ACEP 12 tweeting: Bukata and Hoffman

Those who don’t follow me on Twitter probably have calm, productive lives. Those who do wonder why I twitter at all. Because it keeps me busy and engaged, that’s why.

Here’s an edited compilation of two of the American College of Emergency Physicians Scientific Assembly 2012 lectures in tweets by me from Denver. These encompass about 3.5 hours of lecture by the same two legends, Jerry Hoffman and Rick Bukata reviewing the medical literature as it applies to EM.

I used Storify to put these together (it couldn’t have been easier). I left out a lot of comments from others, not as they weren’t interesting but as I’m trying to tell the story of this lecture.

At the end there’re some pictures of the Twitterers and Bloggers who get together after ACEP. Nice how we’re birds of a feather. For a bonus, at the end are Joe Lex’s 4 Rules of Emergency Medicine, which deserves its own compilation.

Colorado Mass Shooting Tested an E.R. Staff – NYTimes.com

Wow. Amazing.

AURORA, Colo. — More than three weeks have passed, but Daryl Johnson still begins his emergency room shift at the University of Colorado Hospital here with a sense of foreboding.

via Colorado Mass Shooting Tested an E.R. Staff – NYTimes.com.

And horribly frightening. I pray I spend my entire career and not have a night like that.

Chief Complaint of the night

[blackbirdpie url="https://twitter.com/gruntdoc/status/234183229823922177"]

A ten year doc’s advice to newly graduated EM residents…

Recently, I blogged about being at my new job for 10 years. It was a wonderful experience to blog about stability. It’s also illuminating I’ve been here for 10 years and still call it my new job.

Not long after the blog post went up, I got an email from a soon to graduate Emergency Medicine resident who was curious as to what techniques I have used to stay at the same job for 10 years. This caused me some consternation, as I don’t think I really had an actual plan to be at the same place for this period of time. Emergency medicine practitioners are not known to stay in the same place for a long time, so blogging about a 10 year stay is something of an anomaly.

When I was a resident the common knowledge given was that it was important to serve on hospital committees, and to otherwise do a good job and you would be recognized and your life would be fine. This may or may not be true for everyone. I did find that I was on hospital committees, but it was after I’d been here for more than eight years and was interested in serving on them. One of the unusual things about my group is that there is extraordinary longevity, and I’m still basically middle of the pack having been here 10 years. I realize this is atypical for emergency medicine, but I think it will become more normal to have more job longevity as the emergency medicine field matures, and as there are more graduating residents.

What you’ll find helps you in the long run in emergency medicine is being a good colleague to the medical staff. This is somewhat antithetical to the way we’re trained, which is this low-level combat between departments, but ultimately the rainmakers talk to the hospital President, if your group isn’t making it some other group will. This does not mean you have to be a doormat but it does mean that when a consultant calls and asks you for a favor if it’s not unreasonable you should do it. This isn’t bad medicine, this is actually good medicine because you’re helping a smart colleague help out their patient. This service does not go unnoticed. In fact, if you want to stay in your place for a long time, be known to be helpful.

Being competent, you’d think, would be a given; you’d be wrong. Being competent in your job, and collegial with the nurses and staff, goes a long way to being accepted as one of the group and being one of the group means you get to stay.

Nobody wants their doctor to be having a bad day. Nobody who works there wants the ER doctor to be having a bad day. It doesn’t matter that your cat threw up in your shoes, or that your underwear is too tight, you have to try to get along. I’m not going to lie to you and tell you that I’m all roses and sunshine but I’m trying every day to get better at this.

Your reputation is set early, take advantage of that. I have a reputation for always being early; these days I’m about on time. For the first six months, I was about 10 to 15 minutes early for every shift. But, since I was always early initially, my reputation is set. On the same theme, as a colleague says, two minutes late is not on time, it’s very very late. When you’re working your tail off, you don’t want to be wondering when your relief is coming in. You’re very important; so is every single person you work with. Never forget that.

New grads are always interested in, and worry about, hospital politics. Here’s the short version of hospital politics in your first two years of practice: don’t make the directors’ job hard. That’s all you have to do. Just show up, work, practice good medicine, and don’t make the director’s job hard. The director is in that position for a reason; as a matter of fact, they’re so smart they hired you, so you should give them the benefit of the doubt when the iffy call comes out. They don’t want you to bother a certain specialist after a certain time; there’s a reason for that, and you should have a conversation behind closed doors, not at the nurses station.

And, when you do finally step in it, and make the mess that’s going to show up on the directors desk sooner or later, you need to be the one that has the conversation with the director first and they don’t need to hear about it from anyone else. This is basic leadership and you need to get on board with it. If they have the facts, and have your side of the story good or bad, they can help you; if they get called on the carpet and have to defend you not knowing your side of the tale, you will not come out the better for the experience. This is just the way of the world, it’s been the same way since you got punished for your brother knocking over the lamp. Help the guy who’s got to help you.

Also, when you show up, you’re going to be full of new knowledge. This doesn’t mean you’re smarter than the group, this just means you got out of training more recently. Use your new power for good and not for evil. And as you’ve probably guessed, there are about 30 ways to skin a cat, and you got trained in two. Keep your eyes open, and learn from your colleagues. They want to help you, let them help you.

Finally, have a life. Don’t spend all the money, put some away, as you may be like me and have to change jobs the first year. It happens. It happens to a lot of us; this doesn’t mean you’re bad it just means it was a bad fit. Keep trying.

Most of that was platitudes; sorry about that. The realty is if you’re a good person, do a good job, and play well with others you’ll be fine.

 

This was written with the new Mountain Lion operating system for the iMac; it was dictated and now you know that I don’t speak well.

 

Ottawa ankle rules and me

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This reminds me of my experience with the Ottawa Ankle Rules in the Navy.

USMC Infantry is designed to generate ankle sprains, and recurrent ones. Initial sprains as young athletic hard chargers are required to carry big loads over unimproved terrain in the dark, plus seemingly all the time not in direct training was spent running.

The larger problem, and one I was educated on by a fellow BN Surgeon (who was a physical therapist prior to med school) while in Okinawa is that there’s no ankle rehab after a sprain. As soon as you can run on it you do, despite having torn stabilizing ligaments and not having done the training and exercises to get the ankles’ accessory stabilizers up to speed. Then, another sprain. The story of how our medical department got this fixed later.

Sick Call was musculoskeletal city with daily ankle sprains, which by that time in the Marines were usually recurrent. About a year into my assignment, out came the Ottawa Ankle Rules. After a year of negative x-rays, finally, a clinical tool to cut down on useless imaging! I used it in practice, taught it to the Corpsmen (who also found it usable and liked it) and our x-ray utilization dropped hugely and AFAIK we didn’t miss any significant fractures. I was proud.

I was moonlighting (for free, I was that bored) in the Camp Pendleton Naval Hospital ED, and mentioned my new practice and how I was proud to have made an impact.

The response: Please stop doing that. Now when they get off duty they drive down here to get an x-ray”.

Humbled, we backed off a little, but not much.

My response to the above tweet (which I now think I recall as being an @nickgenes original) was “Canadians get exams, Americans get x-rays”, which sums it up nicely.

 

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.