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.

The Milwaukee Rabies Protocol

In case you wondered what was required to diagnose, and how to treat potentially successfully, rabies.  This is from the place that had a neurologically intact survivor (some damage but functional, which beats the norm).

The Milwaukee Rabies Protocol (.pdf)

via Notes from Dr. RW

Balkans.com Business News : One in two emergency care doctors will suffer a burnout during their career

One in two emergency care doctors will suffer a burnout during their career, according to a survey of French physicians, published online in Emergency Medicine Journal. The research was funded in part by the NEXT NURSES’ EXIT STUDY (‘Sustaining working ability in the nursing profession – investigation of premature departure from work’) project, which received more than EUR 2 million under the ‘Quality of life and management of living resources’ Programme of the EU’s Fifth Framework Programme (FP5).

The responses showed that the prevalence of burnout was high, with 1 in 2 emergency care doctors identified as suffering from it, compared with more than 4 out of 10 of the representative sample. Physicians had the highest burnout rate in the two age groups, between 35 and 44 and between 45 and 54.

via Balkans.com Business News : One in two emergency care doctors will suffer a burnout during their career.

Expectedly, it’s International…

Movin’ Meat: Market Economics in Action

… All of a sudden, we started seeing large numbers of herion users, many of them “novice” injectors, still using their veins. Most of them were pretty frank that they had only recently started using heroin, and few of them had any record of ER visits for drugs in the past. So, amateur economist that I am, I started systematically asking the heroin users how long they had been using, whether and what they had used before, and why they changed. …

via Movin’ Meat: Market Economics in Action.

Excellent post about economics in action, as seen by an Emergency Medicine physician.

Nice one.

FWIW, Fort Worth is mostly a cocaine town, with a smattering of meth and black tar heroin only once or twice a year.  AFAIK, our Rx drug problem is hydrocodone (sorry about that word, spam filter, you’re about to get a pounding).  I think Oxycodone and its ilk being Schedule II in Texas, requiring different State prescription pads, has kept that class abuse down (some).

The NNT | Quick Summaries of Evidence-Based Medicine

The NNT | Quick Summaries of Evidence-Based Medicine.

I think I blogged this before, but didn’t describe it much.  Allow me to rectify that mistake.

theNNT.com is an ever expanding site which boils down high quality reviews of medications and interventions, and presents its recommendations in a very much more approachable grren/yellow/red/Warning triangle format rather than some ratio.

While I won’t use this as a single source to change my practice I’m going to have to do some more research on some ofht eh shibboleths of our age ( Octreotide for variceal bleeding, PPI infusions for Upper GI bleeding, etc) are just two of the studies that fly in the face of current practice.

An aside: while inhaled corticosteroids for asthma aren’t beneficial in the review, what it doesn’ tell you is that the Feds think it does, and will grade your asthma care on how many of your asthma patients get a prescription for them.  So, be aware.

Graham is behind this, and good for him.

You know that patient you saw yesterday…

…another in a series.

“You know that patient you saw yesterday?” was how the conversation started.

I did remember, it’s not often I Find the Pony, diagnostically.  A good case, which from my aspect means I had to think, act, and make things happen. Yesterday I was quite pleased with myself.

Now the ‘do you remember’ intro. Never good. Never.

A colleague tells me how the patient I saw yesterday (and made a couple of good, if odd-to-present-at-the-same-time diagnoses) died while getting an x-ray study, in the ED, when one set of their symptoms returned. (Sorry for the vagueness, thank a room full of lawyers who are afraid of their shadows and have rubber sheets).

Darn. The day before, the patient was doing well, thanks to a good diagnosis and getting the right people to buy in and act. And now my patient is dead, from one of the same diagnoses.

Lifetime death rate: 100%. I do what I can, we all do.

But 100% is an absolute. Sorry.

Knowing when it’s That Time

Knowing when to stop trying to save people is hard, especially when that’s how you’re trained, and innately wired.  It’s been a frequent theme on this blog.

Movin Meat has a good post on the subject today (weeks ago, just found this in my drafts folder), and it’s remarkable for two reasons.  First, it’s a well written account of doing the right thing, even though that’s much harder than the easy thing, and secondly, the power of convincing medical writing to influence the actions of physicians.

Movin Meat specifically cites thinking about the recent Atul Gawande piece in the New Yorker, which helped him make sure the option of how to die was presented to the patient and family.  That’s good writing, and it’s something the world could use more of (as long as it’s not preachy, or gratuitously political).

The World Death Rate is steady at 100%.  There’s nothing at all comforting, comfortable or holy about dying on the vent in the ICU.  Talk with your family about what you do, and don’t want.

Drunks More Likely to Think You’re a Jerk | Wired Science | Wired.com

If you’ve ever had one or 10 too many drinks at a bar, you’re probably familiar with this scenario: a drunk guy stumbles past you, spills a beer all over you, and you get angry. You’re convinced he did it on purpose, and you start fuming. According to a new study in Personality and Social Psychology Bulletin, you’ve probably fallen victim to one of the many side effects of booze: assuming that others’ actions are intentional.

via Drunks More Likely to Think You’re a Jerk | Wired Science | Wired.com.

That explains why the intoxicated patient in the ED is very often the disruptive one who gets way out of proportion angry with the very simple rules / requests in any ED.

Now, if they had a cure, or IV Insight, we’d be all set…

ACEP Scientific Assembly 2010 wrapup

I was a little concerned about whether I’d like going to the big yearly ACEP meeting, as I went to a couple of the spring conferences and found them lacking in experience, but the last of those was last several years ago.

This time I decided it was the right thing to do, and hoped I’d be able to socialize a bit.

Mandalay Bay was very nice, if laid out Texas-sized.  It was a 10 minute brisk walk (all indoors) to the three story conference center, which was nice and cool despite the reportedly radioactive heat outside.  There were a lot of exhibitors, and they were knowledgeable and professional.

First, the personal highlight, meeting the EM medbloggers!  I got to meet Shadowfax of Movin’ Meat, Nick of Blogborygmi, Graham of Grahamazon (and now The NNT), Symtym, Richard of his epononymously named effort, and WhiteCoat of Whitecoat Rants (who I thought had acromegaly, as opposed to Shadowfaxes’ remembrance of him as a little person…).  (We tried to take his picture but apparently he’s natively pixellated…).  We had individual and group meetups, and except for being remarkably better looking than the other attendees you couldn’t pick us out of a crowd.  Mark and Logan Plaster of EP Monthly were of course very nice (and flattering), and I also got to meet Edwin Leap, but I’m not sure he knew who I was as I didn’t use my pseudonym…

I also enjoyed the Fresno residency get-together, catching up with resident friends and faculty.  There’s something about those friends – hadn’t talked to some in years, and we picked up like we’d last talked 30 minutes before.  It’s probably the shared intense years, but it was remarkable.

Surprisingly, a few people at the meeting had heard of my blog, and one, who was also twittering from the same conference sought me out to have our picture made together!  It was interesting, fun, and humbling.

Speaking  of twitter, I tweeted the meetings I attended (I was tired and bagged the Friday morning meetings), and I guess I went a little tweet-nuts: according to @takeokun I had 281 tweets for the Tuesday, Wed and Thursday meetings.  I tried to post the highlights of the meetings; you can take from that number there were an awful lot of highlights!  For my tweets, which are part of my normal twitter stream look here, and for all 826 tweets from the Scientific Assembly, look for them under their hashtag: #sa10.

I wanted to hone-down the true practice-honing pearls, but there are so many I’ll just throw out the ones that come from the top of the mind:

  • single unit blood transfusions are now perfectly fine, the ‘two-unit rule’ is dead
  • hip dislocation reduction: use the Captain Morgan technique. Stand beside the bed, fix the pelvis to the bed, put your foot on the bed, put the patient’s affected-limb calf over your leg (right up to the knee), and reduce by flexing your ankle.
  • nursemaid’s elbow reduction: hyperpronation, not the supinate-flex manouver.
  • to more easily reduce an ankle dislocation, flex the knee first
  • in ITP, you can give Rh POS patients rhogam (the antibodies coat the platelets and help prevent splenic sequestration and destruction)
  • 90% of pts held in both ED hallway & upstairs hall preferred upstairs. “we think the other 10% liked being able to go smoke”
  • “medicine is acting for ugly people” – Greg Henry
  • Key clinical picture in thyroid storm is a tachycardia way out of proportion to their fever.
  • Lid lag in hyperthyroidism: see the sclera when pt looks down, think hyperthyroidism.
  • In thyrotoxicosis can use Li instead of iodine if they’re intolerant, as it has the same mech of action.
  • “if the patient sees nothing and the doctor sees nothing, think retrobulbar neuritis”.
  • “before you write anxiety as a diagnosis, remember, people get real anxious just before they die”.
  • “I don’t understand why you would pay money to have someone rub your back; I understand why you’d pay to rub your front.” Greg Henry.

You get the idea…

I had fun, and will be going next year.  We need to get more attendees twittering the meetings they’re in.  (My iPad was the perfect tool for the job).  EM docs, get ready for next year, and get ready to twitter while you’re there!

Texas (National, really) issue: qualifications of your ER doc | Houston & Texas News | Chron.com – Houston Chronicle

Texas is at the center of a heated national battle over the training emergency physicians need in order to advertise themselves as board certified.

At stake is the welfare of patients requiring immediate medical attention. Leaders of the traditional board say allowing physicians without proper training to advertise themselves as board-certified would mislead the public. Leaders of the alternative board say the proposed rule change will undermine the ability of Texas’ rural hospitals to staff their emergency departments with board-certified ER physicians.

A final verdict may only come, given one board’s already delivered threat, in a court of law.

via Texas issue: qualifications of your ER doc | Houston & Texas News | Chron.com – Houston Chronicle.

At stake also are the careers of a lot of practicing Emergency Physicians, many of whom I’m proud to call friends and colleagues.  (And it’s not just docs at rural hospitals, they’re in nearly every ED in Texas, and your lesser state).  They practice high quality Emergency Medicine, and I have no qualms about the practice of those who are alternately boarded.

I’m a residency trained, BCEM doc, so I’m in the group that’s considered Board Certified by definition.  I’m also still in the minority in US ED’s.  The majority are ‘alternately trained’ docs, the vast majority of whom always wanted to practice EM but either there was no such training when they finished med school, or the few EM programs were full.

Most are FP or IM trained, have worked hard and have been and continue to be ED and hospital leaders.  Again, I’m proud to have them as friends and colleagues, and have no questions as to their abilities.  They’re not interested in practicing EM for a few years then establishing a private practice somewhere, they’re EM docs, who didn’t do EM residencies.

In an ideal world would I like all docs in the ED to be residency trained as a requirement?  Yes.  Is that at all practical?  Not unless you want to close a whole lot of ER’s across the country, and the rural ones (where there is arguably more need for an EM doc who knows what they’re about) would be the first to go.

EM is either the newest or the second newest specialty in medicine, and for a primer on the brief history of EM, look here, (and there appreciate the spirit and the gamble that made my specialty):

Unlike the residents of today, those physicians who pursued Emergency Medicine residency training in the early 1970’s faced an uncertain future. They had no opportunity to be certified by a specialty board, and had no guarantee their chosen field would persist. They were pioneers and mavericks in spirit and action.

Now, about the Board Certified thing…

The reason this is an issue is the recognition that physician credentials are important (they are), that it’s desirable for physicians to be Board Certified in their chosen specialty field (it is), and the public is becoming more sophisticated about who’s trained in what (good).  The reason this is a problem is that as of now the only ‘officially approved’ path to Board Certification in EM is to complete a residency, as the ‘practice track’ to grandfather other-trained docs closed in 1988.  It had to close eventually, there would always be some people stuck no matter the chosen date, but it’s done.  (I now think it was closed too early, but that’s not under my control).  Every medical specialty has had the same issue, the conversion from docs who filled a need to specialty-trained specialists in their field.

In 1990 Texas had one EM residency, taking either 6 or 8 residents per year (3 year program) in El Paso.  Texas then had a population of nearly 17 million.  Most EM docs I know work hard, but that seems like a pretty steep workload for those 6-8 grads a year.  (There are now 8 residencies in Texas, with at least one more opening in 2011).

Therefore, Texas ED’s have been staffed (mostly) with other-trained docs who only wanted to practice Emergency Medicine.  A few did the then accepted thing of working ED shifts to supplement their income while they built a private practice then bowed out of the ED, but most didn’t.  Most worked, many ‘grandfathered’ into a specialty that literally developed as they practiced, and more and more residencies in EM started.

So, the practice track closed several years ago when there were nowhere near enough EM training programs for the demand.  These docs worked hard, but needed to demonstrate they were EM pros.  Enter the ABPS which provides Board Certification through an alternate pathway, thus they’re often referred to as ‘alternate boards’.  per their website:

must have practiced Emergency Medicine on a full-time basis for five (5) years AND accumulated a minimum of 7,000 hours in the practice of Emergency Medicine and maintained currency in ACLS, ATLS, and PALS.

In any career, if you’ve been able to do it for 5 years full time you’re good enough to be recognized as able to do it long-term.  Alternate boards are the only path open to anyone who practices EM but wasn’t grandfatherable in the late 80’s.

(My issue with alternate boards is those 5 years of independent practice as an EM doc without EM training, which I’m not a big fan of, but I cannot come up with a reasonable / workable alternative.)  (And stop it with the ‘they should go back and do an EM residency': it’s economically unfeasible both for the residency and the doc, and that would cause a shortage of EM docs as they’d be a) in residency and b) taking slots from new med-school grads who also want to do EM).

I think Texas should accept ABPS Boarding of EP’s for the foreseeable future, with the recognition that in 10-20 years it’ll need to be re-addressed as the number of residency grads is able to take up the slack in US ED’s.  There should not be a permanent need for an alternate pathway to EM boarding.

Pragmatism and practicality aren’t dirty words, they’re how life is lived, and in the ED they’re how lives are saved.  Let’s keep our experienced Emergency Medicine physicians.

Update: reminded by the comments, the standard should be residency training in EM for anyone getting new Board Certification today.  The above argument applies, IMHO, only to those who are already alternately boarded (and yes, there’s another group that’s excluded…)

amednews: Most ED patients willing to wait longer to avoid nondoctor care :: Aug. 30, 2010 … American Medical News

Nurse practitioners and physician assistants account for at least 10% of outpatient visits and increasingly are being used to handle patient care in emergency departments, according to previous research. 

But a new survey said 80% of patients expect to see a physician when they come to the ED. Fewer than half would be willing to see an NP or PA for an ankle injury — they would rather wait two more hours to be cared for by a physician.

via amednews: Most ED patients willing to wait longer to avoid nondoctor care :: Aug. 30, 2010 … American Medical News.

For the record, if I went to the ED with a straightforward, well defined problem I’d just as soon see a PA/NP if it’s quicker.  (And, per the article, I’d like to know who’s seeing me and my problem).

Also for the record, my ED doesn’t utilize midlevels at all, so my knowledge of working with them is from my residency and my prior job, over 8 years ago.

Nearly every discussion I have with colleagues from other departments has a time when they are surprised we don’t have midlevels, and tell me the benefits, which boils down to either a) ‘they make us money’ or b) they do all our procedures, so they’re better at them than we are.

I find ‘a’ objectionable, but that’s just me.  ‘B’ is somewhat more defensible as it at least implies an increased level of patient care, but at the cost of a physician voluntarily relinquishing skills, then using that lack of practice as evidence of the superiority of others.  This has a rather obvious answer, which I’m too polite to point out to them.

I’m not saying there are no roles for midlevels in some ED’s, but I have yet to hear a compelling argument for them from a patient care aspect.

So, school me BUT do it without denigrating anyone else.

How was my night?

Only sorta busy until the 16 EMS’s in an hour.

So, yeah.