This month’s audio summary is now available here and it’s a doozy. Highlights:
-Safety, safety, safety: how me understand, misunderstand, miscalculate, and recalibrate
-Pediatric imaging: is ultrasound more sensitive if the pain has been there longer?
-Procalcitonin, wbc, and CRP
-Septic work-ups for RSV kids between 60 and 90 days?
-Language interpreters: how often accurate?
-PCR testing of CSF for determining pathogen in meningitis
-EMS regionalization, the facts, and a primer
And much much more
Check it out, and email any time! firstname.lastname@example.org
Please send your story to Tracy Napper (email@example.com) today!
I do have an interesting case, basic and not a lot of flair, as I am working my shift tonight in a single coverage ED with a 17,000-patient volume with periodic PA coverage. We were busy up until about 3am when things are starting to run together, just getting my last patient out of the ED, except my 18-year-old who ingested 10gms of tylenol and just finished his 15,000mg of “Acetadote” awaiting psyche eval. I figure if I could just get 1/2 hour, maybe even a 45-minute power nap, I would be good. Two phone calls later, I look at my watch after tossing and turning (for no good reason, except it’s not my bed and I’m not at home), and it’s 3:30. I am finally feeling like I could doze off and suddenly a knock on my door and it’s Tim from Cardiopulmonary who says “…we’re intubating in the unit, do you want the Glidescope?” and I said yes, grab it. As I am walking back to the ED to tell them the plan, I get a little history, “…he was admitted at 5pm with respiratory problems and he’s a full code!” I arrive to our 4-bed unit, 2 nurses, a clerk, a tech and Tim from Cardio are there. They tell me he was on the floor, originally on BiPAP in the ED but “weaned off” to go to the floor on Telemetry. He was found by the tech to have a temp of 33 C, HR 30′s, BP 50/30 and a SaO2 of 60%. He was moved to the unit and the hospitalist on call from home (1 hour away) said “…intubate him, give him fluids and call the ER doc…” in that order, I am told. I arrive to find a pale, very diaphoretic and cachetic eldery male with agonal respirations. He was on BiPAP, barely moving any air, still hypoxic, hypotensive and unresponsive. The nurse yells to me his wife is on her way, he’s a DNR in our computer, but she is the “Durable Power of Attorney” and wants everything possible done, except “…unless it is going to prolong his suffering and he’s not going to get better….” Of course I have the crystal ball to determine that.
I made the “executive decision” to give fluids, atropine, increase O2 and NOT intubate. The wife arrives shortly thereafter, she rushes to the bedside, teary-eyed, to hold his hand. She sees he is not responsive to her and his vitals on the monitor are “in the toilet” (a medical term of course). I tell her I thought this was a terminal event and he was not going to recover (.but who gave me the crystal ball). I did sneak in 2 rounds of atropine, a little diluted epi, a liter of NS with no response. She tells me he has really deteriorated over the past several weeks to months. He stopped eating 6 weeks ago, was hospitalized twice for pneumonia and never has really been the same and was sent to our local skilled nursing facility. Because he was found hypoxic with an altered LOC he was sent to the ER and admitted a few hours before I arrived. By now, their 2 pastors arrived (not at the same time of course) and the wife wanted me to explain what was going on. Just as I finished telling the first pastor, the second arrives and so I repeat it. She again asked if I thought there was anything that could be done. And of course I said no; “it’s between he and the man upstairs,” but I will make sure he is comfortable and not suffering.
I bounce back and forth between the ED and the ICU over the next hour. Now a little after 5am his HR is 20′s, BP 30/20, SaO2 is still hanging on at 97% but he’s still on BiPAP. I return at 5:30am, HR single digits, BP still 32/20 (obviously from several minutes ago). I ask to stop the BiPAP, HR 0, and I ask to turn the monitor off. I go through my normal routine and pronounce him at 0535, 10 minutes before writing this sentence. As I offer my condolences, the wife crying, gives me a hug and says , “thank you,” the pastors shake my hand; I ask if there is anything I can do, or if they have any questions I can answer. I tell them the nurse will have certain questions, the state of Michigan mandate we call “Gift of Life” and funeral home, etc. The nurse tells me, “thank you, I wish they all went like this!”
Now the punch line. It is well published that the last 6 months of life utilizes the highest percentage of health care dollars, also, that ED docs are expected to participate in comfort or palliative care in the ED, with increasing frequency. While ED patient volume is increasing, there are the same number of ED beds and staff, decreasing reimbursements (ie, we all are expected to work harder, more stress with less compensation). We are expected to maintain an excellent attitude to keep our Press Ganey scores up and improve our “…likelihood to recommend,” keep patients happy so they don’t sue us, while all along optimizing patient safety and quality of care. This while spending quality time at home with family and somewhere in there getting enough sleep before our first night shift and thereafter.
Now that I have reiterated the obvious to all of us, this is what we do day (or night) in and day out. I am going to ask yet one more thing of all of us. We are on the front lines and are responsible for a significant expenditure of health care dollars. We spend billions of dollars on defensive medicine and doing what is “expected” versus what we “should” be doing. I do have a strict adage, “…no one should ever die alone or in pain!” I was all ready to intubate my 82-year-old cachetic dying pneumonia patient ( and believe me, I am all about procedures) and even though he was initially a full code, it just wasn’t the “right” thing to do. After seeing both my parents die a similar death; one at a tertiary care center in Los Angeles and my father at home; it was just nice to have someone there who “cared.” This is what I think society wants at end of life, not to suffer, and someone there who cares. I think if we explain to families, DPOAs, etc, what we do to prolong the inevitable they would opt not to do it. That being said, there is definitely a fine line sometimes at end of life. What is “terminal” and what is not may be difficult. But after almost 20 years of doing this, I think we have a pretty good idea. Sir William Osler had it right too, and it still applies!
I would ask that we be cognizant not only about the health care dollars we spend not only at end of life but every day, and after quality of life has passed that we emphasize the “quality of Death.” We as physicians can impact the cost of health care the most by using our judgment of what we expend at end of life and before. This should be a judgment made by the family and physician at the bedside (not at home on the phone). And if this takes us out of the ER and into the ICU then so be it! If we are the only physicians in house then it is incumbent on us to be there for the patient and their family. Our government is doomed to fail (even more), if health care spending is not controlled, and we can control it on our terms and not theirs!
We as physicians are blessed to be in the position we are in. We have a lot of influence on everything. We should use that influence to benefit every aspect of our lives and the lives of others.
Harold K. Moores, MD, FACEP
[This article will be published in the November issue of ACEP News. See the entire ACEP News libary online at www.acepnews.com]
After considerable debate, the ACEP Council voted this month to refrain from participation in the national “Choosing Wisely” campaign in large part due to the other efforts being taken by ACEP to achieve the same and even larger goals.
“Choosing Wisely” is part of a multi-year effort of the American Board of Internal Medicine (ABIM) Foundation to help physicians be better stewards of finite health care resources, according to its website. As part of the campaign, specialty organizations identify five tests or procedures commonly used in their field, the necessity of which should be questioned and discussed by patients and physicians.
ACEP had considered joining this campaign three distinct times since its launch in December 2011. Three different workgroups of various ACEP members, committees and Board members looked at the campaign and decided that while the concept is positive, the scope of listing tests, especially for emergency physicians, was too narrow.
Despite this extensive review by ACEP members, a resolution was submitted by the New York Chapter asking the ACEP Council to decide if ACEP should join the “Choosing Wisely” campaign.
As part of the Council process, resolutions are first debated in a reference committee where members of the Council provide background about the resolution, give testimony to its merit or explain reasons why it should not be adopted. It was standing room only for the debate about this resolution and discussion was spirited. The debate continued the next day with many of the same reasons echoed on the open floor of the Council with mroe than 300 voting members in attendance.
Those in support of ACEP joining the campaign said that 26 medical specialties (except for emergency medicine and anesthesia) have joined or committed to participate. They added that participating could give ACEP more national visibility and bargaining power, and that ACEP could use its participation to educate other specialties about emergency medicine’s particular challenges.
Those opposed to ACEP joining the campaign said that the Choosing Wisely campaign does not involve any negotiation with others in medicine, and that it could lead to unintended consequences, including a lack of liability protection, vulnerability to the False Claims Act and automatic payment denials from insurance companies based on tests that the campaign deems to be “unnecessary.”
One large concern was that the intent of the campaign had already eroded, with several specialties offering only minimal savings and stepping outside of their field and including tests on their lists that are outside the scope of their practice.
The issue generated strong feeling on both sides and the majority of the Council ultimately decided to refrain from participation.
ACEP already had opted to strive to identify cost savings measures without compromising patient care. Three task forces were established in 2012 to work toward this idea – the Cost Effective Care Task Force, the Delivery System Reform Task Force, and the Transitions of Care Task Force.
ACEP’s Cost Effective Care Task Force is developing recommendations on ways to reduce costs in emergency care. Through member surveys, a Delphi approach, and use of the Emergency Medicine Practice Research Network (EMPRN), this group will not only consider unnecessary tests and procedures but also processes with emergency care that might represent meaningful cost savings while improving patient care. This task force is expected to complete its work and offer its report to ACEP’s Board in February of 2013.
It is hoped that these reports of significant recommendations can fuel a public campaign and support health policy advocacy concerning how emergency physicians are not just making a list of tests to cut, but instead are looking at much larger initiatives, processes and transitions that could result in real health care savings while improving patient care.
The Delivery System Reform Task Force gave its report to the ACEP Board of Directors on Oct. 5. It can be found online at www.acep.org/advocacy/federalissues/.
“The emergency department remains at least one of the reasonable solutions for addressing many of the health care system’s most vexing problems from a delivery system perspective,” the report states. “Emergency physicians are well positioned to provide innovation and leadership across the acute care continuum. Even from the perspective of employers, the patients, and payers, the allegedly high cost of care is incompletely characterized, often misconstrued, and lacks sufficient perspective in the broader context of community economics and the health care delivery system itself. Addressing these dynamics will require significant and intensive efforts to bring data, information, and solutions to a delivery system in rapid evolution.”
In addition to efforts that should be continued, the report also lists several recommendations of efforts that should be started or enhanced, including information sharing to primary care providers (and specialists), care coordination for high-cost users, regionalization of patient care resources (mobile technology, telemedicine), cost effective alternatives to hospital admission and others.
The report also recommends efforts that should be stopped or reduced (because emergency physicians are not trained or resourced for it, or could be more efficiently delivered in an alternative setting), such as longitudinal care for chronic illnesses, primary preventative care, non-value driven convenience care, and treatment of medical conditions that have no incremental benefit to the patient or value to the system.
The Transitions of Care Task Force also developed an information paper that was submitted to the ACEP Board of Directors in draft form on Oct. 5. When it is finalized, it will be announced to ACEP members and posted on ACEP’s website.
The Task Force paper notes that “The emergency department has an important, in fact pivotal, role in transitions of care and can enhance its value to the system by implementing more successful transition programs. As the emphasis and oversight of quality and cost increase, successful coordination of patients’ journeys through the health care system will help advance the triple aim of better population health, better patient experiences, and reduced cost to the system. “
To achieve this goal, the Transitions of Care Task Force made several recommendations, including
- improve residency training and continuing professional development for emergency physicians on the importance of handoffs in effective transitions of care
- work with emergency department information system vendors to produce transition support tools
- identify strategies that make handoffs successful, and use them to establish goals for emergency departments
- develop a web-based toolkit that includes resources, assessment and support tools, and best practices
- develop education resources on palliative care in the emergency department to enhance knowledge and increase the number of emergency department-based palliative care programs
- and more.
ACEP has a strong focus on these issues of improving patient care and providing cost savings. To that end, multiple recommendations continue to be developed and adopted by the College. We are dedicated to ensuring that our specialty brings ideas that truly will improve care for the millions of patients we treat and provide real, substantial savings to the nation’s health care expenses.
Please send your stories to Tracy Napper (firstname.lastname@example.org) today!
The night after Christmas day was a busy day in the department. We had already slogged our way through a stream of what seemed like endless patients when Triage alerted the team of a potentially sick patient. “They are coming straight over to the Acute Care side now, and they are turning blue!” With this information, my interest was instantly piqued.
The patient rolled quickly across the ED into a bed via wheelchair. I half-jogged to the room to find a young patient, in no apparent distress. A quick glance up at her monitor revealed normal vital signs, normal oxygen saturations on room air. Hmmm. “What brings you in today?” I started. “My mom told me to come in tonight. She said, I don’t look right and that my face and hands look blue. I feel fine.” It was only then that I was able to see the subtle, but easily recognizable blue hue around her mouth, lips, and her fingertips.
My first thought was, this girl is cyanotic. She sure is. And with the involvement of her face and lips, she has central cyanosis. From what? But, she has normal oxygen saturations, heart rate, and blood pressure. A quick listen to her chest revealed no murmur and no extraneous lung sounds. Hmmm. Very interesting.
I turned my attention to her hands. Closer inspection revealed the subtle blue hue to primarily be located on her fingertips. I squeeze her fingertip to assess her capillary refill, and it was normal. However, when blanched, her fingertip remained slightly blue.
”I don’t know why this is happening to me, I feel fine. I’m a little freaked out right now because everybody looked very worried in triage,” she said anxiously. At this point, she looked very nervous, drumming her fingers on her leg, tapping her foot. I looked at her hands again. She was wringing them, tapping her fingers on her leg, rubbing them together, then back again, drumming her jeans. Her dark blue, denim jeans.
”Did you get some new jeans for Christmas?” I asked. “Yeah….,” she replied, looking very confused. I took an alcohol swab out of the drawer, ripped open the package, and wiped one of her fingertips. I showed her the results. Her face now turned a beet red. “I’m so embarrassed,” she said putting her hands up to her mouth. “It’s a rare disorder, but a very curable case,” I teased.
It’s not every shift you catch a “zebra” like Blue Jean Pseudo-Cyanosis. But when you do, it reminds you why you love this job, even during the holidays.
Jeremy Webb, PGY3
Wake Forest Baptist Health. Winston Salem, NC
The October audio summary/podcast is now posted and available. Highlights include:
-Antidotes for cyanide and organophosphates: routes of administration
-Evidence base on treatment of jellyfish stings
-Epi or hydroxocobalamin for cyanide arrest
-Adaptive and group sequential analyses in trials
-Trial registry fidelity in EM publications
-Syncope: should we investigate cardiac structural abnormalities?
-Treating and considering potential organ donors in the ED
-Opiate prescriptions in the ED: ACEP Clinical Policy
Enjoy, and email any time at email@example.com,
David and Ashley
Please send your stories to Tracy Napper (firstname.lastname@example.org) today!
John Bibb, MD, FACEP
Do you know the difference between a fairy tale and a sea story as told by sailors? A fairy tale starts out, “Once upon a time…”; a sea story starts out , “Now this is no s*!%….”
So this did not happen when I was on duty. Not everything that goes wrong does so when I am on duty. A female patient who was in her 30s comes in with a complaint of lower abdominal pain. She is seen by the emergency physician who sends off a gram stain of the cervical secretions to the laboratory. The lab calls back and says we see gram negative intracellular diplococci consistent with gonorrhea. The patient is informed of her diagnosis. She says, “Is that right? Please send in my husband George.” The patient confronts her husband with the diagnosis and so George confesses about his extramarital endeavors. Then the lab calls back and states that they over decolorized the slide and that their initial reading is in error.
A physician acquaintance of mine is on a mission to promote awareness, especially amongst emergency physicians, of the potential for post-traumatic stress disorder in children who have been attacked and/or bitten by dogs. Thus this blog post. As a practicing psychiatrist, he has treated a number of such children, and he believes that it is very important for physicians who are treating these children for their bite wounds to inform parents to actively watch for signs of PTSD and to obtain evaluation and treatment if indicated. Dr. Schmitt has lectured and published on this topic (Larry Schmitt, MD, Dog bites in children: Focus on posttraumatic stress disorder, Contemporary Pediatrics, Jul 1, 2011). He makes a good case for the need for parents and pediatricians to monitor these children closely after their injury, and for incorporating information about PTSD into post-treatment ED and inpatient discharge instructions.
One may not readily consider the diagnosis of PTSD in children, but after dog bites it appears that children pick up on the guilt and sadness in their parents’ faces, and tend to bury their feelings and avoid discussion of the attack. This of course may precipitate PTSD, and make it more difficult to identify this pathology unless one recognizes the symptoms (excessive anxiety, irritability, decreased school performance, sleep disturbance, reduced creativity, withdrawal, altered appetite, depression, physical complaints, pronounced startle responses, and behavior problems), and relates them back to the attack. Parents need to know not only how to recognize PTSD, but also what to do to mitigate the potential for their child to develop PTSD. Preemptive psychological management is likely to be helpful, and parents need to participate in helping their children cope with this trauma and its psychological impact.
Dr. Stanley Goodman published a pdf on the web which provides an extensive outline of this issue; and he suggests that ‘children need to be helped to understand the following, in order to lessen their feelings of vulnerability and helplessness:
1. that many children become fearful whenever they have reminders of the incident, such as seeing other dogs or even watching movies/TV shows with dogs.
2. that they may feel more nervous when they leave their house, fearing they may be attacked and bitten again by a dog.
3. that they may experience depressive symptoms, such as feelings of helplessness, frustration, and diminished social and/or educational functioning; but these feelings are not a sign of weakness. Rather, they are a foreseeable reaction to having been bitten.’
Emergency physicians treat a lot of children with dog bites, and they have an important role to play beyond caring for the injuries themselves. Making parents aware of the potential for PTSD, providing information about the signs and symptoms of PTSD in written dog-bite discharge instructions, and suggesting referrals for preemptive psychological counseling can all make a significant contribution to the child’s successful recovery from this kind of trauma.
This post also appears in The Fickle Finger
Highlights of the August 2012 Annals of EM Audio:
-A brief alcohol intervention that may change everything
-Oligoanalgesia for the elderly? Yes and no…
-Interventions for hyphema
-Factor VII for non-hemophiliacs
-Observational study methods and bias
And much much more…
Email any time at email@example.com
David & Ashley
Send your story to Tracy Napper (firstname.lastname@example.org) today!
By John Newcomb, MD, FACEP
I am a fifty-five-year-old physician trained in family practice working as an emergency physician in a high-volume rural emergency department. This is my story.
Ever since I can remember, I have wanted to do something that would allow me to help people. My mother told me I should be a dentist. After being rejected by numerous first responder organizations, I resolved myself to enrolling in college. After one year of college, I received a call from one of the ambulance companies with an offer of employment. Despite a budding career in academia, with a stellar 2.0 GPA, I made the sacrifice and left college and took to the streets, literally. My credentials for being a medic were a standard Red Cross First Aid course, a CPR card, and a “willingness to learn.” At the tender age of eighteen I was assigned to patient care while my older, more experienced partner was assigned to the important job of driving the truck!
I served on the ambulance for three years. Little did I know I was living in the beginning of the end of the dark ages in EMS. I was an EMT but I was treated as a TGT (Throw and Go Technician). I had the privilege of taking the first AHA ACLS course ever. No mannequins for us. We practiced our intubation skills on anesthetized patients in the OR. I still feel badly about what happened to that man’s frontal incisors. I took some solace in the fact that lives would be saved and pre-hospital care advanced by the experience; too bad though, he once had a nice smile. It was a time of the esophageal airway tube, mast trousers, and calcium gluconate with its legendary mythical powers of bringing the dead back to life. I particularly miss the passing of the “pre-cordial thump.” Maybe it’s just nostalgia, but it saddens me when I think how emergency care professionals training today will never know the exhilaration one felt when you could literally beat the life into someone.
Today, I am the Medical Director and Chairman of a rural ED with an annual volume of nearly 50,000. I serve on most of the major committees of my hospital and committees that govern the hospital system. Recently, I served as Co-Chair for the Workforce Section of ACEP and as Section Councilor for two consecutive years. I am board certified in family medicine, but this July I celebrated 21 years as an emergency physician.
So much talk today revolves around who is qualified to practice emergency medicine. I recall a time when the idea of paramedics was first introduced. ED nurses saw it as a threat to their position. When mid-level providers were beginning practice, physicians felt threatened. Now I ask you, how would we care for our patients today if it weren’t for paramedics and mid-level providers? Throughout my life I have seen a lot of changes in EMS, but turf battles seem to remain the one constant.
Maybe it’s in my position as medical director, or maybe it’s just because of my experience, but most likely my perspective is the result of both. As emergency physicians, we have been given a tremendous opportunity, and I believe a great privilege, to care for the sick and injured among us. I stress teamwork in my ED. Every member of the department is responsible for the needs of every patient and every member is responsible for making every other member the best they can be. This attitude extends to the registrars and to the ambulance personnel. Despite my commitment to teamwork, from time to time, I still have to resist the urge to give somebody a good “thumping.”
There is a shortage of nurses and physicians to staff our nation’s EDs at a time when volume and acuity are increasing. The turnover of staff makes the task even more challenging. We frequently do not have inpatient beds, we do not always have the specialty care our patients need or the most appropriate diagnostic or therapeutic equipment available. We go to our jobs everyday under the threat of the next terror attack and knowing the next pandemic is inevitable. Because of the high pace, and lack of readily available resources, I lean on my experience more each day to help me to be as efficient as possible. Today there is no place for turf battles in America’s EDs. Our patients and our country can’t afford it. In addition to caring for our patients, everyone will be better served if we look for ways to take care of our own and lift each other up.
To summarize, I’ve learned a couple of things from my life’s journey in EMS. Change is inevitable and usually for the good. Teamwork is essential to providing the best patient outcomes. Experience should not be underestimated. Finally, always consider a mother’s advice.
Sometimes I have a hard time trying to separate fact from fiction; especially when patients start giving me a back story to explain why they haven’t had follow up for a medical problem, or how their narcotics got stolen/lost/misplaced, etc. I sometimes think, seriously? Is that really how bad your life is? Come on…
I know times are hard for a lot of people, but when you’re a 30-something, insulin-dependent, right AKA with non-healing wounds who social work bent over backward following your last admission to get you a clean place to live, home health care visits and arranged for a primary care physician so that you could regularly get medical care and, more importantly, your prescriptions, it’s poor form to miss appointments and get dropped from the practice.
Yes, I know it’s easy to get kicked out of your place within a month for having a dog which wasn’t allowed in the first place and which you acquired AFTER you moved in. What home isn’t complete without a loving pet? And, since you couldn’t afford a place before because of your limited SSI, I am sure adding vet bills, dog feed, and vaccinations to your budget will be no problem at all. And, sure, having a significant other who doesn’t work and who smokes despite the no-smoking policy of the building management is a problem especially when they’re not supposed to be on the property either. Yes, darn those apartment landlords and their stupid rules.
Now, I understand that you had previously been living in your car and had been lucky to have a nice place to live, but why couldn’t you drive that car to the appointment again? I’m sorry, you’re now having to live in it again… is it in working order? How did you get here again? What? It’s a legitimate question since you came 20 miles out of your way from your hometown to our E.D. Sure, yes, well, you’re in luck, we have no beds and are having to send all of our admissions north to our sister hospital. So, you’ll be closer to, um, home… and, besides, those social workers already know you and have done all of the leg work already, so there’s that too.
Then there’s the “I need a drug refill because my meds were stolen after I moved out from the last place I was in.” My answer is simply “drugs and scripts are like money, if you lose it, it’s gone and there’s no replacing it.” Besides, we have pain contracts with the local primary care M.D.’s, and they say, “No.” I still get some interesting stories, though, of backpacks being left “for just a second,” or of drugs disappearing “while I was taking a nap” or of pills in a lockbox in someone else’s house that mysteriously disappear when the person with the key leaves the house to go out to get some smokes. My favorite is the “I left them at my ex’s house, and now I can’t get them back.” “Did you file a police report?” “Well, um, yeah.” “Ok, let me talk to the police department and confirm the report number.” “Yeah, well, um.” “So, which police officer was it again..?” “Um, well, yeah it’s kinda like this…”
Mark Twain once said, “Truth is stranger than fiction, but it is because Fiction is obliged to stick to possibilities; Truth isn’t.” Twain must have worked in an E.D.