Posts Tagged thelife

Reboot

I’m always amazed at how much the ED can just keep going after some code or major trauma or absolute train wreck. Not just at how we as physicians can mentally re-orient ourselves: “Current task over, return to other patients now,” but the entire department. The housekeepers keep housekeeping, the nurses keep nursing, the techs keep teching; the controlled chaos returns after a sudden eruption of hell breaking loose.

This is especially true and eerie after a death. Someone utters “Time of death, eleven thirty seven,” and it’s like you’ve just rebooted our minds. We return from whence we came, doing what we were doing before, but now maybe a little sadder, a little more downtrodden, and a lot more behind. We whisper something to ourselves, pausing for a few seconds to grieve, and keep moving. Try to save the next one.

A couple hours later, the body has been packaged and removed and the room is completely cleaned. Fresh. A new patient sits in the gurney, dangling his legs off the edge of the bed, wondering when he’s going to be seen. He has no idea what just went on two hours ago in the exact same space. You briefly make eye contact as you walk past the room. Ignorance is bliss.

The room is back to how it always is, with nothing left but your memories of what just happened. How you broke the poor woman’s ribs at 100 beats per minute. Crunch crunch crunch crunch crunch. How you stuck sharp things into her mottled, edematous frame. How before all of this, you stuck the tube in her throat and figured things would start turning around once you controlled that airway. And then an hour later, how you ran through your differential one more time, everyone straining their brains as if there’s some obvious procedure or drug or incantation you must just be forgetting that instantly resurrects the dead:

What?
Am?
I?
Missing?

You sigh. And then you call it.

“Time of death, eleven thirty seven.”

Reboot.

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Developing My Burn List

No, this is not a list of my favorite insults (“Oooh, burn!”), as a) that lingo I think pre-dates the Internets and b) I would never share my favorite insults with even you, my faithful four readers.

You know. Your burn list. We all have them; I’m slowly building mine full of near misses and close calls that I never want to repeat again. Causes you to step outside that zone of “I know what I’m doing” and “logical thought process,” making you scan things you probably don’t really need to, or workup things that don’t need working up?

So, what’s yours?

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Standardizing Answering Services Haiku

Can we standardize
A doctor’s call services?
I am losing it.

Sometimes, I hit STAR
Other times, it is SEVEN
One office is EIGHT.

Hold music is nice
Soothing while I am waiting
But please, hurry up!

Let’s just use ZERO!
Quit wasting my time, puh-lease
For courtesy calls.

Slow enough as is
Dialed three numbers already
Awaiting call back.

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Healing Our Health Care: Doing Less

Often in Emergency Medicine, we have multiple influences pushing us to do one thing, when we know the other is right for the patient. Part of it might be fear — of lawsuits, of bad outcomes — part of might be a demanding patient who “knows antibiotics always work for me,” part of it might be access to a new CT scanner, so “I might as well check.” But we all know of patients who’ve had one workup, which has led to another, which has led to some complication — a botched cath, a nosocomial infection — and you can’t help but wonder what if that workup had never been done, and was it really necessary in the first place? What if we were just chasing our tails with incidentalomas? What was our pre-test probability before the test, and even if the test is positive, how much did it really increase our post-test probability, anyway?

We’re in a tough place in the Emergency Department. People have come to us for evaluation, and our job is to Rule Out Badness ™. They’re in the Emergency Department, so we need to make sure they’re not having an emergency. Sometimes, however, I wonder if many patients weren’t better served at a walk-in clinic instead of a walk-in ED, where the mere lack of access to instant lab results and imaging studies might make for a better course of action (combined with watchful waiting as the workup progresses over days to weeks).

In last month’s EMRAP (2 hours of Emergency Medicine I look forward to every month), Jerry Hoffman, NEXUS Criteria creator and EP at UCLA-Oliveview talks about how he approaches these influences, and I think it’s absolutely worth 3 minutes and 53 seconds of your day:

[wpaudio url=”http://thecentralline.org/wp-content/uploads/2009/08/jerryhoffman-doless.mp3″]

(Thanks to Jerry and Mel Herbert of EMRAP for their permission to use this clip!)

Sometimes Jerry’s methods don’t work — but for most people, most of the time, they will. Sure, it’s easier to write the script for cough medicines or order the CT scan than have a discussion, “teaching moment” or even argument with a patient or his parent — but if the two minute discussion saves the patient from a medication side effect they may come back for, or allows us a faster discharge with less brain radiation, then it’s probably worth it for both doctor and patient, right?

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The Social Admission Service

courtesy jamesfischer of flickr

courtesy jamesfischer of flickr

Well, as is bound to happen in the medical blogosphere, a minor kerfuffle has erupted in response to Jesse Pines’ piece about a social admission in the WSJ last week.

In one corner, the respected internist, Robert Centor (yes, of the Centor strep criteria fame) complaining about Dr. Pines admitting an uninsured woman for a cancer workup. GruntDoc, another EP blogger, fires back across the bow that Dr. Centor hates EPs, and Dr. Centor writes back, bringing up an interesting point: why are we paying so much for social admissions? Shouldn’t we have some sort of other option for the uninsured–or the social placements altogether?

I definitely don’t want to give any ammunition to the “the uninsured get all the medical care they need” crowd, (partially because it’s simply untrue) but we all certainly admit people for primarily social–not medical–reasons. (This probably would come as a surprise to the majority of the American population, who luckily aren’t reading this blog. And thank you, our tens of readers, for keeping this such a secret.)

If you look at pretty much any disease, under “Disposition” or “Indications for Admission,” there’s always that teensy tiny little caveat of “If the patient cannot care for himself/herself,” or “Expected clinical decline upon discharge.” From the teen with PID who just won’t take the meds or follow-up to the early-demented patient without help at home, you know they’re coming in. It’s kind of like any psych diagnosis: you can be as crazy as you want to be, talking about the demons in the lightbulbs, but as long as it doesn’t affect your ability to function in your life in any way, it ain’t a disorder. The social really does matter in medicine, just like it does in psychiatry.

Probably too late to tack this on to Congress’s health care financing bill, but what the hell: I hereby propose… THE SOCIAL ADMISSION SERVICE. Dr. Centor’s right; we probably shouldn’t be spending an expensive hospital bed on patients who don’t need hospital care, but GruntDoc is right too; we can’t simply turn away people who will get lost in the system or who can’t care for themselves. So we have a social admission service. Maybe it’s a doctor, some social workers, and a case worker–some sort of “comprehensive care team” that understands there may be a few simple medical issues, but the primary issue is placement, emergency Medicaid, or some simple labs tests/imaging/procedure. Quick admit, quick dispo. Maybe they only need vital signs once a day, maybe they can eat their own food. Maybe they don’t even need to stay overnight, if they’re safe going home. We save ourselves (and our country) some money, ourselves and our colleagues some valuable time, and best, of course, help our patients out of a bad situation.

Pipe dream? Maybe. Awful, terrible idea? Certainly possible. But I’d love to hear better ones, different ones, and solutions. No one’s going to deny that our health care system is in trouble–and not just because of the uninsured, or medico-legal liability, or the aging population, or any one thing in particular–and it’s going to take creative ways to fix it. Outside the box.

Today’s hospital system is based on an acute care, acute illness model, while our patients’ diseases have become almost completely chronic. Who knows? Perhaps acknowledging that “Admit/Discharge” is a bit too binary for today’s patient is the answer that we need.

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Beepers: Buh-Bye

image courtesy flickr's elainegreycats

image courtesy flickr's elainegreycats

One of my favorite emergency physician bloggers, Ten out of Ten, wrote a great piece last week about loathing the beeper, and I can only sing the same tune.

It absolutely blows my mind how much time I can spend trying to page a private medical doctor or consultant.

  1. Call the private’s office.
  2. Try hitting 0, but this only works 30% of the time, and sometimes it’s a random button like “8” to reach the operating service.
  3. Speak with operating service, repeating my name, hospital, phone number, patient’s name, and date of birth three times over, slooowwwly.
  4. Private eventually responds, tell quick story, find out private wants to use the hospitalist or resident service.
  5. Call the hospitalist.
  6. 2-3 pages later, right in the middle of a discussion with another patient, hospitalist responds, or resident service responds, but they’re capped, or I’ve been paging the wrong number, finally sign patient out.
  7. As Ten out of Ten suggests, please for the love of all that is good and efficient, let’s use cellphones. Why are we still carrying around 1980s drug dealer-style boxes when we already have a fancy-schmancy voice and text-capable device with us at all times anyway? (Okay fine, let’s do a big study and confirm, once and for all, that cellphones don’t do anything to medical equipment, and then do away with beepers.)

    And why not use some sort of software/web solution like Google Voice to do all the work? Call one phone number, and it automatically forwards to the on-call cellphone. If the call is not answered, you leave a voicemail, and a text message is sent to the phone every 10 minutes until someone responds. That way you have the convenience of a pager (call back when you’re available) along with the direct-connection of a cellphone. And the call schedule is automatically fed into the system so it autoforwards without anyone intervening; if something gets goofed up, you just login to the website, click a button, and re-route the calls to someone else.

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Guess The Question

And now, in quasi-Jeopardy style, the answers to my most frequently-asked questions outside the hospital, in quasi-conversation style. (God I hate small talk):

  1. I’m an Emergency Medicine resident.
  2. No, I’m 28.
  3. I’m from Kansas.
  4. St. Luke’s-Roosevelt Hospital, two hospitals on the west side. One near Columbus Circle, the other in Harlem, across from Columbia University.
  5. For a few brief minutes, it’s like ER, yeah. But with a lot more runny noses, rashes, and drunk people either passed out or yelling at you. I think Scrubs is more accurate.
  6. Yeah, we see some crazy stuff. Brings out the best and worst in people.
  7. Hmm. Weirdest? I guess recently, I think a co-worker pulled a showerhead out of a butt.
  8. Lady that was hit by a subway car. Really sad.
  9. Doesn’t really feel that admirable. Feels like a job with training. I love it, but I wouldn’t be doing it just because “I get to help people.” Just like you wouldn’t be an X just because you like to Y.
  10. I have no idea why you’re breaking out on the right side of your face recently.
  11. Yeah, doesn’t look too bad. Regular borders, not discolored, small, not growing. But you should see your regular doctor, I’m not a dermatologist.
  12. Uhm, I guess I wish more patients showed more appreciation. And had better manners.

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