Movin’ Meat: I was due

Nothing good ever comes via certified mail, and it was with a sense of dread that I took the envelope, noting the return address from a law firm. I opened it and was hit in the gut by the block type at the top reading “NOTICE OF INTENT TO SUE,” with my name underneath.

Bummer. You’ll live through it, but it still stinks.

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Yet Another Patient Dies Waiting For Emergency Care « WhiteCoat Rants
Mr. Herrera waited 19 hours for care and still had not seen a doctor when he went into a cardiac arrest and died.

Dreadful.  And, unfortunately, predictable.

ED’s are one of those “If you build it, they will come” things, but they’re not funded or equipped (those are related) to see everyone.  I fear the answer will be some bureaucratic “Everyone must be screened within…” (some arbitrary number) and will generate the corresponding foolishness to comply with a foolish requirement.

It won’t change a thing.  Until our ED’s are properly equipped and funded, this will keep happening.

(There’s a WTF in there for ?why is it okay to have patients waiting that long? and where is the administration?  They should have a protocol to call in more of whatever is needed to keep anyone from waiting that long, absent Act of God.  ‘Because we’ve always done it that way’ is an incorrect answer).

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CTV.ca | Man who died waiting 34 hours in ER identified
Man who died waiting 34 hours in ER identified

Updated Tue. Sep. 23 2008 11:29 PM ET

CTV.ca News Staff

A man who died while waiting 34 hours for care in a Winnipeg emergency room has been identified.

Brian Sinclair, 45, died at the Winnipeg Health Sciences Centre WHSC in what some are calling the worst emergency room failure in Manitoba’s history.

Waiting Room deaths are going to go up.  I hope I’m not one of them.

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I’ve read some ED blogs commenting on transfers recently (well, when I started writing this post), and I’d like to add my two cents, as an EM doc working in a facility that accepts more than 2,000 transfers a year.

At my hospital the vast majority of transfer calls are fielded by the EM doc on duty, and it’s an interesting dance: listen to the physician who wants to send, determine if you have the resource the sending docs’ patient needs, and then make a decision if our receiving hospital can medically handle the patient being sent.  This includes a lot of facility-specific knowledge, not just the ‘on call’ list but our special capabilities that aren’t on the call list, etc.  Of course, this is just the “medical” part, then there’s the “Administrative” part, over which I have nor want any influence.

The rules about this are myriad and complex, and typically we err on the side of accepting a transfer.

A style point: if you’re trying to send a patient, start with “I have a patient who needs ENT, do you have that coverage” rather than the much more typical, “Mr. Smith is a 74 year old male with hypertension, diabetes and CHF…” because I will then cut you off and say ‘what do you need, and how can we help you’?.  This is a ‘Just the Facts Ma’am’ conversation, and should be short and sweet, respecting both our times.

And, the hard and ugly truth: transfers have allowed a lot of very dysfunctional hospitals to stay open, IMHO.  A hospital cannot get Ortho coverage (for example, not specific to bones), for the myriad reasons specific to that specialty?  Well, just transfer them to a hospital that does.  In this way, bad hospitals (administrators and medical staffs alike) aren’t confronted with their failures, their failures are transferred.  The inadequate hospital now doesn’t have to face angry patients and their families for their inability to manage their medical staffs, they just defer their responsibility to those who are just that: responsible.

I have told sending docs I would take their patient, but they had to go out and pry the word “Hospital” off their signs.  If it was you I was talking to……..I meant it.

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Movin’ Meat: Contracting with your hospitals

A very nice backgrounder into ED group contracting with hospitals.  He didn’t address due process in his post, though, and I’m hoping to have him blog a bit about that.

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Today I read this snippet, via Newsday.com:

NEW YORK - Two teens went to an emergency room complaining of pain, but police say they really wanted pills, needles and medical supplies from the Staten Island hospital.
…
Police say the pair found a sealed box in an emergency room cabinet, opened it and took medicine and supplies. A witness told a hospital security guard, who called police.

Which reminded me of a recent blog post by one of the very best blog writers, Dr. Edwin Leap:

edwinleap.com
…
The average person, the normal citizen, the otherwise functional patient has no idea of the remarkable degree of dysfunction and deception we see in the modern emergency department. Furthermore, they have no idea of the incredible boldness, the unflinching willingness to lie, misrepresent and manipulate to get what they want; and get it all for no charge.

There’s a reason EM types are a little jaded.

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Repeat ’super users’ are swamping the ER

by Carol Ann Campbell/The Star-Ledger Sunday July 13, 2008, 8:45 AM

Bean-thin and sallow, George tugged on a cigarette in the blistering parking lot of a Camden men’s shelter. Standing on the pavement, his foot on a picnic bench, he recalled how he took his first drink at 13.

George, here talking to a social worker in Camden, is an emergency room ‘’super user,” having been admitted to ERs in the small city between 30 and 40 times in the past year.

The hard living shows in the lines of George’s face — and in his medical history. When he gets sick, which is often, the 55-year-old has no place to go except one of the city’s emergency rooms.

George is a “super user,” a new name coined to describe people who turn to the ER with astonishing frequency and at an astonishing cost to a health system under siege on all fronts.

This is a very well written article, and I’d bet every ED in America has the same group of ’super users’, patients who are in the ED a lot, not because they want to be but because for a variety of reasons they don’t have other choices.  It’s unfortunate that their only choice is horribly expensive and fragmentary care.

Nobody has an answer to the problem, but I applaud New Jersey for trying to do something about it.

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Movin’ Meat: Running Scared

Interesting (and well written) peek into the parctice styles (and motivations) of EM docs everywhere.

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What Did You Say Was Wrong With Me? « WhiteCoat Rants

A must read, if just to see the graphic.

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Shadowfax started a nice thread, and the impressive 10/10 added to it today, a list of advice for new EM grads. Read their advice, but here’s mine:

1. Lease, don’t buy. Way more than half of new grads change jobs within two years. I know, it’ll never happen to you, but here’s the thing: I was you. I got my ‘dream job’, bought a beautiful home in a perfect neighborhood. I sold and moved in 10 months. It’s a really nice way to lose a lot of money. It can happen to you.
2. Be humble. True, you’re at the absolute top of your game, you know the best literature on every subject, and can intubate with your off hand in the dark, blindfolded. Your new colleagues have been practicing EM for a very long time, and while they’d be interested in your incremental knowledge of the state-of-the-art, they’re not itching for you to enlighten them. Open your ears, listen, and learn. (Use your filter: there’s a pony in there somewhere). Read the rest of this entry »

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As I have suspected:

Cancer doctors dodge the death talk - CNN.com
…Only one-third of terminally ill cancer patients in a new, federally funded study said their doctors had discussed end-of-life care.

Surprisingly, patients who had these talks were no more likely to become depressed than those who did not, the study found. They were less likely to spend their final days in hospitals, tethered to machines. They avoided costly, futile care. And their loved ones were more at peace after they died.

I’m often shocked, and saddened, that as an EM doc I’m apparently the first to discuss end of life plans with patients having terminal diagnoses.  (Yes, life is a terminal state, but don’t change the subject).  I do, as it’s what should be done, but it’s often uncomfortable for everyone.

Still, not as uncomfortable as dying in an ICU.

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Mr. Russert has a negative stress test on April 19th and died suddenly of a heart attack on June 13th.

I therefore propose a new sign in medicine, the Tim Russert sign: death (or MI) shortly after a negative stress test.

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Terror attack would overwhelm L.A., D.C. hospitals, expert says - Los Angeles Times

Agreed:

“It is irrational to believe that an emergency system that is already overwhelmed by the day-to-day volume of acutely ill patients would be able to expand its capacity on short notice,” said Dr. Roger J. Lewis, a professor in the Department of Emergency Medicine at Harbor-UCLA Medical Center.

All the ED’s I’m aware  of work at or above capacity daily.  There’s room for maybe a 6 hour surge, but that’s only if most of the patients brought in the surge go home from the ED.  I don’t want to think about pandemic flu, let alone some weaponized bug.

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The patient’s CC: bug in ear.

Physical exam: Pt in mild distress, holding one ear.  Otoscope exam shows the back end of a bug.

I started by filling the ear with 1% lidocaine, to drown the bug so they quit moving (which is apparently painful and freaky in an attached-to-your-brainstem weirdness kind of way).

Then it happened, something that hasn’t happened in years of doing this: the bug came out to keep from drowning!  There’s a little bug running on the bed, which met its maker quickly.  Re-exam showed the inside of the ear none the worse for wear, and the relief of everyone was terrific.

First time I’ve been charged by a bug, though.

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I’m very pleased to announce that Logan Plaster, Editor and Creative Director of Emergency Physicians’ Monthly will be blogging his insights and observations here during this weeks’ 12th International Conference on Emergency Medicine held in San Francisco.

I’m a big fan of EPMonthly, and enjoy reading it cover to cover every month. It’s my honor to host them here (and they have a website supporting their publication that’s terrific, check it out).

Come back often for his updates; he’s going to try to post pictures (and maybe video) in addition to the expected well-written text. I’m looking forward to it myself.

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