Prompted by a series of tweets and buzzes pertaining to the knowledge base of Emergency Medicine bloggers we felt it was time to overhaul our ‘BlogRoll‘ and create a separate table for the Emergency bloggers, their twitter handles and RSS feeds.

via Emergency Medicine Bloggers | Life in the Fast Lane.

Nice list!  If you find an omission, please leave it there, and not here.

The American Board of Emergency Medicine (ABEM) describes itself as:

Welcome to the American Board of Emergency Medicine (ABEM) public website.  ABEM certifies qualifying physicians who specialize in Emergency Medicine and is a member board of the American Board of Medical Specialties (ABMS).  ABMS certification is sought and earned by physicians on a voluntary basis. ABEM and other ABMS member boards certify only those physicians who meet high educational, professional standing, and examination standards.  ABEM and other ABMS member boards are not membership associations.

The thing I’d like to bring your attention to is that it’s a Voluntary organization.  For a voluntary organization they’re adding lots of requirements without asking members…

Since most of you don’t know about Board Certification, it’s a way for doctors to demonstrate (mostly to their peers and employers/hospitals but also to patients) that they not only finished their residency, but paid attention and learned enough to pass the Board Certifying exam.  Yes, it’s possible to be a doctor, finish a residency, but not pass the board exam and have a nice lifelong practice anyway.

I’m Board Certified by ABEM, which required completing an accredited residency, passing first a written then an oral examination.  Okay, I’m done, right?
Emmm, no. I’m BC for 10 years.  In order to re-test to be BC for another 10 years, I have to take (and pass) yearly tests over medical literature, tests payable to the ABEM.  Which ABEM didn’t bother to figure out how to give us CME credit for.  Genius.

Imagine my surprise at ABEMs’ latest addition to hoops to jump through to maintain my Board Certification: the Assessment of Practice Performance.  In a nutshell: show ABEM that 10 patients didn’t hate my medical performance, prove that on 10 hand-picked charts I’m keeping up with published treatment benchmarks (like aspirin for ACS, antibiotics in 6 hours for pneumonia, etc), and self-certify the same to ABEM.

While that’s easily doable for me at Giant Community Hospital where I work (we already keep track of this, and a lot more), it’ll no doubt be harder for very small ED’s.  I agree this sort of performance thing needs to be tracked, and practice outliers nudged back toward the middle, but what on earth does this have to do with being Board Certified?  Where in ABEMs’ mission statement does it say they’re going to certify we’re practicing on par?  Nowhere.

This would be an entirely different argument if Board Certification were required for employment in EM (it’s not), at my hospital (it’s not), in my group (not), exempted me from any state CME requirements (doesn’t), increased my pay (doesn’t), you get the idea.  That’s a lot of work to keep a voluntary certification that gives me back… nothing tangible.  Oh, I’m a Diplomate of the American Board of Emergency Medicine, and with that and $6 I can get coffee almost anywhere.

I find it interesting there’s not much push-back on this new requirement.  ACEP’s President-Elect ‘interviewed’ ABEM President Debra Perina about this latest addition, uncritically and without any challenge: EM Leaders Discuss ABEM’s Maintenance of Certification Program.

To paraphrase the question, why? The answer:

SS: Is it correct to say that the public is asking for more accountability regarding continuing medical education, even between board examinations?

DP: That’s correct. I know that ACEP and the emergency medicine community have been following testimony in House and Senate hearings from consumer advocates requesting assurances that physicians remain competent throughout the course of their practice. The public is questioning boards that test sporadically or in some cases offer lifetime certification.

Hmm.  I genuinely understand the desire of the public to make sure docs are keeping up, and practicing inside norms (and this is not asking for a flaming: I’m aware there are docs who give amoxicillin for everything imaginable, who don’t keep up, etc) but this is a) window dressing on that front and b) if meant to serve as some reassurance to the public, it’s inadequate, at best.

But that’s really beside my point, which is that it’s not ABEM’s role to make certain my practice is up to par, that’s the role of, ultimately, my State (which licenses me) and my peers, who have a lot more impact on my practice than the ABEM.  ABEM should document that the provable (I’m keeping up with my certification, meaning the every 10 year tests, grudgingly the yearly tests*), and that’s it.

In an upcoming rant: competition is good, is it way past time ABEM had some legitimate competition from another Board Certifying organization?

*In either the first or second year of these yearly tests, the article being tested was about Neseritide, which in the article was the best thing for CHF since phlebotomy.  Of course, by the time we were being taught/tested on it, Neseritide was out of vogue as it hadn’t worked out in practice as it had in studies.  But, you had to give the currently wrong answer to the test.  Pitfalls of keeping up through testing.

Scotland Memorial Hospital was locked down Monday morning after a shooting left a patient in critical condition and another man in police custody.

The 3 a.m. shooting appears to have stemmed from a brawl at a McColl, S.C. night club, according to Laurinburg police. Authorities say it involved the victim, his girlfriend and the daughter of the shooter just a few hours earlier….

via The Laurinburg Exchange – Shooting at Scotland Memorial Hospital.

This exact scenario is why most hospitals have some system to anonymize victims of violence in the ED, and sometimes throughout their hospital stay.  (We have one, and I’m not letting its incredibly complex code out…).

That doesn’t make them either invisible or bulletproof, and we’ve seen a few examples of our trying to anonymize them gone wrong when their ‘friends’ start calling and texting once in the ED.

I’m happy no ED employees were injured, and hope the alleged attempted murderer gets a fair trial and the punishment deserved.

Also, don’t get in bar fights…

HT: Glen in West Texas, my news machine

The handle bar of the snowmobile fractured his ribs.

Nice guy. Mid-60s. Talkative and generous in his remarks.

It occurred yesterday. He thought it would heal by itself.

Didn’t want to bother us. But now he was a little breathless.

His lung was punctured. His skin was full of air. It crackled and popped as I rubbed the betadine on his chest in preparation for the procedure….

via richard[WINTERS]md: Skipped a beat..

He doesn’t post much, but when he does, it’s usually good.

Please check it out, and if you like it, leave him a comment you came from here, and thank him for getting me into blogging…

Trying to avoid a painfully long wait in the ER?

One local hospital system is publicly sharing the current average wait time to see a doctor at all its emergency departments.

Akron General Health System recently began advertising up-to-the-minute wait times for its emergency rooms on billboards throughout town.

Six digital billboards in Akron are automatically updated every 20 minutes to show current average wait times to see a doctor …

The average times are computer generated, based on current patient information from the health systems’ electronic medical records…

via Ohio.com – Akron General puts ER wait times on billboards, Internet.

I think this isn’t terrible, as long as there’s some education that a) these are average times and that b) if you have a real emergency you go to the head of the line.

Oddly, I think this is different than the (currently boutique) practice of scheduling an appointment at an ED over the internet.  I think if you have the time to schedule your emergency, you don’t have one.  So, get a doctor and go there.

Bring on the ‘average wait times’, but make sure the same display is visible in the waiting room!

Residents training in large urban centers typically see more than 200 patients a day. They have access to all subspecialty care, typically available 24 hours a day. Residents have around-the-clock access to angioplasty, interventional radiology, hand surgeons, neurosurgeons, and plastic surgeons. Most practice emergency medicine with cardiologists and neurologists in the building or a short phone call away. Decision-making is shared, and occurs with a relative surplus of information and opinions and in a milieu of shared risk.

In reality, though, these very large and highly-specialized EDs with Level I trauma comprise less than five percent of U.S. EDs, according to the American College of Surgeons. The average ED is in a community hospital, and sees fewer than 100 patients a day. This community hospital ED will likely not be designated a Level I trauma center, and the practicing physician will have to make decisions on complicated patients without all of the resources and consultants available at a tertiary care medical center. He will have to make these decisions alone. Given that most graduating emergency medicine residents will practice in such a setting, we should ask ourselves is this the best we can do? Does the current training model best prepare the emergency medicine resident for the kind of practice he will enter

via We’re Failing Our Residents: Training ED Docs for the Real W… : Emergency Medicine News.

Nicely done.

I noticed this myself, first job out of residency.  I could do trauma in my sleep, but had a very steep learning curve at a place with high-end (and high-expectation) cardiology groups.

The reality that in ‘the real world’ there were no surgical consultations, they just wanted to know one thing: do I need to operate or not?  Also in the real world, going from a strong-hand department where the ED was regarded as the best residency with the best residents to being the new guy and the ED is the Repository of All Hospital Guilt, so no matter how thorough you were, the inpatient disaster was phrased so as to be something missed by the ER doc, and not the admitting team.

I did rotate (for one month, at the end of my residency) at a somewhat lower volume community ED, but there’s only so much to be learned while being a visitor for 18 shifts.

This doesn’t mean my trainers were lazy, or bad; it’s the reality that the hospital paying our salaries had expectations we’d be able to see the patients in that joint.

(This is, by the way, one of the better things about moonlighting as an EM resident; stretch yourself, find out what you don’t know while you still have time to learn.  We moonlit at a place about 45 minutes from our Big Center, so there was a safety net to catch us…)  Moonlighting is now Verboten, so there’s another door closed.

I’d like to see the residencies in EM move to decentralize from one place, and give a more rounded experience.  Not going to happen, but it would be nice.

We left the Mythbuster confronted by the evil Dr. Fish the urologist in the Saint -We Never Change Anything in Years hospital. The Mythbuster doesn't lose a step in dealing with a threatening urologist armed with a 100 french cathether.

“Urologist, Huh? Still think you get anything by hydrating renal colic patients? Well look at the Journal of Endourology 20(10) 713 . Flooding patients does nothing for pain perception or lessening of narcotic needs. Sure if the patient is vomiting or dehydrated, but this practice does nothing for stone passage”

Dr. Fish flinched.

via EM Blog – EM-Blog – Our Mythbuster Confronts Dr. Fish by Joseph Leibman, MD.

Pretty good!

Hmmmm:

Emergency spine immobilization may do more harm than good, study says
January 11, 2010 | 3:57 pm
When emergency responders reach a gunshot or stabbing victim, they try to immobilize the spine to reduce the danger of paralysis upon movement of the victim. That effort, however, can have a fatal toll.

A study published in the Journal of Trauma has found that, among these types of trauma victims, those whose spines are held still are twice as likely to die as those whose spines aren’t immobilized.

Read the news article, but they’re talking only (apparently, I don’t get this journal) about penetrating trauma. Those discussing the article wonder if the reason for the increased mortality is “Stay and Play” vs “Load and Go”, the two basic precepts of transporting the ill and injured in prehospital medicine.

While I would agree a collar and backboard on a neurologically intact GSW patient is probably overkill, I suspect it’s a surrogate in this study for injury severity.

Anyone read JOT and want to help us out? I wonder if Injury Severity Scores were compared, in addition to transportation times.

And, my unrelated but sort-of related rant: we’re now getting, as policy, patients packaged for transportation like we’re going to sling them from helos and airdrop them into Afghanistan. Straps, zippers, tape, collars, etc. Very often applied to patients who were walking when EMS arrived on the scene. (I have given up asking EMS why, they just rote-repeat “Policy”), and have so far restrained from asking patients ‘why did you let someone strap you down like Hannibal Lecter’?)

Worrisome spinal tenderness, AMS, or an abnormal neuro exam? By all means. But a lot of it seems to be because they have a hammer, so every trauma patient is a nail…

Except, of course, that it did…

A patient comes in with the entirely understandable complaint of “I have a fishbone lodged in my throat”. Came straight from dinner to the ED. When I ask a stupid question I’m given a stupid answer: “It feels like…a fishbone…”. Duh on me.

Now, I went to a pretty good EM residency, and while there I learned two things: the books say fishbones don’t show up on x-rays of the neck, and, fishbones sometimes show up on x-rays. I’m about 70% positive in my career…

So, I got an xray. See if you can spot the fishbone (hint: there’s an arrow pointing at it…)

So, it’s there… Now what… There are very few wrong answers. Call ENT, etc. My answer: go get it.

With another doc giving the Propofol (I was going to say Milk of Michael, but the visual on that is just awful), pt asleep and relaxed, I did a direct laryngoscopy and pulled out a nice 2″ fishbone with the magill forceps. I bagged it for the patient, who was glad to have a souvenir (and probably a conversation starter with a restaurant manager). Patient awake and alert 5 minutes later, out before the x-ray reading came back.

“…no foreign body…” on the official x-ray interpretation. Sometimes it’s good not to have the reading immediately. Heh.

…to remind me I have one of the coolest jobs in the world.

I came in to start my shift, and the department was abuzz.  Thoracotomy!  Some kind of trauma, open chest, etc.  Big mess is all I saw, and thought about the low yield and hazards.

That’s what I thought about: big futile mess.

Later, as I was getting coffee (yes, I’m back on the sauce), I asked two EMT trainees, in passing, if they’d seen anything interesting.

Their enthusiasm was palpable, and it was because they’d seen the spectacle.  They were completely energized, exited about Emergency Medicne, and will easily finish their studies solely on adrenaline.

It made me consider my first thoracotomy (fear and perspiration, mostly, with the awesomely frightening yet thrilling ‘am I actually doing ths’ moment).  Something I take for granted (and even dislike a little, as I have yet to have a positive patient outcome), but their viewpoint made me realize I’m jaded, and reminded me I have the coolest job in medicine.

“Pt got a Hini shot today and now feels bad”.

Took me a couple of seconds to figure out it wasn’t a hiney shot, it was H1N1.  Which was not given in said region.

Via ER Stories, a reminder of the flow chart every EM resident is taught…

Nicely done…

HT: MovinMeat

Always nice to have an etiology…

Sinus arrest without an escape rhythm...

Because mine no longer makes sense to people…

Many of the abscesses I drain require wound packing (I generally use 1/4” iodoform gauze, so these aren’t giant cavities), and during the procedure I tell the patient why I’m doing a wound packing, and what to expect.

When we’re done with the procedure, until yesterday I used to tell patients to remove their packing in 3 days “Like you’re starting a lawn mower, just get it out”.  That’s when the nurse laughed, and said her mower is an electric start.

I asked the patient if they’d ever started a lawn mower, and the answer was no.

So, what shall I use as a universally understood analogous action to smoothly but quickly pull something?  Zipper?  I’m coming up blank…

Kevin, MD linked to this, and I really must comment.

Here’s the abstract, and I hope you’ll read it all:

For years I’ve heard friends describe experiences of being caught in a web of excessive and unnecessary medical testing. Their doctors ordered test Z to investigate a seemingly incidental finding on test Y, which had come about because of a borderline abnormality on test X.

I often wondered why test X was done in the first place. As a primary care physician, I would have treated them for the likely diagnosis and done diagnostic tests — especially a series of diagnostic tests — only if they didn’t respond as expected….

Naturally, I’d express sympathy or outrage, whichever the speaker seemed to expect, but internally I’d pat myself on the back. I felt fortunate that there was absolutely no way I’d ever be stuck in such a scenario. After all, I’m not only an experienced physician but also an advocate — in fact, a teacher — of standard-of-care practice. When I get sick, I told myself, they’ll have to do it by the book.

That was before last Easter.

Short version: Easter Sunday an experienced physician realized he was breaking out with shingles on his face, and decided that instead of bothering his internist with it he’d go to the ED. What he got there was, to put it mildly, terrible. After the obvious diagnosis (which the patient no doubt gave everyone from the triage nurse up, he’s smart and knew the problem):

“Before you go,” my colleague mused, “just for completeness’ sake, maybe we should have an ophthalmologist and a neurologist take a look at you. What about it, just in case?”

“I don’t know . . . I don’t think so . . . well, okay . . . maybe it’s a good idea.”

No, it turned out to be a terrible idea. Acquiescence to this obvious weakness on the part of the EM doc resulted in two senseless consultations (three if you add in the residents’ time) and a pointless MRI, then read as abnormal, though there was no significant abnormality.

Eventually the patient went home with the correct medications, but with a 9,000 dollar bill. Which was, and is, terrifically stupid.

After an EM doc’s period of contemplation, here’s my opinion:

First, if you have a regular doctor, call them (especially of you are a doctor and know what the problem is. Rx called in, see me Monday, problem solved). However, as most people aren’t, and my patients don’t have regular doctors…

Second, I’m at a loss to explain the actions of the EM doc. All the blame lies with them. Yes, I’m taking issue with the EM doc.

I’m of two minds about this weird consultology on the part of the EM doc. Right diagnosis, sounds like a thorough exam, so where’s the problem? Either it’s fear of suits, or it’s a junior EM doc taking care of a Senior doc.

Fear of suits: New York is rated “F” by the ACEP EM Report Card for their medical liability climate. That’s not an excuse, but a reason. I personally am guilty of getting tests for my lawyer (which were also medically indicated). Mea culpa.

The Junior doc taking care of a Senior doc is also at work here, and is magnified at an academic center (where there are always more tongues clucking about the idiotic decisions / misses in the ED). Add in any perception that the ED is a scapegoat, and there’s going to be a tremendous amount of testing on ‘one of their own’ to preclude an awkward and embarrassing Morbidity and Mortality meeting. Trust me, docs will go a long way to stay away from that spotlight.

I have no idea which drove this horrible decision. I hope everyone involved, especially the EM doc, learned a lesson.

By the way: “Just to be sure“. Therein lies half the evils in medicine. Get a test, just to be sure. Get another test, a consult or two, and admission, just to be sure. Look, if you’re unsure, then fine, do what it takes to care for the patient. Just to be sure, though, is the path to ruin for our profession, and our country.