Really good video!
Behold, a very worthy rant. Recommended.
I’m neither terribly for nor against paramedics working as employees in the ED, but I love people ripping apart straw man arguments.
Texas ENA’s Unprofessional Attack on EMS
Author’s note: I generally avoid posting non-tech matters on my blog, but this unprofessional, unsubstantiated, fear-mongering attack of EMS in Texas has me boiling. I present to you something that doesn’t just affect Texas EMS, but EMS in the entirety of the United States of America. This has been fought in other states, and if it isn’t stopped now, will set a precedent and spill into many more states and regions. If you want to advance, you don’t do it by holding your siblings down in mediocrity and attacking their skills and intelligence. They seem to have taken a page out of the book, “How to Get Ahead in Life by Attacking Your Colleagues.” It is uncalled for.
Go, now, and enjoy.
unless it’s the tail rotor. They will straight up kill you.
I’ve written about scribes in the ED before (here’s one from 2007) and continue to utilize their services. Did I say utilize? Wrong thought: enjoy and marvel in their help is more my experience. I’m spurred to extoll their virtues and my experience after reading “Attack of the Scribes” by the great twitterer @SkepticScalpel (he also blogs at SkepticalScalpel.blogspot.com ).
Read the article, it’s well written though more than a touch odd; why’s a doc who’s never worked with scribes editorializing on their pluses and minuses? The literature review is fair, and there probably isn’t enough scholarship on the issue of whether scribes can have a measurable impact on physician productivity. I think we’ve only scratched the surface with scribing in the hospital, as I think every nurse should have a scribe. Imagine, nurses nursing rather than staring at screens, checking boxes! It would be hugely liberating for them.
I’m going to insert some quotes from the article then answer them:
“The emergence of the electronic medical record (EMR) has spawned a new occupation—the scribe.”
No, scribes have been around since ink and paper, and maybe before. I would accept that the EMR has spawned a new medical occupation, though we used scribes in the paper chart world before the EMR. It is certainly true the EMR has facilitated the explosion of scribe utilization (and companies to fill that need).
“I have no personal experience with scribes, but I suspect their notes would tend to be too long rather than too short. Do we really need longer notes in charts? No. Residents need to learn how to write concise progress notes that do not duplicate what is already in the chart. This would require a culture shift by faculty and senior residents who tend to expect voluminous notes.”
Scribes document something like doctors without scribes: all over the map for volume. Some distill the history in a few sentences, some type verbatim, and there’s a mixture between. In the ED, as the note is pretty heavily templated, and so much fluff and junk are automatically stuck in there, an extra sentence or three isn’t contributing to note bloat. I would never scribe any other than a Senior resident, as learning what and how to document is part of the education.
Additionally, docs 40 and above didn’t grow up with keyboards like our scribes did; that means less information added by poor typists, which isn’t good for the patient or the documentation.
“The presence of a third party during the doctor-patient interaction has not been an issue so far, but it is conceivable that some patients might feel uncomfortable.”
I’ve had one patient ask the scribe to leave the room. I introduce myself, introduce the scribe as ‘my assistant’, and it’s not an issue otherwise. (We do excuse them for the more intimate exams).
“When a scribe enters a note in an EMR, it must be cosigned by the physician. Experience with dictated H&Ps, notes, and operative reports shows that most of these entries are not carefully proofread before they are signed. Using scribes opens up new vistas for plaintiffs’ attorneys if patients experience bad outcomes.”
I disagree; the issue is the quality of the documentation, and it’s irrelevant who pushes the keys. The name at the bottom of the chart is responsible for the content. Before Texas’ Prop 12 several of us were sued, and the use of scribes never came up as a problem in depositions or trials.
“True story. I know someone who had pain in her arms. The scribe documented the doctor as saying “consider a mass” instead of what he actually said, “consider MS.””
Professional transcriptionists get words wrong frequently, and the speech-to-text used by our radiologists is often inadvertently hysterical (‘Sono: Renal and Nasal’ was a recent report header), so communication errors happen. That’s why we read and edit charts.
I don’t need a study to tell me scribes make me more efficient, but we did one anyway. We were very efficient on paper charts, with scribes, and the EMR showed up. We went through the training, and had people time scribe-on-paper vs the EMR for time; the EMR was tremendously slower (40% more time required), which was a big hit in an efficient system. We’ve gotten better, but several of our docs use two scribes to get their speed back (and more; I now see more per hour than I did on paper). We didn’t publish our data. Maybe we should have.
Our scribe company* has gotten a whole lot bigger, and a lot more corporate for better and worse. They turn out trained and enthusiastic scribes, and they’re still wonderful to work with. I showed up very early for work the other day and decided to start early, which reinforced that I can manage the EMR and do my own documentation, and I’m terrifically glad I don’t have to.
Dr. Henry has also been quoted (though I cannot find it) as saying ‘the ER doctor should be a free floating brain’, meaning let the doctor do the thinking they’re trained to do and let anything that not that be done by someone else. It makes zero sense for the highest compensated in the department to be the typist (not a slam on typists, it’s about the best use of time and talents).
Scribes. If you use an EMR, or don’t, get them. They’ll make you money, and they’ll make your day way, way better.
*Full disclosure: I independently contract with a CMG that supported and then spun off our scribe company. I’m also friends with the scribe company senior management, and they’re good folks. I’d say nice things about our scribes if none of that were true, but don’t want my relationship to be an issue.
Posted by Ryan Radecki
It’s been 5 years since the last Cochrane Review synthesizing the evidence regarding tPA in acute ischemic stroke. Clearly, given such a time span, in an area of active clinical controversy, a great deal of new, important, randomized evidence has been generated!Or, sadly, the only new evidence available to inform practice is IST-3 – a study failing to demonstrate benefit, despite its pro-tPA flaws and biases. So, it ought not be a very exciting update, considering the 2009 version included 26 trials, and the 2014 update now includes only 27 trials. Their summary conclusion, with only additional evidence of regression to the mean, ought remain essentially the same, or even less optimistic, right?
Of course not:
Read, and enjoy. Excellent analysis.
Colleagues I can call on and count on.
Recently I was the 11p doc in my ED (the overnight shift), and I knew what my evening had in store when Colleague/suspect1 said “It’s been slow all day”. Oy.
At 11:03P the charge nurse (who deserves a Medal for her actions that night) said ‘you’re getting a level 1 medical and two level 1 trauma transfers in the next five minutes’, and that was in addition to the waterfall of regular patients who heard the word ‘slow’ and ran like very sick possessed zombies to our ED.
The medical was a great case I would have loved had I had no other duties: CHB, external pacer dependent, and I did the right thing for this patient: I called the procedure doc, and turned that patient’s care over to him (
the one who caused this, Colleague1). (I knew what this patient needed, it’s an intubation/cordis/float the pacer/etc, and that’s 20 minutes straight of terrific procedures while letting the department drown). He did as well as you’d think. Maybe better than I would have done.
The other colleague star was Golleague2, the 9P, who never peeped that I wasn’t sending him home, or really even taking his workups. In fact, toward the end of the night he did a lac or two for me, and I kept Colleague1 busy until 3 with procedures. Terrific to have people you can count on.
This isn’t about me, or even these two great colleagues (though I thank both of you profusely), it’s really about all of us. Giving means getting, and I and our mutual patients got the best that night, and get it when we work and play well together.
It’s a great place to work. Thanks to you all.
For the record, I’m all for this, providing it pans out in trials…
PITTSBURGH — Trauma patients arriving at an emergency room here after sustaining a gunshot or knife wound may find themselves enrolled in a startling medical experiment.
Surgeons will drain their blood and replace it with freezing saltwater. Without heartbeat and brain activity, the patients will be clinically dead.
And then the surgeons will try to save their lives.
Researchers at the University of Pittsburgh Medical Center have begun a clinical trial that pushes the boundaries of conventional surgery — and, some say, medical ethics.
By inducing hypothermia and slowing metabolism in dying patients, doctors hope to buy valuable time in which to mend the victims’ wounds.
Hint: Roche stinks, and the Cochrane Collaboration has done all of us a huge favor. Time to stop prescribing Tamiflu.
What the Tamiflu saga tells us about drug trials and big pharmaWe now know the government’s Tamiflu stockpile wouldn’t have done us much good in the event of a flu epidemic. But the secrecy surrounding clinical trials means there’s a lot we don’t know about other medicines we take
Okay, it’s not hilarious, it’s funny that it’s included as a side effect of Tamiflu (treatment for influenza):
I’m not a huge fan of Tamiflu (for the neuropsychiatric side effects), but I saw this last night on my pocket brain, and had to look today to see if it’s really listed.
It is, that’s off the Tamiflu full-download of the medication information (Link on the official Tamiflu page).
So you know, when patients are in studies, basically everything that happens while the subject is taking the medication has to be reported to the FDA, which is how all that oddness gets enshrined as less than 1% side effects. I do find it a little amusing that ‘pyrexia’ (fever) is listed as a side effect, since influenza classically has a fever, and the peritonsillar abscess diagnosis quite possibly indicates the patient didn’t have the flu, they had an undiagnosed condition subsequently diagnosed.
Tamiflu is a Genentech product, FYI.
A concise treatise on the problems with TPa. Well Done!
The Defikopter is a UAV that can be activated by a smartphone app to automatically take to the skies and drop a defibrillator to medical personnel on the ground, shaving precious seconds from the time it takes to receive treatment for cardiac arrest.
The idea for the drone comes from Definetz, a non-profit group dedicated to preventing deaths due to heart failure.
Interesting idea. Won’t work here in the Land o’ the Lawsuit.
There’s a weird risk factor. What’s AB putting in their beers?*
Though Budweiser has 9.1 percent of the national beer market, it represented 15 percent of the of the E.R. “market.” The disparity was even more pronounced for Steel Reserve. It has only .8 percent of the market nationally, but accounted for 14.7 percent of the E.R. market. In all, Steel Reserve, Colt 45, Bud Ice, and another malt liquor, King Cobra, account for only 2.4 percent of the U.S. beer market, but accounted for 46 percent of the beer consumed by E.R. patients.
*Clearly a joke, don’t sue.