Archive for category Residency

Trade Pay for Debt?

Mostly for residents (but attendings as well!): would you accept a theoretical pay cut as an attending for a reduced amount of medical school debt (say, half or none), and some malpractice changes? Vote now and add a comment.

http://answers.polldaddy.com/poll/2646892/

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Brush up on your Ultrasound skills with the iPhone Sonosite app

Sonosite has released a FREE iPhone app that will help improve their ultrasound skills.

The videos are amazing! Containing many tips, pointers on techniques, great sample cases, image gallery.

The app even has an abbreviated manuel for the Sonosite.  The app also contains the latest news concerning sonosite machines.

Here are some screen shots:

For a sample video click here

If you do not like the app, you are out time but not money.

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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 www.huntingtonhospital.com

Company website: www.voalte.com

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iPad and Medicine

The future of health care

iPad Medic

After Apple announced the iPad device, I immediately began to think of   all the medical applications that could be used for this device.

Currently the app store has about 140,000 apps and is growing at an amazing rate. The medical app store has about 1,920. Health apps number about 3,100. According to Apple, most of these apps should work on the  iPhone and will transfer to the iPad as long as you use the same login. It will be interesting to see what the apps that were created initially for the  iPhone will look like on the new iPad device. It is interesting also to note that the device does not have a camera, however the iPod Nano does. My guess is the device would take up more  bandwidth if it had a camera.

I am curious to see if the iPad will  work with apps like Skype and Google Voice.  If they do, then with a $20, 3g plan, you could use the device as a  2nd phone. For example Google Voice allows you to set up a local  phone number that others can use to call you. If you do not answer then you will get a transcribed text with the first couple of lines of  the missed callers message!

What medical applications can we expect from this device?

Blausen Medical App

Patient education company Blausen makes an amazing product that has short video animations on multiple medical diseases. They are very basic and range from half a  minute to two minutes. Electronic medical records would be interesting. You have to wonder how they would work in the ER. I cannot imagine keeping up with an expensive device in the ER. At least one I can’t put in my pocket. I can see myself losing it during a code or dropping it as I run to the floor for a “code blue.”

I am interested in hearing from our readers and seeing how other ER  doctors use technology at work. Currently, I use Pepid, although it is expensive, it has almost everything I need in the app.

Feel free to post if you are likely to purchase the next iPhone (new cell phone carrier to be announced in June), iPad wifi only will  be out around March 27 and the iPad with wifi/3g service around late  April in the United States. The rest of the world will get it after  June which will be just in time for the new iPhone.

I look forward to your emails and post,

Harvey Castro MD

Picture from iPhone life magazine.

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Voices Carry

EMS Along with those patients we see during our shifts, there’s a group of patients we never see…. the ones on the other end of the Medical Direction line.  At the hospitals we rotate through, there are the “Bat Phones” –  the phones on which pre-hospital care providers call us for, well, medical direction.  It’s actually red at one of the hospitals.  Cool.

Interns, not allowed to touch the Bat Phones.  Junior residents, encouraged to field calls.  Us seniors, we’re on it most of the time.  I’ve given orders for medications, orders to keep a patient home, orders to have a patient sign off AMA.  And, I’ve given the order to pronounce a patient in the field.

I don’t think about those too much.  Usually it’s an elderly patient, found down after EMS was called to a home for a welfare check.  “Lividity?”  Yes.  “Cold with no signs of life?”  Yes.  Ok to pronounce.

I did have one funny situation where I was told the patient was “obviously dead” however they still were showing a sinus rythmn at 60.  Pacemaker.  I told the EMT’s to get a big magnet, and/or to make sure that anyone that was going to be handling the body knew about the pacemaker.  Wouldn’t want anyone to get an unpleasant  jolt.

During my overnight shift, though, I had the hardest medical direction yet – pronouncing victims of a house fire.  I got the first call about 3 in the morning.  I could hear the sadness in the usually jovial EMT’s voice, “thirty-something year old found in a burning house;  soot around their face and mouth.  No signs of life.  Asystole on three leads.”  I didn’t know what to say.  How long had they been in the house?  “Unknown.  Found by first responders to the scene.  Fire had just shown up.”  I put them on hold.

Now, I’ve asked my attending about some complicated scenarios that I’ve been faced with.  Early on it had to mostly do with medications during in-the-field resuscitations.  But, last night, I felt I needed his advice.  I told him the scenario.  He too paused for a moment and asked the same question I had asked, “how long?”  We both knew too long.  I gave the order to pronounce.

Saddened by this, I went back to the bustle of the E.D.  Then about 20 minutes later the Bat Phone rang again.  It was the same EMT sounding even more morose.  “I have two more, doc.  Twelve and about 15 years old.  Pulled out by Fire just a few minutes ago.  Soot on the face and asystole on three leads.”  In my head I calculated 4 – 6 mintes for brain damage to start and they had been in the house already longer than the first victim.  Kids have a smaller reserve.  I gave the order to pronounce.

My attending walked over to where I had been on the phone, documenting what I was hearing.  He read over my shoulder.  He walked away quietly.  I hung up the phone and placed the run sheet in its place;  suddenly feeling as though I had pronounced that family in the E.D. instead of from a distance.  I had lost three patients in 30 minutes.

I gathered myself and went to pick up another chart.  As I walked to the patient’s room I glanced at the Bat Phone, wondering when it would ring again, and what my next patient would be.

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How to Save a Life

M*A*S*H

Henry explains the rules of war

“Look, all I know is what they taught me at command school. There are certain rules about a war, and rule Number One is young men die. And, rule Number Two is doctors can’t change rule Number One.” Henry Blake

While I can’t say that M*A*S*H is the reason I went into medicine, I can say that I loved the series, and that several times during my training I have found myself going back to certain episodes that seem especially relevant to a recent patient experience.  Like the one from which this quote is taken.

It’s upsetting to have a patient die after knowing you did everything you could.  It’s especially frustrating to have a patient die and not know why.  What did you miss?  What could you have done differently?  What else should you have done?

I recently had an experience like that.  A patient with multiple medical problems came in with a cough… and, chest pain.  I grabbed the chart and thought, “Oh, great.  Pleuritic chest pain.  Tessalon perles and a chest x-ray.  Probably a pneumonia.  No problem.”  Two hours later as I was writing for a Dopamine drip and calling the ICU, my pulse still normalizing after coming very close to having to do a surgical airway, I was thinking, “What the heck is wrong with this patient?”

Even after the intensivist took over, I continued to keep up with the patient’s progress.  Labs gave no answers.  X-rays and scans gave no further information.  We had cultured every fluid possible, sent off a rapid flu, and empirically started antibiotics, but somehow it didn’t seem like enough.  As my shift progressed, I heard as another pressor was started.  A few hours later, another.  This patient was dying, and I didn’t know why.

Due to bed availability, the patient ended up boarding in the E.D. and died early the next morning.  I came in a day later and asked if the family had asked for an autopsy.  They had.  No saddle embolism, no major coronary blockage, no missed dissection.  Some labs and cultures were still pending.  Still no answers.

I’ll check cultures during my next shift.  I kept a sticker from the patient.  I keep stickers from all my patients.  They help me log my procedures.  They make me think about what I did and what I could do better.  They make me follow-up and see if I missed anything.  They make me remember and not forget certain cases… as if I could.  I fight the war against Rule Two every day.

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Telephone Line

DictaphoneI have a friend who works as a transcriptionist.  She blogs and occasionally talks about her work.  However, she talks about the business side of her work:  how much she makes per line, how she can’t understand what the doctor is saying, how she has to undergo QI, etc.  One thing she’s never mentioned is if she ever takes the time to think about what she’s transcribing.

I’m currently on rotation with a group that dictates their H&P’s along with their assessments and plans.  After a day or two of dictation (which by the way I hate to do because I can’t stand the sound of my own voice) I started to wonder if transcriptionists laugh at some of the content in dictations or if they’re like mailmen who deliver postcards without reading the back.  I know I sometimes chuckle when I get the transcribed note back to sign for the chart… especially when I read things like:

“Patient states they have been constipated for a whole month.”

“87 year old patient states she fell off a chair while painting her ceiling.  She states her bridge club was coming over and didn’t want them to see a brown water spot that was on it.”

“Patient states that she has vomited several times.  The last emesis looked like blood, or it could have been the cranberry juice she had been drinking just prior.”

“Patient denies any alcohol, tobacco or drug use, except for the occasional marijuana use whenever her son is in town.”

“Patient states he thought his abscess was due to an ingrown hair, so he shaved off his all the hair in his axilla thinking it would go away.”

“Patient presents asking for Tamiflu because “there’s a lot of sick people hanging around the grocery store.””

Did I really dictate that…?  Yep, patients say the funniest things…

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Choose Your Fate

tarotWhen I was in medical school, picking a specialty was pretty easy.  I knew I hated clinic and wanted to work in the hospital.  I knew I wanted to perform procedures and have patient contact.  I knew I had the attention span of a two year old and would need constant stimulation.  So, that’s how I went into Emergency Medicine.

Now my colleagues and I are faced with the next major decision of our medical career… where to begin our practice of medicine.  I grew up in Southern California, so I knew I wanted to return back to the Pacific Ocean side of the country.  I knew that while I enjoyed teaching medical students and my junior residents, I really didn’t think a career in academic medicine was for me.  I thought about our rotations, and I especially enjoyed my experience in a rural setting.  So I knew it wouldn’t be the big city for me.

But how to pick a hospital?  I mean, aren’t emergency departments really all the same?  So I called upon the wisdom of my elders, and the one piece of advice I took with me on a recent two week interview jaunt through Northern California, Oregon, and Washington State was to ask at every interview, “So, how do you handle a nose bleed?”

I learned a lot about the local practices in the hospitals I visited when I asked to see their suture cart.  Or, when I asked where their pediatric resuscitation cart was located.  ENT carts are widely varied in their contents as are the supplies in their Eye and Ortho rooms.  I learned more about monitoring systems than I thought I would ever want to know, and I learned that in some places I would have to ask Radiology for the key to where the ultrasound machine was kept and then sign it out with permission from the Tech if I wanted to use it in the E.D.  Really?

“What do you do in case of an imminent birth?” brought everything from portable birthing stations to glazed over looks and mumblings about how that would never ever happen in their E.D. because everyone knew that that the hospital down the road had the maternity ward.  I learned about their stocking of everything from gyne rooms to trauma/resuscitation rooms.  And, I learned to appreciate a well-stocked physician’s lounge for those late night shift munchies.

My interviews are done, and now the fun part begins… deciding where to call home.  I wonder if that Radiology tech would just go ahead and make me a copy of the key to the ultrasound supply room?  Can you ask for your own pocket-sized portable ultrasound during contract negotiations?

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Cowboy Song

Riding off into the sunset

Riding off into the sunset

I never thought much about our “regulars” until I came back from vacation to find that one of them had died.  We’ll call him “the Cowboy.”

I met him when I was an intern.  He was the anginal patient with known severe coronary disease who had suffered from alcohol abuse for many years.  He would come in from time to time;  usually drunk, complaining of chest pain.  We would run some cursory labs and an EKG, let him sober up,  and then send him on his way.

As the months passed, he would start to come in more and more frequently;  trademark hat and boots in place as the ambulance gurney brought him in.  He had developed cardiomyopathy somewhere along the way and had an AICD placed.  He started coming in complaining of it firing frequently and chest pain.  He would be admitted and usually signed out AMA after a day or two.

Over the last 6 months, he was an almost weekly visitor to the downtown hospital, but then we started seeing him at the county hospital where we also have shifts.  The Cowboy started becoming one of those “repeater” patients that become annoying.  You’d see his name on the triage board, sigh, and then go in and ask, “Seriously, Cowboy, what is it today?”

About 3 months ago, though, he really started declining.  His prior history of medical non-compliance and signing out AMA was making it difficult to get him admitted even when his heart failure was severely affecting his health.  Somehow, we would convince the attending that he really did need to be admitted, and true to form, the Cowboy would get diuresed, refills on his nitro, and then sign-out AMA or abscond yet again.

Recently, though, on one of my admissions, I convinced him that he needed to stay for evaluation by the cardiac surgeons who had wanted to take him to surgery during the previous admission.  He agreed only to be told that his disease was so severe that only a specialized center like the Cleveland Clinic might consider his case.  He told me this about a week later when I saw him, yet again.

As soon as he saw me he said, “Wait a minute.  Before you say anything I did stay, and this is what they told me…”  As I was ordering his now routine chest x-ray, EKG, POC troponins and BNP, I looked at the Discharge Summary from his most prior admission.  The angio said it all.  He had severe disease of his left main, LAD and circumflex.  His right was open about 80%.  Basically, the Cowboy was surviving on one coronary artery.

He lived alone and didn’t have much family support.  He was practically homeless.  There was not going to be a life-saving trip to Cleveland.  We all knew he didn’t have long.  During my first shift back I was told that he had presented in fulminant pulmonary edema.  One of my colleagues intubated him, but there was nothing else that could be done, and he died.

I tried to think back to the last time I saw him.  Did I even pick up the chart, or did I leave it to one of the interns?  Did I make conversation with him?  Was I polite to him the last time I treated him or was he just one of the “regulars” who is quickly “treated and streeted” to make room for the “real” patients?  I really can’t remember now, but I know that he’s a patient I won’t soon forget.

So, ride on, Cowboy.  Keep riding;  riding, along.

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Emergency Mnemonics

SalterHarris I used to be the king of mnemonics (dear GOD the Kreb’s cycle is useless) but those have pretty much faded with time, leaving only a few left to occupy brain cells. Which do you still use?

  • SALTR for Salter-Harris Fractures: Slipped (I), Above (II), Lower (III), Through (IV), Ruined (V)
  • MUGR (Mugger): Monteggia Fracture = Ulnar fracture with radial head dislocation; Galeazzi Fracture = Radius fracture with DRUJ dislocation.
  • PIRATES for causes of AFib: Pulmonary process, Infarction/Infection/Intoxication, Rheumatic (Valvular) Disease, Anemia, Thyroid/High Output, Electrolytes, Sauce (Alcohol)
  • Venous near the Penis (easier than remembering NAVEL or NAVY)
  • DOPE for Intubated Patients: Displaced Tube, Obstructed Tube, Pneumothorax, Equipment Failure
  • ABCDEFGH (duh): Airway/CSpine, Breathing, Circulation, Disability, Exposure, Finger/Foley, GTube/Glucose, Human (pain meds, via Dr. Meade)
  • AEIOU TIPS: Alcohol, Endocrine/Electrolytes/Epilepsy/Encephalopathy, Infection, Overdose/Opioids, Uremia, Trauma/Toxidromes, Insulin, Psychosis/Polypharmacy, Space Occupying Lesion/Subarachnoid/Stroke/Sepsis
  • 5 H’s and 5 T’s of PEA/Asystole: Hypoxia, Hypovolemia, Hypothermia, Hyper/Hypokalemia, Hydrogen Ion (Acidosis, Tension Pneumothorax, Tamponade, Tablets/Tox, Thrombosis (Coronary), Thrombosis, (PE)
  • AMPLE FRIENDS (for Oral Boards): Allergies, Medications, PMH/PSH, Last Meal, Events Leading Up, Family Hx/Friends/Witnesses Hx, Records, Immunizations, EMT Hx, Narcotics/Drugs, Doctor (PMD) Hx, Social Hx

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