Big Love for Academic Emergency Medicine

I was pleased when I opened my mailbox today, and the new Academic Emergency Medicine burst out. It’s really a treat, on par with my subscription to the New Yorker. Why? Because AEM really expands my concept of what research, and emergency medicine, can be. I’m not kidding, and I’m not damning by faint praise (and EM is too small a community for me to get away with it, if I were).

The first article that caught my eye was entitled, Laser-assisted Anesthesia Reduces the Pain of Venous Cannulation in Children and Adults. Now, over the past year I’ve become pretty good at starting IV’s, I’m starting to incorporate ultrasound guidance on some tricky, urgent cases. But I’ve never really focused on minimizing pain, as my patients can attest. In the OR I’ve seen the anesthesia residents sometimes use lidocaine (and I certainly give it before a spinal tap) but I had no idea lasers were an option. Apparently, using a handheld laser over the planned IV site will ablate th topmost layer of skin, allowing transdermal anesthetics to seep though. Patients reported less pain in a randomized controlled trial (the patients and researchers were also blinded, though it’s not clear whether it was by design protocol, or from the power of the lasers).

Anyway, the next time I see an administrator strolling through the ED, I’m going to ask for a handheld laser. The evidence supports it, patients love it, and I’ve always, always wanted a laser gun.

Another eye-catching study was called, Single Question about Drunkenness to Detect College Students at Risk for Injury. The question was, "Hey, buddy, want to go grab a drink?"

Ha! No. I kid. The question was "In a typical week, how many days do you get drunk?" Any answer greater than or equal to "1" was associated with a fivefold increase in EtOH-related injury, a more than twofold increase in falls requiring medical treatment, and a more than twofold increase in being sexually assaulted. It’s a better marker than binge drinking, or anything else out there. The study was limited to ten North Carolina colleges — we’ll see if it’s generalizable beyond that. But the ED is a great place to make an intervention in a young college kid’s life, and this one question is a heck of a start.

It’s not all great in this month’s AEM — I was a little disappointed that Childhood Injuries Caused by Falling Televisions didn’t contain any blockbuster revelations (did you know there’s no ICD-9 code for falling televisions? for shame!) but on the whole this journal kind of inspires me. Anyone else out there a fan of AEM?


MedBlogs Grand Rounds 2:37

What would GruntDoc do today? Why, link to this week’s Grand Rounds, and give an excerpt!

Not until the last moment did I realize that my Grand Rounds falls on a day of apocalyptic significance, celebrated by some. My hope is that TMBN’s new ideas will not cause the end of the world and instead bring us "Hell of a Grand Rounds"!

Amen to that. Tune into the Medical Blog Network’s edition of Grand Rounds, and see what everyone in the medical blogosphere is talking about. My interview with Dmitriy Kruglyak is available on Medscape (registration required).

— Nick


Bring It On

Hello, GruntDoc readers! This is my first guest-blogging stint, but I’m a big fan in general of neighborly community behavior. We have friends pick up the mail for you when you’re away, maybe feed the cat, so why not maintain the online presence, as well?

Especially when the online presence is that of GruntDoc, who’s been a dedicated supporter of medical blogging in all its forms, including Grand Rounds (he is a three-time host, I interviewed him once for Medscape). GruntDoc has also been a source of tips and commentary to MedGadget, another blog I contribute to (in fact, when we got the tip about this cricothryroidotomy keychain, I immediately thought of him).

GruntDoc encouraged me to rant during my stint here — I think he’s trying to keep things lively, or maybe he knows how much I have to reign it in usually, as an intern blogging under my real name.

I’m not sure this is a rant, but I do want to address Symtym’s assertions on what’s really an emergency. He quotes a figure I’ve heard, and verified — 100 million visits to US Emergency Departments each year (I’m getting numbers from Richardson AEM Vol 40, p 388).

100 million A huge number, to be sure, especially given the US population of 300 million. So it’s easy to say we’re in crisis now, everything is an emergency, forces have conspired to make people think they should use the ED for hangnails and stuffy noses. right? guess Well, guess how many visits were logged fifteen years ago: 90 million.

OK, now maybe there was wild misuse of emergency services in the early 90’s, too (I wouldn’t really know,  I was in high school). It seems, though, that the problem isn’t that there are more people using ED’s  inappropriately, or at least, this isn’t a terribly new issue. Rather, it’s that there are fewer ED’s around, so we’re all feeling the crunch more.

As for those 100 million visits, does that really mean that one third of all americans go to the ER each year? Of course not. Me and my two friends sure don’t, least not yet this year. Meanwhile, I can personanly vouch that some of our "regulars" chronic homeless alcoholics use the ED 100 times a year. How big a problem is this? I’ve blogged about it before, it’s a big problem and accounts for a substantial fraction of ED expenditures.

What about all the 70-year old diabetic hypertensives with chest pain? They come in every three or four months with disturbing symptoms. The 80-year olds who feel week and dizzy, maybe they blacked out for a second. These are real complaints, real emergencies, they need workup, every time. 

As for the hangnails, the inappropriate use of ED services, it’s actually notoriously hard to calculate how many are seen inappropriately. People have tried (Richardson, again — maybe I’ve worked with her, once or twice). The bottom line is, it’s hard to measure inappropriate ED use, and efforts to deny care to non-emergent situations may end up costing more, and/ or causing bad outcomes. Researchers try to quantify it, but existing denial of care methods just don’t seem to be worth it, and the estimated savings may be exaggerated as well.   

You can blame "themes of entitlement" and whatnot, and I’ve found doing so provides some comfort when you’re stressed and feeling put-upon by those few demanding, unappreciative patients. But, when you really look at it, it’s hard to blame the patients.

And, you know, as an intern, I’m going to get paid the same living wage whether I see a dozen patients a shift, or two dozen. But I keep trying to move quickly, providing good care and pleasant bedside manner, because I want to see as much as I can, and I’d like patients to get a favorable impression of our hospital and ED. If they end up realizing that we, in the ED, can provide services faster and more completely than if they just showed up unscheduled to their primary care doc, well, good for us.

Look, I’m not trying to debate ED access or government incentives to waste — that argument sprouts up every few weeks on the blogosphere and there’s already a good iteration / continuation in progress over at Grahamazon. I’m just trying to, well, figure out the right mindset and perspective to approach my job, and avoid becoming as jaded, down the road, as some others appear to have become.

— Nick