One of the ER Doc curses

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.

Question the Meds

In my practice I try to apply some common sense, adopting a colleagues’ phrase “common things are common”.

This is particularly useful in the diagnosis of new problems that have eluded diagnosis, and I apply a lesson learned from a fellow resident (a PharmD before med school) who told me: new problems, ask about new meds.

So, if my patient has some new problem as part of the history (when did this start) I’ll follow up with ‘any new medications, or change in your meds, around then? (This is often fruitless despite the time investment to go through the meds, the list, then ‘when did that medication start’ conversations, but it’s time well spent).

Many times the reason the patient gets dizzy on standing is the new BP medication, or a BP med that has dehydration as a mechanism stacked onto decreased oral intake…

I’ve made a couple of good diagnoses recently, and it was directly because of questioning the timing of the new meds and the new symptoms, one patient with their second trip to the ED for an unexplained metabolic acidosis (who was taking a seizure med that said ‘metabolic acidosis’ as a known problem with it), so making the call to the pt’s doc for a re-admission and oh-by-the-way I believe the problem is this med that causes this problem. Nice way to have an admitting doc think you know what you’re doing…

Metformin causing diarrhea is a med-school diagnosis, so why it took the med student following me to make it I don’t know, but the patient and family were thrilled to have a reason for their debilitating symptoms. (Thanks, unnamed MS4!)

There are some others, but you get the message: temporally relating new meds then new symptoms, common things are common, and always question the medications.

All Work and No Play

has made my blog barren, joyless, and, well, dull.

It seems I’ve been working nonstop, and when I’ve had time to myself it’s been consumed with plans for my yearly MegaParty for our Scribes. It’ll be a good one (Seventh, for you counters). (Unless you’ve gotten an invitation, you’re welcome to throw your own party).

Work has drama, but it’s micro-political and therefore sounds whiny when I type it out. I’ll spare you. You’re welcome.

Our joint has started being very aggressive about Induced Hypothermia in resuscitated arrests, and I contributed to a success story, something that’s rare in medicine: a resuscitated arrest that left the hospital neurologically intact 1 week later. Anecdotal, I know, but still. I don’t know if I’ve had one of these before. I hope it’s a trend.

As for shootin’ stuff, I’ve had a self-imposed restriction on adding any new calibers of firearms, as at a certain point keeping up with all the different ammo types can be daunting, and expensive. That took care of itself recently when I was shooting my new 357Sig rounds through my Sigs with Barsto barrels (which I had just dropped in, and not had fitted by a gunsmith). I got talked into 357Sig rather than choosing it, but thought it deserved a good try.

That try had 6 failures to feed in 100 rounds, and said gear has been shelved. As I wasn’t crazy about it to start with the extra effort to make it work was easy to avoid.

Therefore, a new caliber opened up. I’ve never owned a .45, and that’ll change soon. I have my eye on the Springfield XD in 45, I’ve shot the range loaner and found it surprisingly likable and well-fitting for a non-Sig pistol (I’m mostly a Sig pistol snob), so different experiences pay off.

For those screaming at their screens that I need to get a 1911-style 45, rest assured I’ve shot several of them over the years, shot one recently, and, eh. I can shoot it, don’t like it, and you may now call me a Philistine.

Tomorrow I get to take another shooting-newbie out and teach him from zero, an experience I relish. So, good. Some play!

Advice for aspiring scribes

I’ve written about Scribes before, and I love ‘em all.

I got an interesting email today that got me recommending my usual lament, that scribes “don’t get it” until they get ‘the buffer’, which I described as such:

[T]he one skill that makes a good scribe is a 2 to 3 sentence
brain buffer. That means, the ability to save in your head 2 or 3
whole sentences, then play it back to write down or act on.

Nearly everyone who starts wants to act on the first 6 words, starts
doing, and loses all that follows the first little bit.

So, there’s your key. Watch tv, listen to 3 sentences, mute the tv and
write them out. A little practice goes a long way.

I base this on watching 8 years of scribes train, progress, and move on, and my own personal experience as a medical student.

Repeat yourself enough as a practicing EM doc using scribes, and you notice when scribes ‘get it’, get that ability to hear everything you say and incorporate that into the record.  And it’s the buffer that does it.

When I was in Med School I got that buffer, a life skill that serves me well to this day.  We didn’t have a note service, or copies of the profs’ PowerPoints, we had paper, pens, and what we wrote down from the lecture.  I wrote a lot, and fear of failure will stimulate the brain.

At my MS2 peak I had about a 5 sentence buffer, and I and my row-mates would be writing long after the lecture ended.

This ability to hear things and keep them in brain-RAM drove my then-new wife nuts; I could watch TV and ‘hear’ her, but when she would say “You didn’t hear a thing I said, did you…” I could very easily repeat her last sentence or two and answer her question.  I still have some of it, though atrophy hits everything not exercised…

So, learn to listen, not just hear: there’s your key.

Emergency Medicine Excellence Award™

Emergency Medicine Excellence Award™

HealthGrades Identifies Hospitals Among the Top 5% for Emergency Medicine

HealthGrades is proud to announce that the first annual analysis of hospital emergency medicine programs found that the best-performing hospitals consistently outperformed all other hospitals for all eleven cohorts studied.

via Emergency Medicine Excellence Award™.

Neat, especially as Giant Community Hospital, where I humbly serve in the ED, is on the list.  As we got the award, I will not question, or even investigate, the methodology…

Nice to be noticed.

edwinleap.com | Relief from EMTALA at last! Call the Dept. of Labor!


But today, dear colleagues, it’s all better.

via edwinleap.com | Relief from EMTALA at last! Call the Dept. of Labor!.

I’m thinking some calls to the toll-free number are in order.

2010 ACEP Scientific Assembly: I’m in

The 2010 American College of Emergency Physicians’ Scientific Assembly is in Las Vegas this year.

I’ve registered, bought plane tickets and have a marker on a box under a bridge (but very near the convention site, so I’m good).

So, time for you EP’s to get in there and register, and, I’m going to blog it (unless ACEP gets a court order preventing it (they weren’t interested in me blogging for their house blog, so only time will tell…)).

Oh, as a service to my three ACEP readers I plan to get enough freebie pens from the exibitors to give one to each of you when I meet you.

Yeah, I’m a giver.  Or a re-gifter.  Whatever.

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…