Suburban Emergency

Not suprising

2009-04-01T16:38:00.000-07:00

Saw this on Yahoo today:

http://news.yahoo.com/s/ap/20090401/ap_on_re_us/frequent_er_patients

I can tell you that for those of us who work in Emergency Rooms this is not surprising in the least. This is a phenomena which is spoke of often amongst myself and my colleagues. And while it is commonplace to us in the ER, it is something that comes as a complete shock to many lay people with whom I find myself discussing my job.

They find it astonishing that people use the ER for anything other than emergencies. I in turn, find it astonishing that they think it is so astonishing.

What people might also find asonishing is that while the article attributes mental illness and homelessness as a major factor in these few patients with incredible numbers of ED visits, I dont find this to always the case. Its easy to assume that people who "do this" must have "problems". They cant have insurance or private Dr's or their own homes. Unfortunately, this just isnt the case.

Here in Suburbia, right off the top of my head I can think of at least 5-6 patient who are seemingly "normal", productive members of society that I see in the ER at least once a month. In my world, while just as prevalent, ED over usage is not as simple as mental illness, homelessness or uninsured. As I have discussed in this blog before, it is multi factorial with no simple answer.

Just ask married, mother of two, kindergarten teacher that I see AT LEAST once a month for chronic back pain and frequent "sniffles". Astonishing.

Head Injuries

2009-03-26T10:29:00.000-07:00

Check this out:
http://www.cnn.com/2009/HEALTH/03/26/head.injury.emergency/index.html

I've worked a few shifts since the Natasha Richardson tragedy and I can tell you, pieces like this are FREAKING people out.

It speaks to a previous post I made that we are seeing a noticeable increase in patients with seemingly minor "head bumps" coming to the ER for "their Cat scan". I've had at least 3 patients specifically mention Natasha Richardson in their histories as they describe their relatively minor injury. They go on to speak of "dizziness" and "nausea" and "horrible headache" which are serendipitously the "warning signs" flashed on the screen with every report of this rare, horrible accident. They all go on to ask for their "Cat Scan" because "they just want to make sure".

Sounds easy enough, right? Just do the scan and be done with it. Unfortunately though, its not that simple. (it never is) But alas, I'm not going to use this post to berate patients for overreacting, nor am I going to rant about the resulting overuse of CT scans.

No, what I'm going to do is speak to the CONSTANT irresponsibility of the media while reporting on medical issues. The Natasha Richardson case is a perfect example. John Ritter is another. The tone of the articles are always less informative and more sensational. Aimed not at informing, but at shocking. In the above article, for instance, why is there need to write of the little girl who was hit by the softball and the fact that "Dr. Cohen told us that if we hadn't brought her in Thursday night, she never would have woken up".

WHY? Why report like that? Why fill these pieces with this sort of sensational garbage and very little medical fact or valuable information. Sure, on the video they manage to offer some legitimate advice on when to actually seek out the ER after a head injury, but only after showing this VERY RARE sensational case and then adding "If you're concerned just go to the ER, IT NEVER HURTS!!" It never hurts? Yikes. See this post and tell me "it never hurts".

I'm still waiting for the piece that doesn't include a horrible, rare, sensational anecdote. I'm waiting for the piece that actually takes the calming angle of "this is very rare" and that Natasha Richardson was incredibly unfortunate and unlucky. Or that she most likely DID have symptoms but ignored them. Or how about a piece that emphasizes that NOT EVERYONE WHO BUMPS THEIR HEAD WILL NEED A CT SCAN? All of these sorts of things would be beneficial to the public and to the health care system.

But you know what? No one would watch them. We don't want facts. We want sensation. We don't want to watch the news and be informed, we want to be shocked. We want 700 stories on the Octomom. We want Nancy Grace and the 400th story on Caylee. We want Dancing with the Stars and Rock of Love. We want Entertainment Tonite and TMZ. And unfortunately, the media gives us what we want. Why wouldn't they?

The public's thirst for the sensational has become just one more variable in our medical decision making. And in her untimely death, Natasha Richardson has become one more hurdle to clear along with Dr. House, Greys Anatomy, and ER as we desperately try to stay objective and provide proper care.

The Tough Ones

2009-03-16T09:11:00.000-07:00

WARNING: The following is a touchy-feely, slightly self indulgent post. Read at your own risk. WARNING

For whatever reason I've had a tough run of cases lately. In the last month I've had two patients in their 30's with MI's. I've made new diagnosis of cancer on a 45 year old and I've intubated two kids under the age of two.

Its not talked about often, but I think if you asked a lot EM physicians, most would tell you that the "young ones are the toughest". While its never "easy" to take care of a really sick patient, it becomes especially difficult when that patient is "young". Somewhere deep in our sub-conscious mind it effects us a little bit more. Now, this in no ways suggests that "older" patients get different care. It simply means that as physicians, when a young patient is sick, it effects us more.

I've found over the last few months that while taking care of these patients has been difficult, it has also reminded me why I do this. It has made me reflect on my interactions with patients. Most importantly, it has made me reflect on the role I play in their lives. Each of these cases has led to an interaction with a loved one where I have realized the magnitude of what we do on a daily basis.

In one case, I had been managing a VERY sick child and had finally gotten the patients stabilized. After it was all said and done and we were transporting the patient to the PICU, I had a moment to speak with the parents. I had been speaking to them throughout the case and they had been present so there wasn't much more to explain. I simply told them I thought their child was going to be fine. (which was true) The scary part was over. What struck me was the immediate change this brought about in the parents. The look of relief and change in body language was something I cannot explain.

Realize, I've given bad news. I've saved lives. I've taken care of TONS of sick patients. I've had patients cry, yell, scream, throw things, hug me, kiss me and proclaim everything from "You SUMOFABITCH" to "You SAVED MY LIFE". For whatever reason though, this simple change in body language and look of relief effected me more than any patient interaction I've ever had. EVER. It may have been the subtleness of the change. It may have been the age of the patient. I'm not sure. All I can say is it was noticeable and it effected me.

I realize that to most people who dont do this every day, it might be unfathomable that we would take our duties for granted. That we could possibly forget how much of an impact we have. That we could even for a second lose track of the role we play. Unfortunately though, many of us do forget this. Like anything else, the more often you do something, the less of an impact it has. The more routine it becomes. We are human and we have the same self defense mechanisms as everyone else. We rationalize why someone is sick. We avoid thinking about poor outcomes. We downplay our role. We forget the enormity of what we do.

Whether it for a second, a minute, a week or a career, we all can lose track of why we do this. We show up for shifts and simply start "movin the meat". We diagnose, treat, discharge and admit. We look forward to the end of our shift, our string of days off and our bi-weekly paychecks. We forget about our interactions. We forget about our role. We forget about our impact.

Sometimes it takes a string of "Tough Ones" to remind us.

A little bit of Obama and a little bit of Rush

2009-03-03T21:57:00.001-08:00

I saw this on Yahoo today:

Overexposed: Imaging tests boost U.S. radiation dose

I have no issue with the study nor with the implication that physicians are ordering "too many" tests. There is a MOUNTAIN of data which implies increasing use of CT scans. Also, while the data isn't quite as clear, there is an increasing concern amongst the health care community regarding the associated increasing radiation and risks it carries with it.

It also seems there is good reason to be alarmed at physicians ordering tests and profiting off them directly.

Unfortunately, the article doesn't mention two things:

1.) Physicians are not only paid for imaging they order, but also the history they take, the exam they do, the surgeries they perform and the labs they send. When we have a medical system like ours, in a free market society, it is impossible to avoid this sort of conflict of interest. On one hand we are paid for "what we do" and on the other we are expected to at all times make decisions based on the Hippocratic Oath and do only whats medically necessary. And while from the sounds of the article, we as physicians need to do a better job at it, I wish it would have taken the tone that this is quite possibly a necessary evil in our "Free Market Health care System". It would have made for a much more interesting article.

2.) There are MANY factors which have led to the increase in imaging over the last few years and I actually think "Physicians making money off the scans" is the least of them. In addition to our decreasing knowledge of the physical exam and crammed schedules and overcrowding which limits our patient contact (both major contributors), I believe one of the most important factors in our increasing imaging is the medical legal climate. Many physicians unfortunately view sophisticated medical imaging as the ultimate "rule out" and feel like they are leaving themselves far to open to lawsuits if they choose to rely on a good history and physical exam to diagnose patients. They fall back on these scans to protect themselves from the one in a million patient which may threaten their livelihood.

So how do you fix the problem? Bipartisanship, my friends. First, shout to the mountain tops "YES WE CAN", socialize medicine and pay all physicians a salary. You'd effectively eliminate the free market and any temptation to fatten our bottom line by ordering frivolous tests. Second, grab your cigar and oxycontin, give a shout out to Ronny Reagan and pass a law outlawing the John Edwards' of the world. No more plaintiffs whores. Then take away any rights of patients to sue their doctors and give physicians complete medical legal impunity except in cases of gross negligence.

VIOLA! No fear of lawsuits. No greedy test ordering. Less cancer. Everyone wins..........

Thank You

2009-02-11T21:17:00.000-08:00

If you had asked me how long it had been since I blogged, I would have said "about a week". YIKES! Its been 5 months. I dont have an excuse, I just havent been motivated to write. Hopefully that will change. Just in case anyone still reads, here's a great story. Its stuff like this that keeps us going.....

I was halfway into my shift when the triage nurse called me to come up front. "Someone wanted to speak with me".

Now, in the city, it might not be a good idea to go up front and explore who it might be. In the suburbs, I was pretty confident I would be ok. I didnt want to make too big of a deal, so without inquiring who it was, I started for the front.

I was greeted by a middle aged gentleman. He had a smile on his face.

"There he is!" he exclaimed when he saw me.

"Hi, I'm Dr. Suburban" I said extending my hand.

"I know! You dont remember me, but you saved my life." he said "I wanted to come shake your hand."

He went on to tell me about his experience. We really hadn't done anything extraordinairy, just followed protocol. What had seemed like a routine patient to most of us in the ER, was anything but to him. We had "saved his life". In his eyes, if not for our intervention, he would have died. We saved his life.

We forget that each and every day we have the potential to give someone more time with their loved ones. We forget just how powerful that can be for people.

On his way out he gave me a hug. A perfect stranger. And I dont mean one of those uncomfortable "man hugs", this was an embrace. It seemed like it lasted forever and when he pulled back he had a tear in his eye.

Needless to say, the rest of the shift was pretty easy.

So when DO I go to the ER????

2008-09-16T12:42:00.000-07:00

My last post about the article which articulates the complex and multi-factorial nature of ED overcrowding elicited the following question from "Anonymous" in the comment section:

"OK, so when should I go to the ER as opposed to my primary care Dr? what symptoms justify or warrant a trip to the er? Thanks."

--Anonymous

Well, the answer to that is very easy. You go to the ER when it is an EMERGENCY. Now, the more difficult question to answer is "when is it an emergency?". That answer is very individual and I cannot define it for you or for society. In fact, I would bet that if you forced 10 ER Docs to define an "emergency" you may get 10 different answers. And those are ER docs! For the general public it becomes much more difficult.

Each person has a completely different idea of what an emergency truly is. That idea is based on ones lifeview, access to care, education level, health status, financial status and many other facts. I have posted about our attempts in the ER of empathizing with patients who show up with minor complaints. When viewed from the perspective of patients it becomes easier to see how they could have been perceived as "emergent".

What becomes difficult is when people use the ER and in no way could their issue be construed as an emergency. I think if you ask most people who work in ER's they would echo this. It is the reason my post about "Cathy" evoked such response. There is nothing worse than having to deal with people who are obviously "abusing" the system when you know there are sick people who need your care.

How common is this? I would guess that 3 out of 10 patients I see are simply in the ER out of convenience. While 30% might seem low, think about it on a larger scale and you may start to understand the frustration.

So the answer, "Anonymous" is very simple. You go to the ER when you perceive your symptoms be an emergency. If you're a reasonable person, and you think you're emergent, then by all means, come see me. I'll do my best to take care of you. Hopefully either I'll fix ya, admit ya, or tell ya nothing is wrong. Either way, its my job and I'm happy to do it.

Just dont show up because you didnt have time to make it to the Dr.'s office. Dont show up because you think its free. Dont show up because you've "gotta know now". And fer crissakes, PLEASE dont show up because your earlobe hurts and you saw a patient on House who died of "earlobinitis".

Wow

2008-09-12T21:19:00.000-07:00

If you enjoy ANYTHING about my blog over the last months, I encourage you to read this article published on Slate.com today.

It really is one of the best articles I have read which deals with ER overcrowding. I wish I could say I wrote it.

I have blogged repeatedly about my attempts to understand and empathize with patients who come to the ER for "minor" complaints. On the flipside, I have also written numerous blogs about the frustrations of people misusing the ER. This is a conflict which arises within many ER Docs. Amongst many great points made in the article is the fact that while it may be difficult to understand sometimes, and frustrating for those of us "in the trenches", it actually turns out that ED misuse is NOT the major contributing factor to ED overuse.

Anyway, its a great article and the authors do a great job of articulating many of the things I have touched on in my blog. I thoroughly enjoyed it.

Never mind.....

2008-09-04T11:05:00.000-07:00

I wrote a post a few weeks ago about House and Greys and ED overusage. Here is a comment from that post:

cathy said...
Nice theory. I'd like to add on to it.

If you're pretty sure you've got a complicated problem, the LAST thing you want to do is go to your regular doctor.

Why? You call your regular doctor. Now you have an appointment tomorrow (if you're lucky). He decides you need a specialist. Now you have an appointment for a specialist next week (if you're lucky). The specialist decides you need some imaging/lab tests. Those tests get run within the next two weeks (if you're lucky). You don't get the results for a month, which is when you are scheduled to see the specialist again. Maybe you find an answer. Maybe it's more appointments, more specialists, and more tests.

All the waiting between appointments (presumably while feeling poorly) plus all the time off from work plus the travel time to/from plus the "doctor is inevitably running late" time plus all the fragmented care (just to MAYBE get to the bottom of your constant abdominal pain) equals frustration with the current system.

When I have a choice between waiting eight hours for an answer or waiting for nearly two months, I would rather wait eight hours, thanks. I'm tired of doing year-long dances with doctors ten minutes at a time until they finally stumble headfirst into an answer.

WHOA!!!!!

Now Cathy, I'm sure you're a wonderful person, and maybe this was all sarcastic and tongue-in-cheek, but for the sake of this rant, I'm assuming you are serious. It is disheartening how many people truly believe exactly what you speak of and have no idea the consequences of their actions.

We have become a selfish, "right now" society. I believe it is one of the main contributors to ED overcrowding. We have decided that we must have everything from our hamburgers to our medical diagnosis' RIGHT NOW. It doesn't matter the consequences it may have on ourselves, our neighbors, or our society. We need to know RIGHT NOW.

People from all walks of life view the EMERGENCY room as one giant "right now" clinic. Simply show up at any time of the day, talk to the magical, all knowing Dr. and he/she will fix you.

Never mind that he/she was trained in EMERGENCIES and has very little knowledge as to the differential diagnosis of your vague symptoms.

Never mind that the EMERGENCY room is for EMERGENCIES. People consistently show up at ER's all over the country expecting us to cram in 8 weeks worth of tests into 8 hours regardless of the acuity of the problem. They "cant wait" for numerous doctors visits. They HAVE to know now. Their belly has been hurting for 3 weeks but TONITE they NEED to know.

Never mind the fact that the bed you take up could have been used for the septic cancer patient who's waiting in the waiting room. Her vital signs not bad enough "yet" to bring her back to a room. So she waits as you, Cathy, take up a bed in the EMERGENCY room because you couldn't stand the multiple Dr.'s visits.

Never mind that by the time we do your 8 hour work up and discover nothing, convince you to utilize the system properly and see your Dr and get you out of the room, she's tachycardic and has a marginal blood pressure and was robbed of precious hours of fluids and antibiotics because you had to know "right now".

Never mind the time spent explaining to you that this is not an EMERGENCY and despite your desire to "know right now", we most likely cannot or will not come to a diagnosis in the ER.

Never mind the fact that those minutes could have been spent deliberating subtleties of an EKG that may or may not have led to a life threatening, EMERGENT diagnosis.

Never mind the time you spent on our CT Scanner getting your pseudo-emergent scan and the time it took to get you off the scanner so we could scan the head of a potential stroke.

Never mind that those precious seconds could be the difference between full recovery and life in a nursing home.

Never mind THOUSANDS of extra dollars it takes to do this work up in the ER instead of as an outpatient. The insurance companies pay for it.

Never mind the fact that those dollars get spread back to you and eventually forces a single mom to drop her coverage, lose her PMD and leads to her bringing her 4 year old to the ER for an earache thus completing the cycle.

Never mind the fact that the EMERGENCY doctor was looking up the differential diagnosis of your vague symptoms instead of picking up the chart of the "chest pain".

Never mind that it turned out to be a patient with an aortic dissection who ended up coding and dying because his blood pressure wasn't controlled on time.

Never mind any of those things, Cathy, because you need to know right now...........

A shame

2008-08-21T10:29:00.000-07:00

I've seen numerous versions around the internet recently of this article on Yahoo. While I understand some parents skepticism in light of the "media blitz" over a few marginal studies done years ago and the occasional anecdotal story, I just cannot fathom making the decision to undoubtedly put your childs health at risk because of this skepticism.

Now, I'm not an immunologist, nor a pediatrician and I cannot claim to be up on the worlds literature regarding the risks of vaccinations. What I can tell you as a physician, is that vaccinations save lives. Ask any physician who has been practicing over the last 20 years or so, (before and after the Hib vaccine for instance) and they will tell you how much less often we see things such as meningitis, orbital cellulitis, or epiglottitis. Again, I cant quote literature, but anecdotally, vaccines work. We just dont see these entities NEARLY as often as we used to.

The reasoning behind skipping vaccinations obviously lies in parents fears that the vaccines "cause" autism and various other disorders. I would bet most parents who refuse vaccines are not fully informed as to the "chances" of these vaccines causing those disorders versus the "chances" that the vaccine would prevent a deadly infection.

From my limited experience, it seems many of the decisions to not vaccinate stem from fears bred through either the mainstream media's sensationalizing of a few limited studies OR from parents anecdotal experiences with "a friends child who has autism because of a vaccine". I always wonder if parents would feel the same if they also "had a friend" who experienced the horror of watching their child respiratory arrest because their epiglottis was the size of a grape.......

The Phelps Effect

2008-08-19T09:30:00.001-07:00

I'm a sucker for the Olympics. I eat it up. I love sports and I love "once in a lifetime sports moments". I'm not a Tour de France guy, but when Lance was going for 7, I was GLUED to the internet. I hate the Patriots but I was PISSED when Eli ruined "The Perfect Season". So like a lot of the rest of the country I bought into the Michael Phelps hype, hook, line and sinker.

So a week ago he's racing in "The Relay" and I'm at work. I had actually forgotten about the race as it was quite a busy night. I came out of a patients room and noticed about 8 staff members in an open room looking up at the TV. I arrived just in time to see Phelps finishing his leg. For the next 2 minutes we stared up at the TV riveted. Each of us saying stuff like "Cmon, CMON!!" And "He's not going to do it! He's too far behind!!"

When Lezak touched and they flashed that American flag we all ERUPTED in cheers. It was cool, but not the cool part. You see, in Suburbia we have TV's in each of our patients room AND in the lobby. So simultaneously, every patient room AND the lobby EXPLODED in cheers. It was one of the coolest things I've seen.

Gotta love it.

Its JONATHAN!

2008-08-19T09:00:00.000-07:00

I learned a lesson the hard way last week. It was a busy night shift and I was drowning when the cops brought in a drunk. Now one thing to keep in mind is that drunks in the inner city and drunks in the 'Burbs are two separate things. Most (if not all) hospitals in the inner city have drunk tanks, isolation rooms, lots of staff and lots of big, beefy security. We dont. We've got a code room, 3 overnight nurses, 1 doc, 2 techs and 1 security guy who may or may not be 70 years old.

So the cops bring in a drunk who they knew well, "Big Jon" one of the cops called him. They found him drunk outside his house. He's never a problem, one of the nurses tell me. He was fine in the rig. He's calm and collected in the department. He falls asleep and all is well. I'll let him sleep it off and discharge him in the am. Now its a TOTALLY separate blog as to whether or not the cops should even have brought him to me. This one though, is about what happened next.

For whatever reason, an hour later, "Big Jon" decided he wanted to smoke a cigarette. For whatever reason, I didnt want him to. I calmly entered the room, began talking to "Jon" trying explain to him my reasoning. I shockingly wasnt making much progress. I was desperately trying to avoid an escalation because its a bit difficult in Suburbia to "show force" to a pissed off patient. Especially with a guy named "Big Jon". Usually I'm pretty good at breaking down a drunk and getting him to co-operate. This time though, I was making it worse. "Jon, listen to me, I'm going to send you home, I just need you to rest here for a while." "No Jon, I cant let you go smoke." "Jon, I'm on your team here, just work with me."

Suddenly with a bolt of fury he yelled at me in a voice straight out of the Exorcist:

"ITS NOT JON, ITS JONATHAN!!! YOU $%#$%@^*(&@$##!!!!!! YOU CALL ME JON ONE MORE TIME AND I'LL KNOCK YOUR BLOCK OFF!!!"

My heartrate jumped to about 130 bpm. I backed up. "Sorry Jonathan. I shouldnt have assumed......."

After a few tense moments. Wondering if he was about to destroy me and the entire emergency department, he thankfully calmed. I was shocked. A few moments of calling him "Jonathan" seemed to do wonders. Earlier it hadnt mattered WHAT I did, it was apparently the "Jon" part that was driving him nuts.

So the lesson? First, never reason with a drunk. Second, dont assume people want to be called by their obvious nickname. It might just get your "block knocked off".

Scumbag, Sleazeball and Scumbag

2008-08-14T07:02:00.000-07:00

I've written posts before about how things in Emergency Medicine seem to come in spurts. It really is uncanny. One night could be "GI bleed night" and the next "febrile kid night". Its pretty interesting.

Well a week or so ago I had one of the strangest "spurts" I've ever had. It was "I suffered a silly injury and I called an attorney and he told me to go to the ER" night. Seriously.

The first was a 40ish male. Unemployed. Trucker hat. Dirty shirt. Cigarette in ear. He had been at the movies with his "gal" and apparently had gotten into some sort of altercation with another Rhodes Scholar. The cops had come and in the process he had been cuffed for a time. He had some wrist pain from the cuffs. No other injuries. Just some wrist pain. Anyway, he had gone home that night and called one of our world famous personal injury firms, "Scumbag, Sleazeball and Scumbag". Some idiot screener he talked to told him he "might have a case" and that he should go to an ER right away. So there he was, red mark on wrist. Full range of motion. Mildly tender. Normal xray. Good luck in court. Thanks for coming.

The second was a none the less entertaining. 38 year old female. Obese. Long fake fingernails. Big hair. Receptionist. She fit so many stereotypes, she looked like a Saturday Night Live Character. Slipped on a broken sidewalk coming out of work. Believe it or not she had actually NO complaints but she too had called "Scumbag, Sleazeball and Scumbag". Here was my convo with her:

Her: "I was walking out of work, blah, blah, blah, broken sidewalk, slipped, blah, blah, blah"

Me: "Ok, ma'am, I'm sorry to hear that. Where do you hurt?"

Her: "Oh, nowhere, I didnt really hurt myself"

Me: "Um, so what can I do for you in the EMERGENCY ROOM?"

Her: "I dont know, I called Scumbag, Sleazeball and Scumbag and they suggested I come get checked out to see if there was anything wrong."

Me: "They told you that?"

Her: "Yep. So is there anything wrong with me?"

Me: "Tons."

And if that wasnt enough, towards the end of my shift, after a relatively slow night, in walks our last "client". 26 year old female. 4 crabby, young kids in tow at 1am. Unemployed. Was at the grocery store two days ago, was reaching up to get something off the top shelf when she somehow lost her balance, fell backwards and in her words "bruised her butt". She too, unbelievably had called "Scumbag, Sleazeball and Scumbag" and had been told to get "checked out". I asked her why she had come in at 1am instead of earlier and suggested maybe her kids were crabby because they were tired and that perhaps she could have seen her regular Dr. She was BAFFLED at my suggestion that it MAY have been inappropriate to bring her three kids to the ER at 1am for an injury that happened 2 days ago and didnt even seem to be bothering her that much. I xray'd her pelvis, shockingly there were no fractures. She demanded percocet. I resisted. We argued. She got angry and walked out without a limp, threatening to include me in her lawsuit.

There is so much in the way of commentary I could add but alas, for the sake of brevity I'll bite my tongue. I think the stories probably speak for themselves. Take from them what you wish. But it did remind me of a joke I once heard:

What do you call 100 lawyers buried up to their necks in sand?

Not enough sand.

Thanks folks, I'll be here all week........

Uninsured and TMI and the internet

2008-08-11T11:48:00.000-07:00

Annals has a couple of articles this month regarding ED overcrowding. One of them addresses the uninsured patients use of the ED and it reiterates two pretty interesting points.

First, ER visits are SKYROCKETING upwards.

Second, its not just simply the uninsured or indigent using the ER because they cant get care anywhere else.

Its a popular misconception amongst many people I know both medical and non-medical. The conversation usually goes something like this:

Them: "Oh man, you work in the ER? That must be pretty exciting"

Me: "Yeah, it can be pretty fun."

Then: "I bet you see some pretty crazy stuff huh? Like gunshots and car wrecks???"

Me "Yeah, some of that. But you know mostly its just regular people and sickness. Heart attacks, runny noses, rashes, strokes. You know, things like that."

Them: "WHAT???? You see RUNNY NOSES in the ER????????? THATS CRAZY!!!! Must be a lot of poor people without insurance or doctors. That even happens in the 'Burbs, huh?"

People in general are incredulous to learn that laypeople FREQUENTLY got to the ER for trivial things. They assume people use the Emergency Room for Emergencies. Whats funny is how often I get a call from these same people telling me about their own trip to the ER for their own trivial symptoms that they were CONVINCED was something bad.

In my sleepy little Suburban Emergency Department, our census has gone up almost 75% in the last 3 years. In our case it is multi-factorial, but visits are going up all over the country. Interestingly, no one really seems to be able to put a reason to why this is. Its easy to assume its the uninsured inappropriately using the ER because they dont have Primary Docs, but paper after paper seems to suggest this isn't the case. People just simply are using the ER more often.

So why is this? If visits are increasing and its not just the uninsured as many people assume, why did visits to ERs go up by almost 30 million over a matter of a few years? Well, as with many things of this nature, the reason is multi factorial. It most likely involves a combination of complex access to care issues. I though, have my own theory. Its the Internet. Yep, THE INTERNET, Greys Anatomy and Dr. House are the reason ER visits are increasing at alarming rates, contributing to overcrowding, hindering patient care and ultimately putting patients at risk. Its all the Internets fault. Seriously.

I believe that people in general, across all races and socioeconomic groups are using the ER's more frequently because they are constantly bombarded on TV and in the news by shows like Greys Anatomy, House and the Discovery channel by all the HORRIBLE things that can happen to them. They see the newly wed with the rash who is dead 12 hours later. They read on the Internet about Bernie Mac dying of a pneumonia that started as a cold. Seemingly reasonable people get scared that even the most minor of ailments could end up literally being the death of them. They hear about these things and immediately rush to the internet where they find confirmation that yes indeed, horrible diseases have many seemingly trivial symptoms.

I would say on any given shift, of the 20 or so patients I see, at least 5-8 of them are "worried well". People who just simply want reassurance that their side ache isn't a ruptured spleen like they saw on House last night. Most of them went on the Internet to "research" their symptoms and saw all the horrible diseases that could conceivably cause their symptom and want reassurance from me that they aren't going to die. "I just want to know I'm know gonna die". I hear that literally 3 times a shift.

So that's it. Take away the Internet. Cancel House and Greys Anatomy and you'd solve the ED overcrowding problem. I don't care about "throughput" and "output" and "multi-factorial". I don't wanna hear about papers suggesting "ED Overuse" isn't nearly as bad as physicians believe it is. Its the Internet. Its House. Its Greys Anatomy. And its the Worried Well. Thats my story and I'm stickin to it.

Its good to be back.

three and a half months

2008-08-10T16:02:00.000-07:00

Did you miss me? Thanks for the inquiries while I've been gone. Despite the worries, my self imposed exile has been based solely on me enjoying whats been a wonderful summer. Between the beach, golf, company and what has seemed like endless lawn mowing, I hardly had time to sit down and put my thoughts to keyboard. I must admit, I missed blogging. So much has happened which will make for interesting posts. I often would work a shift and think to myself "That will be PERFECT to blog about!" Alas, time always seemed to get away from me and I never had the discipline to sit down and type.

So as we start the dog days of summer (are we really there yet or do we have a few more weeks?) between the olympics, a few more rounds of golf and a few more weekends at the beach, I promise to work in a few posts. I'm sure you'll wait with baited breath.

Stay tuned.....................

Microsoft, Google and HIPPA, oh my!

2008-04-17T07:59:00.000-07:00

The NY Times has an article today regarding Google and Microsoft's entry into the medical records fiasco.

I say fiasco because as anyone involved in health care who has ever tried to access medical records can tell you, it is a nightmare to try and get valuable information on a patient from another medical provider no matter the urgency.

Assuming you can get a hold of the medical records department at another facility, you then must fill out paperwork, have it signed by the patient, fax it and hope to God it gets to the right place and is handled by someone with the necessary skills to find the record and then fax it back to you. Usually this takes a MINIMUM of 2 hours.

In the meantime, you have a patient in your ER who is "circling the drain" as you contemplate interventions which may or may not be affected by previous ailments, medications and most importantly, patient wishes.

HIPPA as it was originally intended is a good thing. In theory. It would be dangerous and scary to have ones medical information out there for all to see. Unfortunately, like many acronym filled government forays into Medicine, what was started in the interest of patients has in many cases become a barrier to patient care.

What is most maddening for physicians is that the rise of computer based medical records, should male it easy to access a patients medical record regardless of the facility. Yet, because of competition among vendors and "incompatibility" of the different software, coupled with the complexity and inadequacies of HIPPA, these new systems do nothing to aid in record transfer among institutions.

On the surface then, the Google and Microsoft idea is a GOOD thing. Having a centralized area for one's medical records would be a GOOD thing. Allowing physicians to access vital information which may save a patients life is a GOOD thing. Having the the privacy issues worked out in a reasonable and straightforward manner is a GOOD thing. (HIPPA is neither straightforward nor reasonable)

Here's the rub. Both Google and Microsoft allow patients to determine what is entered into their "records". This is a BAD thing. It allows untrained patients to determine what is important and what is not. They are allowed to edit information to their own liking. I shouldn't need to expand on how this is detrimental to patient care and dangerous for patients. What initially sounds like a great idea (web based medical record depositories) is being implemented in a way which will actually hinder care rather than help it.

So what is the solution? Easy. A national medical records system. (GASP! Did you say government intervention into helathcare??????) Yep. I believe this is the one area where government intervention could UNEQUIVOCALLY improve patient care. You could even leave all the silly HIPPA laws in place. Create a National Medical Record system, mandate hospitals and insurance companies to subsidize it and VIOLA! problem solved. Granted, we would have one more bureaucratic mess to deal with but I'm confident the system could be implemented and operational. Just look at the VA's medical record system. It is feasible.

Physicians all over the country could see the results of that stress test, access old EKG's, see old cat scans, compare old lab results, have complete med lists and most importantly have complete understandings of patients end of life wishes.

Now THAT would be a GOOD thing.

Cmon Alice

2008-04-08T18:29:00.000-07:00

While normally insightful and respectful, Dr. Alice has an interesting post that takes a shot at us Trench Docs. Ironically, it comes just a few days after my own "Stereotype" post. I couldn't resist, I had to respond.

Where I trained we had a surgical resident who was an absolute shining light in a surgical residency filled with weak, insecure, angry, cynical surgical residents. We'll call her "Dr. Sunshine". I never heard her utter a condescending word. She had a smile on her face no matter her hours, no mater how overworked she was. I had the pleasure of spending a month on her service. It made what is usually a brutal month, one of the most rewarding of my residency. She saw consults in the ER timely and fairly. She accepted patients without hesitation because in her words "someone has to take care of them". She never blocked. Never argued but had countless discussions regarding the best care for the patient. She involved interns in decision making. She was encouraging and inspiring. She was without a doubt the best "person" I have ever worked with in medicine. (and that's saying alot)

Alice, I wonder what Dr. Sunshine would say when faced with a consult in the ED that appeared to be everything BUT appendicitis. What about that medical resident forced to make a needless consult? Remember, there are always two sides to every story. "Examine the patient and think for two minutes!" is offensive. You're better than that.

But never mind, I enjoy your posts and think you too will be a ray of light in an often difficult, cynical and harsh specialty. Give my best to your chief and offer him my thanks. For even though its out of character for me, the next time a lazy surgical resident tries to block my admission or requests a "pre-op" or medical consult for a patient with diabetes or hypertension, I will simply respond with "You know, I'm not asking you to be a surgeon, just a doctor, now get down her and take care of a patient for once........."

What kind of Doctor ARE you?

2008-04-07T11:06:00.000-07:00

As I've blogged about in the past, the 'Burbs are an interesting place to practice emergency medicine. Where I work, I can go a whole shift and see only ortho cases and urgent care stuff or I can see consecutive Acute MI's, separated by a kid with an ear infection.

The other night, I was working the overnight, I was single coverage and things were going fairly smoothly. I had a patient with a kidney stone getting some fluids and analgesia, and an ankle sprain who was waiting for her ankle xray. That was it, an exceptionally slow Friday night. It was about 2 am and all hell broke loose.

I was chatting with the tech about the recent Sports Guy batch of links and the Celtics chances of winning the title when one of our better, older, charge nurses came rushing up to me "We need you in room 12, NOW". As anyone who has ever worked in an ER knows, it takes a lot to get a "grizzled charge nurse" excited. My heart rate immediately began to accelerate.

I walked into room 12 and there before me was a 23 year old girl who had been out with her friends for a celebration. They had been doing shots all night and on the way home, they thought she had stopped breathing in the car. There she was, pale, blue, unresponsive with a heart rate of 35 and an O2 sat of 78%. Yikes. Instinct kicked in, she was intubated without drugs, lines were started, atropine given, she stabilized rather quickly. Her etoh level was 410. Thats a lot of shots.

Unbelievably, as I had just finished intubating her and was checking for breath sounds, the triage nurse wheeled by us with a younger looking male who was gasping for breath. "Dr. Suburban, can you follow me?" she asked as she hurriedly rushed past to one of the other resuscitation rooms. With my shot girl relatively stabilized, I followed the triage nurse into the room. In the wheelchair was a 19 year old, slender male gasping for breath. We got him to the bed. His O2 sats were low 80's. He had bulging veins, and the most remarkably deviated trachea I've ever seen. It was like I was looking at a text book. So I did what any good ER doc would do and ordered a chest xray. (settle down, just kidding) With my program directors words echoing in my ear "Dont ever hesitate with the needle if you think its a tension pneumo", I took a deep breath, 2nd inter space, mid clavicular line................pssssssssssssssssssttttttttttt.

"Wow, first time I've seen that" I thought secretly to myself. Immediately, our guy improved. Heart rate came down, sats improved, he was much more comfortable. Granted he was freaking out a little because he still had a needle sticking out of his chest, but he was better. I looked up at the triage nurse (recent grad) who was looking at me, her eyes like saucers. "Holy shit" she mouthed to me. I smiled on the inside, "can you call xray and set me up for a chest tube?"

Now here's the good part. I walk out of the room and the grizzled charge nurse is walking towards me. "How's our girl in 12?" I ask.

"She's ok. Vitals are stable, but you arent going to believe this. EMS just called, they're on the way with a full arrest. The whole city is on divert so we have to take it."

Before I can even protest the ambulance bay light goes on and in comes a team of paramedics, cpr in progress, 48 year old male, collapsed at home on his way to bed. I proceeded with a mega-code of Ruthian proportions. The guy was in and out of V-fib, he'd stabilize then go right back into it. If its part of the algorithm, we did it. It was quite an ordeal.

Unbelievably, we were able to get a pulse back on him. He stabilized and we got him to the cath lab. 100% occluded Left Main, the "widow maker".

2 hours later, the guy is in the cath lab, our girl is being transferred to the ICU, (her parents are present and IRATE at the friends) and our kid with the pneumo has his chest tube and is waiting for his bed. I sit down, let out a sigh and realize I have three other patients still waiting for dispo, and 5 other people have come in since this all started. I take a deep breath and walk into the ankle sprain room with xray results.

"FINALLY" she says "I know you guys are busy, but this is ridiculous! I've been here 4 hours! What kind of Doctor are you?????"

And there it is.

Stereotypes

2008-04-04T09:19:00.000-07:00

When I started Medical school and had no idea why I wanted to be a doctor, let alone what type I wanted to be. I assumed I would figure it out as I went along. I did.

I remember about 8 months into medical school, a professor told me “You’re going to be an ER Doc.” I was shocked. I had never considered myself an “adrenaline junky”. I didn't like uncertainty and I thought I was WAY to “compassionate” to be a “trench doc”. This prof though said he had a feeling. My personality “fit the mold” he said.

Well he was right. And you know what? I remember looking around my classes at about the end of my 2nd year and being able to almost perfectly pick out what kind of doctor many of my classmates were going to be. It was uncanny.

The jocks became orthopods. The intense, cynical ones became surgeons. The “nice guys” went into family practice. The brainiacs are internal medicine specialists. The goof offs were pediatricians. The intense women all became ob/gyns. There were obviously exceptions, but for the most part, people fit "the mold".

I swear. Its true. Now before anyone jumps down my throat. I would agree that in most instances, stereotypes are destructive, preconceived notions that lead to prejudice and ignorance. Sometimes though, as difficult as it may be to admit, they can be viewed as “averages” or “means”. In medicine, this almost seems the case. Be clear, there are always exceptions. There are laid back, silly surgeons. There are intense, prickly pediatricians. But on AVERAGE, you have certain personalities in certain specialties. You take all the surgeons you've ever known and average out their personalities and you just might end up with a pretty smart, intense, and often cynical person. Some might argue it takes exactly that type of person to get through the residency and do such grueling, meticulous, difficult work. Others might say that people gravitate to specialties where they see people that are "like themselves". Others might say I'm full of fooey. Maybe I am.

But that Prof, who thought I would be an ER Doc was right. The stereotype fit and here I am, blogging about being an ER Doc, trying to decide if I should tell you about the abuse case I saw last night.

Dr. Jess' epiphany

2008-03-18T09:00:00.000-07:00

Picked this up from Gruntdoc. Dr. Jess had an epiphany and I applaud him/her. I thought it was interesting.

Dr. Jess hits on two things which I think are important. The first is one that is brought up often. That is: Its easy to second guess an ER Doc's decision the next day. (12 hours is a long time for a vague shortness of breath to declare itself NOT ACS). Things are much different during that moment in the ER. Things are murky. Stories are incomplete and we have to try and do whats best for patients.

Second, and this is spoken of less often: how much do we need to do in the ER for patients before we send them upstairs? This is less clear. Do we need to wait for the Cardiac Enzymes to admit a chest pain rule out? (probably) Do we really need to start the antibiotics on a pneumonia? (JHACO be damned!) And what about the sick patients? Do we have to place a central line in the septic patient? (Manny Rivers says yes, but does it have to be done in the ER or immediately in the ICU?) Like I said, I dont think the answer is clear.

One argument would say that once we've identified an admission, we need to get the patient upstairs so we can see more patients! But doesnt this further the ignorant belief that we're just triage nurses?

The other argument might be that we must fully stabilize every issue and come to a diagnosis regarding every complaint. While this allows many to show off their diagnostic and management skills, is it really feasible in a busy ER?

Alas, as with most things, the answer lies somewhere in between. Isnt that a Dave Matthews song?

Privacy

2008-03-15T05:59:00.000-07:00

KevinMD has a post about this MPR piece.

Scalpel has blogged about it too. The question of patient privacy on these blogs is one that is murky at best and the answer seems to be hotly debated.

The NPR piece is interesting and brings up some interesting points about patient privacy. I'm not so sure though, that Docs who "vent" on medical blogs need "therapy" as espoused by Debra Peel in the NPR article. That seems pretty harsh. I do think that at times, some may need to be a bit more mindful of their tone, though.

Telling the stories I think are interesting and making commentaries that I think are important while trying to avoid coming across as bitter or uncompassionate is something I have struggled with since the beginning of this blog. The very nature of some of the more "interesting" stories makes sometimes makes it difficult to avoid. We come into contact with unique and amazing people and situations every day. This makes for marvelous story telling and interesting blogging. And it seems the stories which one would find "interesting" are either:

a. inspirational

b. heart wrenching

c. humorous

d. unbelievable

Figuring out how to relate these stories to an interested public can be challenging. It is easy to tell the stories relating to a and b without sounding condescending or being offensive. Writing about c and d becomes more difficult. It is a thin line between entertaining and offensive when we are dealing with others misfortunes or lack of "insight". It is a fact though that in medicine we come across unbelievable and humorous scenarios nearly every day. And it is also true that people like to hear these stories. How else do you explain the whole cottage industry within television dedicated to telling these types of stories? Your average episode of "ER" or "Scrubs" or "House" (I wont even mention Grey's Anatomy because it is so totally ridiculous) are filled with cases which I'm sure are composites of actual cases seen by the "writing consultants" on the show.

So how is this different from the stories told in the blogosphere? (assuming it is done in a manner in which patient privacy is protected) Most of the blogs have disclaimers which make it clear that stories are not wholly factual and that medical blogs should not be taken as medical advice. It just seems to me that while bloggers do need to be mindful of their tone and scrupulous in protecting patient privacy, to say that Drs. who vent on medical blogs need "therapy" seems more irresponsible and sensational than even the "harshest" medical blogs.

The Voices in My Head

2008-03-14T10:22:00.000-07:00

Ask any ER Doc and they'll tell you. We hear voices.

It happened to me the other day. I wont recount the specifics of the case because it is too unique and would easily identify me to anyone who was even tangentially involved. You'll have to trust me that it was THAT extraordinary and THAT amazing. What I can tell you though, is that after an incredibly vague history filled with inconsistencies and nonspecific symptoms and a fairly normal physical exam, something just didn't feel right. The pieces didn't add up. I had no idea what was wrong, and had no idea of where to go with the case. Looking back, I could easily have simply done some cursory studies, given some symptomatic treatment and sent the patient home for follow up. I don't think I would have been "wrong". And I know many doctors would have done exactly that.

Thankfully, on this occasion, I didn't. Something just wasn't right and I heard that voice. Some might call it divine intervention. Others would say its instinct. Some might say its the voice of an overly cautious attending. Others would say its your inner self, picking up on subconscious clues and energy. Whatever it was, it led me to order a test that ended up unquestionably saving a patients life. The most ironic part of the case is that this test was probably not even necessarily medically indicated. I could never and should never have been expected to order it. Had I done what would have been arguably "medically appropriate" under the circumstances the patient would have died. But like I said, I ordered the test, and the patient lived.

You would think that I'd be thrilled. Ecstatic that I fulfilled my destiny as an ER Doc and saved a life. I wasn't. And I'm not. I'll admit, that initially I gave myself a pat on the back and few silent fist pumps. But after the adrenaline wore off I began asking myself "What if I wouldn't have listened to the voice". "What if I wouldn't have ordered the test". More so, "how often do I hear the voice and ignore it"?

The difficulty in wading through convoluted, incomplete histories and trying to make sense of vague, seemingly random symptoms and THEN identifying whether or not to listen to that "voice" is incredibly difficult and often comes down to luck. You see sometimes that voice is correct and all knowing. However sometimes it is simply paranoia. And other times it can be filled with bias. Knowing when to tune it out and when to embrace it is an extraordinarily difficult task that is impossible to understand unless you experience it.

Our job is a difficult one and we make difficult, sometimes split second decisions every day. In doing so, we often call upon every skill in our armamentarium. We remember pearls we've heard, lectures we've had and journals we've read. We try and recall our experiences. We're cautious. We're thorough. We think about specificity and negative predictive values. We do our best to connect dots that sometimes are unconnectable.

Its amazing in the end, how often it all comes down to the voices in our head.

And a little bit of luck.......

My Advice

2008-03-13T08:32:00.000-07:00

There was an article on Time.com this morning which pertains to something I've been thinking about for while.

I would say (without any evidence to back it up) that, in suburbia, roughly 70% of the kids I see in the ER end up being totally healthy with nothing wrong with them other than maybe a cold. This number was probably even higher in the inner-city. Because of this, most of my interactions with parents end up consisting of me trying to convince them that their child is ok and suggesting ways to deal with "normal" childhood issues. I offer tips on how to deal with a crabby 1 year old. I suggest what to put in their bottle and when its OK to let their child eat table food. Sometimes I suggest ways to avoid constipation. Sometimes I simply tell them "your doing a good job with Little Johnny." (Like I'm Dr. Spock himself)

Most of what I suggest or do is based on either limited personal experience or things I have heard second hand. Almost none of these "practical parenting tips" are things they teach us in medical school. Sure we have one or two lectures on child development and maybe even half of one lecture dedicated to "parenting" but in no way am I an expert on simple parenting.

I am trained in "Emergency Medicine". Yet once I've determined that the child I'm seeing is indeed "healthy" and in no need of emergent intervention, most of what I end up doing is offering "parenting advice". This just always seemed strange to me. I suppose its just another example of how our ER's have become one-stop Medical Shopping Marts. (More on that in my next post)

Nice Guys

2008-03-09T19:19:00.000-07:00

"I'm kinda worried, he's got the 'Positive Nice Guy Sign'"........

Those were the words my colleague spoke to me just before his patient coded. I wont get into the details, but suffice to say, it was very difficult.

As those of us in the medical field know all to well, the "Positive Nice Guy Sign" isnt a good thing. It was actually mentioned in a comment to one of my earlier posts. Its amazing sometimes how some of those old medical axioms, uttered often in jest, can be so true, so often.

The "Positive Nice Guy Sign" means simply that the nicest, most congenial patients often seem to be the sickest. The 21 year old who glows has a headache that ends up being cancer. The good ol boy with chest pain who says "Yes Ma'am" and "Thank you kindly" ends up going into V-Fib right in front of you.

Its uncanny and unfortunate but it seems to happen often. Of course it could simply be us in the medical field possessing selective memories. It could be that we remember the cases where nice people get bad diseases and forget about the cases where the "meanies" get the same. It could be a self defense mechanism somehow, even though it seems more like a self "flogging" mechanism. Its probably an interesting comment on the human psyche. It definitely is one of the things that makes this job tough.

Fever

2008-03-03T09:12:00.000-08:00

Here's a link about fever I found on Yahoo today. It keeps with a theme I've posted on lately. Its actually pretty good advice. I wish I had a nickel for every conversation I've had with patients over the last few weeks that echos this article!

I think the most telling part for us in the ER is the last statement:

Fit's Tips: If your fever persists for more than five days, or it goes over 104° F, call your doctor and get some medical advice immediately.

Notice it makes no mention of an Emergency Room. Interesting.

Now contrast it to this article from Minneapolis, MN.

Imagine being a new mom and reading this article. How would you react the next time your child woke up in the middle of the night with a fever? Think you might get worried?

Its a perfect example of the mixed messages the general public gets regarding this stuff. How do we expect the public to wade through these sensationalistic stories and not become alarmed every time they catch a chill? The story of a child dying quickly from Influenza is absolutely tragic but why is there a need to broadcast this tragedy? And if we are going to broadcast it, why not focus more on the fact that the mother truly did nothing wrong. Talk about how exceedingly rare it is for this to happen. How it is usually completely appropriate to give your child some tylenol and call your doctor in the morning. I don't think its an overstatement to say that this sort of journalism is irresponsible.

So the next time its 3am and you see that worried mom with her 5 year old who has a fever of 100.6, think about this article, take a deep breath and repeat to yourself in your best Robin-Williams-from-Good-Will-Hunting voice: "Its not her fault, its not her fault......"

5 Hour Wait Part Deux

2008-03-01T15:41:00.000-08:00

So I've been thinking about the "5 Hour Wait" post ever since writing it. One thing I didnt mention (the post was getting quite long) and I dont think it came across in my writing is that I sometimes (most of the time??) actually can empathize with the "non emergencies".

Here's how: As a resident it used to drive me absolutely BONKERS that people came to the ER for such piddly stuff. I would rage about the "idiots" who didnt know serious from not serious. I would say things like "When I was a kid my mom would NEVER have brought me to the ER for this!" One day, one of our more thoughtful attendings heard me complaining to one of the nurses. She broke in and told me how she used to feel the same way. It used to drive her nuts. What she did though, was start to really empathize and practice looking at symptoms through the eyes of the patients with absolutely no medical training to base it on. Relying only on horror stories told by friends and the media about the unfortunate few who die suddenly of zebras. She put herself in their shoes, so to speak. What she found was that often, she was able to realize how symptoms which were so meaningless to us as physicians could be perceived as serious by a layperson.

Granted, this does nothing for the "hurt finger at 3 am" or the "fever with no fever at midnight". There are certain patients and certain complaints which completely defy any and all attempts at empathy. What I found though, was that by practicing this "visualization" with patients, often I was able to justify the visit. I began to see how the "chest twinge" that is so ridiculous to me could possibly be perceived as serious. The diarrhea for 24 hours, if truly extensive enough might just be enough to worry a "normal person". It made my job easier to not be SO concerned all the time with ridiculous complaints.

Now, before you go start to think too highly of me or my well-grounded attending, let me finish the story.....

The very next shift following my little "talk" with Dr. Compassionate, we had a patient come in on a very slow, beautiful Sunday morning. Chief complaint was "toe pain". The attending and I interviewed the patient together. She took off her sock and with a look of great concern stared at us and asked: "Do I have cancer???"

Swallowing hard, I looked her right in the eye and said: "Nope, you have a bunion.............."

On the way out of the room I asked the attending how she possibly could justify that one.

She looked at me, her cheeks blushing, and said "You cant empathize with stupidity."

Astonishing

2008-02-28T21:15:00.000-08:00

I just posted about this, but I had to mention it again.

This really happened yesterday:

49 year old. Healthy as a horse. Had an ORIF of Distal Tib/Fib and discharged TWO days ago.

Presents with post op pain. Intense. No fever. No redness. Just intense pain. He's totally legit, just has crazy pain.

Dr. Orthopod is in the hospital doing surgeries so he comes down between them and talks with patient and says to me:

"Well, see what you can do, but I guess if you cant control his pain.......sometimes they have to come in."

"Ok, I'll see what I can do" I said. "If not, I'll admit him to your service?"

With a straight face he says "You know, I guess just put him on Dr Primary's service. I'll follow"

Ok. In all seriousness, can someone give me a non-cynical, real explanation for why this happens? Seriously. I want answers. I want the truth...............

5 hour wait

2008-02-26T18:07:00.000-08:00

We had a busy night in Suburbia a few nights ago. I havent looked at our stats in a while, but I would think we have an average "door to doc" time of about a half hour. The other night though, we had people in our waiting room for at least 3 hours. For whatever reason, it seemed everyone in suburbia decided to have an "emergency" on the same night.

(As a side note, I have always found it remarkable that the ER is predictably busy at certain times, I plan on posting about his sometime)

On this night though, we were busy and people were sick. By about 3 am, things had started to slow down and I started to churn out the few urgent care type patients who had stuck around. I picked up a chart of a 13 year old with a chief complaint of "cough". He had been in the ED for a total of 5 hours. Now, we see all types of things in the ED. On any given day, I will see someone who, without my intervention, could very well die and 5 minutes later see a patient with absolutely nothing wrong with them. Most of the "public" likes to think that the one thing these two patients have in common is that they both at least "perceive" that they have an emergency. Sometimes, I'm not so sure.

As I walked into this 13 year olds room, at 3 in the morning, on a school night, after them having waited for over 5 hours, I was expecting the worst. I assumed I would find an irate parent who had waited forever with what they thought was a very sick child. Why else would any sane person still be waiting to see me? I rehearsed what I might say if the child indeed had "just a cold" as the triage nurse had told me.

What I found surprised me. A completely healthy appearing, calm 13 year old sat on the bed playing with his PSP. His dad sat next to him, in a chair, staring blankly up at Sportscenter on the TV.

"Hey, I'm Surban Doc. Sorry about the wait tonite, its been crazy busy. What brings you to the ER?" I said

"Oh, he has a cough." Said his dad, barely looking away from the TV.

"Ok. How long has he had a cough?"

"Oh, I dont know, I guess it started this morning."

No fever. No sore throat. No vomiting. He had a stuffy nose and a cough. I couldnt find one solitary thing which a reasonable person would identify as a reason to even go to a "minute clinic" let alone an emergency room.

His brother was just getting over the same thing. His dad actually said to me that they had brought his younger brother in 3 days ago and were told he had a "virus".

So, lets recap:

1.) He brought his 13 year old to the EMERGENCY ROOM on a school night.

2.) He brought his 13 year old to the emergency room because he had a cough

3.) He didnt have a fever. He didnt even feel particularly sick. He had a cough and a sniffle.

4.) They had been in the ER 3 days ago, with his brother, and were told he wasnt sick.

5.) Once at the ER, for his cold, they waited FIVE HOURS to see me.

6.) By the time I saw them, it was 3 in the morning.

7.) They seemed totally indifferent to the 5 hours or the 3am part

8.) Did I mention it was a school night

Why? How? Noone knows except dad (and probably mom). If you look through Annals of Emergency Medicine over the last few years you'll find TONS of articles dealing with emergency room overcrowding. Each paper/editorial seems to have a different spin and comes to different conclusions. One thing in particular which isnt totally agreed upon is the role emergency department "misuse" plays in overall overcrowding. If you ask your average trench doc though, the perception is that "misuse" is the major factor in overcrowding.

Perhaps we could commission a study in suburbia that looks particularly at patients labled as "misusers" and identifies their individual reasons for being at the ER. It would be fascinating. Can you possibly imagine what this father would say if you blatantly asked him "Why on earth did you wait 5 hours to see the physician, on a school night, for a cold." Do you think Annals would publish it?

Surgeons

2008-02-20T10:25:00.000-08:00

Enough with the deep stuff, lets talk about surgeons....

I remember in residency, some of the biggest, ugliest "battles" I ever had were with surgeons who didnt want to admit patients to their service. Each shift was like a UFC main event. Me against the surgical resident. No holds barred. A fight to the death. I took it personal. I never gave in. I never tapped out. Sometimes I won, sometimes I lost, but I never gave up. You had to win by knockout.

If I was calling surgery, even for an obvious appy, I gathered my thoughts, took a couple deep breaths, visualized my opponent and anxiously awaited the call back. You see, our surgical service had tricks up their sleeves that I had never even DREAMED of in medical school. The periumbilical pain that settled in the RLQ could be crohns and should go to medicine wiht a surgical consult. The cold, pulseless foot might be dealt with by intervential radiology so it should go to medicine. The post-op patient who returns with a bowel obstruction might improve with conservative management.......you know the rest. I had to constantly stay on my toes. Anticipate every argument and every attempt at a block. I needed to have journal articles at my ready and lab results at my fingertips. It was stressful to say the least.

Many of the residents were friends of mine outside of work. When you would ask them why this happened and how it happened they would give multiple reasons. Most of them centered around workload and service size. Their services were overrun with cases so to take patients from the ER was almost impossible. They spoke workloads and census size and long hours. Most shockingly though, they spoke of a culture of "blocking". It seemed that the residents we in the ER despised most were worshipped by surgical residents and praised by the attendings for keeping the census low and "blocking" the Triage Nurses (ER Docs) downstairs.

When did this start? In the 50's and 60's, the "golden age" of surgery, did surgeons do this? I wonder what Debakey or Cushing would say to know that surgeons no longer think they can manage "complicated medical patients"? (i.e. 54 year olds with diabetes and htn). Is this good for the hospital? More importantly, is this truly good for patients?

As a resident, it infuriated me. Now, as an attending, I'm no longer into UFC. I have submitted. I tapped out. Retired. I took my lumps and no longer have the time nor the energy to fight. I will say that I was actually surprised that even in Suburbia, with private surgeons anxious to help out, make money and take care of patients almost everything is STILL admitted to the medicine. I have accepted though, that only the healthiest, most clear cut appendicitis' go to the surgeons. (MAYBE) Cholecystitis goes to medicine with a surgical consult. Undifferentiated abdominal pain....goes to medicine with a surgical consult. Cold pulseless feet......go to medicine with vascular consult.

In my corner of the medical world, surgeons have become king of the medical admissions octagon. With their money making same day surgeries and powerful department heads they have the ultimate "finishing move" and I never stood a chance. Do not fret though, while I may have given in, the fight goes on in residencies across the country. At this very moment, in some inner city ED, with pandemonium raging all around, there is a resident sitting quietly, eyes closed, waiting for an overworked surgical resident to call him back. With lab results running through his mind, the Rocky Theme song thumping in his head, his heart racing, and a drop of sweat at his brow. He will not give up. He will not give in. His patient is going to the surgical service...........

Smoking is Bad

2008-02-20T09:15:00.000-08:00

So it looks like it took the Italians to show a public health benefit to smoking bans. I havent read the actual study, but here's a link to a laymen article about the study: Smoking Study

I understand that some people simply believe whether or not I smoke is none of the governments business and infringes on ones "personal liberties" as granted by a little thing called The Declaration of Independence. I just dont agree. I believe it is possible to protect ones personal liberties even in the face of government regulations. And that certain regulations are necessary and dont have to automatically lead us down the slippery slope towards socialism/fascism.

We have gotten to the point in this country where we all are tied to each other in so many complicated ways that each or own individual actions directly effects the livelihood of our neighbor. To simply say that "we each can do whatever we choose" without any regard for anyone else simply isnt realistic anymore. Unless you are a true blue libertarian who believes the government should only function as a national defense and road builder, then you would agree that there are simply some cases where government should intervene.

The smoking ban is one of those issues. When you look at the smoking ban as a public health issue and not simply as a government overreach, it becomes clear that it is beneficial and just. Even without "Hilarycare" each of your neighbors health decisions directly effects you. Through increasing healthcare costs, insurance premiums and drug costs. A "sicker" country costs more for you, regardless of which system you think we should live in. We have made the decision that we must take certain steps to ensure a healthy society and save us money. The smoking bans are one way to do this. The Italian study is the first of many which I believe will demonstrate its veracity. We have chosen to sacrifice one small liberty for the greater good of society.

!!!!IMPORTANT DISCLAIMER!!!

That last line will send shutters down the spine of many readers as they envision our slide towards communism. Remember though, we are humans blessed with a cognitive ability to interpret individual situations separately, apply reason and arrive at conclusions which will differ depending on multiple variables. We are not dogs who react to instinct. Making one decisions like this does not mean that suddenly we will be mandating every possible action of every individual "for the greater good of society". The "slippery slope" argument need not apply.

The Fix

2008-02-17T08:48:00.000-08:00

One of my great interests in medicine is the workings of our system as a whole. I read policy papers, I attend lectures, I constantly think about whats good and whats bad. I think, deep within me there is a (gasp!) administrator dying to get out. It is not a novel statement to say that our system is broken. It likewise isnt too original to suggest that the "brokeness" is multifactorial as is the solution.

I had often thought about (and had indeed started on) a "manifesto" of sorts proclaiming all I thought was wrong with our system. Somehow though, in the midst of google searches, Blogrolling and multiple revisions, with myself worked up into a substantial lather, my thoughts struggling to coalesce, I stumbled upon The Happy Hospitalists post regarding what ailes our Healthcare system.

There it was. Everything I was trying to express had already been formulated in one concise, perfect post.

With each new line, I found myself saying "YES!" and "THATS IT!!". Many of the ideas I had formulated in my head were already there, in numbered list for all to see.

Relieved, I shut my computer, turned on Sportscenter and had a beer. My work was done. The Happy Hospitalist had done it for me. Here it is:

Happy Hospitalists Big Fix

Thank you Happy Hospitalist. Thank you.

What a guy.......

2008-02-12T12:09:00.000-08:00

I’ve only been doing this a few weeks but I realized that most of my posts had taken on somewhat of a negative bend. Most of the time this was done with the intention of igniting thought and hopefully conversation regarding issues that arise while practicing Emergency Medicine. I figured though that to avoid getting pegged as a curmudgeon I should post something positive.

So with that:

I really enjoy emergency medicine. I enjoy the spontenaety, I enjoy the diagnostic dilemmas and I enjoy the challenge of instantaneously developing a rapport with a prickly patient. I especially enjoy emergency medicine in the ‘burbs. As a whole, my patients generally believe they need my services and for the most part believe they do indeed have an “emergency”. They, for the most part are concerned about and are active partners in their healthcare. This particularly is something I enjoy that I have heard others identify as a negative about caring for the “suburban” population. I view it as a perk.

Most importantly, I enjoy the people I work with. Many, (dare I say almost all) of the consultants I deal with every day are happy to help. They are curteous and seem to have the best interests of the patient in mind.

Some though, stand out above the rest. Dr. Highton (not his real name), is one who is a true gift to our profession. He’s a Family Physician of the highest order. He cares for his patients like they are his family. His patients speak of him with reverence unheard of in todays atmosphere of urgent cares, huge clinics and multiple speciatlies. They adore him and I can see why.

Calling Dr. Highton to admit a patient or to obtain follow up or simply gain some insight is a dream. I relish it. He immediately knows who you’re talking about. He listens intently. He doesnt interrupt. He doesnt ask questions that I have already clarified. Never, and I mean never, have I called him and had him be anything but curteous. At the end of my “presentation”, he calmly asks some clarifying questions. Sometimes, he may not agree that the patient needs to be admitted. Sometimes he may think the patient should be transferred. Never, AND I MEAN NEVER, have I gotten the feeling that he simply wants to avoid work. His decisions and actions are invariably tied to whats best for the patient.

His H and P’s are pristine and complete. His discharge summaries full and easy to read. He sees his patients as soon as they’re admitted and never asks for us to “call the consult” or “write some quick orders” so he could sleep a few more hours. He’s gracious. He’s polite. He says “hi” in the hall and offers updates on patients we admitted.

I wish I could end this post with some witty final comment. Some “gotcha” moment like “Dr. Highton is really my Dad”, or “Dr. Highton was my mentor” or something like that. I cant though. There’s no revelation, no big finish. Dr. Highton is just a really good doc and he deserves to be acknowledged.

One thing I can do, as one final demonstration of what an amazing sort of guy he is and in the most melodramatic way possible, is end this post the way Dr. Highton ends each and every conversation he’s ever had with me:

“Thanks for taking care of my patient, and thanks for doing what ya do in the ER”.

What a guy.

Bob Knight and Bad Docs

2008-02-07T13:03:00.000-08:00

Bob Knight (a famous college basketball coach) retired. Boo Hoo. I think there are two types of people in the world: Those who like Bob Knight and those who dont. Its one of those cultural bellwether issues like “Leno or Letterman” or “Red Sox or Yankees”. The Leno/Letterman debate says alot about your comedic intelligence. Your Red Sox/Yankees allegiance indicates your sporting philosophy. And how you feel about Bob Knight sheds light on how you think we should interact with our fellow humans.

There’s no doubt Knight was a great coach. His 902 wins are testament. The way he treated his players, staff, referees, the media and even his superiors also leaves no doubt as to his abilities at being a person. Through the course of 902 wins, he threw media members/fans in trash cans, hoisted a chair across the court, choked a player, kicked his son, threw a plant, lashed out at staff members, bullied his bosses and who knows what else.

Why? Why do certain people insist on treating other people this way? I had a fellow resident who was NOTORIOUS for being rude to physicians who called the ED wanting to send us a patient. Why? There are surgeons, internists, pediatricians, cardiologists etc, who are horrible to deal with on the phone and in person. Why?

I’m not sure. Sometimes it may be lack of confidence. Other times its supreme confidence. Sometimes, they just don’t understand how they’re treating people. Others would tell you they do it purposefully “to get things done”. Sometimes they’re just miserable people in general. Sometimes they’re simply socially retarded. Sometimes they had a bad day.

What would Bob Knight say if you asked him why he is the way he is? Would he be shocked? Would he blame the media? What would that resident say? Would he blame the “idiot PMD’s dumping on us”? What about the surgeon we all dread having to call a consult to? He’d probably blame “idiot ER docs who cant do anything but triage”?

If you believe any of the stories, (and there are many) Bob Knight went through his career consistently treating people horribly without any justification or more importantly, ramifications. What harm was done? Thats debatable I guess. I suppose a lot of feelings were hurt. Alot of people around him were probably miserable. But in the end, Bob Knight won games. His bosses let him get away with treating people terribly. Irresponsible parents continued to send their kids to him. Life went on, right or wrong.

But what about that Surgeon? What about that Resident? Or that Cardiologist? How many times do you think a primary Doc avoided sending his patient because of some interaction he had with a rude accepting ER doc? Were there ever any negative consequences? How many ER Docs avoid calling a consult because of that condescending surgeon and their usual interactions? How often do our inabilities as physcians and humans to interact appropriately have a negative impact on patient care?

Maybe never. Maybe as physcians we are so absolutely confident in our decision making that it doesnt matter how our colleagues will react to our consult, we call them anyway. Maybe we’re strong enough as people to look past the stress of bad interactions and not let it influence our patient care (Its what we’re trained to do). Maybe we’re superhuman (unfortunately, its what we’re expected to be). And maybe we dont make mistakes (Its what the public and the courts demand of us).

Again, I dont know the answer, I just hope I never have to call a consult to Bob Knight.

I'm an ER Doc.

2008-02-06T14:22:00.000-08:00

The conversation usually goes like this:

Me: "nice to meet you, I'm Fred (not my real name)"

Them: "Hey, likewise". Blah Blah Blah "I'm a professor of Modern Art" Blah Blah Blah "What do you do?"

Me: "I'm an ER doc"

Now, one of the cool things about my job as opposed to say a mailman (no offense to our fearless carriers) is that this usually leads to a head-nod or some other gesture of approval and is followed by:

"Whats that like?" or "Is it like the TV show?"

As you can imagine, I like to spin a yarn so its a great conversation starter. I'll tell a cool story and off we go....

Now, the point of this post is, ever since I graduated Medical school, despite the perceived "coolness" of my job, I've had a difficult time answering this question. "What do you do?"

Granted, when I first graduated, it was kinda cool to say "I'm a doctor", but after your first few 100 hour weeks in residency, that quickly wore off. I began saying "I'm a resident." Most people didnt understand what I meant. (And I have to admit, when I started Medical School, I didnt know the difference between an "intern", a "resident" and a "regular doctor") Saying I was a resident usually led to a quick explanation of the training and how I was "training" to be "a real-life ER doc". It was relatively simple.

Now, its a bit tricky. Seriously. Think about it. A cardiologist says "I'm a cardiologist" and everyone knows that that means. Likewise, a sureon needs to only say "I'm a surgeon" and people get it. For us lowly Trench Docs, though, its not so clear. I'm constantly conflicted on the best, easiest way to answer.

"I'm a physician" sounds pretentious.

"I'm a doctor" sounds like I'm lying. (because most physicians answer with "cardiologist", "surgeon", etc.)

"I'm an Emergency Medicine Physician" just sounds weird and people often arent even sure what that means.

So I've settled on "I'm an ER Doc." Now I know that purists will flinch. "Its not ER, its EMERGENCY MEDICINE!!" But everyone gets ER Doc". Its casual, its easy and ti requires no further explanation. We can either quickly move on to the subject at hand, or they'll ask me about my job and I'll tell a tale. Piece of cake. I'm an ER Doc.

"The kid in 8 is a real Sweetheart"

2008-01-30T20:29:00.000-08:00

15 year old male comes in with his Mom. He's a real tough guy. He looks like the bully in "A Christmas Story" and acts like him too. He yells at mom. Answers only half the questions you ask him. And stares wickedly at everyone who walks into the room. Whats worse is that Mom seems like a sweetheart. Her biggest crime is probably being to nice to this "Satan Child".

"The kid in 8 is a real sweetheart" says the charge nurse.

"I went in there to get his vitals and he swore at me!" says the tech.

"I actually heard him call his mom the "C Word" in the lobby!" says security.

"I cant wait to go talk to him" says me.

I walk into the room and he's exactly as promised. Rude. Angry. Annoying. Embarrassing. His mom starts trying to explain the story, he's interrupting her and insulting her every chance he gets. He's got vague back pain. Not much to it. And not suprising the patient wont talk about it.

I walk out of the room baffled. There's hardly any story. It didnt seem to be muskuloskeletal and what really bothered me was that through all his BS, he really did seem to be in pain. I cant shake how rude he is though. I walk out of the room with my blood boiling. This guy has negatively effected everyone he's been in contact with thus far.

I give him some Ibuprofen. Order a urine and get a white count. (maybe its pyelo)

An hour later, I've finally calmed down from my interaction with the kid and I get a call from the lab. The tech wants me to hold for the Pathologist. Its 9pm.

"Hey, listen" he says, "I was still in the lab working on a project and the tech wanted me to look at this guys differential. He's got blasts everywhere.............."

I just about fell over. Suddenly, my "rude kid in 8 with back pain" became my "15 year old with newly diagnosed lymphoma in 8".

Its amazing how quickly things can change. The lessons in this story are too numerous and too obvious for me to even point out. It was almost like an "Afterschool Special".

See, sometimes it is like TV.

Difficult Parents

2008-01-30T19:50:00.000-08:00

So here's a difficult case/interaction that I wasnt actually part of. It happened within our group quite some time ago.

Its late at night, its REALLY busy and a mom brings in her 4 year old. He hit his head and had a 3 cm lac at the apex of his scalp. It wasnt huge, just enough so it absolutely needed to be fixed. The kid was BONKERS. He was wild, crazy and totally out of control. Mom had no control. The child wouldnt sit still and he was absolutely TERRIFIED of physicians and nurses.

The physician (one of our grizzled Vets) wanted to put 3 staples in and avoid any unneccessary trauma for the child. He didnt think the child would let him sew it and from how the child was responding, he wasnt so sure he could even "papousse" him well enough to hold him down. There wasnt enough hair to simply "tie the hair together" and he thought it was too deep to try and steri-strip.

So The Vet, explained to the mom that he was going to try and have the Mom (or Nurse) hold the childs head while he quickly placed 3 staples. They had applied some Let in triage so The Vet said the child wouldnt really even feel it.

Mom wasnt having it. She was ADAMANT that her child would not get staples in his head. If he needed to have it closed, they would have to stitch it. The Vet apparantly tried to persuade the mom that staples would be ok, and the easiest. Again, mom wasnt HAVIN it. When he suggested possibly using dermabond, in his words "all hell broke loose".

So Dr. Vet reluctantly agrees to strap the youngster down and try and sew the wound. He explains how they would do it and explains to mom how he thinks the child will respond. Now, I wasnt there but appearatly, the kid went absolutely BANANAS (just as Dr. Vet had suspected) and within about 30 seconds, Mom is worse. She's screaming for it to stop, yelling at the nurses, getting the kid even more worked up and literally grabs the child, mid stitch, tearing him out of the makeshift pappouse and yelling at everyone in the room for abusing her child.

So now, Dr. Vet has a hysterical 4 year old with a wound on his head that needs to be closed, a Mom who wont let him touch the child and an Emergency Room full of patients.

So what do you do? Steri strips? Transfer? Wait and try again? Call a pediatrician? Call a surgeon? Conscious sedation?

He eventually sedated the child and put 3 sutures in.

Now that sentence was really easy to type, but it played out over 2 and a half brutal hours. Doc Vet has been around a LONG time and has said he never had a conversation with a patient as long, as lengthy or as stressful as trying to explain to the mother the risks, benefits and alternatives to consciously sedating her child. They had to figure out a way to get an IV in him, set up the room, get RT, do the sedation, sew the wound, and recover the child.

There are LOTS of tough things in this job. I would say a "difficult" parent ranks right up there.

A Tale of Two Nurses

2008-01-28T08:11:00.000-08:00

Case One: 45 year old. Healthy, comes in with SHARP pain in his upper right shoulder. He's healthy, reasonable, works in Healthcare and says "Somethings wrong". He's writhing, sweating and my first thought is: Dissection.

EKG looks PRETTY good, he got an aspirin, some morphine and I rush him to the scanner. Thankfully, there's no dissection, no PE, no nothin. Problem is, he's still uncomfortable (but improving). Sharp pain, right sided. Nitro doesnt help. Cardiac Enzymes are negative. Finally with some Ativan and more morphine he calms.

Right in the middle, another fairly critical patient comes in. I leave the room and think to myself "I have NO idea whats going on here, I have to remember to recheck his EKG though, that first one just didnt look right"

An hour later, I'm dictating the critical patient, his nurse (a new nurse) comes up to me. "Hey Doc, that guy just keeps making me nervous, I thought his rhythm strip looked a little funny so I ran another EKG, here, it looks kind of bad"

The guy now had ST Elevations inferiorly. YIKES. Thank you, Nurse.

Case Two: 33 Year old, terrible family history, comes in with chest pain. Its a decent story and he's got lots of risk factors so he kind of made me nervous. Of course, because he's 33, he was put in a back room and the nurse (an older, usually exceptional nurse) was blowing him off. I asked her for an EKG, and put the chart in the order slot. A half hour later, I ask her for the EKG and she says "You were serious? That guys' got muscle pain, I thought you were kidding!" Nope, I wasnt.

So EKG shows some mild depressions, I dont know if they're old. I decide I better start the heparin and we move him up front. I'll wait for the enzymes and call the cardiologist.

An hour later, no enzymes, I ask the nurse if she's heard from the lab. She responds "We didnt send any, you didnt check any boxes". Whoa. I had forgotten to check the box that asks for cardiac enzymes. We had started heparin, moved him to a different room but because I didnt check the box, nothing else was done.

They ended up being negative, but because of the EKG, the guy went to cath the next day and had a couple stents placed.

COMMENTARY

There are good mailmen and bad mailmen. There are good teachers and bad teachers. There are good docs and bad docs. And there are good nurses and bad nurses.

The intent of this post is not to rag on nurses, I wanted to point out that nurses and doctors have a very interesting dynamic and if not played right, the consequences for patients are potentially disastrous. From what I gather it used to "Yes Doctor" all the time. I imagine, this made things run pretty smoothly (for the docs) but I'm not so sure it was a good system! Nowadays, we really must function as a team. It can be difficult to oversee EVERY aspect of the ER when it gets busy. I rely on the staff to be double checking, making sure things get done and yes, believe it or not, using some discretion to get things done without me having to ask. (or check the box)

I realize some docs would say "NO WAY". They want total control over every little thing done to their patients. They want robots to do only what they are asked and to not question it. They would argue that only THEY know whats best and when things should happen, and nurses or techs doing their "own thing" could be dangerous to the patient and more importantly the physicians license. Unnecessary tests would be run, things could be missed, blah, blah, blah.

I would argue though, that there are certain things that need to be done on particular patients, regardless of whether I "checked the box". There has to be a happy medium between "do ONLY what I ask and never question" versus "just order what you think we need". There has to be a trust between Doctors and Nurses that allows for some amount of autonomy and discretion. At the VERY least, there should be conversation. "Why are you starting heparin and moving this guy, but not sending enzymes" would have done wonders.

Busy Weekend

2008-01-28T07:50:00.000-08:00

Lest you think all we see is runny noses and back pain, here is another list of a particularly busy shift I had this weekend. I left them in actual order of what I saw. Its pretty remarkable:

1.) Wound Check

2.) Strep Throat

3.) URI

4.) Acute MI

5.) Acute MI

6.) Acute MI (yep, thats right, three in a row. Its not as bad as it looks because we can get them to our cath lab or our sister hospital's lab pretty quick. But you should have seen the cardiologist)

7.) Acute Exac. CHF (ended up intubating)

8.) Pneumonia (sick, admitted)

7.) Back Pain

8.) Back Pain

9.) Back Pain

10.) Back Pain

11.) Migraine

12.) Migraine

13.) Head Lac

13.) Eybrow Lac

14.) Kidney Stone

15.) Acute Appendicitis

16.) Back Pain

17.) Anxiety

18.) PE

19.) Acute Appendicitis

20.) Abdominal Pain NOS

Wow. Ok, so for those scoring at home thats THREE AMI's, FIVE Back Pains, TWO Migraines, TWO Acute Appy's, ONE PE, and a partridge in a pear tree!

It was a really nutso day. On one hand I kept thinking to myself, "This is why we go into this! I love it". On the other hand it was "This is absurd, how can anyone function like this, I gotta get an admin job".

It brings up two interesting points of Emergency Medicine though:

First, on any given day we can see the most benign, minuscule stuff, then immediately turn around and enter a room where our decisions will make or break a life. Now I know in almost every specialty, this can be the case, but in no place else is it as pronounced as the Emergency Room.

Second, (this is a little less profound) things come in spurts. They really do. I have always thought it would make an interesting study to actually look at what we in ER perceive as a actual phenomenon of Emergency Medicine. Ask any one of us and we'll tell you things come in clusters. Back Pain, Appy's, Pneumonia's, all of em. What I think would be interesting would be to see whether its our perception simply because we remember only specific cases or if in fact things cluster. I bet a sociologist or economist could have fun with the study as well. Anyone read Freakonomics??????

The Good, the Bad, and the Ugly......

2008-01-25T10:21:00.000-08:00

The Good:
20 year old skateboarder comes in with a lunate dislocation. Perfect xray, spilled teacup. He's in moderate pain. Well, I had never actually seen one so I certainly wasnt going to attempt any sort of reduction myself. LUCKILY, in suburbia, even Hand Surgeons gleefully come in to help out knowing the payer mix is PREEEEMO. I call the surgeon, he says. "Well I guess that is one I really should come do, its pretty difficult. Just have all the sedation and the C-arm set up for me, willya?

"Nooooo PROBLEM. Thanks, man, I'll see ya in a bit".

One of the things I love about working in the Suburbs is the responsiveness of most of your consultants. There basically are two groups for everything and they're competing for business. Each knows that one bad, rude, condescending interaction could decrease their business. SOOOO for the most part, most fo them are very responsive and good guys/gals.

The Bad:
As I'm working with one of the newer nurses, setting up the propofol, calling respiratory, and checking my airway stuff, in walks the charge nurse......
"Dr. Suburban, are you going to do this in the ER? Cant you have the hand surgeon take him to the OR? We dont have the staff to tie up a nurse for conscious sedation"
I look up at the board, 6 patients in the department, 3 in the waiting room. Noone is very sick. Two nurses are playing sodoku at the work station.
"We'll be fine. This is done all the time." I say confidently.

One of the things I dont like about the Burbs is that the staff, (myself included sometimes) gets so used to things being easy that they shy away and in fact fight things which are commonplace in very busy, large ED's. Its easy to admit. In the Suburbs, its easy to get someone into the ICU. Its easy to get follow up. Its easy to just "send someone to the OR". Becuase of this, the moment for whatever reason, we need to do something "difficult", it can send the department into a tailspin.

The Ugly:
I convince the Charge Nurse that we can indeed do this. It will be just like a shoulder, I'll be tied up with sedation but no one will die in the meantime. Dr. Nice Guy Hand comes and we start setting up when someone gets wind that the actual length of sedation might exceed what is allowed "according to policy". Suddenly there is chaos. Nurses are refusing to participate. Respiratory Therapy is uneasy. The Nursing Supervisor is down in the department. The Medical Director is called. I half expected the Governor to walk through the door.

The poor hand surgeon is caught in the middle. I'm faced with simply ignoring the concerns and continuing on my own and risk alienating the entire staff. Or I side with the nurses and make life difficult on this consultant who was so gracious. Both sides are playing the argument "whats best for the patient". The nurses dont want to "risk" the sedation in the department. And the hand surgeon wants to get it done as soon as possible "for the patients sake". I just want to move on to my next patient with a URI.

Self Serving Commentary:
The end result isnt important. What I think IS important though, is how symbolic this scenario is of what I perceive as a major problem in every emergency room I've ever worked in. That is, no matter how much we like to think otherwise. Often times decisions are made and arguments framed based on convenience to the provider, yet cloaked in "whats best for the patient."

I could break down the above scenario a hundred ways and argue from either side. I believe both are relevant and valid. However, I think at the heart of each argument is convenience. No matter how much you say "its for the patient". Many times it boils down to convenience. It was more convenient for the nurse to sent him to the OR. It was more convenient for the Hand Surgeon to do it in the ER. And it was more convenient for me to not have any conflict and just get it done.

I think its best in these situations to step back, take a deep breath and truly practice the empathy they preach to you in medical school. I try to I ask myself, what TRULY is best for this patient, regardless of my convenience, regardless of the nurses or consultants or occupancy level of the ER. Its tough to do and I'm not always very good at doing it.

Perfect

2008-01-23T11:52:00.000-08:00

Here's a great article from Emergency Medicine News. I picked it up from Executive Physicians Blog. Good stuff. In fact, PERFECT stuff. Even in the 'burbs we have days and moments like this. LINK

The 37 minute wait

2008-01-22T14:44:00.001-08:00

So its 1030 at night. I walk into the room. Chief complaint says: Abdominal Pain. I skipped over the "back pain" and "hand lac" thinking this abdominal pain might be a little more urgent. MAYBE. Sitting on the bed is this fluffy 38 year old female. She's in no distress but holding her left upper quadrant. Her husband looks bored.

"Oh my god, I was getting ready to leave. What took so long? I thought this was an EMERGENCY ROOM." She said.

"Sorry ma'am, its been sort of busy, I had a guy in the other room who had a heart attack, I had to take care of him. Sorry about the wait. We do things as quickly as possible here."

The heart attack bit didnt phase her. Without blinking she said, "Well, I think its unacceptable, we've been here a long time."

She proceeds to tell me about her gas pains. She had some crampy abdominal pain and ONE episode of diarrhea. She rushed to the ER because the cramp hurt. ONE CRAMP.

As she was talking I looked at her check-in time on the chart. She walked through the door 37 minutes ago. Thats right, 37 minutes.

Patient List

2008-01-21T08:21:00.000-08:00

Contrary to popular belief of those who practice in the inner city and/or at large tertiary care centers, we in the suburbs do actually see a pretty good mix of patients. USUALLY.

Here's the chief complaint list from a recent, relatively slow 8 hour shift:

1.) Back Pain

2.) Back Pain

3.) Migraine

4.) Nausea and Vomiting

5.) Diarrhea

6.) Back Pain

7.) Cough, SOB

8.) "Plugged Ear"

9.) Lab Draw

10.) Migraine

11.) Chest Pain (ended up being an acute MI)

12.) Nausea and Vomiting

13.) Foreign Body in Nose

14.) Pilonidal Cyst

15.) "I think I broke my nose"

16.) Back Pain

17.) Chest Pain (ended up having pneumonia)

Not exactly like the TV show is it?

Fighting Darwin

2008-01-20T20:00:00.000-08:00

44 year old comes in. Retrosternal pain, pressure like, radiating into arm. EKG shows tombstones.

For some reason, this guy doesn't want to talk to me. His girlfriend dragged him here for his chest pain and he wants nothing to do with this. He REFUSES to elaborate on his pain. He will not respond to whether or not nitro helps his pain. He's yelling at nurses every time the blood pressure cuff starts. He's scowling at me as I ask him about his pain. He stares wildly at me like I'm a cop interrogating him about his latest murder. Through it all, I'm proud to say the entire staff treated this guy with respect and kindness. I'm the first one to take responsibility for bad interactions, but this was ALLL on this guy. It was surreal.

I began calmly explaining to him that he's having a heart attack. His arteries that supply his heart are clogged and cardiac cath lab, you could die, blah, blah, blah.....

I get done, he looks up at me with the most evil eyes I ever saw and says, "Just tell me if there's gonna be any more needles."

"Well sir" I start slowly, "Like I said, they will have to use a needle to gain access to the vein in your leg, you'll be sedated...."

Before I finish, he stands up, pulls out his IV, starts ripping off the chest leads and begins yelling "THIS IS BULLSHIT, NO MORE NEEDLES, I"M OUTTA HERE"!!!

After 20 minutes of myself, the charge nurse and the patient advocate pleading with him, he finally calmed down, laid back down and consented to cath and let me give him some ativan. Somehow he made it to the lab and had a 90% LAD. Now hes in the CCU on a balloon pump.

Like we used to say in residency, "fighting Darwin one patient at a time".

Honesty

2008-01-17T15:49:00.000-08:00

The other day I had an interaction that shocked me. A middle aged woman came in with a rash. She had fractured her hand and had been placed in a splint a few days ago. Today she began to itch incredibly under the splint. She also began to notice a rash which was familiar to her. She had experienced it previously when exposed to certain plastics. She said it had happened to her a few times in the past and she was sure it was the same reaction only this time it must be from the splint.

Easy case, right? Right. EXCEPT, the looks of this rash were "concerning" to say the least. She had LARGE fluid filled bullae, with some surrounding erythema. No crepitus. No tenderness. No warmth. But this "rash" looked really awful. At first glance it almost looked like Stevens-Johnsons or even necrotizing fasciitis. She was non toxic though and only had itchiness.

So I told her I was concerned. I agreed that it could be a severe contact dermatitis but that it really looked awful and could be something more severe. I told her I would have to talk to a dermatologist and that I might even consider bringing her in for observation. (I know, admitting for a rash...SUBURBAN EMERGENCY!!)

I spoke with the Dermatologist, did some quick research and came to the conclusion that indeed this sort of severe contact dermatitis was possible. She wasnt going to die. She'd be fine. I went back into the room to tell her my conclusions.

To my suprise, before I even got one word out, she was PISSED.

She proceeded to tell me through tears that I scared her. That I shouldnt make patients nervous. That I need to measure my words and never come across as negative when talking to patients. She really was irate and quite frightened.

I was shocked. I felt horrible. I've always considered myself a pretty empathetic doc. I take more time with my patients than most docs. (sometimes at the expense of my bonus) I get lots of thank you letters. I think my communication skills are above average. I am though, almost always perfectly honest with my patients. Apparently to a fault. If I dont know, I don't pretend to. I tell my patients frequently that I'm not sure whats happening but that I'm going to look into it. I tell them when I'm very concerned. I tell them when I think they look sick.

Should I? Should I always be honest. Or should I always be positive, no matter my concern. Should I withhold from patients when I am concerned? Should I explore serious diagnosis' while telling a patient "its nothing, dont worry"

Jerome Groopman wrote of this in his book "How Doctors Think". In his book he more than implies that patients WANT honesty. They want their doctors to admit when they are stumped. And they dont want doctors to always paint a rosy picture when their isnt one to paint.

Apparently my patient didnt agree with Dr. Groopman.

Tough Case

2008-01-17T10:03:00.000-08:00

Its near the end of my shift. EMS brings in a 87 year old female. On CPAP, sats 82%, gasping for breaths about 30 times a minute. Blood pressure is 85 systolic. Heart rate is about 130, wide complex. EMS guys tell me "he's DNR/DNI, but he's sick. Nursing home called for respiratory distress".

She IS sick. One look at her and you know she's probably breathing her last breaths. I think to myself, there is a TON I could do for this patient but I dont think any of it would be successful. She's DNR anyway so it sounds like we'll make her comfortable, start some antibiotics and fluids, get her a bed upstairs and hope for the best. Whatever that may be.

The nurse is looking through the paperwork. "Hey guys, where is her DNR paperwork?". Oh no. We begin frantically looking for the paperwork, its not there. All we have is half of an MAR and a face sheet that has "DNR" typed into one of the lines (which isnt even the correct line). No accompanying paperwork, no doctors order. Nothin.

So now, we have a choice to make. On one hand, the patient obviously needs intervention. On the other, she's supposedly "DNR" and to intubate, cardiovert/meds, and start pressors could be considered battery. And yet on the other hand, she's so sick, even if she wanted us to "go all out", I'm not sure any of it would be beneficial.

We're trying to figure it out and the family shows up. Meanwhile, she is dwindling. I sit down with the family, and begin a very difficult conversation. I explain to them how sick she is. I ask if they are aware of her "code status" because it the paperwork sent isnt totally clear. It turns out the husband has stayed out of the decision making. Understandably unwilling to make the decision to let his wife of over 50 years die. The daughter believes she was made DNR/DNI by the oldest sister and father during a recent family meeting. The husband however cannot bring himself to say it.

To make a very long, difficult story short, it became apparent after a phone call to the nursing home and the oldest daughter that she was indeed DNR/DNI. They faxed us the needed paperwork. The rest of the family showed up. We transferred the patient upstairs and she died a peaceful, dignified death.

How though, could there ever be ambiguity? Besides this being a difficult case for me, imagine what the family went through as I had to tell them how sick she was, tell them that she was in the process of dying and then put it to them whether or not I try life saving measures that may or may not be successful. Imagine making that decision at a moments notice. Its difficult for me and I'm trained to do it.

Suburban Emergency

2008-01-17T09:32:00.000-08:00

I trained in the innermost-inner city. Emergency Medicine at its "best". I could go all day and see only uninsured patients with no where else to turn. I could go a whole shift and see only HIV positive patients. I'd successfully use Narcan at least once a day on obtunded patients. Our security guards were beefy and armed. Patients were in our lobby for a minimum of 6 hours before being seen, then, if sick, they'd stay in the ED for another 8 before MAYBE getting a bed upstairs. I was told often throughout my training "you've got all these great stories, you should start a blog". Alas between Truama rotations and 23, 12 hour shifts a month, I had no time.

Now, I'm

an attending. I have moved away from the inner city. I practice in a medium sized, suburban Midwest hospital. Patients are upset if they wait an hour to see me. And even the most leng

thy abdominal pain work ups (CT, US, pelvic, labs, etc) take less than 3 hours. I work 13, 12 hour shifts a month. Our gua

rds are pleasant and wear polo shirts. Its the middle of winter, its cold, and I cant golf. There's no time like the present.

I plan on using this place as an outlet. A depository of my everyday life as Emergency Physician in the Suburbs. The stories are different, but none the less entertaining and I hope occasionally insightful. This is, SUBURBAN EMERGENCY.