The last several days have seen the backside of the crest of the tidal wave of patients in my ED. Finally, it’s just a regular ED and not an utter madhouse like it has been 24/7 for the last three months.

And, it’s too late. We’ve lost several of our experienced ED nurses to other departments and other hospitals. "A nurse is a nurse" you say, and you couldn’t be more wrong. Nurses in the ED environment are an unusual breed, and frankly it takes trying out about ten to find one who can really hack it, and one in twenty really gets it.

That doesn’t make the hackers immune from burnout, unfortunately, and we’ve been burning the brightest candles at both ends for months (metaphor alert).

When I hired on 3 1/2 years ago a traveler (traveling nurse) was unique, now there’s a bunch in our ED. That’s not to say travelers are bad, they aren’t; usually they’re experienced and smart. Unfortunately, they’re also temporary, so all their training leaves at the end of their contract. Thus, the institutional knowledge leaves.

ED’s aren’t run by the docs, but by the nurses, and when we lose one it diminishes us. I miss them all.

Neils at Haversial Canal has some good advice for those just being accepted for Med School: Recent Thoughts on Medical Education

I recently got an e-mail from a friend who was just accepted to medical school. Congratulations to him! In his e-mail he asked if I had any recommendations on what he could do before starting. Here’s my answer, refined:

Yeah! Start producing study aids now that will help review the week, or weekend before the test. Don’t, don’t, don’t take notes on a laptop. Use 8.5×11 or notecards. Preread means skim, and then, from the time you’re in lecture on, all ‘studying’ should be focused on creating a product you will use to review for the week before the tests, like a big stack of notecards, diagrams, that sort of thing. Handwrite and draw it all. The tactile and visual feedback is rich input to your brain.

There’s a lot more there, and to my memory it’s all good.

One of the best blogs extant is Dr. Crippen’s NHS Doctor blog (and it’s a must-read for all the single-payor socialized medicine types out there).

I have a couple of family members who smoke, and I don’t understand. Really, I don’t get it, at all. I know that means I’m a lifelong non-smoker but it continuously baffles me why anyone would want to smoke. In the ED I do no smoking cessation, other than telling smokers “time to quit”. No lectures, no guilt trips, but an acknowledgement that we both know it’s not good for you.

Dr. Crippen has been, apparently, a smoker, and he’s got A Plan:

It is no good the doctor, and sadly some still do, just writing out a prescription for patches and having the patient out of the door in ten seconds. It needs a little more than that. In our practice we have discussed with smokers and ex-smokers the best approach to stopping smoking and have devised a plan.

We do not claim a monopoly of wisdom, nor do we say that our way is the only way, but nonetheless it is a plan with which we have had considerable success. So here goes.

The Crippen Stop Smoking in 28 days Plan.

I’ve read this, and think there’s something there. It seems both simple and reasonable, and there’s an explanation of the social cues that set off smoking in the first place.

Recommended reading, and recommending.

…is today. Be nice to any 4th years you see today, they’re a little stressed.

Update: no wonder they’re stressed: It’s tomorrow!  Aargh, I hate when I mess up like that. 

A totally non-medical post…

I like open wheel auto racing, and used to be an avid CART fan; then the IRL split and, well, it’s still okay racing but the edge is gone. Thus, I have found myself following Formula 1 racing these last few years, which 3 years ago wasn’t very good racing and has become quite good over time. I did watch the few F1 races shown in the US back in the ‘pre-Speed channel’ days, and enjoyed them.

It’s never really bothered me that there aren’t US drivers in F1, though the US coverage is always gaga when an American driver is in the field. Until this year, Michael Andretti in ?93? was the last, and that was more of an embarrassment than effort (and it pains me to say it, as I’m a big Mikey fan, but the effort was awful). Before Mike? Eddie Cheever. "Eddie Cheever, the only American driver in the field" was apparently a required line for announcers when he was driving, and it was said so frequently it was comical. In fact, were I to call my brother and just say "Eddie Cheever" he’d finish the sentence. So, there have been Americans racing in F1 before.

This year, it’s Scott Speed driving for Scuderia Toro Rosso (horrible Flash site). Before you get your hopes up, he’s an incredibly talented young driver in the terrible former Minardi team / car, the only bright spot being there’s probably more money there than before as it’s Red Bull’s second team. He did well, and SpeedChannel did a good job of pointing him out but not doing a Cheever every time he showed up.

I have to wonder about his security. As an American he’s going to be a lightning rod for every nut with a grudge, and this series runs in some countries that you’d be silly to advertise your American-ness without a dedicated security group.

I was thinking about that while watching a procession of the country flags before the race (yes, the US flag was there), and then wondered how crowds will react listening to the National Anthem should he wind up on the podium (okay, that won’t happen given the car, but it makes an interesting wonderment).

Speed qualified 16th, finished 13th (both behind his main teammate Liuzzi, 15/11). The series looks to be good this year.

Now, if we could just get CART and IRL to fuse (and occasionally turn right) I wouldn’t need a present for my birthday.

And it’s that time:

This week, an experiment: exactly how much work is it to host Grand Rounds? This topic has been discussed back and forth for a little while now, with various formats proposed as solutions to the growing number of submissions. To contribute to this process, I’ve included every submission I received and kept track of the time involved, while trying to avoid my usual excesses in writing the thing!

Another outstanding episode!

A little while back this email hit the inbox:

…I am looking for advice from experienced Doctors. I am hoping you can answer a quick question for me. In your opinion, is it impossible to successfully get through Medical school, residency, etc. with children? I am hoping to become an RN, and then continue my education to become a Physician. I admit that I don’t know much about what it takes other than the basics, and that is why I am reaching out for advice from Doctors who have already been there. Any help you can offer would be much appreciated.

It is certainly NOT impossible. I had classmates with kids, and they made it through (anecdotal but real information). As I recall they were a touch older than the ‘straight-through’ students, and their kids were in the ‘can take care of themselves’ age bracket. Everyone you ask will give a different answer (I hope!), and I asked my wife what she thought. In only the second topic here she’s weighed in on, this is her input as to what the life is like:

Med Student Spouse…. 3′rd year medical student has a day off. It’s close to Christmas, mid-school year, and the 3′rd grade son has a holiday program at school. The entire family loads up in Dad’s car to attend the program: Dad is tired but game. He backs out of the garage, stops, and says, " I don’t know where [sons] school is". [Son] has been at the same school for about five months and Dad has no clue where the school is located.

He has been away from home so long that just to see him walk in the door is a bittersweet treat. I know he’s hungry, tired, and yet wants to inter-act with the family. What a struggle it has become, trying to balance it all.

As the spouse of a med student you must be able to function as a single parent. Pay the bills, shop for food, prepare the food, clean up the mess and most likely work a 9 to 5 job and WHEN the spouse is off work (and not sleeping) included them in the family functions. It is a very odd lifestyle, Spouse is working extremely hard, but not earning one dime to contribute to the budget. The reward will come much, much later (note to self, check insurance reimbursement rates). They are remotely connected but so immersed in school and medicine, that the study takes over their life.

I also remember on one occasion I actually called the hospital [ed: this was during my internship], asked for the chief resident on surgery, and told him I would pay the ransom, if I could just see my husband again. At that stretch, I think he had been at the hospital for 4 and 1/2 days.

Some habits die hard, I will always shop the clearance rack first, only call spouse at work when absolute needed, be thankful for days off work. See, I can rant also. Mrs. Grunt Doc

I was able to do it with a family only because I have been blessed with a very strong and independent spouse who can handle things in my absence (for instance). If I had to tell you the One Thing you’d need, it’s a supportive and committed family behind you.

As an aside, I think the RN first is going to be a deterrent to going to medical school. I’m not saying that it’s either a mistake or that people cannot go to med school after obtaining their RN, but I have seen people take that route and stop at RN (same for PA). Why? Being a nurse is a full-time occupation, it is its own profession with a real knowledge base, and frankly once you go from student to making RN money another 7+ years of being financially upside down isn’t terrifically attractive. Nurses are becoming more scarce, and thus more of a commodity, and that trend will only continue.

…"I take the Fifth" now joins "recommend clinical correllation" in the radiology lexicon…

The rant-muse has abandoned me, hopefully temporarily.

However, I read this in today’s WSJ (subscription required):

The silicosis lawsuit scandal rolled into Congress last week, and it was quite the spectacle. The highlight was the sight of three doctors raising their right hands to swear to tell the truth, the whole truth, and then taking nothing but the Fifth Amendment.

Ray Harron, Andrew Harron and James Ballard were three of the dozen doctors singled out last summer by federal Judge Janis Graham Jack for supporting 10,000 phony silicosis claims that she said had been "manufactured for money." Her opinion piqued the interest of House Oversight and Investigations Subcommittee Chairman Ed Whitfield, who invited the doctors to testify as part of a probe into public health and legal fraud.

The doctors declined to appear voluntarily, so they were subpoenaed. They still haven’t provided documents to the committee, and in the hearing last week all three were lawyered up and hunkered down. You can decide what this says about their honesty, or their potential vulnerability before the federal grand jury now probing sham diagnoses.

The dumbstruck docs were a lot more energetic when it came to their assembly-line diagnosis of both asbestosis and silicosis, a disease caused by exposure to silica particles found in construction materials. For their effort, they were paid millions of dollars by X-ray screening companies hired by plaintiff lawyers. The Manville Trust — one of the largest asbestos funds — recently disclosed new statistics about the doctors who have sent the most such business its way.

…

Innocent until proven guilty, remember that.

And now some disconnected thoughts: when the system of setting up a very select few radiologists to be asbestos screeners was set up, was there no oversight provision? Talk about a potentially abusable situation! Send 2% of the films to another screener, blinded, and look for discordances. In retrospect, I’m sure nobody thought it would be necessary. I suspect they were wrong.

Why is ‘assembly line’ always pejorative in news articles? I know it’s supposed to bring up all sorts of 20′s and 30′s black and white images of laborers being abused by The Man, but have a brief scan around your room and ask how much of what you have came from a dread ‘assembly line’. (I’d be willing to bet the WSJ is, itself, printed out on an assembly line).

What’s the role of the Radiology professional societies here? Will they investigate? Now that the defendant doctors are all ‘lawyered-up’ I doubt they’d participate meaningfully in any investigation that could cost them their Board Certification.

Code: the Web Socket

I handed my supervisor my letter of resignation today. In two weeks I start the new adventure…

Let’s have a nice word for Alwin, on his blog.

Replacement : KaleCoAuto, Hard to find automotive items!

My brother the engineer finally parted with some of his "insider" knowledge and told me about a place where unobtainable auto parts can actually be, you know, obtained.

I have a set of these on order!

Read the rest of this entry »

Dr. Rangel is dead-on here:

With so few Americans knowing what their rights are and not even understanding what the concept of "right" means, it worries me when I see surveys like this one that found that 77% feel that health care should be a right guaranteed by the government. But health care is not a "right". Health care is an entitlement in this sense. It worries me that people use "right" and "entitlement" so interchangeably.

 Health care is a service that requires others to provide and these providers must be compensated. However this compensation does not come from the government. As Dr. Peikoff (PhD) pointed out, "Government is not a productive organization; it has no source of wealth other than confiscation of the citizens’ wealth, through taxation." Government simply acts as a collector and distributor. The actual compensation comes from us or rather those of us who pay taxes. Taking something from someone and giving it to someone else does not make it a "right".

 (Emphasis mine)

I’ll never think of this without the (paraphrased) PJ O’Rourke quote "If you think health care is expensive now, wait until it’s free."

Read the rest of Dr. Rangel’s post, it’s excellent.

Yesterday, another snake in the house. Little snake, and its release to the outside world was a relief to the snake and a profound sense of loss for the cat, as it hadn’t had a toy that was nearly as much fun before.

This makes it Four for our family (that we know about). For the be-all and end-all snake-in-the-house story, here’s a prior tale of mine.

Emergiblog: Welcome To Grand Rounds (Redux)

I’ve chosen our Dixie Cup nurse as the Grand Rounds mascot this week because this is exactly how I read Grand Rounds every Tuesday. With a cup of coffee (or three!) in my hand.

I do not, however, drink from a dixie cup.

Who’d drink coffee from a dixie cup? The Grand Rounds aroma is fine.

via Bloodletting

The best description of Emergency medicine ever…

Emergency Medicine.

Lifeguards working the shallow end of the gene pool.

Hahahahahaha!

Update: The SciGuy at the Houston Chronicles’ blog picked up Doc Russia’s quote above, and had this to say at the end:

Wow, that’s pretty harsh. Do all emergency docs feel as frustrated? GruntDoc seems to approve.

Frankly, I found it more amusing than harsh, but I’ll entertain the thought for a moment.

One the one hand, poorly-thought-out behavior of virtually any sort is a risk factor to meet professionally in the ED, so I suppose shallow gene pools could well be overrepresented in my patient population. I do think the none-too-bright are overrepresented in my ED, but that’s likely just observational bias. (Don’t write letters: accidents and illnesses happen to everyone, so it’s hardly universal that being in the ED = consanguineous parents.)

Harsh? I don’t read it as harsh, just as ironically humorous commentary on what we do and for whom we do it. Frustrated? Everyone in the ED is frustrated to some extent. Read this blog and the comments for a few examples.

I don’t have one of these t-shirts and don’t want one, but as a throw-away line, it’s pretty funny.

Hat tip to reader Gunjan for the link

Let one patient skip to top of waiting list; rightful recipient dies

 
LOS ANGELES, California (AP) — St. Vincent Medical Center received a rebuke from the national organ-donation network for allowing a patient to skip to the top of the waiting list for a new liver in 2003, bypassing others who were sicker.

It was the first time the United Network for Organ Sharing publicly sanctioned a member.

"It sends a message about the overall importance of patient safety and regard for the public health," the network’s executive director, Walter Graham, said Thursday.

St. Vincent admitted in September that its doctors had improperly arranged for a Saudi man to receive a liver intended for a higher-priority patient. Federal inspectors also found that the hospital removed the rightful recipient from the waiting list without telling him that it was doing so. The man later died.

The rebuke requires the hospital to alert about 4,000 of its patients about the discipline, but it doesn’t prevent it from performing other organ transplants or taking on new patients. Graham said the network stopped short of asking the federal government to suspend St. Vincent’s other transplant programs because it didn’t think patients were in imminent danger.

St. Vincent issued a statement saying it would challenge the sanction in court. The hospital, which closed its liver transplant program in November, argued the action was unjustified because it is now complying with transplant rules in its heart, kidney and pancreas programs.

Most private insurers have already removed St. Vincent from their lists of preferred providers or stopped referring patients there.

Unless you’re a Saudi.