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).
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.
Expectedly, it’s International…
… 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. …
Excellent post about economics in action, as seen by an Emergency Medicine physician.
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).
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.
…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 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.
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.
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…
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.
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.
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.
I put a post up a few days ago about an NG tube that went poorly.
The post went just as badly as the tube (though with lesser consequences), and when I tried to fix it the new and improved WordPress rebelled. It refused to accept the change, and just got worse.
So, go read ImpactedNurse‘s post. And cringe.
I’ve internalized all the dogma of medicine, for good and bad.
When I was an EMT, green as a twig in an ER, I’d learned the basics: for any wound with hair employ the razor, and get the hair away from the laceration so the doc could do a good closure.
So, employment week 3, eyebrow lac? Shaved that sucker clean off. ED doc freaked out, and I learned some Dogma: don’t shave eyebrows, they don’t grow back. Heard it later, too. All the way through training, in fact.
Hmm. My now older-guy eyebrows would like to disagree…..
I shave my face, nearly daily. All the hair comes back. I have women in the home, who bemoan their razor-rituals. I see younguns with cuts deliberately made in their brows, with blithe unconcern they might be permanently bald there…
I’ve never, ever seen a person come in with one normal and one shorn-off brow, never. (I’ve seen people with shaven brows and penciled in, unlikely shaped, eyebrows but that’s an interesting choice).
So. Myth of EM? I think so. I seek the wisdom of the learned crowd.
Forwarded by a friend of his, and I have the authors’ express permission to run it.
Another amazing and emotional day yesterday. I try to write about things that impress me professionally, emotionally, and spiritually. Yesterday I was again impressed.
At 5:00 a.m., the Giant Voice (the base PA system) announced two incoming casualties. I reluctantly roused from my slumber and made my way to the E.R. On arrival, I found two victims of an accidental grenade explosion, one critically injured and one more stable. The critical patient had third degree burns to his face, neck and upper chest and severe penetrating abdominal injuries. He was in shock and was taken directly to the O.R. by the surgical team. The other had multiple burns, but fairly superficial. He also had eye injuries and he was essentially deaf from the blast, but he was stable. While the unstable patient was in surgery, my team and I evaluated and treated the stable patient, managed his eye injury (severe ocular contusion with corneal burns), CT’d him, cleaned and dressed his burns and expedited his helicopter evacuation to the ophthalmologist at the larger Bagram hospital (we don’t have one here).
The story of how the accident happened was initially unclear, but, when things settled a bit, my patient told me the following: He and the other soldier (both trained weapons specialists) had returned from a mission and were in the ammunition bunker, returning unused grenades and other weapons to the stock. One of the weapons they were handling was a “flash bang” grenade. These are the ones that they use as their team is initially entering a building by force. They toss it in and it explodes with a very bright light and very loud sound, designed to temporarily blind and deafen the people inside so that the soldiers can enter the building with the element of surprise. SWAT teams use these a lot. They’re not designed to kill.
He states that, as they were working, he heard a “click” noise, looked back and immediately saw that the pin had somehow popped out of one of the “flash bang” grenades that his buddy was holding. He looked up and saw a look of terror on his teammate’s face. My patient just had time to turn away as the grenade exploded. He was stunned and isn’t clear exactly what happened next, but somehow they were both loaded into vehicles and rushed to the hospital. From the pattern of the explosion on the severely injured patient who was holding the grenade, it appears that, in the brief instant he had to decide what to do, he made the decision to pull the explosive into his gut and take the force into his body. By doing so, he minimized the blast effect to the other soldier and to the stored ammunition inside the shed, preventing a possible catastrophic chain reaction of explosions. Faced with the split second decision to either toss the grenade into a corner and run, or take the blast himself to save the life of his friend and possibly others in the immediate area of the ammo shed, he chose to sacrifice himself.
In surgery, the severely injured troop had multiple severe abdominal, chest, and head injuries and burns. He required massive amounts of blood. Our little hospital keeps around 30-50 units of blood products available at any one time, but we were a bit low because of a lot of recent trauma activity. It was clear that if this soldier were to have any chance of survival, he would likely need more blood than we had in stock. In addition, we always have to be prepared for the next trauma activation (which, incidentally, came about four hours later, four patients from a Taliban attack on a civilian minivan, including a 14 year old boy, but that’s another story). After discussing this with the surgeons, the hospital commander made the decision to activate the “walking blood bank”.
The walking blood bank is something unique to the military. In the civilian medical world, blood is collected at donation sites and very carefully screened for infectious diseases such as HIV, hepatitis, and others. Then it is broken down into its various parts: red blood cells, platelets, and plasma. These are then separately packaged and stored for later use. The military does the same thing for routine blood use. However, in a combat emergency, we have the ability to short cut the process when we need blood immediately. Essentially, everyone in the military is “pre-screened” because we are all checked for HIV, hepatitis, etc. and given a million immunizations prior to deployment. We also have our blood typed and that information is printed on our dog tags and our military ID. We’re ready to donate and receive blood at any time.
The Giant Voice broadcast across to the base: “All O-positive soldiers report to the hospital immediately!” Our Utah medics, and others in the hospital, mobilized and immediately established impromtu “donation centers” in the outpatient clinic and the dental clinic. Within 10 minutes, they were taking blood from the first volunteers. Within 30 minutes nearly one hundred soldiers were lined up to donate for their fallen comrade. The line filled the clinic, the hallway, and went outside the door of the hospital, down around the corner of the building. All of these troops lined up look like they were waiting to get in a concert or a movie theater. As each precious, life-giving unit of blood was drawn from a troop, it was immediately taken around the corner to the operating room where it was infused, still warm, into the critically injured soldier on the table. Over the 4 hours of his surgery and attempted resuscitation, he received nearly forty units of whole blood taken directly from these donors, as well as banked blood and platelets, plasma, and other blood products. Tragically, the surgeons, despite herculean efforts, were unable to save him and the soldier was finally pronounced dead. The news hit everyone very hard. This incredible soldier, the accidental victim of a grenade malfunction, had died trying to prevent further injury to his fellow troops. He gave his life to protect them. In turn, those donating blood gave a very real part of themselves to try and save him. That is what soldiers do for each other.
Later, I witnessed the solemn and emotional completion to this story. The Army has a battlefield tradition called the “Hero Flight”. When a soldier dies, his body is flown home for a funeral with his (or her) family. The first step of this flight for this Hero was a helicopter ride from our base to the main air base at Bagram. A special ceremony was held as his body was moved from our morgue to the helicopter to begin his journey home.
At about 11:00 pm last night, Soldiers from the fallen soldier’s unit, the hospital, and from all over the base lined up in formation along the hundred yard route from the hospital to the helicopter pad. Everyone was dressed in full uniform; no shorts or tennis shoes.
I don’t know if I’ve ever mentioned it before, but we’re a “black out” base, which means no lights are allowed at night. This is to minimize us as a target at night. We all walk around with little tactical (very dim red or green) flashlights. It’s really dark here. So there we stood, silently and reverently in the darkness, two long columns of soldiers lining the route to the landing area, lit only by the stars in the brilliantly clear and quiet sky and a couple of glow sticks placed along the way. It occurred to me that many of the people standing in silent tribute last night had also given their blood to try and save the life of this soldier. Then, in complete darkness, two helicopters roared out of the night and landed, pulling up to the loading area, the wind from their rotors whipping the hair and faces of the silent line of troops. On cue, they simultaneously cut their engines and the rotors spun slowly to a halt. Into the ensuing silence the First Sergeant issued the command: “Task Force, Attention!”. We all came to attention, face forward, perfectly still. “Present Arms!”. Every soldier, all 250 or so of us, snaps and holds a salute as the body of the fallen soldier, draped in an American flag, is wheeled slowly between the two columns of troops and is placed reverently on the helicopter. “Order Arms!” We dropped our salutes, remaining at attention. The chaplain said a prayer for the soldier, for his family, and for his team, who must continue their work, their mission, without him. In the darkness, I heard soldiers, warriors, sniffling quietly as they suppressed their tears. Me too. As we were dismissed and silently began to depart, the two helicopters fired up their rotors and launched into the dark Afghan night, carrying the body of this young man home to his family.
It is difficult to describe the emotions this long day held for me. Many conflicting but very powerful feelings come to mind as I write. The tragedy of the accident. The heroism of this man’s selfless act protecting his fellow soldiers. The pride I had in my fellow docs and nurses who raced him into surgery and in our Utah medics who quickly and efficiently organized the blood donation operation. The amazement I felt as soldiers from all over the base, few of whom knew the injured troop, lined up to give blood without question. The disappointment when the soldier died despite everyone’s heroic efforts. The pride, respect, and honor of the silent Hero Flight ceremony as we paid our last respects to our brother in arms. A very dramatic, very sad, and very real day here at the War. I just wanted you to know about it. These kinds of things need to be shared.
It’s my pleasure to share this with you.
I was reminded of one of our particular curses the other day, reminded in the way we often are, when somebody reacts to what we do. Sometimes embarrassingly.
Yesterday, I was taking a history, and this was of a patient with a long, complex one. That much I knew from a quick perusal of the EMR prior to going into the room.
So, I and my scribe were there, along with the patient and their family member; because of the medical problems, the family member was giving the history. Family member was pleasant, knowledgeable, and good. Terrific history, and it was flowing. On point, not too many spurious details, and I was enjoying it.
One detail was “…so we went home Saturday…”, a totally innocent thing, pertinent to the history, correct, and natural. That’s when I looked at my watch.
“I’m sorry, I’m trying to be as brief as I can” said the historian, and I realized what I’d done: I’d given the universal signal for ‘you’re taking a long time’, inadvertently.
(What I was trying to do would be familiar to every ER doc, I was looking at my watch because it tells me what day it is: we usually have no idea what day it is. Work 24/7/365 a few years, and that whole ‘work week’ is something to be envied; most of us are at work because we have a shift, not because we have any idea of time otherwise…).
I immediately interrupted and apologized, telling them what I just told you, but in briefer form (“I was looking to see what today is…”), and life moved on.
It did have me make a mental note, though, to be more surreptitious in looking at my watch: my orientation to the calendar won’t change until I retire.