Welcome. Welcome back to episode number four of the Michael Rothman, a new podcast. And I'm glad, to see that you're coming back. I hope that you found it interesting, and I have a lot more to talk about. And today, I thought we would switch gears. But before I get into it, let me let me just say that the opinions of that I express are mine and may or may not be, those of Space Labs Healthcare who is my employer. So with that said, what do I wanna talk about today? Well, first three episodes were on a very, serious topic. That is the topic of sepsis. I'm not gonna go back over that. Watch episodes one, two, and three. Today, I wanted to go to the beginning. And in this case, what I mean is the beginning of what was what has come to be known as the Rothman index. Where did it come from? Why was it developed? Why was it created? Who did it? And when I talk to hospitals, I usually bring this story along, for what I think is an important reason. And that is I work for a vendor, and vendors sell things. People that I get to speak to are inundated with people trying to sell them things. I sort of feel sorry for them in a way. And in the way of the world, a lot of what a vendor tells you is not going to be absolutely true. And so the audience is very skeptical. Well, when we started this, we started for a really important reason where we were not selling software. We're not selling widgets. We had a purpose, and I wanted to distinguish ours distinguish us from that group of sales folks who are not believed. In fact, one One of our early meetings was with a large hospital system in the Southwest. I had met with a couple people and they brought me to a large meeting, a large conference table, probably twenty five people around this conference table. And I told the story, how this began. I talked about what we did, what what the science was, how we validated the work, how it was used, what kind of results we've gotten. And my sponsor basically kicked me out of the room after the presentation and then came back a little while later. And we signed a deal, which was unusual. Those of you in this business know that it's unusual. Normally, these things take a long time. They drag on before you come to a meeting of the minds. And I spoke to a physician later who became a friend, worked at this hospital. I said, you know, how did what was going on in that room? What it came down to was they believed me. They thought I was sincere, and I was. And, yeah, you can think of coming up with presentations that are very slick and well tested and so forth, and mine was cruder, homegrown, and they believed me. So how did this all begin? I had been working in the area of data analysis and modeling for, Well, for about twenty years before I started this. My my PhD is in quantum chemistry, and that was all mathematical modeling. And I sometimes have wondered, you know, was there why should I spend all those years learning about quantum mechanics? But it did teach me about modeling, and that is what I've been doing since. So I was working, building models. I won't go into that right now, but my mom was sick. She was just tired all the time. And, you know, she'd get up and do something, and then she'd have to lie down. And it got to be difficult. It turned out she had what's called aortic stenosis, which is a buildup of calcium around one of the heart valves. And, you know, don't hold me to this. I'm not a I'm not a physician, but it is the way I understand it. I build up of calcium around one of the heart valves and the result is the valve is doesn't close securely. It's leaky. And so when your heart pumps, it does not pump as effectively as it should. And your body gets, therefore, gets less oxygen. And the result of that is fatigue. And that was what was happening to my mom. This was not a required operation. It wasn't it it was a choice. But these days, that operation is relatively low risk. So I know one of the people who is gonna listen to this is gonna say, what? Low risk? Well, relatively low risk where they would do this operation on an eighty seven year old woman, my mom was eighty seven at the time, without, particular concern. Now it was riskier than doing the same operation on a fifty year old. You just don't have the same resiliency when you're eighty seven as you do when you're fifty. But the chance of something going wrong was described to us as less than five percent. Now that's not zero. And I know, you know, working with numbers over all these years, I know there's a huge difference between less than five percent and zero. But my mom was in good health otherwise. You wouldn't think she was eighty seven. She looked a lot younger. And so she chose to go ahead with this. So, she had the operation, and it's one of these miraculous things. You pop out the old valve and you put in a new valve. I don't remember whether it was a mechanical or, it was a pig valve. That's one of the ways they do this. But they put a new valve in, and it's it's a mechanical thing. It's plumbing. All of a sudden, her heart valve wasn't leaking, and so she got more oxygen. So she felt great. And she was going to PT the day after the surgery, and the physical therapist was having her getting up out of a chair and sitting down and so forth, and she was doing well. Yeah. So much so that after, you know, two or three days, I don't know exactly how long, she was transferred to the rehab unit at the hospital, but a separate section for rehab. It was at that point that she started to deteriorate. I wasn't there. My brother was there. And so I I get this story secondhand, but she was deteriorating. She started to slur her speech. She didn't feel well. She wasn't eating. It's not a good sign. And, she drank some coffee, which is actually a diuretic. My brother who was with my mom became very concerned, and he told the hospitalist about his concern about his observations of our mother, and, you know, I should interview him. I'm gonna have guests on this podcast. I'll interview my brother. That'll be a trip. Anyway, he had concerns. He expressed his concerns to the hospitalist who was caring for our mother at the time. And this is the story he told me. The hospitalist went in to my mother's room, and he took my mother's shoulders in his hands, and he shook her. And he said, missus Rothman, you've got to eat. And he left. You know? There must have been somewhat more to the story than that. That's the part that cut through to me. But, when this guy left, my brother went was very unhappy. And he spoke to the doctor and said, look. If there's a psychological problem, I want a psych psychiatric consult. If there's a neurological problem, I want a neurological consult. And so to this guy's credit, he arranged for both of those. It turned out we we knew the the psychiatrist or who came to see our our mother, a friend of the family. And she spoke to my mother, and she so there's nothing no psychiatric concerns that she had. But the neurologist, when he came, he did what is called the Babinski test. And you stimulate the bottom of someone's foot, and you see which way their toes curl. And I don't I don't remember which way is which, but, one way is normal. The other way is an indication of, brain damage. And that was the way that my mom's toes curled. And so they they moved her from rehab back to the the regular hospital and, hooked her up to an IV. And it turned out her her immediate problem was dehydration, which can be a very serious problem in the hospital or outside of the hospital. And when they gave her enough fluids, she came around, her speech recovered, and she was there for two or three more days at which point she was discharged. Now my father, who was with her also at the time, wanted the doctor to do a a repeat echocardiogram to look at her heart just to make sure everything was working properly. And they didn't. That turned out to be the wrong decision. But she was discharged from the hospital. And then I I was there at that time. My brother had been with my mom. So I was there, and she was very weak. But, you know, I I didn't know any better. I I sort of expected that, you know, you spend a week in the hospital or eight days or ten days, whatever it was. And, you know, you get deconditioned and you're weak. And and then I had I don't know how long I'd been at my mom's they lived in Florida. But I had plane reservations to go home the next day. And I spoke to my folks and said, you know, do you want me to stay? No. No. No. Know, get back to your normal business. They told us it was gonna take a while for recovery. So I left. And that was on a Saturday, I think, on Sunday. Was talking to my mother and spoke for a little bit, and then she said, I I can't talk anymore. Anyway, I hadn't meant to go through all the details of this, but I'll go a little further. Maybe I'll get back to more of this story in another episode because I wanted to talk about the genesis of the Rothman index, not just my mom. But she was the inspiration for all this work, and she is the reason that a lot of people are alive today who wouldn't be otherwise. Anyway, the the next day, Monday then, she was seen by a physical therapist who said, you know, you're too weak, we can't do the physical therapy. Alright. I'm not gonna go into the details, but she had trouble breathing. She was taken to the emergency room, and her heart stopped in the emergency room. It stopped because of cardiac tamponade, was the name of the condition. And what that means, I'm sure many of you do know, but for those of you who don't, your heart is actually in a sac in your chest. And if you get enough fluid in that sac, because fluid is not compressible, it actually prevents your heart from beating. When your heart beats, it actually expands. If you have enough fluid in your cardiac cardiothoracic sac, it will actually prevent your heart from beating. It's a mechanical thing. So in the emergency room, when they realized finally what was going on, they reopened her stitches and relieved the pressure and her heart started beating. But it was it had taken them too long. And by the time that that happened, she was she was essentially dead. She lived a couple of days in time for me to come back and be with her and my father. She was on a respirator. Anyway, they turned off the respirator, and we said goodbye. So that's my mom's story. What my brother and I came to understand was that our mother's death was avoidable. It should not have happened. I have theories about what had gone on, why the chain of events which unfolded happened. I'm not gonna go into that today. But I am going to talk about how my brother and I took this. And we talked about it a lot. We did consider taking legal steps, and we we rejected that for a couple of reasons. One is it was gonna be very difficult, but the the major reason was it was pointless. There was wasn't gonna bring our mother back, and the money just didn't mean anything if if we got money. And, you know, this was a waste just a waste. So we talked about it, and one of the things that we came to understand after talking about it enough was there had been a failure in terms of continuity of care. And my my brother was with my mom in the hospital and found out there was some someone called a case manager. I thought, oh, great. Someone in charge of the overall care of our mother. Good thing. Yeah. Except that there was one case manager on Friday, and there was a different case manager on Saturday, and there really wasn't significant continuity. And the important thing was in rehab, there was a clear trend that our mom was deteriorating, which was lost. It was not lost. It's it's just not visible. It didn't it didn't rise to anybody's attention. And so what we came to understand was that although all this data was in the computer, it wasn't wasn't knitted together in any meaningful way. And so we had several ideas. One was about continuity of care, and I give my brother enormous credit. I never would have done this. He and my sister-in-law made an appointment with the CEO of the hospital who was a physician. He told them the story of what happened to our mother and said that we have some ideas and we'd like to come into the hospital and try them out. We weren't asking for any money, but I was convinced. I had worked in consulting for years. I I was convinced that this gentleman would say, well, you know, we're very sorry for your mother's, for your loss, for your mother's passing. But, unfortunately, these things, you know, happen and, you know, there's no. We we couldn't possibly let you come into the hospital. That's what I expected, but that's not what happened. What happened was I got a phone call from my brother, and he said, how soon can you get down here? And that started what became known as the Rothman Index. That was the point of origin. And just to give you an idea of the timeline, our mother died in April of two thousand three, and we went into the hospital, my brother and I, in January of two thousand five. So this took a while. And I think I'm gonna give you a little more of the story, and then I'm gonna stop because I think I've been going on for quite a while now. We were received royally at this hospital. And in fact, my brother was had had an RV in Florida at the time, and they let him park his RV in the executive parking lot and run a power cable into the hospital to get electricity. They gave us an office in the executive suite, and the CEO of the hospital basically gave passed the message around, be nice to these these two guys. People didn't really understand why we were there, what we were what was the point of all this. But by and large, the the doctors and nurses were generous with their time. We were there for three weeks. The only remuneration was they gave us passes for the cafeteria. So we we got free lunches and dinners. But we spoke to quite a number of physicians and nurses. Nurse informaticists worked with us. We got data on seventy patients from a cardiac step down unit. And at the end of that time, the end of those three weeks, and we were there across both shifts, hung out at the nursing station. And but at the end of those three weeks, we had come up with a sort of crude model to quantify acuity. One of the questions that we had was, why isn't there just a simple measurement which tells you how sick you are so that someone could follow it and see if you were getting better or getting worse. It may seem obvious and it may seem you know, of course, they know that you're getting better or getting well, not all the time. Generally, yes, they do. Not all the time. Sometimes people are getting worse and the doctor and the nurse, doesn't appreciate that. They may think that patient's going home the next day. And they may they may go home the next day, but, probably they shouldn't have. They may be deteriorating, and it's not easy to quantify acuity so that you can see a trend. We worked with an expert diagnostician and did this experiment. We took a case where we knew there was a bad outcome, I guess the patient had died, and asked them to look at the medical record and see if he could see a trend. And not easy. Not easy at all. There's a lot of data. But as I was saying before, it's not knitted together. It's basically, you have a a digital filing cabinet with a lot of information in it, and it's up to you to put it together. So by quantifying acuity and especially by quantifying modest levels of acuity, you could see a trend and you would and give the nurse, give the doctor the opportunity to get to the bedside before there's a crisis. You know, that's the key. And we were looking into, are there systems that quantify acuity? One of the things we came across was a system that many of you are probably familiar with called NEWS. It's an acronym that stands for modified early warning system. USE in a lot of hospitals developed in nineteen ninety nine, I think the original paper was. The purpose of USE was to identify patients in a medical ward who were at risk for a cardiac arrest. Once you identify that patient, you would move them to an intensive care unit so that if they did have a cardiac arrest, they would have a better chance of being revived. That was the point of MUSE. But it had been used for years in conjunction with what was called a rapid response team. If your MUSE score was four or five or whatever, it would activate the rapid response team, and they would reevaluate the patient's condition and intervene if necessary. So we we came across MUSE and used some of the ideas that they had in their model. Their model was a heuristic model, and that just means it was constructed. It was put together by a group of intensivists in the UK, who took each of about a half dozen physiological measurements and rated them in terms of risk. So if you're for example, if your heart rate was between fifty and a hundred, that was no extra risk. But if it was between a hundred and a hundred and ten beats a minute, they'd give you one unit of risk. If it's between a hundred and ten and a hundred and thirty, they'd give you two units of risk and so forth. So we knew about muse. We used some of the ideas in muse in the first instance of what became known as the Rothman Index. But we were able to quantify acuity, middle levels of acuity in a important and unique way. And I think that is where I'm going to leave the story, because I don't want these podcasts to go on too long. Oh, I see. I've been talking for more than half an hour, and my goal was twenty twenty to twenty five minutes. So it's going to have to be in episode five. So for you loyal podcast watchers, keep watching. You'll hear more of the story, and I I hope I have a lot of that there are other interesting things. Hope you find this interesting. There are other interesting things that I have to talk about. And, also, just to let you know, I will be inter I will have guests. I I know a lot of people in in this world, and I'd love to get their their take on health care and life and saving lives and mathematical modeling, changing human behavior, and other things. And with that, I thank you for listening, and hope you have a great rest of your day. Thank you.
