How I feel about ATLS, in someone else’ tweet

Perfect.

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Scribes in 2014

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.

Here’s Greg Henry (ACEP past President and EM lecturing fixture) being interviewed about scribes by Nick Genes (genius and blogger/twitterer):


ACEP 2012: Greg Henry v. Nick Genes Part 3 – Scribes from Logan Plaster on Vimeo.

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.

 

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Emergency Medicine Literature of Note: The tPA Cochrane Review Takes Us For Fools

 

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:

via Emergency Medicine Literature of Note: The tPA Cochrane Review Takes Us For Fools.

Read, and enjoy. Excellent analysis.

Another reason I like my job

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.

ED patient: word to the wise

If your driver has a personality disorder, it will reflect on you. It’s unavoidable.

please ask them to wait for you in the waiting room. Or in the car. Or on Venus.

(EMS not included).

Definition of cold: Killing a Patient to Save His Life – NYTimes.com

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.

via Killing a Patient to Save His Life – NYTimes.com.

What the Tamiflu saga tells us about drug trials and big pharma | Business | The Guardian

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

via What the Tamiflu saga tells us about drug trials and big pharma | Business | The Guardian.

Hilarious Tamiflu side-effect

Okay, it’s not hilarious, it’s funny that it’s included as a side effect of Tamiflu (treatment for influenza):

2013-11-26_16-53-35

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.

Why we should be very wary of using clot busting drugs in CVA

Why we should be very wary of using clot busting drugs in CVA.

A concise treatise on the problems with TPa. Well Done!

Defikopter drone air-drops a defibrillator to EMTs on the ground

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.

via Defikopter drone air-drops a defibrillator to EMTs on the ground.

Interesting idea. Won’t work here in the Land o’ the Lawsuit.

Budweiser is most popular beer among injured ER patients, pilot study says – NBC News.com

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.

via Budweiser is most popular beer among injured ER patients, pilot study says – NBC News.com.

*Clearly a joke, don’t sue.

I met several CPR survivors today; I was involved with some of them

At the Fort Worth Municipal building, a gathering of AED/CPR survivors. I was told 10 of them; they came with their families, and there were a lot of lay rescuers and EMS, who as usual deserve the credit for a ‘save’, as if they don’t get the heart restarted in the field there’s not a lot we can do in the ER.

I was also told I was involved in the care of 4 of them. Crazy odds.

Two patients knew of me (probably from billing, frankly, none were awake in the ED), and they were 100% neurologically intact. We had nice chats, and I got my photo with both, but as I didn’t ask their permission to post them, I won’t.

Still, wow.

It’s incredibly humbling to have follow-up on a happy ED case, and when it’s neurologically intact CPR survivors, it’s the equivalent of a Moon shot for an ER guy, and today I got four. Four.

(It’s an occupational hazard in the ED that we meet/greet/diagnose/stabilize and disposition, and what that individual patients’ medical future holds we have no idea unless we go out of our way, and we’re busy enough nobody I know goes out of their way to follow up cases).

I am renewed. I’m not a Pollyanna doc (read the blog), but this has my attention: the practice has changed, and it works.

Hallelujah.

Our unrealistic attitudes about death, through a doctor’s eyes

We all die. Here’s just a snippet from this doctors’ experience:

…Sometimes an estranged family member is “flying in next week to get all this straightened out.” This is usually the person who knows the least about her struggling parent’s health; she’ll have problems bringing her white horse as carry-on luggage. This person may think she is being driven by compassion, but a good deal of what got her on the plane was the guilt and regret of living far away and having not done any of the heavy lifting in caring for her parent.

via Washington Post.

I’ve seen this many, many times in my ED; the child of the nearly-deceased who has been doing all the caring comes in, says essentially ‘let them die comfortably’, then come in the ones who haven’t been doing the work, haven’t seen the daily decline, and they browbeat the first into a retreat. ‘I think I misunderstood, we need to do everything’ they say to me while watching the floor; my job is nothing compared to the needless suffering they’ve consigned their dying parent to experience.

Shame on us for making dying foreign, and not the end of a life well spent.

An open letter to central line packaging engineers

Dear Sirs,

First, thank you for putting all the tools I need into one sterile package, minimizing the amout of running around finding little pieces to start central lines on my patients. (A central line goes into the central venous circulation, allowing the use of hypertonic medications and monitoring of venous pressures to guide fluid resuscitation).

Now, to my gripe: apparently none of you have thought about the order in which these devices are used when starting a line. Yes, everything has a special place, but it tells me you haven’t thought out the actual use of the kit when I have to dig the Seldinger wire out of the bottom of the kit despite its use being necessary very early in the process, and getting it out dislodges many of the other items from their pockets, then making the whole shebang a mess.

Therefore, I offer my assistance in designing a kit that makes more sense when it’s used.

Respectfully,

GruntDoc

FYI, here’s a nicely done animation of how to place a central line:

I do mine a little differently (direct sonographic guidance usually), but this is good for the gist. (The wire is there, but it’s really hard to see…).

Delusions of Benefit in the International Stroke Trial | Closer to the Truth

More TPa for stroke…

Delusions of Benefit in the International Stroke TrialResults of the largest and arguably most important trial ever of thrombolytics clot-busting drugs for acute stroke were published last week in The Lancet, and the study’s conclusions are breathtaking. Not because of the study results, which are unsurprising, but because the authors’ conclusions suggest that they have gone stark, raving mad.

via Delusions of Benefit in the International Stroke Trial | Closer to the Truth.

Well, that’s not good.