Wednesday at the ACEP Scientific Assembly

Yeah. On Twitter, again.

If you missed yesterday you missed over 100 posts with some dang funny quotes. Don’t miss today!

If you’d like to follow, I’m here:

Tuesday at ACEP Scientific Assembly 2010

I’m here, but all my blogging is over on Twitter.

If you’d like to follow, I’m here:

Segway Scooter Injuries On the Rise; ER Docs Recommend Helmets

Injuries sustained while riding Segway transporters are significant and on the rise, according to a study of emergency department visits published online in Annals of Emergency Medicine.

“The Segway may seem cool, but there’s nothing cool about a head injury,” said Mary Pat McKay, MD, MPH, FACEP, of George Washington University in Washington, D.C. “One-quarter of the patients who came to our emergency department with Segway injuries were admitted to the hospital. Forty percent of the admitted patients were admitted to the ICU because they had traumatic brain injuries.”

via Segway Scooter Injuries On the Rise; ER Docs Recommend Helmets.

Wow, sobering data.

I have enjoyed riding Segways, and if I had any use, any at all, I’d have one.  And a helmet, which I’d wear.

Segways are pricey, good helmets aren’t cheap, but the ER visit is going to bill out for about 15-30 really nice helmets, so get one, and wear it.

ACEP 2010 post 1

Off to ACEP. If you want to meet up, drop me line through the contact form (not in the comments please).

Texas (National, really) issue: qualifications of your ER doc | Houston & Texas News | – Houston Chronicle

Texas is at the center of a heated national battle over the training emergency physicians need in order to advertise themselves as board certified.

At stake is the welfare of patients requiring immediate medical attention. Leaders of the traditional board say allowing physicians without proper training to advertise themselves as board-certified would mislead the public. Leaders of the alternative board say the proposed rule change will undermine the ability of Texas’ rural hospitals to staff their emergency departments with board-certified ER physicians.

A final verdict may only come, given one board’s already delivered threat, in a court of law.

via Texas issue: qualifications of your ER doc | Houston & Texas News | – Houston Chronicle.

At stake also are the careers of a lot of practicing Emergency Physicians, many of whom I’m proud to call friends and colleagues.  (And it’s not just docs at rural hospitals, they’re in nearly every ED in Texas, and your lesser state).  They practice high quality Emergency Medicine, and I have no qualms about the practice of those who are alternately boarded.

I’m a residency trained, BCEM doc, so I’m in the group that’s considered Board Certified by definition.  I’m also still in the minority in US ED’s.  The majority are ‘alternately trained’ docs, the vast majority of whom always wanted to practice EM but either there was no such training when they finished med school, or the few EM programs were full.

Most are FP or IM trained, have worked hard and have been and continue to be ED and hospital leaders.  Again, I’m proud to have them as friends and colleagues, and have no questions as to their abilities.  They’re not interested in practicing EM for a few years then establishing a private practice somewhere, they’re EM docs, who didn’t do EM residencies.

In an ideal world would I like all docs in the ED to be residency trained as a requirement?  Yes.  Is that at all practical?  Not unless you want to close a whole lot of ER’s across the country, and the rural ones (where there is arguably more need for an EM doc who knows what they’re about) would be the first to go.

EM is either the newest or the second newest specialty in medicine, and for a primer on the brief history of EM, look here, (and there appreciate the spirit and the gamble that made my specialty):

Unlike the residents of today, those physicians who pursued Emergency Medicine residency training in the early 1970’s faced an uncertain future. They had no opportunity to be certified by a specialty board, and had no guarantee their chosen field would persist. They were pioneers and mavericks in spirit and action.

Now, about the Board Certified thing…

The reason this is an issue is the recognition that physician credentials are important (they are), that it’s desirable for physicians to be Board Certified in their chosen specialty field (it is), and the public is becoming more sophisticated about who’s trained in what (good).  The reason this is a problem is that as of now the only ‘officially approved’ path to Board Certification in EM is to complete a residency, as the ‘practice track’ to grandfather other-trained docs closed in 1988.  It had to close eventually, there would always be some people stuck no matter the chosen date, but it’s done.  (I now think it was closed too early, but that’s not under my control).  Every medical specialty has had the same issue, the conversion from docs who filled a need to specialty-trained specialists in their field.

In 1990 Texas had one EM residency, taking either 6 or 8 residents per year (3 year program) in El Paso.  Texas then had a population of nearly 17 million.  Most EM docs I know work hard, but that seems like a pretty steep workload for those 6-8 grads a year.  (There are now 8 residencies in Texas, with at least one more opening in 2011).

Therefore, Texas ED’s have been staffed (mostly) with other-trained docs who only wanted to practice Emergency Medicine.  A few did the then accepted thing of working ED shifts to supplement their income while they built a private practice then bowed out of the ED, but most didn’t.  Most worked, many ‘grandfathered’ into a specialty that literally developed as they practiced, and more and more residencies in EM started.

So, the practice track closed several years ago when there were nowhere near enough EM training programs for the demand.  These docs worked hard, but needed to demonstrate they were EM pros.  Enter the ABPS which provides Board Certification through an alternate pathway, thus they’re often referred to as ‘alternate boards’.  per their website:

must have practiced Emergency Medicine on a full-time basis for five (5) years AND accumulated a minimum of 7,000 hours in the practice of Emergency Medicine and maintained currency in ACLS, ATLS, and PALS.

In any career, if you’ve been able to do it for 5 years full time you’re good enough to be recognized as able to do it long-term.  Alternate boards are the only path open to anyone who practices EM but wasn’t grandfatherable in the late 80’s.

(My issue with alternate boards is those 5 years of independent practice as an EM doc without EM training, which I’m not a big fan of, but I cannot come up with a reasonable / workable alternative.)  (And stop it with the ‘they should go back and do an EM residency': it’s economically unfeasible both for the residency and the doc, and that would cause a shortage of EM docs as they’d be a) in residency and b) taking slots from new med-school grads who also want to do EM).

I think Texas should accept ABPS Boarding of EP’s for the foreseeable future, with the recognition that in 10-20 years it’ll need to be re-addressed as the number of residency grads is able to take up the slack in US ED’s.  There should not be a permanent need for an alternate pathway to EM boarding.

Pragmatism and practicality aren’t dirty words, they’re how life is lived, and in the ED they’re how lives are saved.  Let’s keep our experienced Emergency Medicine physicians.

Update: reminded by the comments, the standard should be residency training in EM for anyone getting new Board Certification today.  The above argument applies, IMHO, only to those who are already alternately boarded (and yes, there’s another group that’s excluded…)

2+2=7? Seven things you may not know about Press Ganey Statistics

…The time you spend with critically ill patients may make another department’s satisfaction scores better . . . while making yours worse…

via 2+2=7? Seven things you may not know about Press Ganey Statistics.

A nice evaluation of Press Ganey and its current application in the Emergency Department.

I have No Idea why hospitals pay for this service, when they could do it themselves for a lot less moolah, have much higher data capture rates, and get actually usable data.

Why a doc might want to blog anonymously

Yesterday came another of the tiresome ‘all doctors should blog using their own names, not anonymously’ blog posts, with the predictable reasons cited: nobody will take the anonymous blogger seriously, and because I’m a doctor and I said so.  Never underestimate the Physicians’ belief that what they believe is correct, even (especially) if it’s out of their sphere of training.

If you’re a doc in private practice, trying to build a practice and make a name, use your name, and have fun.  If you have a burning desire to change the world, and feel that you have deep points to make the need to be taken seriously, use you name.  Embrace being googleable!

However if you’re a hospital-based doc, or you’re blogging to entertain yourself, you mom and 9 people with nothing to do, there’s no real reason to use your true identity, and several not to.  Your hospital, contracting company or hospital might not like the idea you’re blogging, even if you never say anything bad about your colleagues or the joint.

I tell everyone who asks how to start blogging to start anonymously, as a) you’re going to be new to it and might type out something you’ll want to disown, and anonymity can help you avoid repercussions of the permanently-cached world, and most find they have 6 posts burning in their brain, get those done, get bored and quit.  A pseudonymous blog is really easy to quit.  (Allegedly, I have yet to try myself).

I fit paragraph 3 here, by the way, and have no pretensions to change how the world works, and absolutely never want anyone who reads this blog to think it’s medical advice (hint, it’s not).  Also, you have to take my word for it I’m a doc, and it’s not all that important to me anyone think I am a doc when reading my posts.  Am I a doc?  Yes.  Do I care to drop the pseudonym to prove it?  No, why would I?

And the sadly obligatory: if you’re blogging pseudonymously to say bad words about your boss, denigrate your patients (beyond pointing out the usual irritations), because your mom didn’t love you and you need therapy, or you just love to type f-bombs, reconsider.  There’s no such thing in the long run as anonymity on the internet, and you’ll be found out if there’s enough motivation.

So, there are many ways to be a doc, and many ways to blog.  It’s not a one size fits all world.  Just do it the way you want.

Feel like you’re not getting enough mail?

Sign up for the American College of Emergency Physicians Scientific Assembly.

I did, months ago, and it’s been quite a while since I’ve been. I don’t recall the direct mailings being this voluminous. “We’re going to be at ACEP, in booth xyxy” they say. All very slick, professionally produced.

I wonder if this is required by ACEP, otherwise, what’s the point? Pretty much everyone visits the exhibits at least once (as I said, it’s been a while, and I noticed a distinct drop in visitors when the free pens ran out, but that was the Philly ACEP), and I have a question: does anyone* read the mass mailing and say ‘hey, I was going to blow off the exhibitors, but now I’m definitely going to check them out’?

There are some things about business and advertising I don’t get.

*All bets are off if you’re looking for a new job, I get that. Were I looking (and I’m not) I’d have a diagram and an itinerary for those looking to hire.


My wife said tonight “We need to diversify”.

I pointed out we maintain several calibers…

She didn’t answer.

Did I say something wrong?

Sickening People | Are Diagnoses a Form of Avoidance?

Sickening People | Are Diagnoses a Form of Avoidance?.

A very thoughtful post from Dr. Rob.

Obama gives TCU rifle team a warm welcome at White House | Fort Worth | News from Fort W…

WASHINGTON — The five female members of Texas Christian University’s national championship rifle team were already beside themselves to be on the South Lawn of the White House on Monday evening at a celebration of all NCAA sports champions when President Barack Obama gave them the first shout-out.

“We’ve got the sharpshooters from the TCU rifle squad. Where are they?” asked Obama as the team members, standing near the camera risers, screamed. “I think that they may be able to give the Secret Service a run for their money.”

The TCU rifle team came in for some extra attention because it is the first all-female national rifle championship winner in NCAA history — the sport can have all-male, mixed gender and all-female teams.

via Obama gives TCU rifle team a warm welcome at White House | Fort Worth | News from Fort W….

Good for them!

The Charles Prize for Poetry, 2010

It is with great pleasure that I announce the winner of the poetry contest. Over 125 poems were received with a general theme of medicine or science. 7 judges were consulted, representing a diversity of training in medicine, science, and the humanities. A few of the judges were moved to tears at times, and all expressed their wonder at the quality of writing.

via The Charles Prize for Poetry, 2010.

Congrats to the winners!

Humbling Life Moment #4.7225K

So, I was going to get an MRI of my shoulder (no worries, minor problem).

This started with the expert placement of contrast into my shoulder under flouroscopy (and Conray tastes like magnesium). Yes, you can taste the contrast even though it’s injected elsewhere in the body. (Conray was so the radiologist knew where the gadolinium was going, for better delineation of the shoulder structures for the radiologist).

Then comes the MRI.  Never had one, but I’ve ordered several.  I’m wearing my very fashionable gown, lie down and the two nice techs start getting me ready.  I got some sort of contraption put over the shoulder that plugs into the table (pretty cool), get bolstered into place so I can’t wiggle, and some headphones playing classic rock.

They gave me a little black bulb ‘to squeeze if there’s a problem’.  I thought that was amusing.  All this happened out in the open, and life was good.

Then came the tunnel, and the first thing I thought of, looking at the fiberglass tunnel lining with two light strips embedded in it was HAL from 2001, which is weird.  Then I realized my heart rate was up, my hands and feet were sweating.

“Wow, this isn’t going to happen to me, is it?” was the higher-brain function; ‘get me the heck outta here’ was what my midbrain was yelling.  I’m a rational guy, so I can think my way through this.

Just by putting my chin on my chest I can clearly see I’m out of the tunnel from the knees down, I can see the control room windows, I could relatively easily wriggle out.  “Not. Having. It.” sayeth the midbrain, and by this time the lower functions have decided to side with the midbrain, now I’m starting to hyperventilate, a little, and the upper brain had a realization that’s never happened before: “You’re not going to reason yourself through this, and you’re going to have a full on panic attack if you don’t get out of this tunnel”.  Doesn’t matter I’ve never had one, if it’s imminent you know it.

That amusing little black squeeze bulb then got a touch of a workout.  Quicker than I would have expected “Yes?”  Surprisingly calmly I said “I need to get out of this tunnel Right Now”.  Not being slow, and having seen this a million times before (they said later) the tray of doom began moving me out of the tunnel.

When I got out I was shaky, hands and feet dehydrating me involuntarily, and the relief to be Out Of There was palpable.  I was effusively apologetic (I think I apologized to the tunnel and the door as well as both techs, several times).  They were very nice, said not only was I not the first, I wasn’t the first today.  One offered to stand at the bedside and talk to me during the procedure, but I was pretty sure I’d shot my chance for the day, and declined, apologized my way out the door, and went home.  Humiliated.  I’m a middle aged man, a doctor, I knew what this would be like, and it went almost as poorly as it possibly could.

I had no idea this was even possible for me.  I’ve worn all kinds of restrictive masks/headgear, been in several spots tighter than that, etc.  No reason to think my brain would stage a tunnel coup.

I’ll also say I now have more empathy for those who tell me they’re claustrophobic in the MRI tunnel (I have ordered sedation liberally before, and will continue to).  But, I always thought, in the back of my head, ‘what’s up with that?’, and now I now.  In spades.

So, I’m going to have to reschedule and repeat the thing, but this time I’m going to have some sedation.  It’s not for me, it’s for my midbrain.  Seems a little nervous about the tunnel of noise.


They call me “Doc…”

Tuesday, August 18, 2015 Posted by admin at 9:06 PM |

It is difficult sometimes to describe to people just what it is that I’ve done for a living in the Navy. It is especially difficult to talk to civilians about my job because they have no concept of even my basic skills, but even to people in military medical occupations it is hard to explain.

via SanDiegoNavyDoc.

In case y’all aren’t reading him, you need to.  Add him to your daily reads, please.

9 years later

On 9-11-2001, when the first tower was struck, I was dead asleep, comfortably. I was halfway through the second month in my new job, right out of residency. I’d worked the 7p-7a on Sept 10th, and it was just another day.

My wife woke me up, as when she’d gotten home from the school run she’d turned on the TV and heard about the first plane. “A plane has hit one of the World Trade Center towers, you need to see this” is what I recall her saying, and even though I was about 45 minutes into sleep I thought ‘it has to be a light plane, bad weather, somebody trying to run VFR’, etc. But, I got up.

That’s why I was watching TV when the second plane hit the second tower. It wasn’t a mistake.

I’m a little embarrassed to admit that I thought about myself briefly. I was still in the Inactive Reserve then and had joked, until that moment, that “it’d take an Act of Congress to bring me back to active duty”, and I immediately realized Congress was going to be ready to do a lot of things in response to this attack.

And then, I had exactly the same response as everyone else who didn’t lose a loved one: shock, anger, disbelief.  Amusement at the line of people at the gas station in Midland, and wondering what the future would bring.  Sadness a the loss of life in the planes, the first responders, in the buildings.  Senseless loss and death brought to us by barbarians who hate us.

I’m quite disappointed in the TSA security theater when I fly today, unhappy that the `100% bag matching’ doesn’t work, and sad that we’re all inured to the realization this is the best our government can do, or has the will to do.

Prayers for the dead, and those who lost.  Respect and Love for those who defend us, and hope we’ve learned enough to prevent a recurrence.