ICEM, Part I: Bat out of hell

First of all, a special thanks to GruntDoc for allowing me to host the blog this week while I attend the ICEM conference in San Francisco. A short travel story, without which any conference coverage would be incomplete. My wife and I arrived in the Bay Area last night after an uneventful flight and then promptly hopped into the cab from hell. Our driver looked sweet enough as we climbed in the car, but then we discovered that his right foot was made entirely of lead. He hurled through highway traffic at 90 mph. I kid you not. 90. In traffic. Let’s just say I’ll have to leave my scenic viewing of the Golden Gate Bridge to another ride.

But on to the show. ICEM is put on in coordination with the International Federation of Emergency Medicine (IFEM), a group which began as a small collection of countries with highly developed EM systems, but which has exploded in recent years. The meeting rotates through member countries, and the landmark international gathering will not take place in the United States again for at least 14 years. The conference will celebrate a year of unprecedented progress in the advancement of emergency medicine around the globe, such as in India where the specialty has finally made serious inroads thanks to the efforts of a little group of physicians called the American Association for Emergency Medicine in India (AAEMI). I have no doubt that the EM developments around the world will have far-reaching affects on the specialty in the United States.

-Logan Plaster

Emergency Physicians Monthly

Guest Host this week: Emergency Physician Monthly’s Logan Plaster

I’m very pleased to announce that Logan Plaster, Editor and Creative Director of Emergency Physicians’ Monthly will be blogging his insights and observations here during this weeks’ 12th International Conference on Emergency Medicine held in San Francisco.

I’m a big fan of EPMonthly, and enjoy reading it cover to cover every month. It’s my honor to host them here (and they have a website supporting their publication that’s terrific, check it out).

Come back often for his updates; he’s going to try to post pictures (and maybe video) in addition to the expected well-written text. I’m looking forward to it myself.

Expectations, or Letting People Down

One of the big joys of Emergency Medicine is helping patients. It’s truly enjoyable to suture a laceration, to reduce the dislocation, to give solace to the suffering (usually pain medicine, but not always, sometimes it’s a hand to hold). These are almost always patients who present with a sudden-onset problem, be it trauma or bowel-obstruction, and that’s why I’m there (and why my colleagues are there, as well). Patient faces begin with apprehension, and are often back to normal when they leave (and some leave with a satisfied look I take as the reflection of a job well done).

Then there are those patients I cannot help but let down. They come to me with vague complaints that have gone on for years, a pain they cannot describe or can describe too well, a discomfort that nags, a rash that won’t wane, a twitch that won’t stop or a balance that won’t start. They have seen specialists too numerous to mention, have tried medicines/potions and remedies that run the gamut of medical experience, they’ve done their exercises and, still, they want for a remedy.

I have finally learned that there are some patients I probably won’t be able to help medically and that it’s actually cruel to let them think otherwise. For instance, the patient with the low back pain that’s been to seven neurosurgeons (had three operations), been to the Mayo Clinic and to innumerable chiropractors, who looks at me and says “I need to get better”, what’s causing the back pain? Realistically, what can I offer that a myriad of specialists couldn’t? Oh, I’ll do the entire LBP exam, do a history looking for zebras and other horrible causes of back pain, and occasionally I’ll want to do some tests to rule out an emergency.

I used to leave the room with the generic “We’ll get you some pain medication and do some tests”, and then return to the room after some time, when the tests are back, and go through a prolonged ‘isn’t there anything you can do’ session with the patient and their family. They know there’s not, really, but I left that door open, and it’s at least partly my fault.

So now I let them down early. Yes it’s disappointing but I think it’s healthier for them (and me), in the long run. “You’ve had this for x years, you’ve seen about a dozen specialists; as a general rule, if a bunch of specialists cannot figure it out in their offices with all the studies, tests, etc. we’re unlikely to in the ER” is now my general start-of-the-letdown, and even the least reasonable from an expectations standpoint seem to get it: I’ll try, but it’s unlikely. Now the patient doesn’t spend the next hour-plus building up hopes to be dashed-yet-again. As memory serves I’ve never made the terrific diagnosis for the unfixable complaint, and it’s not for lack of trying. Some things I cannot change.

It’s disappointing for me, too. I’d much rather say ‘here’s the diagnosis, and the cure’, but it doesn’t work that way in real life. Maybe some of the letdown is for me. Okay, no maybe about it.

We’re pretty good in the ED with acute problems, less so with the chronic ones, and dismal with the ones nobody can solve. Sometimes expectation management is the best we can do, for everyone.

(General disclaimer: I do a real history, a real physical exam, and listen to my patients. I don’t prejudge anyone, and the above applies only at the very very end of the patient interaction, and not before.)

TPA and Stroke 2

Geez, the NY Times (obscure liberal paper in the Northeast) has interviewed several neurologists (and exactly one Emergency Medicine Physician) and has written a four-page article on stroke. They got little right.

It’s a tour-de-force in obfuscation of fact, presentation of tragedy as preventable, and the presentation of TPA as an ignored wonder-drug, MRI should be the standard of care for new strokes, and frankly there’s no redeeming value within. Nevertheless, I shall persevere, and even if it makes nobody other than me happy, I shall fisk to my hearts’ content. (Many thanks to Notes from Dr. RW for bringing this to my attention, and for taking the hit for the rest of us and reading the NY Times, you poor wretch).

I was going to address this in the article as I got to it, but it’s too good / on point to bury below the fold. Here’s all you need to know about tPA for CVA (from AAEM), in a nice graphical form:

Lost Chances for Survival, Before and After Stroke


Dr. Diana Fite, a 53-year-old emergency medicine specialist in Houston, knew her blood pressure readings had been dangerously high for five years. But she convinced herself that those measurements, about 200 over 120, did not reflect her actual blood pressure. Anyway, she was too young to take medication. She would worry about her blood pressure when she got older.

Then, at 9:30 the morning of June 7, Dr. Fite was driving, steering with her right hand, holding her cellphone in her left, when, for a split second, the right side of her body felt weak. “I said: ‘This is silly, it’s my imagination. I’ve been working too hard.’ ”
Suddenly, her car began to swerve.

“I realized I had no strength whatsoever in my right hand that was holding the wheel,” Dr. Fite said. “And my right foot was dead. I could not get it off the gas pedal.” …

Dr. Fite is one of an estimated 700,000 Americans who had a stroke last year, but one of the very few who ended up at a hospital with the equipment and expertise to accurately diagnose and treat it.

Dr. Fite has been active in the practice and politics of Emergency Medicine for a good while, and I was unaware of her stroke. I hope she’s recovering well.

Stroke is the third-leading cause of death in this country, behind heart disease and cancer, killing 150,000 Americans a year, leaving many more permanently disabled, and costing the nation $62.7 billion in direct and indirect costs, according to the American Stroke Association.

But from diagnosis to treatment to rehabilitation to preventing it altogether, a stroke is a litany of missed opportunities.

Many patients with stroke symptoms are examined by emergency room doctors who are uncomfortable deciding whether the patient is really having a stroke — a blockage or rupture of a blood vessel in the brain that injures or kills brain cells — or is suffering from another condition. Doctors are therefore reluctant to give the only drug shown to make a real difference, tPA, or tissue plasminogen activator.

This is a truckload of hooey. Any Emergency Physician worth the title does this for a living, and while it’s challenging to sort wheat from chaff, it’s why Emergency Medicine exists as a specialty. Yes, there is a tremendous differential diagnosis, but that goes with the territory. And reluctance to administer tPA for stroke is more than reluctance, there are solid reasons to be very very careful with the decision.

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