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A year ago I was in Vegas attending ACEP SA and looking forward to starting my new career as an attending physician.  Now I am an attending physician looking forward to attending ACEP SA in San Francisco.  It’s been quite the year, with a LOT of things learned along the way…

– With a good supporting staff you can run two codes at the same time.

– It’s never easy when a patient dies… it’s even harder when they come back to life after you’ve pronounced them.

– Suddenly the painful bread and butter patients become your bread and butter.

– Nights and weekends,  you’re the central line, intubation and OB specialist.

– Draining an abscess is still satisfying.

– I hate dictating.

– I realized one day about six months in, that I will probably be here to see some of my pediatric patients grow up, some of my elderly frequent fliers die, and I will end up with some “private” patients.

– The surgeon who yelled at you one day will be the one who comes in and places a chest tube and central line for you the next when you’ve got a major trauma and a full board and growing rack.

– The Darwin Awards exist for a reason as exemplified by the girl with the C2 unstable fracture that left AMA because I wouldn’t “schedule” her a neurosurgery appointment and who “had too much to do” to be transferred to the other hospital up the road.  She ended up driving herself about 2 hours later to the hospital and couldn’t be taken to surgery until later that night because she’d stopped at McDonald’s for a full meal… while wearing her C-collar at least…

– Really sick peds patients still scare me.

– Necessity really is the Mother of Invention

A year ago when I became an attending at this small rural hospital,  I posted a blog about being thrown into the water not sure if I would sink or swim.  A year later, I think I’ve mastered dog-paddling; this next year I will probably be learning some simple strokes.  Just keep swimmin’ Just keep swimmin’…  I look forward to seeing you in San Fran!!

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A Must Listen From the Patient’s Perspective

Thank you, Mom, for finding a really fantastic, funny, insightful reminder about what it’s like to be a patient in today’s health care system from Andy Borowitz, from The Moth Podcast. Everyone should take the 15 minutes to listen.

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Separate Lives

Now that I’ve been working in this small community E.D. for a while, I’ve come to realize that you develop a very skewed view of people. 

After seeing your fifth or sixth toothache of the day with severe dental caries, you begin to think that everyone smokes meth.  After talking to your third or fourth 20-something who’s on disability for their “chronic pain,” you start to wonder who’s actually working in the community.  When your second or third morbidly obese child comes from one of the outlying towns, you wonder about the strength of the local gene pool.

I’ve sometimes left the E.D. at night worrying about the people in my new community.  While this community doesn’t have the Knife and Gun Club I left behind in the city where I trained, I feel like the perceived social environment may be more insidious.  But, like I said, I have a skewed view.

Then one day I had an epiphany as I drove the main street of this small town.  Even though it seems like we see half the town in one day in the E.D., it’s actually a very small percentage of the people who live here.  The people who come through the E.D. aren’t the people I see working in the grocery store, delivering the mail, running the gas station, etc.  Ok, well, sometimes those people do get hurt too, but they aren’t the chronic back pains, chronic dental pains, chronic anythings.  They are the people with the emergencies.  They are the people who I got into Emergency Medicine for… and somedays that thought is enough to keep me going through one more shift.

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My Way

It’s a new year so I’m going to let you in on a little secret… I stress about every post I place here.  I sweat and I struggle.  I write, delete, write, edit, delete, write, delete, delete, delete, then finally come up with something resembling a post which is worthy of a professional, medical website.  So that is why I post so infrequently.

Sure, at first I tried to condition myself to posting once a week.  I was a new senior resident, about to graduate;  I had a lot to talk about.  Then, as the year progressed, time became a factor.  I was in the middle of interviewing, finishing requirements, and thinking about moving my brood cross-country which entailed packing and moving the accumulation of 13 years’ of stuff and memories.  Then, once I got settled, I did have some fodder for posts being a new attending and everything.  But now, it’s back to the sweating…

See, I’m going to let you in on another secret…. I’m just a simple country E.D. doc.  I’m not an academic.  I’m not a politico.  I just go to work and take care of patients in my little corner of the world.  And, I write about those encounters;  cases that make you stop and think a bit, patients that are a reminder that we are linked by common themes, and those particular cases that teach you that there is still so much more to learn.

This is what I write about.  And, I’m ok with that.  I hope you are, too….

I’m finishing the week here in Bonita Springs, attending the NAEMSP conference.  Boy, do I have some work to be done in my area.  And, along with that I am sure some new themes for future blog posts.

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Peer Review Is Dead! Long Live Peer Review!

CC from Flickr user wenzday01

CC from Flickr user wenzday01

The internet has fundamentally changed the way we understand and interact with the world: not just as physicians, but in our daily lives; however medicine (especially academic medicine) still lives in the dark ages. The ways of old are starting to show signs of wear, that this is beginning to change. And as things in the age of information move at an ever more-rapid pace, I think the changes will be here before we know it. I, for one, welcome our new data overlords.

The medical journal was initially created as a forum: a way to publicly share information with your colleagues, and get credit for the discovery. Say you wanted to tell the world of a new surgical technique. Or a new drug that you’ve discovered to help your patients. You could discuss it with a few colleagues in the hospital. But if you think you’re really onto something — something that really might be great and really might help not just your patients, but everyone’s — you’ve got to spread the word. And that’s how the journals started. Not with research, but with physician opinions and approaches and case reports and “Hey look what I found out”s. If you go back to the early publications of the New England Journal of Medicine — which now allows you to search from their archives from 1812 on — you can see some pretty cool stuff. Punch in your favorite subject and you’re transported back in time to when physicians like you were still trying to figure out what the hell was going on with this patient, instead of the biochemical cytokine pathway of today. It’s pretty incredible.

So here’s my first point: look how we share information today (and honestly, we’re just getting started): Twitter, Facebook, emails, blogs, text messages, Google, Wikipedia. Sure sure, we still share some very important information through medical journals, but they simply can’t keep up. Hundreds of new medical journals are launched every year, for everyone’s own sub-sub-specialty out there. Yet the hunger for publication and knowledge continues to grow. Let’s just consider the case report, for example. Imagine you’re staffing a hospital in the late 70s/early 80s in New York, or San Francisco, or Los Angeles, and you find these small crops of patients with really, really weird infections. You scratch your head, dig in a little deeper, and publish what you’re finding in the New England Journal of Medicine in the December 10, 1981 edition. Four months later, several replies are published: it’s marijuana use; no no, it’s the amyl nitrates that the gay men are using; of course not, it’s the CMV they’ve been exposed to; no, you’re wrong, this is something entirely new we’ve never seen before. It’s an absolutely fascinating read of the natural course of HIV’s research pattern, but one that I imagine would be very different today (and will be different when the next HIV/AIDS-like disease hits):

(Sorry for sticking words in your mouths, gentlemen.)

(Sorry for putting hypothetical words in your mouths, gentlemen.)

Okay okay, so fine, that’s just case reports. And medicine and science and the scientific method evolved, and It Was Good, and then medical journals became the place to publish research. Big trials. Lots of money. Which brings me to my second, unforunate point: peer review is not all it’s cracked up to be. Some concerning data (ironically, yes, published in the journals):

Now, I’m not saying that peer review should be discarded, or that journals should cease to exist, or that we should throw the baby out with the bathwater. I am, saying, however, that I think there’s room for another option, using the internet, social networks, and crowdsourcing. (NB: In this topic I am building on existing ideas from Chris Nickson/LITFL’s Time to Publish Then Filter? and The Wisdom of Crown Review which also references these BMJ and Annals of EM opinion pieces.) I agree with Chris: I don’t know exactly what form this should take, but something like an academic Twitter (Trip Database’s TILT?) might not be a bad start. I hate to make this all a popularity contest (mostly because I lost those so vigorously in high school), but the cream typically rises to the top when something is put to the crowds.  (But sadly, not always. Okay, at least, the academic crowds.)

Or perhaps it’s meta-reviews of the data. It’s online Critical Care Journal Clubs, or it’s a rating system to articles with ratings from colleagues you like and trust (and who know the literature better than you) like Leon Gussow’s 5/5 Skull and Crossbones at his Toxicology blog. Or podcasts reviewing a single topic. I’m not sure if it’s centralized. Who knows. Someone will build it and get it right (maybe me?) and we’ll go from there.

And all these great online links and resources lead me to my final point: “academic” works cannot and should not be limited to the length of one’s search in Pubmed as author. Yes yes, I’m suggesting the beginning of an academic new world order, and should be burned at the stake for such heresy (especially since I’m going into academics). But “publish or perish” should not simply mean “get your name in a journal.” Academics is the pursuit of knowledge, the pursuit of teaching and education. Case in point: Rob Reardon, narrator of so many of those fantastic ultrasound videos that I’m forever loving, is a well-published article in the journal world as well. But I guarantee you this: the amount of education that Rob has produced on his website — and that people have learned from — already exceeds the amount of whole-world educational impact of his Pubmed career. It’s simply exposure from the internet versus exposure through one journal.

Like-minded people (frequently education-minded, tech-oriented like myself) are doing this all over the web. They’re frequently (but not always) affiliated with some sort of academic place — be it an official medical school or simply an area where residents rotate — and do it because they enjoy it. And none of it would make it into a journal article. It’s too short, or too fast, or too digital, or simply too practical — but yet clearly useful. And it should be valid and appropriate academic work, recognized by our peers. (Let the crowds do the peer-reviewing of these publications if they like. Don’t like one of Rob’s videos, or disagree with him on something he says? Leave a comment or send a message on Twitter for all the world to see.)

There is a huge, huge volume of really high-quality learning on the web, especially in Emergency Medicine (much of which I’ve documented here), and it’s only becoming better.

Journals are here to stay — and I welcome them. They provide an important resource to develop and publish research and trials, and are still the biggest forum available to spread one’s medical ideas. But at the same time, there is content and ideas and a wealth of knowledge and information-sharing going on that is occuring not in sequence — but in parallel with them. Information that is simply out of the realm and scope of the journals and old-fashioned peer review. We are starting to develop the tools to share this information, and I look forward to where the next 10 years take us. (Hopefully to at least a modicum of technologic advancement in the snail’s pace at which medicine frequently changes.)



A baby died today;  a very small infant.  One minute I’m excited by the end of my overnight shift quickly approaching, and the next I am hearing the words you never want to hear come over the radio, “En route to home for infant not breathing.”  I think the whole ED staff stopped for a minute waiting for the next report.

Then we begin to organize.  Prepare a room, grab the pediatric resuscitation cart, where’s the Broselow tape, get respiratory alerted.  The on-coming attending arrives, and I tell him what is going on.

The next report comes over the radio, “Attempted intubation, bagging via BVM, chest compressions ongoing, no IV access.  Five minutes out.”  Ok.  Grab the ultrasound, do we have the right sized needle for the EZ IO, call an overhead infant code.

The infant arrives.  One, two, three, gently over to the gurney.  Let’s take a look.  Intubation attempted.  Ultrasound shows no cardiac activity.  Temperature is 31 rectally.  The parents are hovering expectantly, holding onto each other tightly, watching our every move.  The other attending and I look at each other.  We know there is no hope.  We try to make our attempted resuscitation last as long as possible for the sake of the parents.  But soon the staff understands our motions.   We take one last look with the ultrasound.  Silent snow.

We turn to the parents.  They have a sense of what they’re going to be told before a word is even said.  They look around at us and our staff and see our eyes looking down, looking sad, tearing up and looking at them wordlessly.  Cries of anguish fill the ED.  The infant is gently wrapped and the parents are brought to the bedside.  We file silently out to give them their last moments with their child.

I go to dictate my last patient’s chart, stopping to hug the nurse who stepped into my work area to “get it together” before heading back out to the other waiting patient in the E.D.  She apologizes, and I tell her it’s ok to show her emotion.  She starts to shake as tears run down both of our cheeks.  She quickly recovers and steps out.  I take a deep breath, dial the familiar number, and begin my dictation.

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A Whole New World

Our group covers the Urgent Care connected to the larger hospital in our area, and yesterday I worked my first shift there.  Wow.  What an experience.  If this is the future of healthcare under the current system, I want to know if I can switch specialties… like to pathology.

We saw, in our humble Urgent Care, about 80 patients in a 12 hour period.  Now, I know I had colleagues who moonlighted during residency and had 200+ days in our Western NY town, but the volume for me was frantic considering I see about 20 patients a shift during my 12 hours in my E.D.  Luckily, I was with an experienced “old timer” who talked of the days he worked the UC by himself, and a nurse, with just a bottle of PCN and a stethoscope that was missing an ear piece.  But, I digress.

I almost felt as though I was somewhere in a third world country.  And, the scary part is that most of my patient population was under the age of 30.  Now, I know there’s a lot of methamphetamine use in this part of the country, but the dental caries and disease I saw in the “never used drugs ever” crowd was pretty scary.  I began to wonder what’s in the local water.  I also found out there’s a three month wait time to see a dentist.  Even longer if you’re on state funding and have to wait for the one clinic that takes MediCal.

Then there’s the No PMD crowd that come in with their back aches, shoulder aches, neck aches, etc., and who seem to have never heard of acetaminophen and ibuprofen.  But, somehow, they do know about “Norco’s and Perc’s” because they always have a “friend with some extras” and that seemed to work really well on that pain.  Yeah, they’re not too happy with my “no narcotics” philosophy, although they don’t mind the work note giving them a three day weekend.

The ones I worry about are the “I have a PMD, but they don’t do anything.”  There’s a two to three month wait time to get an appointment with a primary care physician;  more if you’re not an established patient.  I had several patients come in with chronic problems who wanted me to give them a “quick fix.”  Let’s see… you just saw your PMD three days ago, you didn’t address this problem with them even though you tell me it’s been bothering you for three weeks, and now you’re not going to see your PMD again for 4 months.  Yeah, mhmm…

Seriously,  is this the future of healthcare?  Or are we allowing for a “dumbing down” of our patients into a “take care of me” society?  Please, don’t even get me started on the “can you write me for a Tylenol script because then I get it for free” patients.

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One Week

*with props to BNL

7 Days and 7 Nights

It’s been one week with my new ID;

the kind that says “OK, you can now sue me”

One week since I got the key

to a sleep room that I will probably never see

Four days since my last day off

How long is it that you’ve had that cough?

Yesterday since you had no pee?

And your primary said you had to come to see me.

My first patient was a hoodwink

the kind that made me stop, think

is he real or is this just a scam?

He’s allergic to all meds

Really gives me the dreads

Want to just say no

He wants narcotics, “Yes, please, thank you Ma’am.”

Run to do triage when the door chimes

It’s all about times

Because people want value

Now watch them start to throw fits

You try to match wits

So that JACHO doesn’t bust you

Need to take a break, I start to shake

and I feel a slight headache

I need to eat, but the board is getting busy.

Gotta see the injured toe

make me some dough

my med school debt it will still grow

though it’s been so long now

I think my head is getting dizzy

How can I help you if you won’t tell me what is going on?

I know you’re two but your parent is just too far gone.

Tell me you’d have the pain now for a whole year

Today it hasn’t changed, so?

Well, now I’m here.

I have to see the kid pulling on their ear,

And take a history on “found down drunk”

It’s been one week with my new ID

My new white coat is already grubby

One week, now where’s that knee?

Another pelvic?  no way, seriously…

Three nights till my next day off

Drop your drawers, now turn your head and cough

Yesterday having pain in your belly?

And your primary said you had to come to see me.

And your primary said you had to come to see me.

We’re open 24 hours, so you come and see me.


On My Own

Facing the Onslaught

It’s very different being an attending.  Being the only one in the E.D.  Working alone for the first time.  I felt a little lonely.

My site director showed up at the beginning of my shift with a cup of coffee.  He hung around for about 30 minutes and then just disappeared.  No safety net.  No chance for me to second guess myself and ask him about a patient.  Just me making the decisions.

Today the hospital changed to a new tracking board and patient EMR system.  Luckily it was one I had worked with before.  The nurses were trying to learn the new system just as I was.  We were learning together.

Nurses really do help pull you out of yourself.  Just when you think you really suck and feel you are falling so far behind that you will have everyone leave due to long wait times, the charge nurse will stop and tell you that the flow is going great.  Another will pat you on the back and say, “Great First Day for all of us so far.”

Then you start to believe you can do it.  You pull from somewhere deep inside, and you jump in feet first and continue to face the deluge of patients.  You were thrown out into the water to sink or swim by someone who trusted you would start paddling…. and amazingly, you’re able to keep your head above water.  Guess you were ready after all.

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Pretty Vegas

I’m seeing the world through a brand new set of eyes…

The last time I went to a Scientific Assembly, it was in Chicago, and I was a resident.  I spent most of my time attending and being involved in EMRA events as I was my residency’s representative.  The lectures I attended were ones I hoped would help me continue to learn and grow as a resident.

This year I graduated.  After a brief hiatus, next week I start off life as a brand new attending…. by myself… covering a small E.D. in Northern California… Yes, Miss, I guess I will have that Bloody Mary after all…

While choosing my courses this year, I thought about the things that would help me most as a youngish physician starting out.  Unfortunately, there wasn’t a “Cut the Apron Strings Already or How to Leave the World of Academia and Start Your Own Path” lecture.  While my attendings gave me a fair amount of independence over the last six months, there was always that cushion, that support, that feeling of someone watching over your shoulder.  I relished at the times my attending would ask if I ordered this or that test, and I would say, “Why, yes, sir, I already did.”  And, I shuddered at my “doh!” moments wondering if it wasn’t too late to apply for a fellowship and who would take such an idiot like me.

I digress… I chose my seminars based on what I hoped would help in the real world;  things that weren’t really covered during my residency… like rashes.  I still can’t handle rashes.  Is it wet?  Is it dry?  Is it anything I want to be in the room with while not wearing a level 1 HAZMAT suit?  And dealing with psych patients.  There’s a growing concern about the abuse that E.D. physicians and staff are starting to see more and more.  We had a psych unit and four very husky security guards just a button push away at the facility where I trained.  At my new location, I might be able to find a well-armed veteran nurse and a housekeeper.  And I hope when I call 911 someone’s not across the river herding an errant cow.

So, that’s what I’m here for… to learn, to grow, to meet my colleagues who are on the same journey and gain some wisdom from them.  And to hopefully meet some of my colleagues from the Central Line…!

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