ABEM ConCert prep course recommendations?

This is my renewal year for ABEM, and as you can imagine I just want to take a $1,700 test once (you read that right, that’s my cost to voluntarily take a test to remain Board Certified). (Board Certified rant pending).

What have other ABEMers taken, either as in-home or travel-to courses that you’d either recommend, or scare me away from? I’d actually prefer a travel-to course (fewer distractions), but am open to whatever works best.

Please add a comment, or send me a message through the ‘contact’ form.

I’ll let you know how it comes out.

 

Pride is a Fall Risk

Stick with it.

I’m good at intubating (the procedure by which a tube is passed through the vocal cords into the trachea to assist ventilation). I’m not the world’s expert, and I haven’t written a book about it, but I know what I’m about. I was trained by people who knew what they were doing, and I (and my patients) owe them a debt of gratitude. (Lotta I’s there, sorry).

Very occasionally, I get to help out my partners in Emergency Medicine practice when they’re in a bind with this procedure, and I do.  It’s always fun, and a little gratifying, to ‘get the tube’ when a colleague (and their patient) is in trouble.

As Ron White says, “I told you that story so I could tell you this one…”

Pride goeth before the fall.

I have come to learn that one of the worst sins of a physician is Pride. This is strictly different and separable from confidence, in that confidence is a normal and rational belief in ones self and abilities whereas Pride is based in ego, irrespective of confidence. Or logic, for that matter.

The worm turns, and I’m the one who cannot get the tube in the trachea. I’ve preoxygenated, sedated, RSI’d, and taken 3 tries. I’ve changed tubes, blades (the laryngoscope has differently sized and shaped blades), and patient positioning which are among the things that should be adjusted in the event of intubating failure. The good news? This patient can be oxygenated and ventilated easily with the bag valve mask. The bad? I’m now no closer to getting the airway secured with a cuffed tube than I was when I started.

This is where not having Pride came in: I asked for help. The Prideful EM doc (or the one in solo practice, and I respect the heck out of all of you) will keep trying, and will eventually help the patient and assuage their ego (or their situation) by getting The Tube. This can come at a cost to the patient in airway trauma or worse, and it’s desirable to avoid that.

My colleague physician came in, smiled, and helped my patient and me out of a bind. Colleague made it look ridiculously easy, with a first attempt intubation. Just like I’ve done before…

He was amazingly humble, and didn’t rub my nose in my failure to intubate. I truly hope I’ve been as nice to my colleagues in the same situation. Really, he was as nice as a human could have been while pulling chestnuts from a fire. Mine, to wit.

And I surprised myself by asking for help with a procedure I’m normally good at. No Pride, no Ego, just what’s good for the patient. I’m getting this Doc thing.

 

Emergency Medicine Literature of Note: Yet Another Highly Sensitive Troponin – In JAMA

Wow. Short, and sweet, and painful.

…peddling the same tired phenomenon of magical thinking regarding the diagnostic miracle of highly sensitive troponins…

via Emergency Medicine Literature of Note: Yet Another Highly Sensitive Troponin – In JAMA.

Nice! Go and read.

via @nickgenes on that Twitter thing

The ED of the Future

Let’s say, hypothetically, you could design the ED of the Future. I say hypothetically as there may be a new (like New) ED in my future. Maybe; it sounds like a heck of a challenge. Considering we’re a Trauma Center and currently see nearly 100K/year in volume, and have an admission rate that’s between 18-35%,

What would that new ED look like, from the following viewpoints :

  • the patient
  • the triage nurse (is there one?)
  • the treating nurse
  • the ED doc
  • the consultant
  • the hospital admissions team (billing)
  • the OR
  • the Tele units
  • the Floor units
  • ED discharge areas
  • physical plant

I have a few ideas, but am frankly hamstrung by a lack of ‘out there’ imagination. Let’s hope you’re not similarly limited. Don’t feel like you need to answer all of these, but I’m interested in your ‘out of the box’ ideas…which you’ll get full (if ephemeral) credit for.

Xigris Pulled from Market

The irony here is that Eli Lilly has advanced sepsis care (as a prelude to using their drug), and while Xigris hasn’t panned out, aggressive sepsis resuscitation has.

Eli Lilly is withdrawing drotrecogin alfa (Xigris) from all markets worldwide after a major study failed to show a survival benefit for patients taking the drug.

Xigris should be discontinued immediately in patients currently receiving it and should not be started in new patients, the company said.

The trial with the bad news on Xigris was called PROWESS-SHOCK, a placebo-controlled study with 28-day mortality as the primary outcome and planned enrollment of nearly 1,700 patients.

via Medical News: Sepsis Drug Pulled from Market – in Product Alert, Prescriptions from MedPage Today.

At ACEP the reviewers of this study said it favored placebo over Xigris. Tough to market a very very expensive drug when not using it is better…

Best of my ACEP 2011 Twitter feed

If you don’t follow me on twitter, you missed my play by play of the recent ACEP 2011 Scientific Assembly from San Francisco. Several of us attending twittered (and it was terrifically entertaining to meet them and socialize)!

These are trimmed from my tweets ( http://twitter.com/#!/gruntdoc ) and should you be interested, all the Scientific Assembly tweeters were using the hashtag #sa11.

My rough count for the ones I included here is 95. Some are more interesting than others. Enjoy.

Asplin says its harder to collect from high deductible/HSA pts than from self pay. Seems odd. Asplin

1% of population accounts for 30% of all spending in a given year, 5% account for HALF. 20% spend nothing. There’s your problem.Asplin

Understatement: there’s a gap between the vision and the reality of the Medical Home. Asplin

ER docs make the most expensive routine decision in healthcare: admit or home? We have little to no control over readmissions. Asplin

[Read more...]

ACEP Scientific Assembly 2011

It’s in San Francisco this year, and starts in the morning. While I’m NOT a morning person I’m going to make as much of it as I can, as the lectures are good, and worth the time.

I plan to live-tweet my conferences tomorrow, so if you’re interested follow along on Twitter @gruntdoc. Last year I had more than 200, and some people liked them. We shall see, some lectures, and lecturers, are more quotable than others.

Yes, people watching here.

Really good Ultrasound in EM case

Via hqdmeded.com:


20 yo M with “abscess” from hqmeded.com on Vimeo.

To Admit or Not to Admit? That is the Question. | WhiteCoat’s Call Room

Gastroenterologist Michael Kirsch put up a post on his blog that was then reposted over at ACP Hospitalist asking where the threshold for admitting a patient to the hospital should be.

He asserts that there should be more collaboration between medical colleagues to determine whether or not a patient needs to be hospitalized…

via To Admit or Not to Admit? That is the Question. | WhiteCoat’s Call Room.

Another WhiteCoat tour de force.

Overhead, overheard

“Would any EMS unit that can leave, leave now? We’re out of bays.”

When you run out of EMS bays (and we have several), you’re having a bad day.

In Fort Worth, MedStar’s Community Health Program cutting costs, improving patients’ well-being …

Kudos to MedStar (our Fort Worth EMS provider) for their excellent work on this project:

 

The Community Health Program was started in 2008 after MedStar officials discovered that 21 patients were using a big chunk of ambulance and emergency department resources. Those patients triggered more than 800 ambulance calls and cost the system more than $962,000 in charges, most of which were never collected because the patients lacked health insurance.

Nine of the 21 were selected for the program. They experienced a 77 percent reduction in their need for services during a 30-day test.

via In Fort Worth, MedStar’s Community Health Program cutting costs, improving patients’ well-being ….

Caffeine? Who needs caffeine?

I walked into one of my first patients’ rooms last the other night, and saw this 3 Lead strip sitting on the counter:

It was for a different patient.

Took me a minute to recover, though…

Compression Only CPR video

Okay, it’s kind of amusing, and I hope it induces someone to learn compression only CPR. Which is WAY easier to do, and teach, than what I started with back in the day (15 compressions, 2 breaths, rinse/repeat).

But if this makes Disco come back, is it worth it?





via Ace.

The Case of the Crazy Rabid Squirrel | WhiteCoat’s Call Room

Read the rest, and wonder. Others practice risk-avoidance to the ED, and then we wonder why our patients are unhappy and give us poor scores.

Man and squirrel fight it out in man’s driveway. Squirrel scratches him twice, man runs inside grabs BB gun and plugs squirrel ala Elmer J Fudd. Man then calls health department for advice about what to do. Health department tells him to go to ED for rabies shots.

via The Case of the Crazy Rabid Squirrel | WhiteCoat’s Call Room.

Dr. Perfect | WhiteCoat’s Call Room

…Actually, statements like that do serve one purpose. They make it a pretty good bet that none of the doctors in our department will ever refer another patient to you or your your hospital…

via Dr. Perfect | WhiteCoat’s Call Room.

Sing it, brother.