The most embarrasing thing I’ve done in a while

Recently, in the ED, I was seeing a patient who was left with something of a stammer/stutter after a prior stroke.

It was kind of a long history, and probably longer for the patient, who had to work very hard to be understood through their unwanted speech impediment.

Inexplicably, when I walked out of the room I started stuttering; I wasn’t trying to make light of the patients’ problem, and I had to stop talking for a few moments before I could speak in my normal cadence (and while in the patients’ room I was speaking normally as well).  It was super-strange, like my brain heard the new cadence and said ‘oh, this is how we do it’.  Awful.

It was embarrassing, and weird.  Fortunately the patient didn’t hear it, and I apologized to the staff that did.  I have no idea why my mouth/brain combo picked that anomaly to repeat.  Strange.

Anyone else have this?

Breaking News: EPs Push Back Against ABEM MoC : Emergency Medicine News

Wow, I’ve been promoted from crank to prominent critic!

A prominent critic of the process is Allen Roberts, MD, who blogs as Grunt Doc. http://gruntdoc.com. “I'm a proud member of ABEM,” he said. “I know they have this continuous certification thing going that has been forced on them by ABMS. And I understand the idea behind the yearly test [the Lifelong Learning and Self-Assessment].

via Breaking News: EPs Push Back Against ABEM MoC : Emergency Medicine News.

I remain a critic of this Continuous certification, and find some of the responses to be laughable, but I’ll save that for another post.

(Are there any other critics of this, or is it really just me?)

Matador gets Spain and suffering – NYPOST.com

Mess with the bull, you get the horn!

via Matador gets Spain and suffering – NYPOST.com.

A picture is worth a thousand words.  And some OMF surgery.

OMF?  OMG!

K2 has made it to Fort Worth

K2, the ‘legal marijuana’, has made it here.

I know that because my first patient with an adverse reaction to it came to see me in the ED.

Introductions are made, etc…

Me: Have you tried this before?

Pt: oh, yeah

Me: (wondering why a bad reaction now to something without a reaction before): anything different this time?

Pt: well, this was strawberry flavored, and it’s the first time I’ve tried that one.

Me: Aah.  Stay away from the strawberry, then…

Yes, preventive medicine in the ED.  It’s gratifying.

Super Sexy CPR: you won’t think about it the same way again

» Features » Super Sexy CPR..  Go over to Ian’s, and enjoy the hands-down most interesting CPR training video, ever.

Probably NSFW, that’s how interesting.

There’s been a Panda Sighting

I am an Emergency Physician and every day I go down the rabbit hole into the insane world of American Medicine.

via M.D.O.D.: My Favorite Year.

He’s over at MDOD.  Hasn’t lost his touch with the truth.

News Flash: Emergency Physicians frequently interrupted

via CNN, an Australian study on interruptions in the ED:

(CNN) – Interruptions in the emergency room may exact an unhealthy toll on patient care, a group of Australian researchers reported Thursday.

The researchers, from the University of Sydney and the University of New South Wales, found that interruptions led emergency department doctors to spend less time on the tasks they were working on and, in nearly a fifth of cases, to give up on the task altogether.

The researchers carried out a time-and-motion study in the emergency department of a 400-bed teaching hospital, observing 40 doctors for more than 210 hours.

So, an average of 5 hrs observation per doc.  Not bad, but not exactly an average of a full shift for any EM Physician.

They found that each doctor was typically interrupted 6.6 times per hour; 11 percent of all tasks were interrupted, 3.3 percent of them more than once. They calculated time on task and found that physicians spent less time on interrupted tasks than on uninterrupted tasks. In addition, doctors were multitasking 12.8 percent of the time.

That seems low to me, but my thoughts are anecdotal.  Sure, I can spend 30 minutes with no interruptions, then get 3 a minute for what seems like forever.


Other studies have shown that interruptions can result in lapses of attention, memory or perception, they wrote.

“Further, interruptions add significantly to cognitive load, increase stress and anxiety, inhibit decision-making performance and increase task errors,” they said.

Yep.

The interruptions included a doctor being asked a question while trying to write a prescription.

“Now, most people think it’s very acceptable to interrupt,” but doing so can be dangerous, lead author Westbrook said. She urged hospital emergency department directors to teach hospital personnel when it is acceptable to interrupt and when it may be better to find an alternative strategy.

“We really have to look at ways to try and reduce unnecessary interruptions,” she said.

Amen.


On average, doctors completed tasks that were interrupted once in about half the time they would have taken if they had not been interrupted. That perplexed the authors, who speculated that the interruptions led clinicians to try to compensate for the “lost” time by working faster and cutting corners. They said there was a strong need to develop processes that minimize unnecessary interruptions and multitasking.”Our results support the hypothesis that the highly interruptive nature of busy clinical environments may have a negative impact on patient safety,” they said.

Or, they stopped dithering and started making decisions.  We need fewer hypotheses and a specific study.


Other industries have recognized interruptions as dangerous, including the airline industry, which has developed strategies to reduce interruptions to the flight crew during takeoff and limited unnecessary communications with the cockpit.

“In our society, we get very used to interrupting each other,” Westbrook said. “Sometimes we need to stop and think about that.”

Yes, and I’ll agree right now that interruptions work both ways. to and from the doc.  The chaotic environment enables some less than wonderful behaviors, and one of those is a lack of respect for the time of others (people seem to like to talk to me while I’m working on the computer, when I need the most concentration, but I’m quiet and still, and therefore I’m chatted up).

All of us in the ED could do a better job on stifling interruptions, we need to focus on those times when we should not have any interruptions, and change behaviors from there (realizing that culture eats strategy every day).

Will Insurance Deny Payment if You Leave AMA? | WhiteCoat’s Call Room

Fifty seven percent of all health care providers (and probably just as many patients) believe that if you leave the hospital or the emergency department against medical advice, insurance companies will not pay for the visit. Half of doctors surveyed have told or would tell patients that insurance would not pay the bill if they left AMA.

via Will Insurance Deny Payment if You Leave AMA? | WhiteCoat’s Call Room.

Go and read for the answer, which surprised me, though not 57% worth…

Lesson Over a Latte // Emergiblog

Some of our patients are made, not born…

(The story you are about to read is true.)

The day was uncharacteristically warm.

via Lesson Over a Latte // Emergiblog.

Senate weighs bill proposing to shield emergency-room personnel from malpractice suits – Florida – MiamiHerald.com

Senate weighs bill proposing to shield emergency-room personnel from malpractice suits

A GOP-sponsored bill would make all emergency room medical providers — even at private hospitals — ‘agents of the state’ thus giving them sovereign immunity in medical malpractice lawsuits.

BY JOHN FRANK

Times/Herald Tallahassee Bureau

TALLAHASSEE — Even as the GOP assails President Barack Obama’s healthcare overhaul as a “government takeover”, top Florida Republicans are pushing a measure that opponents say would do the same for the state’s emergency rooms.

State Sen. John Thrasher, the Florida Republican Party chairman, is pushing legislation to make all emergency room healthcare providers — nurses, doctors and even paramedics — “agents of the state” and consequently immune from medical malpractice lawsuits.

Florida is a MedMal crisis state.  It’s not a big surprise different ideas are being floated to help those on the front lines.  I’m not a big proponent of Sovereign Immunity (or the Federal Tort Claims Act), as yes, a provider cannot be sued directly but there’s no free lunch; the Government that gives you immunity can then restrict your practice at their discretion.

Again: No Free Lunch.

And then, a weird bit of editorializing spin in a non-editorial:

So if a doctor at a private hospital makes a reckless mistake, the state would pay the claim, subject to the current sovereign immunity cap of $200,000. To recover more, victims would need to file a claims bill in the Legislature, a process that can take years.

via Senate weighs bill proposing to shield emergency-room personnel from malpractice suits – Florida – MiamiHerald.com.

So, if a doc at a public hospital makes a “Reckless mistake” that’d be okay for the government of Florida to cover?

Reckless mistake?  What the heck?  They didn’t say “Ambulance Chasing Attorney” to balance that out, even….

Emergency Medicine Bloggers | Life in the Fast Lane

Prompted by a series of tweets and buzzes pertaining to the knowledge base of Emergency Medicine bloggers we felt it was time to overhaul our ‘BlogRoll‘ and create a separate table for the Emergency bloggers, their twitter handles and RSS feeds.

via Emergency Medicine Bloggers | Life in the Fast Lane.

Nice list!  If you find an omission, please leave it there, and not here.

ABEM is over-reaching their role

The American Board of Emergency Medicine (ABEM) describes itself as:

Welcome to the American Board of Emergency Medicine (ABEM) public website.  ABEM certifies qualifying physicians who specialize in Emergency Medicine and is a member board of the American Board of Medical Specialties (ABMS).  ABMS certification is sought and earned by physicians on a voluntary basis. ABEM and other ABMS member boards certify only those physicians who meet high educational, professional standing, and examination standards.  ABEM and other ABMS member boards are not membership associations.

The thing I’d like to bring your attention to is that it’s a Voluntary organization.  For a voluntary organization they’re adding lots of requirements without asking members…

Since most of you don’t know about Board Certification, it’s a way for doctors to demonstrate (mostly to their peers and employers/hospitals but also to patients) that they not only finished their residency, but paid attention and learned enough to pass the Board Certifying exam.  Yes, it’s possible to be a doctor, finish a residency, but not pass the board exam and have a nice lifelong practice anyway.

I’m Board Certified by ABEM, which required completing an accredited residency, passing first a written then an oral examination.  Okay, I’m done, right?
Emmm, no. I’m BC for 10 years.  In order to re-test to be BC for another 10 years, I have to take (and pass) yearly tests over medical literature, tests payable to the ABEM.  Which ABEM didn’t bother to figure out how to give us CME credit for.  Genius.

Imagine my surprise at ABEMs’ latest addition to hoops to jump through to maintain my Board Certification: the Assessment of Practice Performance.  In a nutshell: show ABEM that 10 patients didn’t hate my medical performance, prove that on 10 hand-picked charts I’m keeping up with published treatment benchmarks (like aspirin for ACS, antibiotics in 6 hours for pneumonia, etc), and self-certify the same to ABEM.

While that’s easily doable for me at Giant Community Hospital where I work (we already keep track of this, and a lot more), it’ll no doubt be harder for very small ED’s.  I agree this sort of performance thing needs to be tracked, and practice outliers nudged back toward the middle, but what on earth does this have to do with being Board Certified?  Where in ABEMs’ mission statement does it say they’re going to certify we’re practicing on par?  Nowhere.

This would be an entirely different argument if Board Certification were required for employment in EM (it’s not), at my hospital (it’s not), in my group (not), exempted me from any state CME requirements (doesn’t), increased my pay (doesn’t), you get the idea.  That’s a lot of work to keep a voluntary certification that gives me back… nothing tangible.  Oh, I’m a Diplomate of the American Board of Emergency Medicine, and with that and $6 I can get coffee almost anywhere.

I find it interesting there’s not much push-back on this new requirement.  ACEP’s President-Elect ‘interviewed’ ABEM President Debra Perina about this latest addition, uncritically and without any challenge: EM Leaders Discuss ABEM’s Maintenance of Certification Program.

To paraphrase the question, why? The answer:

SS: Is it correct to say that the public is asking for more accountability regarding continuing medical education, even between board examinations?

DP: That’s correct. I know that ACEP and the emergency medicine community have been following testimony in House and Senate hearings from consumer advocates requesting assurances that physicians remain competent throughout the course of their practice. The public is questioning boards that test sporadically or in some cases offer lifetime certification.

Hmm.  I genuinely understand the desire of the public to make sure docs are keeping up, and practicing inside norms (and this is not asking for a flaming: I’m aware there are docs who give amoxicillin for everything imaginable, who don’t keep up, etc) but this is a) window dressing on that front and b) if meant to serve as some reassurance to the public, it’s inadequate, at best.

But that’s really beside my point, which is that it’s not ABEM’s role to make certain my practice is up to par, that’s the role of, ultimately, my State (which licenses me) and my peers, who have a lot more impact on my practice than the ABEM.  ABEM should document that the provable (I’m keeping up with my certification, meaning the every 10 year tests, grudgingly the yearly tests*), and that’s it.

In an upcoming rant: competition is good, is it way past time ABEM had some legitimate competition from another Board Certifying organization?

*In either the first or second year of these yearly tests, the article being tested was about Neseritide, which in the article was the best thing for CHF since phlebotomy.  Of course, by the time we were being taught/tested on it, Neseritide was out of vogue as it hadn’t worked out in practice as it had in studies.  But, you had to give the currently wrong answer to the test.  Pitfalls of keeping up through testing.

The Laurinburg Exchange – Shooting at Scotland Memorial Hospital

Scotland Memorial Hospital was locked down Monday morning after a shooting left a patient in critical condition and another man in police custody.

The 3 a.m. shooting appears to have stemmed from a brawl at a McColl, S.C. night club, according to Laurinburg police. Authorities say it involved the victim, his girlfriend and the daughter of the shooter just a few hours earlier….

via The Laurinburg Exchange – Shooting at Scotland Memorial Hospital.

This exact scenario is why most hospitals have some system to anonymize victims of violence in the ED, and sometimes throughout their hospital stay.  (We have one, and I’m not letting its incredibly complex code out…).

That doesn’t make them either invisible or bulletproof, and we’ve seen a few examples of our trying to anonymize them gone wrong when their ‘friends’ start calling and texting once in the ED.

I’m happy no ED employees were injured, and hope the alleged attempted murderer gets a fair trial and the punishment deserved.

Also, don’t get in bar fights…

HT: Glen in West Texas, my news machine

richard[WINTERS]md: Skipped a beat.

The handle bar of the snowmobile fractured his ribs.

Nice guy. Mid-60s. Talkative and generous in his remarks.

It occurred yesterday. He thought it would heal by itself.

Didn’t want to bother us. But now he was a little breathless.

His lung was punctured. His skin was full of air. It crackled and popped as I rubbed the betadine on his chest in preparation for the procedure….

via richard[WINTERS]md: Skipped a beat..

He doesn’t post much, but when he does, it’s usually good.

Please check it out, and if you like it, leave him a comment you came from here, and thank him for getting me into blogging…

Ohio.com – Akron General puts ER wait times on billboards, Internet

Trying to avoid a painfully long wait in the ER?

One local hospital system is publicly sharing the current average wait time to see a doctor at all its emergency departments.

Akron General Health System recently began advertising up-to-the-minute wait times for its emergency rooms on billboards throughout town.

Six digital billboards in Akron are automatically updated every 20 minutes to show current average wait times to see a doctor …

The average times are computer generated, based on current patient information from the health systems’ electronic medical records…

via Ohio.com – Akron General puts ER wait times on billboards, Internet.

I think this isn’t terrible, as long as there’s some education that a) these are average times and that b) if you have a real emergency you go to the head of the line.

Oddly, I think this is different than the (currently boutique) practice of scheduling an appointment at an ED over the internet.  I think if you have the time to schedule your emergency, you don’t have one.  So, get a doctor and go there.

Bring on the ‘average wait times’, but make sure the same display is visible in the waiting room!