The classic model of history, physical, testing, diagnosis & treatment does not apply to us. I think we do 3 things in emergency medicine:
- Risk stratification
- Care coordination
Resus is the fun sexy stuff that we stay up late at night having twitter arguments about. As much as I love ketamine, I can go a number of shifts without using it, and very little of what we do is resus. Most of what we do is risk stratification and care coordination.
Read it. It’s good.
Hint: it’s not good. A terrific article from Weingart and Faust.
If the drafted CMS measure goes into effect, we are hosed. Because data will be collected retrospectively, hundreds of patients will be deemed severe sepsis who were never actually sick.
Government organizations do not invent this stuff. Behind every measure there is, somewhere, a group of physicians that made it happen. Just as medical malpractice would not exist without plaintiff witnesses, these measures would not exist without us. Let’s fight back before it is too late.
Hint: it’s too late. Enjoy the people who wrote the tax code legislating your care.
For a primer, from 2007, here.
Another patient, another absent MAR (if you don’t know that acronym, you didn’t read the lead in article!). Usually they send when we call, but not recently. Here’s an amalgamation of some cases:
Calls are made by the nurses at my behest. The MAR Will Not be Sent.
Per nursing, whom I work with daily and trust implicitly, here are the objections proffered:
1) It’s illegal to send our signatures
Really? No, it’s not.
2) It’s our policy not to send MAR’s
Good luck with that policy. It’s going to get you in trouble.
3) You don’t need that.
As it’s a patient who has a) gotten meds from you and b) that timing is a question and c) we don’t know what the timing is, yeah, we and the patient you sent to us need that.
4) We sent you a med list
Yes, you did. That’s a List of Meds, but we don’t know what’s scheduled, PRN, given, held, parameters, etc. That’s a dodge.
Allow me to quote me:
This is outrageous. A chronically ill patient is sent to a higher level of care for an acute problem, and without a complete information base; but not just that, information crucial to the care of the patient that’s being intentionally withheld.
It is a situation that makes me, frankly, nuts. When did intentionally withholding critical patient care information become acceptable? Seriously, have these people not learned from history? The coverup is always, always worse than the crime, and is looked upon less favorably and punished more severely that any original offense. You could ask Nixon, but he’s dead.
Send me all the info you have, and our patient will live or die based on their problem(s); withhold information I need, and it’s on you, Nursing Home nurses.
– See more at: http://gruntdoc.com/2007/06/nursing-home-mars-sent-to-the-ed-with-all-times-removed-a-new-and-horrible-trend.html#sthash.k1mXnxiK.W4zJDG1c.dpuf
And if you’re from the Texas NH Regulatory agency that emailed me after the first posting, please recontact. I’m ready to send you some facility names going forward.
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