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.

My first medical checklist

Laugh if you want, this helps my life, at least at work.

For months after starting my current gig, I would sometimes get to work with everything in all my pockets, and sometimes not.

I’d forget my ID, or my pen, or my phone, or my…well, there you go.

Then my OCD started to kick in, and, a Mental Checklist was born.
I now have to get 6 things, and set them on the table or I screw it up every time.

  • ID
  • stethoscope
  • my phone
  • work phone
  • pen
  • sharp stick (I’ve written about this before, but cannot find it. You should search an ER blog for the word ‘knife’ and then wonder why you bothered).

Last week I apparently went against the checklist, and halfway through the shift realized I’d lost my ID. Of course, after about a combined half-hour of fruitless search I gave up, and found it in my bag on the way out. Geez.

Yeah, it sounds stupid. But if it’s stupid and it works, it’s not stupid.

 

 

Medical Apps? There’s a Doc for That

When emergency physician Harvey Castro asked a nurse to start a dopamine dose for a hypotensive patient one day, he watched the nurse leave the room, find the book that could guide her to the titratable dose, look in the index and then flip through until she found what she needed. Castro wondered, Isn’t there a more efficient way?

via Medical Apps? There’s a Doc for That.

A fellow DFW doc who’s done well in the Medical App world ( Deep Pocket Series ).

Dr. Castro was nice enough to let me play with some of his apps about a year ago, and while I never found a big use for them (my practice style, no knock on him) they were well done and approachable for me.

Kudos to Dr. Castro!

Attention ABEM Diplomates: LLSA now comes with (additional cost) CME!

This may be old news but I found out about it today, in an email from AAEM:

ABEM 2011 LLSA CME ACTIVITY APPROVED FOR “AMA PRA CATEGORY 1 CREDIT™”

The “new” ABEM 2011 LLSA CME Activity is now available to Diplomates preparing to take the 2011 Lifelong Learning and Self-Assessment (LLSA) test. LLSA tests are one component necessary for maintaining certification with the American Board of Emergency Medicine (ABEM). Upon completion of the CME Activity and a passing score of 85, Diplomates will be able to earn “AMA PRA Category 1 Credit™.”

Here’s the complete ABEM press release as a .pdf file.

How much CME? 15 hours (.pdf file). It’s way better than nothing, which was what we got before, and the cost of this CME is an additional $30, so it’s very reasonably assessed.

The ABEM site is full of warnings that you MUST register for the CME FIRST in order to get it; start the LLSA, then remember you wanted the CME? Too bad.

Here’s a screenshot of my ABEM page, and I’ve highlighted the new CME box:

CME for the 2011 LLSA!

I added the highlights, but it’s not hiding, so as long as you know to do it in advance you’re better off than before.

Two more things: First, I’ve been pretty hard on ABEM for requiring these yearly tests with nothing but a self-printable certificate and the opportunity to take more tests, so this is a welcome change. It’s several years too late, but at least it’s here now, so a half-a-kudo to ABEM for getting this belatedly right.

Second, I haven’t said anything (I don’t think) but my favorite LLSA study course is the one given by Drs. Abrahamian and Lovato from UCLA-Olive view, called MEGA-LLSA. It’s well organized, entertaining, and they have it all figured out. I have done my last 4 or 5 years’ tests with them, and provided they have their March course in Disneyland again in 2012 I’ll be there for that one. I recommend it. (A caveat: their communication between paying for the course and the starting place/date/time is poor to non-existent; plan on having to scout out here in the hotel the course is yourself, and showing up early to ask when your class starts…).

Movin’ Meat: Medical Malpractice Self-Insurance — Is it right for your group?

ShadowFax is doing all EP’s a favor by explaining one of the more frustrating, and opaque areas of Emergency Medicine, group insurance. His group self-insures (apparently), and he knows way way too much about it:

One of the more painful elements of running a group practice is the ritual abasement before the god-like executives at the insurance company annual malpractice insurance re-bid. It’s kind of like a visit to the dentist: guaranteed to be uncomfortable and with the potential for a very unhappy surprise. Also, it leaves your face numb and drooling. The only thing that matches it in pain is writing the check every quarter, year after year, and then looking back at your actual, you know, losses, and seeing that you have paid for insurance way way more than you ever lost in liability claims. It’s got the all visceral satisfaction of lighting a pile of money on fire.

via Movin’ Meat: Medical Malpractice Self-Insurance — Is it right for your group?.

He’s got another, just as informative follow-on post, and the promise of at least one more. Frankly, it’s a primer for groups who are considering this (and AFIK, mine isn’t).

I take my job for granted

until a student of medicine shows me it’s unusual…

We have (mostly) non-EM studs rotate through our ED on their sometimes mandatory, sometimes killing a month elective ED tour. There is little reason for EM destined students to rotate in our place, as we don’t have a residency and we’re not part of the club of EM residency directors ( i.e. letter of rec writers). So, usually not EM hard chargers. Nothing wrong with that, but they’re not my cuppa tea.

Today’s lesson: shoulder reduction for the non-EM Stud, and for me in What We Do Isn’t Usual.

As is our norm, after a thorough Hx, PE, Xrays and Time Out, was in on a 2 doc reduction; One does the sedation, one the reduction. I don’t typically have students follow me: I don’t dislike the students, but I don’t have them. Personal preference.

Today, a shoulder reduction. My colleagues’ student. Not destined for a life in the ED (already matched, not in a remotely EM specialty). My colleague is on the sedation, and I’m on the reduction. I, after discussing the technique, in my presence and under my direction, allowed the stud the first attempt at reduction after sedation. No go. Good effort, not enough muscle.

Second attempt was mine, and when we got the happy “clunk” (with the accompanying interesting sound), I was happy but the Stud wasn’t. While not actively vomiting, the Stud wasn’t uber-happy. At all. Wide eyed, in fact. Unpleasantly surprised, in reality.

After a period both the patient and the Stud recovered. One with a shoulder that’ll work, and one with an appreciation for what it takes to reduce a dislocated shoulder.

And I got the indirect lesson, that what I do isn’t common, and is actually a skill.

Students teach, too.

Thank you for the lesson.

 

 

This is what one kind of stroke looks like

Update 2-17-11: Not a stroke, thank goodness, but a stroke mimic, a complex migraine:

LOS ANGELES — A TV reporter who lapsed into gibberish during a live shot outside the Grammys suffered a migraine, her doctors said Thursday.

KCBS-TV reporter Serene Branson was doing a stand-up Sunday outside the Staples Center where the award show was held when her speech became incoherent. The station quickly cut away, and she was examined by paramedics and recovered at home.

Branson’s incoherence fueled Internet speculation that she suffered an on-air stroke. But doctors at the University of California, Los Angeles where she went to get a brain scan and blood work done ruled it out.

I’m glad for her. The smart move is to assume this is a stroke until proven it’s not, and I’m glad it wasn’t.

Original Post:

The site I found this on assumed it was on-air jitters, and called it ‘the flub heard ’round the world‘.

Except it’s not a flub. This is one way a stroke can present (watch the video, it’s short and unforgettable):
I cannot suppress the autoplay, and for that reason the video and the rest of the post is below the fold. Apologies.
[Read more...]

The trouble with observation in medical settings

I have experience with this, from both sides. Both involve hand-washing. Still, a clean story.

Washing of hands is the right thing to do for health-care providers, between seeing patients, for infection control reasons. And, I’ve gotten ‘the letter’ from a VP charged with signing them, citing me for not washing my hands between patients.

Except, I did. This is the problem with observational medicine.

Several years ago I saw a patient at the end of an irregularly-shaped hall, which has an alcove area at the end. There are alcohol dispensers there, I used them on the way in and out of a patient interaction there. That wasn’t enough for the observer: she veritably gloated ‘I got you’, meaning she got me not washing my hands into/out of a patients’ room. (I’m not perfect, nobody is, and I’ve probably botched this somewhere, but not here; I knew she was there, but didn’t think she was dense. I was wrong). I pointed out there are dispensers out of her vision, to no avail. I got the letter from the VP who hasn’t touched a patient in a decade, and oh well.

I think of this sometimes, as my ED’s Fast Track was not designed, more just cobbled together from available space and good intentions. The resulting arrangement has the doc station less than an arms’ breadth from the primary patient restroom. To say this affords ample opportunity for totally unavoidable observational medicine is an understatement. Trust me, we’d love to avoid it, but that’s not an option.

We’d love for the count from fully audible flush to door opening ot be, oh, a 6 count: long enough to reach the sink, run some water over the hands, then hit the door. (Problem: we cannot hear the water run in the sink, or it’s never happened, so we prefer to think we cannot hear it). Yeah, it’s Usain Bolt speed, but that’s preferable to the alternative, no washing. And yet, speed like that is hard to believe from the general ED public.  It doesn’t happen. Flush, door open within a 4 count. Nobody dries their hands on their pants, like, you know…people in a hurry.

So, given my experience, I’m forced to accept the alternative: people clearly wash their hands, then flush, then exit the bathroom with super-dry hands. Yes, it goes against everything I know about humans and the behavior, but then so does the majority of the ED population.

It’s the trouble with observation in medicine.  It’s unreliable.

(In case you’re slow, this isn’t an indictment of my patients, it’s about hand washing observation and its limitations). (I might not be the clever writer I imagine).

Tats and lacs

I like lacs (lacerations).  It’s bread and butter in EM, and it’s a way to demonstrably help a patient immediately and visibly.

Visibly is where the tattoos come in. While I don’t have any skin art, many of my patients do. It’s interesting how many lacerations go through my patients’ tats.

While with the USMC in Okinawa, a patient went through a window. Whether he jumped or was pushed was a point of contention, but that mattered not to me. What did matter was the roughly 2 foot long, razor-straight laceration of an upper-through-to-lower arm, going through an ornate tattoo.

Due to the natural stretch of skin (Langhers’ lines) when skin is cut it doesn’t fall one side to another like a steak, but will ‘spring’ into different directions…. which makes deciding what to tie to what a little complicated.

Unless there’s a picture embedded into the skin. Then, it’s a relatively easy ‘connect the dots’, putting the picture back together.

I spent the better part of a couple of hours doing my best, and in the end even the patient was happy with the result. He did say that he’d get it touched up after it healed… (Someone educate me here, how do scars take tattoo dye)?

Yes, lacs happen, and we try to make the resulting closure first functional and then as cosmetic as we can. The tats make it a lot more interesting.

Want To Avoid Unnecessary Tests? Stick To One ER, Researchers Say – Kaiser Health News

On a recent Friday night at the Boston Children’s Hospital ER, Dr. Fabienne Bourgeois was having difficulty treating a 17-year-old boy with a heart problem. The teen had transferred in  from another hospital, where he had already had an initial work-up – including a chest X-ray and an EKG to check the heart’s electrical activity. But by the time he reached pediatrician Bourgeois, she had no access to those records so she gave him another EKG and chest X-ray. He was on multiple medications, and gave her a list of them. But his list differed from the one his mother gave doctors, neither of which matched the list his previous hospital had sent along.

via Want To Avoid Unnecessary Tests? Stick To One ER, Researchers Say – Kaiser Health News.

This is excellent advice.

Every ED has seen a patient, probably today, with “they saw me at the ER across town, but they didn’t do anything and I’m still sick”.  While it makes some sense not to return to a restaurant that gave you a meal that wasn’t to your tastes, medicine is quite different.

If a patient gives me this history, I now have a blank slate, and need to essentially start at zero with them.  So, I will do the correct workup to exclude the life threats based on the history and physical exam, which may be exactly the tests they had yesterday.  I’m not going to assume they did the same tests, or that they were normal.  It’s the standard of care at this time, and I have very very few alternatives.

Let’s flip this around: it’s a patient we saw a day or three ago who comes back to us and says “I’m not better”, that’s so much better for the patient, and us!  We have immediate access to their records and tests, and will not have to repeat studies we already know the result of.  Therefore, the patient avoids unnecessary testing, and gets better care.

Yes, you say, you could get the records from the other hospital, and the answer is, maybe, someday, better during M-F business hours (when hospitals are set up to work, still), less on Sunday AM on a 4 day weekend.  Someday EMR’s will be inter-operational, but frankly that’s going to require legislation as hospital systems want to own ‘covered lives’ and they see contro of medical records as proprietary information as theirs and theirs alone.  (Also, who’s going to spend money to give away their information)?

So, stick to one ED.  Yeah, sometimes you have to go back a couple of times.  That’s okay.  It’s the right thing for you.