Archive for category Medical Errors

What is Defensive Emergency Medicine?

So I read all the time that defensive medicine costs all this money (and depending who you talk to, it’s a lot of money or not that much), but I still don’t know when I’m practicing it or when I’m not. So I came up with a few scenarios and want you to vote on what you think. I’ll leave the poll open for the next week, and then post the results after that. Real cases we all see daily (I don’t necessarily practice this way, just giving examples!):

Scenario 1:

52 year-old woman with hypertension and dyslipidemia, got in an argument with her daughter, had 3 minutes of left-sided chest pain and “my left arm was numb,” with maybe some shortness of breath (“sometimes,” she says, which doesn’t really answer your question), self-resolved. Now in the ED feels fine, EKG unchanged and unremarkable from the last one. No prior stress test. You admit her for rule-out ACS. “This could be unstable and new angina!”

Scenario 2:

40 year-old male with a history of PE on coumadin, with three weeks of non-pleuritic 1/10 chest pain and shortness of breath. Gradual onset. EKG and chest x-ray are normal, and INR is therapeutic and perfect: 2.5! You CT angio the patient for pulmonary embolism. “If it’s a PE and he’s therapuetic on his coumadin, he needs an IVC filter!”

Scenario 3:

4 year-old male had a brief LOC after his brother opened a door quickly and hit him in the forehead. Healthy kid. Normal vitals, normal neuro exam, no signs of a basilar skull fracture. 2cm hematoma. PECARN suggests observation vs. CT. You CT the kid. “I would hate to miss a subdural in a 4 year-old, that’d be devastating!”

Scenario 4:

26 year-old healthy female with a day of vomiting, no diarrhea. Says she has abdominal pain, but belly’s not tender. Tachy 106, otherwise vitals are normal and she looks well. Plan is for fluids and reglan and re-assess. Your resident orders a CBC and BMP for some reason, and the WBC comes back 24.8. Patient feels a little better, is tolerating PO, and abdomen is still not tender. You order a CT scan of the belly anyway, “That’s a really high white count! I’d hate to send an appy home!”

Scenario 5:

36 year-old female with a history of anemia on iron with heavy vaginal bleeding, history of heavy periods. Not pregnant. 2 days of bleeding, says she’s going through 8 pads a day, this is heavier than her normal “heavy” vaginal bleeding. Well-appearing in the ED, BP is 130/66, HR in the 70s, no signs or symptoms of symptomatic anemia. Vaginal exam has some pooling of blood in the vault, no active bleeding from the os. Her prior hematocrit in the computer system from 6 months ago is 34.3. You order a CBC. “Maybe it will be really low and she’ll need a transfusion!”

Answer the survey.


Can We Rename Epi Already?

People often say to me, “Graham, you are a crazy person,” and I say “Yes, I know that.” It is in this vein (yes, pun intended), I’d like to ask someone smarter than me (that’s you, readers): Why the hell do we still call Epinephrine “One to one thousand” and “one to ten thousand?”

The thought’s come up on several occasions over the past few months: working a few shifts with bad allergic reactions, a recent EMCrit podcast, an EMRAP episode, a recent Annals article, and a near-miss with a colleague where he wanted IM and the nurse almost gave IV.

Epinephrine seems to be the only drug that’s written as a ratio, as opposed to a concentration or percentage, and I’m scratching my head to figure out why. Maybe it’s because there’s less confusion over someone verbally saying “one-thousand” versus “ten-thousand,” compared to “zero point one percent” and “zero point zero one percent?” But come on, is this really the best we’ve come up with? “One” versus “ten” is our safety measure with a drug like epi, that’s pretty much only used when people are already super sick or super dead, and by definition people are not reacting calmly? One study shows when dosed as ratios, people give way more epi and take way longer to give it.

Here’s what we’ve got right now:

Ratio Concentration Percent
1:1,000 1mg/mL 0.1%
1:10,000 0.1mg/mL 0.01%

I propose something else entirely: let’s give it a word, and label it that way. Color, too. (Maybe dark red vs pink or something to show one is more dilute.) Some ideas:

  • High vs. Low Concentration
  • Concentrated vs. Dilute
  • Skin vs. Intravenous
  • Strong vs. Weak
  • Muscle vs. Cardiac

There’s a limited number of people who give epinephrine: us (ahem, our nurses), the intensivists (and that’s usually in drip form), paramedics, and other nurses during codes. Why not set a new standard and fix this once and for all?

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Emergency Room Communication

One of the key ingredient to running an efficient Emergency Room is good communication. Depending where you work finding charts, immediately finding a nurse  or calling radiology can take longer than expected. Huntington Hospital is currently using an Iphone/Ipod device that allows the health care staff better communicate with each other. It does this via VOIP (Voice over Internet Protocol), basically the set up the system in the hospital to call each other using these devices instead of the hospital PBX or screaming across the ER. The Voalte One system provides voice, alarm and text services all on one device. Overall helps reduce the noise level and makes it easier for the staff to text each other or call each other.

Over all points:

  • Receive Voice calls, alarms, and text messages all on a single device
  • Easily manage multiple text message conversations
  • Intuitive user interface and ringtones
  • Allows simple alarm acceptance or rejection
  • Custom, user-generated “quick messages” facilitate instant messaging of common items to other users or a web-based client

Overall I see both pros and cons, on one side I think it would be useful to have one device to do it all.

On the other side, I worry that it might make it to easy to interrupt us from patient care. In the end it is all about the balance act.

Huntington Hospital is a 636-bed  trauma hospital. For more information, visit

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