Posts Tagged thelife

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.

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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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The Hospital Socks Followup Program

When you’re working in an urban emergency department with at least 20 different hospitals in the area, you certainly get your share of frequent fliers. Often these patients are undomiciled and/or have substance or psychiatric problems — but they often also have significant medical disease burdens as well. Combine all this together and you quickly get a significant patient population who are poor or difficult historians. Many come in with head injuries, staples, or other visible signs of trauma — and many even carry stacks of discharge papers with them from hospitals around the city.

Introducing the Hospital Socks Followup Program. Each hospital is given a different color of no-slip socks: “Blue, they were just at Bellevue!” so that you can get an idea of where a patient’s been recently, and perhaps find out if the patient recently had a CT scan, a chest pain workup, or prior surgery.

(Of course, I’d prefer an actual medical record sharing system. But that’s seeming more and more like a pipe dream.)

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I’m Baaack!

Super Fail Sorry for the long hiatus, faithful one reader remaining. Sorry for the holiday lapse in posting, busy with family and presents and eating and then working and working. But I have a lot of new ideas for the new year, and I’m ready to start ranting again!

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Crazy Trippy Post-Nights Dreams

Sorry for the dearth of posting lately. Been in web design mode, updating the with a few extra neat-o features, as well working on a top secret, really cool, hopefully really-helpful new website for therapies in the ED. More on that later, trrrust me.

So I had a big long slew of nights-and-days-and-nights-and-days last week, and wanted to see if my freaky dream phenomenon persists amongst my five readers. My current strategy for resetting my clock goes something like this:

  1. Finish final overnight. Go home, get to bed around 8am.
  2. Fall asleep. Force myself to wakeup and stop sleeping around 1pm.
  3. Do something — anything — to stay awake and out of my bed.
  4. Try to time it so that I hit the “bedtime sweet spot” where your body is tired enough it’ll sleep through the night, but also not too early in the evening so it doesn’t just think you’re taking a nap.
  5. If you time it just right, you wake up ready for work the next day, refreshed and feeling great.
  6. If, however, this did not go as planned, you wake up at 2am, completely, totally wide awake after a deep, deep sleep. With really freaky-deaky, very vivid dreams. Usually about work. Most recently was that I was putting a line in a French teenager, got bloods, took the tourniquet off only to realize his hand had gone completely gangrenous and necrotic from the tourniquet, only having a bony distal radius and ulna left.

Uhm, yeah. And that happens whenever I’m finishing night shifts. Is this a common phenomenon that everyone has, but just has the common decency not to discuss it? Or is it just me? (I have, on occasion, been accused of lacking common decency, for what it’s worth.)

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Non-Clinical Clinical Prognostic Indicators

Good Prognosis:

  • Your doctor hasn’t seen you yet, and you’ve been waiting for (insert average wait time) hours.
  • You’re in a bed in the hallway.
  • Your complaint consists of “months” or “years” of pain/nausea/headache/X Y Z.
  • You’ve come to the emergency department for a second opinion, despite multiple subspecialist evaluations.
  • You answer yes to every symptom the doctor asks you about.
  • You get a blood draw, but no IV.
  • The only medication you’re given is tylenol.
  • Your doctor says the words “probably” and “virus” in the same sentence.
  • You are talking on your cellphone, playing a game, or chit-chatting.
  • You are talking on your cellphone, playing a game, or chit-chatting and the doctor has to ask you to stop.
  • You “just wanted to get it checked out.”
  • Your primary care doctor sighs on the phone when the emergency physician calls him or her.

Bad Prognosis:

  • You get not one, but two IVs.
  • You remark, as my GI bleeder did last night, “Boy, I’ve never been to a hospital so attentive and efficient!”
  • You get your own personal doctor to take you to the CT scanner.
  • Multiple doctors, nurses, and staff greet you in your room.
  • The triage nurse walks you to your room and points at you while speaking to the doctor.
  • You get a room all to yourself.
  • You get a monitor.
  • Your monitor keeps beeping, even though you’re not doing anything.
  • Your doctor keeps checking on you.
  • Your doctor sticks a finger in your bottom.
  • You don’t argue with the doctor about getting this treatment or that one.
  • You are kind, good-natured, and have been a good person in this life.

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Dirty Talk

courtesy wikimedia commons

courtesy wikimedia commons

Upon reflection, and despite being a polyglot and the easy access to translator phones, I often find myself needing to say or understand the word for “poop” in other languages. I’ll either have just hung up the translator phone, or someone is trying in broken English to explain something to me involving their stools (often either a parent of an infant, or an elderly person). My nominations, in order of “getting the point across” (or at least thinking it got across) include, in order of frequency:

  1. Caca
  2. Poo poo
  3. Ca-kie
  4. Poop
  5. {Me squatting and motioning inappropriately}

I’m also guilty of the “louder will somehow translate the word into native tongue” business, especially when it’s an elderly person. You know, as in, maybe they’re just not hearing me. Put the two together, and apparently you quickly become quite the comedic entity for the nearby doctors when yelling “POOP! POOOO! CACA! POO POO! WHEN DID YOU LAST POOOOOOOOOOP? YOU KNOW, CACA? WHEN?”

And that is all.

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Trust (Part Three)

courtesy wikimedia commons

courtesy wikimedia commons

Boy do patients trust their physicians. I write this, truly, without a drop of sarcasm. (And that last line without one, too. No, seriously.)

Despite the variation in the patients we see every day, it’s often easy to clump them together. “Oh, another cocaine chest pain,” or “Pregnant vag bleeder,” or “Fever, headache, rule-out meningitis.” But every so often there’s something special about the patient — perhaps their name, face, or mannerisms — that makes the patient encounter a little deeper, a little more personal.

Recently it was another one of those “Fever, headache, need-to-LP” patients for me. My “younger than her stated age”, stylish, yoga-enthusiast patient spoke with a cute slighty-European accent, and with her neck stiffness, I figured I had to stick a needle in her back. While I was consenting her, talking through the procedure, and how I avoid the spinal cord, it dawned on me that this was a pretty remarkable amount of trust she was giving me by signing on the line. This idea of trust was something I thought greatly about in pre-clinical medical school, where the patient is an abstract concept. A theory, an idea. A “doctor-patient relationship.” But as I go further down the rabbit hole of becoming a full-fledged, root’n toot’n attending, this trust is something you simply acknowledge and accept. Waxing philosophic does not a successful procedure make, and certainly does nothing to treat or diagnose meningoencephalitis.

Putting myself in her shoes for a minute, she’s meeting a young, ravishingly handsome, courageous and beneficent physician for the first time.* She’s never met this person — for all intents and purposes, a complete stranger — before. He says he’s going to get me feeling better (yes please), do some blood work (okay, I guess), give me some fluids (sure, fine), and also stick a long needle in my back in between my back bones to make sure I don’t have meningitis (wait, whaaat?).

*This is, of course, how I assume most people view me, not as the “dorky, way-too-young-to-be-sticking-a-needle-in-me, wow-you-have-a-lame-sense-of-humor YOU’RE my doctor? guy with slightly wrinkled scrubs” view of me with which I am sometimes confused.

I’ve gotta say, that’s a leap of faith, and an amazing level of trust in the medical profession that exists nowhere else. While we as physicians often struggle with trusting parts of a patient’s story, or what their body is telling us, it’s much more often than not that a patient gives up a lot of autonomy and lets us as physicians do whatever we think is right.

It’s often those patients that lack our trust that I find myself often labeling “difficult,” even though it’s usually a wrong diagnosis, poor treatment or bad outcome in a hospital or by a physician that made them skeptical to begin with.

With great trust comes great responsibility, and that’s the simple lesson that we all know yet can always use the reminder: we’re professionals. We try to do right by the patient, help more than hurt. We put their needs ahead of our own. Thanks, random patient, for bringing that reminder back into view. And I’m glad you don’t have meningitis.

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How I Missed The 6 Hour Pneumonia Antibiotics Window

When you come in morbidly obese, in this corner, weighing in at 350+ pounds and your physician is having to confirm that you will not break the CT scanner, let’s all just admit that everything gets a lot harder: making diagnoses, finding veins, dosing medications.

When you’re a nonsmoker, nonasthmatic morbidly obese person who comes in short of breath with leg swelling for the past several days, you’re on Lasix at home, and you’ve got some wheezing in your gigantic lung fields, and your chest x-ray looks like pulmonary edema, your doctor thinks he’s made the diagnosis.

But you’re very hypoxic — O2 sat in the 70s on room air — even after 6 hours in the ED, after lasix and some nitroglycerin. So we scan you for pulmonary embolus, worried about a PE. You have no PE, not really much pulmonary edema, but you have evidence of pulmonary hypertension (hi, obstructive sleep apnea) and a small consolidation, even without cough, or fever rectally, we hang your classic ceftriaxone/azithromycin. Missed that all important “6 hour window.”

And thus, our rant begineth.

Similar to my medical errors rant, I think a lot of emergency physicians have problems with these guidelines, which are described as quality indicators and let the public evaluate a hospital based on these guidelines. This assumes that a score of “100%” is the absolute best score for a hospital. So, batter up:

  1. Hey! Medicare! These are guidelines. Not rules. These are to help us physicians guide our therapy, not to control it for us. Individual patients come with individual problems that cannot always be boiled down in a document.
  2. Give humans (in this case, physicians) a perverse incentive, and we’ll start acting perverse. This can go in two ways.
    • Don’t want to be dinged for not giving antibiotics on time? Admit the patient with a diagnosis of “shortness of breath” instead of “pneumonia.” If you’re not in the inclusion criteria, you’ll sneak right by. (I’m not suggesting that physicians actually do this in practice, just giving an example.)
    • Want to make sure you meet those all-important guidelines? Maybe there’s an “early pneumonia,” or the diaphragm’s a little hazy on a portable film? Just give antibiotics to cover your ass (and your hospital’s), even though it might not be what’s best for the patient (example: the patient with hyponatremia who just last week finished a 2-month long battle with C. diff.)
  3. Scientific evidence indicates that the following process of care measures represent the best practices for the treatment of community-acquired pneumonia. Higher scores are better. Okay, so, what’s the data say?
    • One of the leading advocates of this is Dr. Peter Houck, who’s done a bunch of research showing better outcomes with early antibiotic administration. The problem? It’s all retrospective, data-mining from large data sets. (A huge slide deck from Dr. Houck from 2006 provides some rebuttals to this argument.) The data also shows that there’s a difference between antibiotics at before versus after 8 hours; perhaps the magic 6 hour window is a compromise?
    • Another “quality measure” is blood cultures before antibiotics given. And this one is simply just foolish. Antibiotics for pneumonia rarely if ever change clinical practice. This has been shown in multiple studies, from the pulmonology literature to the British Emergency Medicine literature (“30 (1.4% of all cultures) were “true positives” and 4 (0.18%) influenced subsequent patient management.”). Also multiple studies in our own Emergency Medicine journals refuse the need for cultures, too. They rarely, if ever change clinical management, yet they’re “quality indicators.” We might as well have a guideline to order ESR/CRP on patients with suspected pneumonia, too. Give me a break.
  4. And finally, the concept of an acceptable miss rate is — unacceptably — missing from the discussion. Like the general surgeon who misses a few appies or who removes a few normal ones, we should be wary of anyone that reports or preaches 100% compliance to some of these guidelines: are these physicians thinking about risks and benefits and weighing options, or just blindly following? Should we aim toward always getting things right 100% of the time? Absolutely. But the real and theoretical worlds collide. There probably is some small benefit for early antibiotics, and most people most of the time should get them earlier rather than later. (We already have incentives to do this: they can leave the ED faster and move to the floor!) But there should always be a small percentage of cases that don’t fit inside the 95% confidence interval (usually around 5% of them): a group of people who live outside the standard deviations. Aspirin for an MI? Almost always. But how about the MI with the GI bleed with the hematocrit of 10? Or the patient with the anaphylactic aspirin allergy? Risk, benefit. No right answer.

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Psychosomatic Scabies

courtesy wikimedia commons

courtesy wikimedia commons

… is that syndrome where, after unglovedly touching a patient, he/she/the nurse/the nursing home paperwork/the family member/the prior ED visit summary mentions scabies and you magically begin itching immediately. This also applies to words like “lice,” “ringworm,” “fungal infection,” “elimite cream,” “permethrin,” “that skin medicine you have to leave on all day” or even just “I have this rash and it really itches,” depending on the patient.


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