health, not just healthcare services,” meaning that, too often, we utilize unnecessary healthcare services that do not actually improve health. This is supported by numerous studies, which have said that unnecessary healthcare services account for over $200 billion dollars. Conway also cites the fact that US drug prices have increased at a faster rate than other developed nations, due in part, in his opinion, to the fact that many other developed nations utilize value-based drug pricing. Value-based drug pricing allows for drugs to be priced based on patient health outcomes after using a particular drug, and agreements between manufacturers and purchasers can even include providing refunds for adverse health outcomes caused by a drug. The current US system does not embrace a value-based system; instead, Medicare reimburses hospitals for drugs based on the Average Sales Price of a drug on the market plus 4.3%. Some say that this encourages drug companies to drive prices up as they know Medicare will continue paying for whatever the average price is, regardless of the drug’s efficacy.

Conway also discussed a fundamental issue with our healthcare system, which is the need for greater investment in preventative medicine. The CDC actually estimates that 75% of all healthcare spending could be avoided through preventative care, which is why patients should not only have access to free preventative care (a stipulation under the Affordable Care Act), but they should be encouraged and possibly incentivized to utilize this care. Greater preventative care for chronic diseases would not only directly reduce overall healthcare costs, but it would also prevent the estimated economic output loss of $260 billion due to patients being unable to work because of their disease.

As the director of the Center for Clinical Standards and Quality, Dr. Conway worked to implement MACRA (Medicare Access and CHIP Reauthorization Act of 2015), which is beginning to fundamentally change the way doctors are paid for treating patients with Medicare. Under MACRA, alternative payment models have been created in order to link payment for a provider to the quality of the care provided. Right now, approximately 90% of providers are paid for on a fee-for-service basis, meaning that medical services are paid for without regard to whether the service actually helped the patient or not. This means that providers are paid based on the quantity of care provided rather than quality. Alternative payment models aim to move away from fee-for-service by rewarding providers for performing procedures that improve the health of patients and penalizing those who conduct procedures that do not improve patient outcomes. Payment models are classified into different categories, with fee-for-service being category 1. The category 2 model makes the first step towards tying quality to compensation by incentivizing hospitals to report their data on quality of care. Providers can also receive benefits for more positive overall statistics, such as a reduction in number of hospital-acquired infections.

Dr. Conway believes that categories 3 and 4 create the biggest impact on patient care. Under the guidelines of these categories, payments involve two-sided risk, meaning that based on certain quality measures and patient outcomes, a provider’s pay may be increased or decreased. For example, providers in a hospital may receive bonuses for reducing hemoglobin A1c levels in their diabetic patients over a certain period of time. In theory, this incentivizes hospitals to do whatever they can to improve quality of care. Category 4 also includes bundled payment, which is a single payment for a particular episode of service. For example, when you go to a surgeon for a knee replacement, the final bill will state that the fee for the surgery itself is separate from the fee for the anesthesia used, even though the anesthesia is necessary for the surgery to take place. In a bundled payment model, all services needed for a specific operation are “bundled” into one price. In theory, this model reduces unnecessary care by encouraging providers to utilize resources efficiently and effectively because their compensation stays the same for a particular procedure, regardless of what additional resources are used. Conway believes that moving hospitals away from categories 1 and 2 into categories 3 and 4 will help in reducing costs of care and improving quality.

I also asked Dr. Conway about the plans proposed by some of the democratic presidential candidates. In terms of Medicare-for-all, Conway believes that a traditional Medicare-for-all plan would not necessarily work. Right now, when a doctor bills Medicare for a procedure, Medicare pays for it with little regard to whether or not the procedure was actually necessary. As Conway says, “People will get care, but from a cost-control standpoint, traditional Medicare-for-all is not a high-functioning system,” which is why the system is actually set to go bankrupt in 2026. Conway believes that private insurance companies are important here because they are able to actually manage appropriate care and control costs. A more legitimate policy conversation, in his opinion, involves Medicare Advantage, which is a public-private partnership system in which the public pays for the system, but private insurance companies manage the care provided.

From a bird’s-eye view, value-based care and bundled payments appear to be part of the “answer” to our nation’s rising healthcare costs. However, as we dive down into these issues, the answer is not so clear. Last year, researchers at Harvard Medical School found that the value-based care system implemented by the government has not only failed to improve quality of care, but instead may have increased healthcare disparities. This may be due to doctors being less encouraged to see sicker patients who are likely to bring down quality scores, which will ultimately increase physician compensation. Refusing to see sicker patients or even refusing to try out a treatment that may not result in greater compensation can lead to increased health disparities, exactly how the Harvard researchers described. In terms of bundled payments, researchers from the Agency for Healthcare Research and Quality looked at 58 studies on bundled payments and concluded that there is very weak evidence showing that bundled care actually reduces costs. It is critical to note how many of the policies described earlier work very well in theory; however, in a practical sense, they may cause physicians to play, what some call, “quality games,” in order to avoid reductions in their compensation. What is agreed upon, however, by researchers, policy-makers, and providers is that preventative medicine must be furthered. Additionally, we must continue to test out different models of care delivery so that we can create a cost-efficient, high-quality healthcare system for the American people.

*I spoke with Dr. Patrick Conway, the former CEO of Blue Cross Blue Shield NC, about how we can reduce healthcare spending in the US*

Sources:

How Preventive Healthcare Services Reduce Spending for Payers. (2017, August 29). Retrieved from https://healthpayerintelligence.com/news/how-preventive-healthcare-services-reduce-spending-for-payers.

Hussey, P. S., Mulcahy, A. W., Schnyer, C., & Schneider, E. C. (2012, August). Closing the quality gap: revisiting the state of the science (vol. 1: bundled payment: effects on health care spending and quality). Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/24422914.

Lyu, H., Xu, T., Brotman, D., Mayer-Blackwell, B., Cooper, M., Daniel, M., … Makary, M. A. (2017). Overtreatment in the United States. PloS one, 12(9), e0181970. doi:10.1371/journal.pone.0181970

McNair, P. D., Bates, D. W., Singh, H., Cutler, D. M., Sahni, N. R., Harris, B. D., … Kurtzman, E. T. (n.d.). Medicare’s Policy Not To Pay For Treating Hospital-Acquired Conditions: The Impact. Retrieved from https://www.healthaffairs.org/doi/full/10.1377/hlthaff.28.5.1485.

Medicare will become insolvent in 2026, U.S. government says. (2018, June 5). Retrieved from https://www.latimes.com/nation/nationnow/la-na-pol-medicare-finances-20180605-story.html.

Pearl, R. (2017, September 25). Healthcare’s Dangerous Fee-For-Service Addiction. Retrieved from https://www.forbes.com/sites/robertpearl/2017/09/25/fee-for-service-addiction/#2a47c016c8ad.

Preventive care benefits for adults. (n.d.). Retrieved from https://www.healthcare.gov/preventive-care-adults/.

Roberts, E. T., Zaslavsky, A. M., & McWilliams, J. M. (2018, February 20). The Value-Based Payment Modifier: Program Outcomes and Implications for Disparities. Retrieved from https://annals.org/aim/article-abstract/2664654/value-based-payment-modifier-program-outcomes-implications-disparities.

Sarnak, D. O. (2017, October 5). Prescription Drug Spending Why Is the U.S. an Outlier? Retrieved from https://www.commonwealthfund.org/publications/issue-briefs/2017/oct/paying-prescription-drugs-around-world-why-us-outlier.

Congress’s Overdue Baby is Named ‘Paid Family Leave’

Republicans and Democrats have found every way to disagree when it comes to health policy, and this has caused us to lag behind on enacting legislation that will move our country forward. One of those policies is paid family leave following childbirth. There are not many similarities between the United States and Papua New Guinea, but surprisingly our great nation and New Guinea are two of very few nations that do not provide paid family leave after childbirth. But, we are at the perfect time for change. While the Family and Medical Leave Act, which provides up to 12 weeks of unpaid and job-protected leave, was passed under Clinton, President Trump has been a leader in the Republican party by being the first Republican president to endorse paid family leave for mothers and fathers after a newborn or an adopted child.

The first months of life are the most critical for a child. Poor upbringing can negatively impact a child’s entire life, and right now, only 17% of private industry workers have access to paid family leave. In our fiercely capitalistic society, almost 80% of Americans live paycheck to paycheck, and this makes taking time off to care for a newborn more challenging than ever before, which is why 25% of mothers must return to work within 10 days of giving birth. Researchers using data from the U.S. National Survey of Family Growth found that mothers who have access to paid leave are more likely to begin breastfeeding their newborn and are twice as likely to continue breastfeeding at 6 months compared to mothers who do not have access to paid family leave. Without breastfeeding or adequate time for bonding, a child’s full potential may be hindered. Unfortunately, there are no long term studies on the effects of paid family leave; however, it could be argued that the severity of future issues for a child and the likelihood of the child to utilize social welfare during adulthood is reduced if proper care during infancy is provided. This system overwhelmingly negatively affects the poor, who are often kept in cycles of substandard academic performance, but legislation on the floor of Congress could break that cycle.

Women who receive paid family leave have a higher likelihood of returning to their job, which benefits the entire system involved—the employer benefits from not having to spend additional money on training a new employee and the US economy benefits from a higher and more dedicated labor force. However, the largest challenge to the enactment of paid family leave is the possibility that some employers will choose not to hire women who are likely to have a child. This notion is substantiated by empirical data from New Jersey, which implemented statewide paid family leave in 2009. A 2016 study in New Jersey found that employment rates for women aged 22 to 34 fell about 8%. However, data is limited and states such as California have found that 90% of employers felt positively or neutral about paid leave after it was enacted statewide in 2004.

Now, with all this said, what are the plans currently being debated on the floor of Congress? As with the majority of our politics today, all the paid family leave proposals in Congress can be represented by two main plans: a fiscally conservative plan, led by senators Marco Rubio and Mitt Romney, as well as a liberal plan, led by senator and democratic candidate Kirsten Gillibrand. The two significant plans are briefly described below, and the best path of action is highly debated… where do you stand?

Gillibrand’s FAMILY Act: A working parent can receive 12 weeks of paid leave at 66% of normal wage with a maximum benefit of $4000/month. This plan would be paid for with a 0.2-0.4% payroll tax on all working American employees and employers, depending on your employment status. This is how the system is paid for by states like New Jersey that have already implemented statewide paid parental leave. One of the main concerns with this plan is that it adds a new tax. Despite a great federal deficit, our current administration and Congress voted on and passed a significant tax cut in 2017. Because of this, it is very unlikely that a plan proposing to add a new tax to working Americans will be well received by Republican congressmen.

Rubio and Romney’s New Parents Act of 2019: Working employees and employers contribute to social security, and this bill allows parents to tap into their future social security benefits to finance their leave, which can be up to 12 weeks. You are essentially paying for your own leave with money you were going to receive. In exchange for using this money earlier, a parent may work for 3-6 months past retirement age and continue contributing to their social security during this time, or they may receive small reductions in their social security benefits upon retirement. Similar to the FAMILY Act, parents will receive about 66% of their normal wage until a maximum benefit is reached. Overall, this mitigates the cost burden on employers, employees, and companies as a whole.

A significant issue is that there is bipartisan agreement that something needs to be done; however, neither side has been willing to accept the other’s way of acting, and this has blocked the enactment of any substantial federal bill regarding this issue. Right now, Democrats may need to accept that a full-benefit bill (FAMILY act) may not pass because of the added new tax stipulation that is highly unfavored among Republicans, who currently control the Senate and the Presidency. It may be important to start slowly with a more moderate bill like the New Parents Act proposed by Republicans, which is a more practical and feasible solution in our current state of no federal mandate for paid family leave.

Sources:

Burtle, A., & Bezruchka, S. (2016, June 01). Population Health and Paid Parental Leave: What the United States Can Learn from Two Decades of Research.

Jou, J., Kozhimannil, K. B., Abraham, J. M., Blewett, L. A., & McGovern, P. M. (2017, November 02). Paid Maternity Leave in the United States: Associations with Maternal and Infant Health.

May, A. (2017, May 18). Paid family leave is an elite benefit in the U.S.

Mirkovic, K. R., Perrine, C. G., & Scanlon, K. S. (2016, March 17). Paid Maternity Leave and Breastfeeding Outcomes – Mirkovic – 2016 – Birth – Wiley Online Library.

O’Dea, C. (2019, February 11). Lawmakers Move to Improve Paid Family Leave Program in New Jersey.

Vesoulis, A. (2019, May 16). Americans Could Finally Get Paid Family Leave. But Who Pays?

Warner-Richter, M. (2017, October 27). Paid parental leave is rare, but good for kids.

Congressional Research Service: Paid Family Leave in the United States

National Partnership for Women & Families: The Family And Medical Insurance Leave (FAMILY) Act

S.463 – FAMILY Act 116th Congress (2019-2020)

S.920 – New Parents Act of 2019 116th Congress (2019-2020)

America is Bleeding, and Congress is Trying to Stop It

With 16 physicians in Congress, America has taken great steps toward putting healthcare providers in a position to address our nation’s most pressing healthcare issues. We have all heard about the most prevalent causes of death in America such as heart disease and cancer, but trauma is actually the leading cause of death for Americans aged 1-44. Whether it’s a car accident, a fall, or even gun violence, trauma kills over 200,000 people per year in the US alone. The figures abroad are in the millions. Every year, trauma-related injuries cost the US almost $700 million. Many of these deaths are caused by massive blood loss, and around 20% could be prevented. With millions of dollars and thousands of lives to be saved, Congressman and physician Dr. Brad Wenstrup (R-OH) and Congressman Alcee Hastings (D-FL) have introduced bipartisan legislation, the Prevent Blood Loss with Emergency Equipment Devices Act of 2019 (H.R.2550), also known as the Prevent BLEEDing Act, which would require blood loss equipment such as tourniquets (a device tightly wrapped around an arm or a leg to stop bleeding) and clotting bandages in public spaces like libraries, schools, and malls.

I sat down with the Chairman of National Stop the Bleed Month Andrew D. Fisher, a fellow Aggie, to talk about this bill and other ways we can improve trauma care in the United States. As a Major in the US Army, Andrew Fisher’s military and civilian experience is extensive. He has completed over 500 missions with a total of 30 months deployment in Iraq and Afghanistan as a physician assistant, and he is a recipient of the Purple Heart. Fisher’s military prowess led him to be named the 2018 U.S. Army Hero of Military Medicine. Now, at the age of 46, Fisher has over 40 publications in peer-reviewed medical journals and is in his last year of medical school at Texas A&M College of Medicine.

Many Americans know how to perform CPR, but Fisher points out that after receiving CPR, only around 10% of patients survive to the time of discharge. However, Fisher says that in the case of massive blood loss, the application of a tourniquet yields a higher survival rate. His previous unit in the US Army brought prehospital mortality from blood loss down to zero after proper blood loss training was given. So far, tens of thousands of people have been trained in bleeding control through National Stop the Bleed Month, and all the training has been completed for free and supported by the American College of Surgeons. Furthermore, traditional CPR/AED courses should add basics about bleeding control. A Texas study found that the mortality rate after a severe vascular injury to the arms or legs was 8% without the application of a tourniquet immediately after injury. However, the mortality rate drops down to 3% for patients who receive a tourniquet. Learning how to use a tourniquet could be vital in a deadly situation.

My own uncle passed away six years ago in a bus accident, and his life could have been saved through the use of a tourniquet. His arm was severely injured in the accident, and he was bleeding out. In a perfect situation, a tourniquet would have been available on the public bus. In this case, a bystander would have wrapped his arm above the site of bleeding, and the tourniquet could have stopped blood from leaving the major artery in his arm. Even where a tourniquet is not available, any type of band, scarf, or long piece of fabric can be used to tightly wrap the arm or leg above the site of bleeding.

When I asked Andrew Fisher about the Prevent BLEEDing Act, he said that he appreciates Congress’s efforts, but noted that the federal government is “a little late to the game.” Fisher pointed out that a few states, such as Georgia, have taken matters into their own hands by equipping every Georgia public school with bleeding control kits. Actions by the slow-footed federal government may not be the most desirable; however, the ratification of this bill would greatly advance bleeding-control education, provide a federal mandate for the availability of blood loss supplies in public spaces, and situate blood-loss prevention as a nationally recognized issue.

Mass shootings in public spaces, such as the Las Vegas Shooting in which 58 people were killed and 851 were injured, have become more common. Bullets can cause major bleeding in an extremity, and death can occur in minutes, which is why time is essential. After the horrific shooting at Sandy Hook Elementary School in which 20 children and 6 adults were killed, the Hartford Consensus was created to improve the response to mass casualty and active shooter events. The Hartford Consensus calls for bleeding control bags to be present in places such as schools. And although it’s debated whether or not teachers should be armed, there are no apparent downsides to having teachers learn basic bleeding control techniques in the case of an emergency.

Fisher emphasizes that one is unlikely to be a victim of a terrorist attack or a school shooting; however, the chance of being in a car accident is much greater. This is where the vitality of emergency medical technicians (EMTs) and paramedics comes into play. These emergency responders are the first experts to the scene, and their actions frequently determine the life and death of a patient. One of the most common injuries from a major car accident is internal bleeding, which cannot be stopped through the basic application of a tourniquet. However, a procedure called REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) can be done by inflating a balloon in the aorta to temporarily stop blood loss. Currently, only trauma-related physicians are able to perform this procedure. However, Fisher along with countless others in the field of pre-hospital medicine, are calling for the training of paramedics to perform the procedure in a life or death situation. Fisher, a former paramedic, says that it is a challenging skill, but it may save more lives after traumatic injury. In addition to REBOA, Fisher believes that all paramedics should be trained on the administration of ketamine as a pain-reliever. Trauma related injuries can cause excruciating pain that warrants care, which is why first responders must be trained to administer safe pain-relievers to severely injured patients. Only half of paramedics report learning about ketamine during their training; however, ketamine has been vetted through research and has been shown to be a powerful and safe tool for pain relief in the pre-hospital setting. Fisher also believes that EMT standards should drastically increase to broaden their understanding of anatomy and pathophysiology, noting that professional hairdressers have to complete over 1000 hours for their program while based on national averages, EMTs only have to complete a total of 120-160 hours. Overall, furthering the knowledge and clinical skills of our medical responders has the potential to better stabilize patients before they reach the hospital and ultimately save lives.

Thousands of bills flow through our legislative bodies, and the majority of the bills signed into law are sponsored by Republicans and Democrats. The Prevent BLEEDing Act, which would appropriate $10 million to making blood loss supplies more accessible in public spaces, has already gained bipartisan support, and this bill along with other improvements in emergency medicine would have a positive impact on trauma care in the United States.

*Major Fisher and I met to talk about trauma care and prehospital medicine*

Sources:

Buckland DM, Crowe RP, Cash RE, et al. Ketamine in the Prehospital Environment: A National Survey of Paramedics in the United States. Prehospital and Disaster Medicine. 2017;33(1):23-28. doi:10.1017/s1049023x17007142.

Civilian Prehospital Tourniquet Use is Associated with Improved Survival in Patients with Peripheral Vascular Injury. Teixeira, Pedro G.R.Vu, Megan et al.Journal of the American College of Surgeons, Volume 226, Issue 5, 769 – 776.e1

DiMaggio C, Ayoung-Chee P, Shinseki M, et al. Traumatic injury in the United States: In-patient epidemiology 2000-2011. Injury. 2016;47(7):1393–1403. doi:10.1016/j.injury.2016.04.002

Hastings and Wenstrup Introduce the Bipartisan Prevent BLEEDing Act of 2019. U.S. Congressman Alcee L. Hastings. https://alceehastings.house.gov

Hax SD, Davis K, Stone B, Bledsoe B, Hodnick R. Ketamine’s Versatility Makes it a Powerful Tool for EMS. Journal of Emergency Medical Services. https://www.jems.com/articles/print/volume-42/issue-2/features/ketamine-s-versatility-makes-it-a-powerful-tool-for-ems.html. Published February 1, 2017.

Stop the Bleed – Georgia – Georgia Trauma Foundation.

Zero Preventable Deaths After Injury. Washington (DC): National Academies Press (US); 2016 Sep 12. 1, Introduction. Available from: https://www.ncbi.nlm.nih.gov/books/NBK390332/

https://firstcareprovider.org/blog/tk-how-to

Giving Life Twice

Most mothers only give life to one child at a time, but about 800,000 women worldwide give life to two… and I’m not talking about twins. I’m talking about the donation of their umbilical cord blood, the blood that remains in the umbilical cord after childbirth. Most commonly, the umbilical cord and the placenta are thrown away after birth, but these organs contain precious stem cells that have the capacity to save lives… to give a second life to someone else.

Harvesting umbilical cord blood and utilizing it for treatment is a relatively new scientific advancement that started in the late 1980’s. Scientists and doctors have realized that umbilical cord blood is rich in stem cells, specifically multipotent hematopoietic stem cells. These are big words to describe a simple yet incredible cell. Multipotent hematopoietic stem cells are cells that can give rise to all the blood cells, which is why these cells are invaluable to someone suffering from a blood disease. So, how does all this work and what does it treat? Well, first of all, the procedure is painless for both the mother and the child, and it takes 2-5 minutes. To collect the umbilical cord blood after a baby is born, the physician first cuts the umbilical cord then simply puts a needle into the blood vessels of the umbilical cord before drawing out the blood. This blood is then stored and frozen at -196°C. Mothers who have donated this blood have described it by saying that they did not even know it was being collected until after the doctor told them that they were done. After this blood is tested and stored, it can be matched with a blessed patient somewhere around the world who needs a blood transplant. Umbilical cord blood can be used to treat patients with various types of common blood cancers and diseases, such as leukemia, lymphoma, as well as sickle cell anemia.

Numerous advantages exist for umbilical cord blood, including the following:

No/very little risk to donor
Easily stored
Cells collected are immunologically immature and have a high growth potential
Low incidence of Graft vs Host Disease, which is a disease where the grafted stem cells detect the normal cells as foreign, resulting in the stem cells attacking the healthy body cells
Blood type matching is easier with stem cells harvested from cord blood compared to the conventional stem cells harvested from bone marrow

Now, you may be wondering where all this blood is stored, and this is where the debate comes in. There are two options you can choose from for where your cord blood goes: public banks or private banks. Public banks are completely free, and this is where your cord blood goes into a world registry where a matching donor can be found and treated. However, private umbilical cord blood banks make up a several hundred-million-dollar industry. When the private bank option is chosen, the blood is collected and stored for the sole use of that family. These blood banks say that their service is “biological insurance” for your kid if anything goes wrong in the future, and this is simply misleading. Numerous marketing techniques are used on pregnant mothers to sell them a cord-blood bank plan, but the chance of the child ever actually using this cord blood is trivial. Some studies show the rate of private bank blood used being 0.09% while other studies show that public bank blood is 30 times more likely to be used than private. Furthermore, numerous studies have shown that the quality of cells and the number of stem cells are lower when kept by private cord banks versus public. As one study published in the journal Transfusion said, “Quality parameters of privately banked umbilical cord blood are inferior to those stored in public banks.”

Very few blood diseases can be treated with one’s own umbilical cord blood because if the disease is genetic, then the stored blood has the same genetic abnormality, thereby rendering it useless for the kid. Almost 90% of transplants are between unrelated people with the remaining 10% being between family members, which is another powerful benefit of umbilical cord blood. For example, if you have a kid who has been diagnosed with leukemia, and you also have another kid on the way, then the umbilical cord blood for the second child can be harvested and used for the baby’s brother. This can be done through public bank systems at little to no costs. I keep talking about how public banks do not cost you anything because of the striking difference between public and private banks. Private banks are very expensive! For example, let me tell you about one of the several well-known private cord blood banking companies. According to the company’s website, to store your cord blood, the company charges $1,575 for the collection of the blood and an annual storage fee of $175. That already sounds like a lot, but a greater opportunity cost exists here. At the time of your child’s birth, if you put $1,575 dollars into a mutual fund that grows at a conservative rate of 8%, and you contribute just $175 to that fund every year, here’s how much your kid will have after….

20 years: $15,000

40 years: $80,000

65 years (retirement): $560,000

Many people never attain more than half a million dollars in their entire life, and now your kid can have it just for them at the time of retirement. The sad reality is that while 800,000 women have publicly banked their blood, 5 million have used private banks. Umbilical cord blood is much better off in the hands of a public bank, and this notion is supported by the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and many more. As Dr. Paul Harker-Murray at UT Southwestern said, “Umbilical cord blood is an underutilized medical resource with immediate life-saving clinical applications,” which is why it is so important for pregnant women to strongly consider donating their umbilical cord blood to a public bank.

Sources:

Ballen KK, Verter F, Kurtzberg J. Umbilical cord blood donation: public or private? Bone Marrow Transplantation. 2015;50(10):1271-1278. doi:10.1038/bmt.2015.124.

Kurtzberg J. (2017). A History of Cord Blood Banking and Transplantation. Stem cells translational medicine, 6(5), 1309–1311. doi:10.1002/sctm.17-0075

Newcomb, J. D., Sanberg, P. R., Klasko, S. K., & Willing, A. E. (2007). Umbilical cord blood research: current and future perspectives. Cell transplantation, 16(2), 151–158.

Shenoy S. (2013). Umbilical cord blood: an evolving stem cell source for sickle cell disease transplants. Stem cells translational medicine, 2(5), 337–340. doi:10.5966/sctm.2012-0180

Sun, J., Allison, J., McLaughlin, C., Sledge, L., Waters-Pick, B., Wease, S., & Kurtzberg, J. (2010). Differences in quality between privately and publicly banked umbilical cord blood units: a pilot study of autologous cord blood infusion in children with acquired neurologic disorders. Transfusion, 50(9), 1980–1987. doi:10.1111/j.1537-2995.2010.02720.x

Waller-Wise R. (2011). Umbilical cord blood: information for childbirth educators. The Journal of perinatal education, 20(1), 54–60. doi:10.1891/1058-1243.20.1.54