Posts Tagged emergency medicine

Linguaphiles welcome

Every year, linguaphiles salivate over the release of the release of the latest edition of Webster’s Dictionary and the new words that made the cut.  I proffer these new phrases for  your consideration:

History alternans– the change in a patient’s history between triage and the time the attending sees the patient.  A common variant is found at academic centers where a team consisting of medical students and residents are interpolated between triage and attending, called history alternans mulitforme.

Narcotics inflation– the escalating narcotics requirements for common pain complaints.  Where once hydromorphone was reserved for terminal cancer patients, it is desperately needed for ankle sprains and nausea.

Dead celebrity effect- the surge in patient volume when a celebrity suffers from some severe or deadly process.  A related process is the Hystericus reportercillium in which whatever illness is in the news is immediately contracted by one third of your patient population (e.g., Swine Flu), even those without any symptoms.

Tooth to tattoo ratio– the ratio of teeth to tattoos, which has an inverse correlation to the risk for trauma.  If tattoos=0, then the ratio is undefined and may not be used to estimate trauma risk.

Politicus apoplexy– the overwhelming frustration that overcomes both participants when discussing health care policy with someone who holds the contrary position.  Because they are clearly wrong.  Whatever their positions.

Pucker effect- an involuntary visceral twisting sensation you get upon arrival at work and your collegue says, “Hey, do you remember that patient you had last night?”

Five-second pain delay- five seconds after you leave a patient’s room, the nurse approaches you for pain medicine for the patient who just assured you that he was feeling much better and ready to go home.


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Getting the Job Done in Haiti

A Day. A gasp. Day number three of gasps.

Courtesy Dr. Melissa Barton

I found myself no longer counting the respiratory rate. It was rapid.

The pulse oximeter remained 72% on a 100% nonrebreather. No worse but certainly no better.

His wide-open eyes conveyed fear while also demonstrating the strength of the human spirit to survive. No translation was necessary to decipher any spoken Creole words.

There were no ventilators available in the entire city of Port-au-Prince and I had the misfortune of watching an otherwise healthy 18 year-old boy slowly deteriorate before my eyes. Coincidentally and due to poor luck, he had somehow managed to develop trilobar pneumonia around the time of the devastating earthquake in Haiti.

Four emergency medicine residents and myself arrived at a busy hospital overwhelmed with victims of the recent earthquake. Our trip was funded through a local professional football player’s foundation. I admit I had never heard of him prior to this trip. Now I will never forget his name or his efforts even though I have yet to meet him.

Although we had no reservation, we were greeted at the hospital door by a remarkable nursing supervisor clearly open to any help offered.

“Where are you all from?” she asked with a slight twang in her weary, exhausted voice.

“We are emergency physicians from Detroit,” I answered.

“That’s great. Would you be able to staff the Intensive Care Unit tonight?”

And that’s how the greatest humanitarian crisis in the Western Hemisphere entered into my life.

The teenage boy started off in a general medical area with difficulty breathing. His mattress on the floor was a luxury compared to many patients using blankets only on the hard concrete floors. His care was a coordinated effort by many health care professionals that crossed continents. “Team Sweden” provided excellent care given the austere conditions. The pneumonia, however, was rapidly progressing along with its counterpart, a large pleural effusion. I found myself supervising a thoracentesis performed on this mattress while the father lovingly wrapped his arm around his son. Over 700cc of fluid was removed, improving his work of breathing though the pulse oximeter remained poor. He was transferred to the ICU.

Courtesy Dr. Melissa Barton

The ICU was a simple room of critically-ill patients and those who had undergone multiple, major orthopedic procedures. Overall, it was not unlike the remainder of the hospital though it did have a physician designated to that area only. The absence of any monitors beeping, nurses talking or ventilator machines breathing made his gasping only that much more unavoidable to hear. And then there were those eyes.

This patient wasn’t a challenging case. Any emergency physician would know that he needed to be placed onto a ventilator with aggressive pulmonary care. He was already receiving multiple antibiotics and some TLC but needed so much more that would be readily available in the United States. We had arranged transfer to a hospital in the United States but funding for the private jet fell through at the same time that the US government halted humanitarian visas. He was stuck at our hospital, as all other facilities were full with no additional resources to spare. I faced the problem of patient boarding on a worldwide scale. Patients needed to be transferred off the Navy ships to allow hospitals in the city to offload their patients and make room for more injured or ill people.

Courtesy Dr. Melissa Barton

During the final night of our stay, the hospital was down to only one oxygen tank that was designated for this patient. There were no other tanks for the entire facility with the next shipment due in over 12 hours. It was at this point, the thought of this boy suffocating, that I hit bottom. Tears flowed briskly. His father could see that our transfer wasn’t going as planned. “Ma vie,” he said softly. My life.

We had met several Army personnel during our stay who were aware of our predicament. In fact, the entire hospital staff, volunteers, and other patients and their families were aware. It was about 5 hours into our 8-hour supply of oxygen that an Army team returned saying they had a ventilator. The sense of relief when the medical team entered the ICU cannot be conveyed in words. They only had a cot, however, and the ventilator was at their disaster base and not accompanying the team. We had no choice.

Loaded into a chair along with a bed sheet, the patient was placed in the back of a HumVee and driven away into the night. Dogs barking replaced the sounds of the gasping to which we had grown accustomed.

Back home in the United States, efforts continued to transfer the patient to a more definitive place of care, specifically the USNS Comfort. The next day, I received a phone call from a medical commander stating that the patient could not be located but a spot was available for him on the ship. The US government as well as our charity organization had been searching for him all day. I repeated the location and provided them with the father’s phone number to no avail. This had quickly turned into our version of “Saving Private Ryan.” More than 16 hours passed and he was nowhere to be found.

Finally, a charity staff member reached his family who was aware that “the United States government was looking for them.” Likely the context was lost in translation somewhere. We were able to gather specific information as to the location of the patient within the disaster unit. To date, he is graciously and skillfully being cared for by medical personnel aboard the Comfort.

The gasping has stopped.

A radio talk-show host asked me today if we needed some “downtime” upon returning home.

“We’re emergency physicians. We are trained to keep going. We have patients here in Detroit who need us just as much as the Haitian people. Fortunately, we have the necessary resources here to get the job done.”

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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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Doing Everything for Everyone Everyday Forever

So I get this little insert in my ACEP Newsletter, which looks like it’s under the editorial control of GlaxoSmithKline Vaccines (which is its own posts in and of itself), and the authors are arguing for replacement of the regular Td (tetanus-diphtheria) vaccine with the new Tdap (tetanus-diphtheria-and-pertussis, Boostrix! sounds more exciting) vaccine. They make the case that, wow, shock, awe: adults aren’t getting vaccinated for pertussis to prevent the 600,000 adult pertussis cases every year.

They then go on to talk about how the Emergency Department is “in a unique position” to immunize people and “overcome racial, ethnic, and socio-economic barriers.” (Skeptical me thinks it’s really all about GlaxoSmithKline wanting to enter the tetanus vaccine market and make a couple bucks a pop, but again, skeptical me.) So voila, yet another “Look what good you can do in the Emergency Department!” spiel.

And the argument is true: our referral bias is one of the anti-doctor crowd. One that prefers not to get regular checkups, or prefer homeopathy and The Vitamin Shoppe, or don’t see the need to see a physician when they feel just fine. We do see people that other doctors don’t. And part of what makes our jobs great is that our interventions do matter more than other physicians. I give aspirin to 42 people with STEMIs, I save one of their lives. Other doctors give a baby aspirin for primary prevention and need to treat 10 times as many people.

But I can’t help but feel like it’s yet another request for our already strained and closing Emergency Departments. We have to see more impatient patients, faster, with fewer resources available and more things asked of us. Domestic Violence Screening. Rapid HIV testing. Vaccinations. Smoking cessation counseling. And blood cultures within 6 hours, before antibiotics. (Kind of kidding on the last one. But only kind of.)

Please don’t misunderstand me: I’m a public health advocate. Public health and vaccinations and sewer systems and hand-washing have impacted and saved more lives than I will one thousand times over, but I gotta ask: Could we get a little help around here?

Yes, the less pertussis the better. Yes, as an emergency physician I’m proud to stamp out tetanus. Yes, there’s a large portion of HIV+ people out there who are infecting other people because they don’t even know they’re positive. Yes, I want to be able to offer victims of domestic violence information and options and safety. But who else is coming to the party? And are they bringing drinks?

I mean to say this: if public health wants emergency medicine to help its cause, then why not scratch our backs as well? Case in point: want us to offer rapid HIV testing? How about letting us offer rapid HIV testing and giving us bedside, point-of-care troponins? Something to recognize that we’re already stretched thin, and maybe we’ll break even if we get both.

(And to the public health folks out there, how about recruiting some other people in “unique positions?” How about pharmacies that sell cigarettes and alcohol? Get them in on the game to offer HIV tests and vaccines. And smoking cessation. Or why not have anesthesiologists screen for domestic violence? They’re often in a more private setting than we are. Or why not encourage those “lifestyle” specialties — looking at you, dermatology and radiation oncology — to start screening as well?)

I support these additional requests, because I think we really can have an impact that other specialties simply can’t — but if we as a medical community as a whole agree that these things are important to the health of our patients, it’d sure be nice to have the issues framed as “uniquely addressed in the Emergency Department” rather than “only addressed by the Emergency Department.”

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Trick of the Trade: Laryngoscope Lifting Strength

Intubation of mannequin

You are about to endotracheally intubate a patient. As you struggle to elevate the laryngoscope more anteriorly, has your left hand ever trembled while trying to see the vocal cords? Before you say, “I think the cords are too anterior, hand me the [insert your favorite backup airway adjunct]“, let’s focus on some basics.

How can you gain significantly more laryngoscope lift strength? You can do more left arm bicep/tricep exercises, or…

Trick of the Trade
Hold the laryngoscope handle as close to the blade as possible.

Grabbing part of the blade helps to stabilize against the “waggling” of the handle. Furthermore, it is easier to pull exactly along the long-axis of the handle at this grip point. I would avoid holding the laryngoscope handle as shown in the image above. Is the physician intubating or holding a fragile cup of tea?

Proper holding of larynoscope handleThe most stabilizing larngyoscope grip
which provides maximal lift strength.

For other airway Tricks of the Trade, take a look an older post.

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Monday, Monday. Can’t Trust That Day.

What is it about Mondays in the E.D.?  I’ve talked to several colleagues of mine, and we all agree:  Mondays bite.  It’s the one day of the week when you can count on the mad rush of humanity coming in through your open doors.  Our residency program does sign out at 0700.  There’s usually  a few EtOH metabolizers or waiting for social work placement patients taking up a few beds.  The dental and STD patients started to arrive about 0630, so they’re good and ready to be seen by the fresh crew.   By 0800, ambulances start making their geriatric runs dropping off the weaknesses, AMS, choking episodes and difficulty ambulatings.  Around 0900 the next wave of gurneys arrive with the abdominal pains and short of breaths.

By 1000, the walking wounded begin to arrive:  back pain, leg pain, headache, and chest pains.  This is also the time when the “expect calls” start.   “Hi, I’m sending in this Marfan’s patient who’s had their aortic valve replaced, multiple abdominal surgeries, who by the way also has diabetes, HTN, and a liver transplant who came to the office this morning complaining of a strange pressure in their mid-abdomen, maybe in their chest. Would you please check them out?  It’s a half day in the office for me today, but I am sure the hospitalist service will be happy to admit them.”

1100 is when the real fun starts, the early HD patients start coming in with bleeding from their AV fistula sites, syncopal or hypotensive episodes that did not allow them to complete HD.  Oh yeah, they still have a potassium of 7.  Or, they missed their morning HD session and now need urgent dialysis because they visited their girlfriend who lives out of town and didn’t think to take any of  their medication with them.  This is also about the time that that coronary who thought they’d just had bad sushi for lunch realizes they’re having an MI and walks in the door.

Are your beds full yet?  It’s 1400 and you’re finally getting the last of your LOLs in NAD dispo’d.  You haven’t eaten.  You’re grumpy, and, all the patients who are supposed to be NPO for thier 10/10-I-need-that-Dil-ah-something abdominal pains have been complaining about not being able to eat or drink anything despite the fact they just swallowed down about a liter in contrast and told you earlier they haven’t been able to eat in three days.  Around this time, PMD’s offices begin closing or referring their patients to you.  You start getting the “I called my PMD about my nausea and vomiting for the last 3 weeks and he told me to come to the E.D.” patients.

At 1700, you’re swimming against the tide.  Fast Track is closed.  All the leftover lacs, ankle sprains, med refills and wound checks start filling up the waiting room.  The hospital housekeepers drop from 3 on the inpatient floors to about 1 on the floor, so your admits are sitting waiting for a clean bed.  Your dispo’s are all pending return calls from the PMD’s or consultants who are driving home and caught in traffic and unavailable to answer thier pages.  Ambulance gurneys are lining the hallways waiting to unload their shortness of breaths and abdominal pains that waited all day to call their PMD’s and then called late in the afternoon only to find the office was closed. This same group will stop deep breathing into their NRBMs and moaning and start yelling and raising a fuss when the gurney with the non-compliant, diaphoretic, hypertensive CHF exacerbation comes tearing into the ED and bypasses everyone to go straight into the Code Room.

That last hour you’re just watching the clock.  Should I see that GIB or leave it?  The lac can wait.  Maybe I better page the MICU again.  Can I get that 84 year old with no family admitted since I saw them at 1755 and Patient Placement leaves at 1800?  Where is my pen?

Sign out is at 1900.  “Sorry the board is such a mess.  But, you know how bad Mondays can be.”

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Annals audio summary and podcast for August

The August edition of the Annals Audio Summary is now posted. Content for this month includes::

-Risk factors for VTE

-Ketamine and cerebral oximetry for pediatric sedation

-Local anesthesia for IV’s

Also, articles on cardiac arrest resuscitation including:

-Cost effectiveness of public access AED’s

-Termination criteria for prehospital resuscitation

-Post-resuscitation care for survivors

-Disparities in survival in the U.S.

…and much more.

Check it out!

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Scientific Assembly Returns with Education, Networking, and More

 

Kenneth C. Jackimczyk, Jr., MD, FACEP

Kenneth C. Jackimczyk, Jr., MD, FACEP

If you haven’t signed up for this year’s ACEP Scientific Assembly in Boston, you should do so today!

 

The educational programs are awesome – with over 300 sessions covering the latest advances in clinical care, critical management, and health policy issues. The Colin C. Rorrie, Jr., Lecture will feature a discussion on health care reform, one of the year’s hottest topics.

 

Special sessions such as LLSA article reviews, the New Speakers Forum (which features up and coming presenters), Research Forum, and hands-on skills labs offer a wide variety of learning experiences.

 

The always popular Exhibit Hall will feature over 300 companies allowing you to meet and discuss new products and technologies with the people who make them.

 

Finally, don’t forget the social aspects of this meeting! Scientific Assembly gives you the opportunity to meet up and spend time with old friends and colleagues. Make plans before you leave on our Facebook page. And while you’re in Boston, take advantage of the historical sites, and maybe take some time to feast on clam chowder and seafood in the many great local restaurants.

 

Whether you are a first-time attendee or a seasoned veteran, you are sure to enjoy this spectacular conference. Check out the Scientific Assembly Web site and register today for the courses and social events you want!

 

Kenneth C. Jackimczyk, Jr., MD, FACEP
Chair, Educational Meetings Committee

 

 

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Encouraging Signs for Emergency Medicine

ACEP's Washington, DC Staff

ACEP's Washington, DC Staff

It is 2009 and we have a new administration, new impetus for health care reform and new hope for meaningful change. It seems everyone agrees that the current system is not sustainable, but that seems to be all anyone agrees on. Everything else is anybody’s guess.

ACEP has worked hard to include emergency medicine in the current debate. It has been a struggle, but fortunately, the ACEP-supported “Access to Emergency Medical Services Act of 2009” enjoys bipartisan support in the House and Senate. More than 120 legislators are now co-sponsors and ACEP continues to working closely with key legislators and their staffs to promote the legislation.

One very positive note was passed on by ACEP’s Washington, DC office yesterday. Legislative staff in the House and Senate have said that various provisions of the bill have been submitted to the committees writing the health care reform bills. That is very good news and it looks like the work of the thousands of ACEP members who have called, written and visited their members of Congress is starting to pay off.

Their efforts are part of a comprehensive three-pronged approach. First, there is a strong direct lobbying campaign on Capitol Hill by ACEP staff members, including Brad Gruehn, Jeanne Slade and Gordon Wheeler. This dovetails with a grass roots lobbying campaign supported by the 1350 members of the 911 Legislative Network. These ACEP and EMRA members have developed relationships with their Senators and House members and contact them regularly to relate ACEP’s positions on legislation and regulatory initiatives. In addition, hundreds of other ACEP and EMRA members have participated in ACEP’s “Contact Congress Campaign” and are demanding that emergency medicine’s issues be addressed in upcoming reform legislation.

The third part of this approach, and a key piece of ACEP’s ability to influence the debate, is the National Emergency Medical Political Action Committee, better known as NEMPAC. This ACEP-supported organization is now one of the top-five medical specialty PACs in the country, and contributes more than $2 million per election cycle to federal legislators who support emergency physicians.

Change comes slowly in Washington, DC. But ACEP will continue its decades long work to make sure that when a bill is put on the President’s desk for his signature, the concerns of emergency physicians will be included.

CMS establishes new Toolkit, PQRI helpline

On the regulatory front, CMS recently posted 2009 implementation advice for the 2009 Physician Quality Reporting Initiative (PQRI).

Tools include a downloadable numerical listing of all codes included in the 2009 PQRI for incorporation into billing software, and a link to measure-specific worksheets for reporting each measure. CMS has also established a new help line for PQRI participants with questions regarding participation procedures, feedback reports, and bonus payments. The telephone number is 866-288-8912, and will be in operation between 7:00am and 7:00pm Central time.

CMS plans to create a new email address for inquiries as well. Additional information about these tools and the PQRI program may be found at the CMS PQRI Web site.

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A Clear Path?

Today we have heard a variety of opinions from close observers of, and one participant in, the early phases of development of health care reform legislation.

 

The participant was Neera Tanden.  Ms. Tanden was a senior vice president for Academic Affairs at the Center for American Progress before being appointed Hillary Clinton’s policy director for the 2008 presidential campaign.  Then, late last June, she was recruited to become Director of Domestic Policy for the Obama campaign.  She is now the point person on health reform for the Department of Health and Human Services in the Obama Administration.  After making relatively brief remarks as the luncheon speaker at ACEP’s Leadership & Advocacy Conference, she invited questions.

 

Most of the questioners focused on enlarging her understanding of the emergency medicine perspective on reform of the health care system.  She did her best to assure us that our concerns were not unfamiliar to policy wonks in the Administration and among the leaders and staffers of key Congressional committees.  And she was forthright in asserting that the Administration has learned from the errors made during past, unsuccessful, efforts at comprehensive reform.  One member of the audience (can you guess who it might have been?) asked if there is reason for us to believe that the president’s “clear path” toward universal coverage does not represent more ineffective incrementalism on a “long and winding road” (apologies to Paul McCartney).  Ms. Tanden was certainly the most optimistic of the speakers who addressed us today, asserting that President Obama did not come to the White House to accomplish small things, that his approach to reform will be bold and aggressive, and that it will be weeks to months, rather than years, before we are firmly on that clear – and short – path toward the goal of covering every American.

 

An earlier speaker had pegged the likelihood of enacting substantial health care reform legislation this year at no better than 50-50.  Let us hope that Ms. Tanden’s optimism proves to be well founded.  As Mr. Obama has said repeatedly, the cost of inaction is unacceptable, and doing nothing is simply not an option.   

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