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22 November 2011
I have been working as an ER doctor for over a decade, and in that time I have come to recognize that there are certain complaints, and certain patients who bear these complaints, that are very challenging to take care of. I'm trying to be diplomatic here. What I really mean is that there are certain presentations that just make you cringe, drain the life force out of you, and make you wish you'd listened to mother and gone into investment banking instead. Among these, perhaps most prominently, is that of the patient with cyclic vomiting syndrome.
The diagnosis of cyclic vomiting syndrome, or CVS, is something which is only in recent years applied to adult patients. Previously, it was only described in the pediatric population. It has generally been defined as a disease in which patients will have intermittent severe and prolonged episodes of intractable vomiting separated by asymptomatic intervals, over a period of years, for which no other adequate medical explanation can be found, and for which other causes have been ruled out.
That is not seem to exist much in the way of good literature about this disease entity, which is surprising, because it is something that I see in the emergency department fairly regularly, and something with which nearly all emergency providers are quite familiar. These patients are familiar to us in part because we see them again and again, in part because they are memorable because they are so challenging to take care of.
Some things about the cyclic vomiting patient that pose particular challenges:
- The intensity of their vomiting symptoms tends to be very severe, and refractory to most standard antiemetics.
- The amount of affective distress the patient demonstrates is usually quite disproportionate to the severity of their symptoms, which is actually saying something, since they can at times be fairly ill. This often manifests itself as a patient who is ultra-dramatic, writhing on the gurney, or hyperventilating and sobbing in a knee to chest position, refusing to talk to the care providers. This can create the perception among care providers that the illness is psychogenic, a perception which is reinforced by the fact that there does seem to be significant association between CVS and mental health diagnoses.
- Patients often will engage in behaviors which seem to be willfully making their symptoms worse, such as compulsively drinking water or being seen to induce vomiting by putting their fingers down their throat.
- Coexisting with the vomiting is often a fairly severe complaint of abdominal pain, for which no clear diagnosis can be established, requiring in some cases high doses of intravenous narcotics. CVS patients are interesting in that sometimes the only agent that will stop the vomiting is hydromorphone. (For the nonmedical readers, it is worth noting that hydromorphone has no anti-vomiting properties, and in fact causes many people to vomit.) This requirement for narcotic medication supports a perception that the patient is drug addicted or drug seeking, itself reinforced by the fact that patients tend to come back to the emergency room several times in quick succession for recurrent vomiting. (For this reason, some have referred to CVS as an "Abdominal migraine.")
All of this makes management difficult in the setting where there is fairly little in the way of evidence-based guidelines, or even much in the way of expert recommendations or academic agreement on the definition of the syndrome. My observation, over the years, is that while Zofran and Reglan and Compazine can in some cases be helpful, in most cases they are not. I have however, had very good success with the use of benzodiazepines such as lorazepam or midazolam. Benzodiazepine seem to work in 2 ways: they are well known to have anti-emetic properties, but they are also quite sedating, and the patient does need to be awake to vomit. Interestingly, while use of normal vomiting medications seems to drive patient requests for narcotic medications, when I use the benzodiazepines, I almost never have to co-administer a narcotic. Since I have made these observations and implemented them in my personal standard treatment protocol, I found that CVS patients are much easier to care for, both in the sense that they're less emotionally draining for me and in the sense that they get better quicker and go home feeling better. It's not clear to me whether this treatment protocol results in fewer bounce-back presentations to the emergency room, but I would be very interested to find out if that is the case. (Interestingly, the use of hydromorphone seems to increase the likelihood of bounce-back presentations.)
I'm a little curious whether propofol could be used to manage the vomiting of CVS, since it is also known to have anti-emetic properties, but given the demise of poor Mr. Jackson, I suspect such off-label uses of that medication are not going to be encouraged.
One thing which I've recently become aware of, in part through our good Aussie friends at Life in the Fast Lane and in part from a journal club that I recently attended, is that there seems to be a fairly strong association with marijuana use and CVS. In fact, there has been proposed a disease entity called cannabinoid hyperemesis syndrome which may possibly represent the same clinical syndrome of CVS, or at least a significant overlap. This is particularly interesting because marijuana is in fact generally perceived to have antiemetic properties. Leon Gussow, a toxicologist who blogs at The Poison Review, has a nice write up over at Emergency Medicine News, where he speculates:
Because cannabinoids are lipophilic and have long half-lives, they may accumulate with chronic heavy use to the point where they start to exert a paradoxical effect. This may be related to their well-described ability to delay gastric emptying and decrease gastrointestinal motility.However, I would temper that against the observation that in CVS patients gastric motility and gastric emptying is often increased.
Since I have become aware of this association between marijuana use and CVS type presentations it has been my “good fortune” to care for nearly a dozen patients in the emergency department who self-reported diagnosis of CVS. Curiously, of these patients about 10 admitted active marijuana use, and the 2 who denied it had positive urine screenings for marijuana. This does not exactly make a case series, but is certainly another interesting observation. Of course, since the prevalence of marijuana use in our Emergency Department seems to approach 100% sometimes, this also may not be a statistically significant association! Each of these patients was counseled about the possible causal relationship and advised to stop smoking the devil weed. Lord knows whether they will or not, but maybe it will actually do something to reduce their ER visit frequency.
I'd be interested to hear your observations on this matter, whether other ER folks have noticed the same thing.
UPDATE: Comments closed as they have been getting excessively abusive.
Posted by shadowfax at 10:34 AM
21 November 2011
Okay, I am officially overwhelmed. I am about as well plugged in to the bureaucracy of medicine as any nonprofessional administrator can be. I am familiar with the joint commission audits, with the physician quality reporting program, with CMS core measures, with hospital compare, with HCAHPS, with meaningful use, with the hospital inpatient quality reporting program, with leapfrog and a variety of other patient safety and quality initiatives. Yet it seems that every time I turn around there is a new set of quality metrics being developed and implemented. I can't keep track of them anymore. It turns out, unsurprisingly, that our hospital is preparing for a new set of measures which will be tracked as of January 1, in addition to the measures that I was only vaguely aware of which they had already been tracking for the last 2 years.
This is, of course, the Hospital Outpatient Quality Reporting Program. You all knew about that one, right? Cause I didn't. So what this is, apparently, is yet another quality data reporting program. In these programs, the healthcare provider, in this case a hospital, is required to report their performance on certain quality performance metrics. If they comply with the reporting requirement, they receive the full payment update for their Medicare outpatient services, and if they do not report the measures, then they are penalized 2% of their Medicare outpatient dollars, a figure which can run into many millions of dollars for the typical hospital system.
It's important to understand, that at least at this time, hospitals are not being paid for how well they are performing these measures, simply for reporting them. It is not unreasonable to presume, based on experience with previous quality reporting initiatives, that ultimately payment will be linked with performance rather than just for reporting.
So what are the reported quality metrics which are relevant to emergency department care?
The existing metrics are:
- Acute MI: median time to thrombolysis
- Acute MI: thrombolysis within 30 min.
- Acute MI: median time to transfer for PCI
- Acute MI: aspirin on arrival
- Acute MI: median time to ECG
- Nontraumatic headache: Use of CT scan (medicare patients only)
- Troponin results within 60 min. for chest pain or MI patient.
- CT head interpretation for acute stroke within 45 min. of arrival
- Left without being seen rate
- Door to Doctor time
- Median time from arrival to departure for discharged patients.
- Discharge instructions
- Time from arrival to pain medication for long bone fractures
While I understand the overall crisis in healthcare costs in this country, and I understand the need to cut costs, and I also understand the need to improve standardization and quality of care, I do not like the fact that cost-cutting has essentially been piggybacked onto quality measurement. However, this appears to be an inexorable force that we are all just going to have to live with.
So, there you have it: enjoy! Another year, another set of quality metrics to measure and manage to.
Posted by shadowfax at 4:52 AM
20 November 2011
18 November 2011
We respond to certain "Code Blue" situations in our hospital. In the ED, of course, and in the outpatient areas and radiology, and if needed as back-up in the inpatient units. The hospital issues one of those overhead calls when there is a code blue -- a cardiac arrest or other collapse, person down, injury, etc, but we also carry a pager in the ER in case we don't hear the overhead call. The pager also signifies which doc is designated to respond to such a call, since we often have 8 docs working at once. It's a little ritual we have at change of shift, passing off the pager and the spectralink phone, like the passing of the torch to the oncoming doc.
So of course I took the pager home the other day and had to make an extra trip to the hospital to return it. Ugh.
How bizarre is that, when you think about it? This device ought to be a relic in a museum of outmoded technology. This device was in use before the iPad and iPhone, before smartphones at all, before digital cell phones. When this device was first put to market, the internet barely existed, if it did at all, computers all had CRT monitors and the fastest computers out there was running a 200mHz Pentium Pro.
Yet it remains in widespread use, having never been updated, improved or (as far as I can tell) altered in any way whatsoever. Where else will you ever find a piece of technology still in use unchanged for a decade and a half? What industry is so ossified and hidebound that it would fail to adapt to the rapid improvements in communication technology?
Only in health care, my friends, only in health care.
Posted by shadowfax at 10:31 AM
13 November 2011
10 November 2011
Doctors are, famously, workaholics. That's just the way it's been forever, at least as far back as my memory goes.You work crazy hours in residency, you graduate and work like a dog to establish your practice or to become a partner in your practice, and then you live out your career working long hours because there just aren't enough hours in the day to do everything that needs to be done. I remember, growing up in the '80s, that my friends whose parents were doctors were latchkey kids whose dad (usually the dad, then) was never at home when we were hanging out in the rec room playing Atari.
Yeah, Atari. Look it up, kids.
Not much had changed by the time I went to medical school. There was recognition of the fact that burnout was an issue -- that divorces, alcohol abuse and suicides were more common among physicians than in other professions. The unspoken implication was that being a doctor was difficult and stressful, which increased the risk of these consequences of an over-burdened professional life. These stresses were accepted as part of the turf, as a necessary part of "being a doctor." It wasn't optional, and indeed, most physician teachers that addressed the matter chose to sublimate it into a mark of nobility. Being a physician was a calling and a duty, and a physician must gladly subordinate his or her own happiness and well-being to the service of their flock.
But things have changed, or at least a slow shift is in progress. It was probably ongoing when I was in training, though I was pretty oblivious at the time. I see it more and more clearly as time goes on.Young physicians have different priorities now, and they are making career decisions based on a more self-centered set of values.
For example, a study in Amednews, cited by @Skepticscalpel, revealed that graduating residents place "free time" and "lifestyle" as their top priorities in choosing a position, above even financial considerations. Young doctors are opting for large multispecialty practices and for hospital employment in droves -- stable and predictable practice environments -- and the practice model of small group or independent practitioners withers on the vine. At the same time, driven by slightly different motives, residency hours are being restricted.
This has provoked a chorus of curmudgeonly disapproval from many, especially from within the surgical specialties. Skeptical Scalpel himself mused:
Does all this bother anyone else? I wonder what people expected? Did they not know that being a doctor involves commitment and self-sacrifice?One commenter was rather more direct:
Being a doctor is not a job like being a banker or contractor. It is a life. The decision to become a doctor should carry as much weight as the decision to enter the priesthood. Medicine is not a dilettante's profession. Make the commitment or get out.Which, I think, aptly summarizes the position of the "old guard," the guys who paid their dues and expect the next generation to do the same. But we (and I still include myself in this group) who are younger don't agree, at least not entirely. It seems like the demands of this profession are, in part, not intrinsic to the job but rather culturally and institutionally generated -- and thus, subject to change. Why should I spend my entire career working 60 hours a week? Is that necessary to maintain my skills? Is is worth the cost to my family and my personal life? Is it more important to me that I be a "good doctor" than it is that I be a good father and a good husband? I don't think so, and in fact, personally, I identify myself more as a father than a doctor.
Note that I am referring to a career, not to training, where there is some argument in favor of intense experience. That is a different topic.
So I am entirely in favor of the movement towards more humane and livable practice environments for physicians. And I do not think this movement is going to reverse itself, but rather, will become the new standard going forward. The phenomenon of cohort replacement, or "the replacement of old guards of organizational members and leaders with newer cohorts who have different beliefs, opinions, and values," will likely slowly but inexorably change the culture of medicine towards one in which the accepted, default position is that physicians have robust extra-professional lives.
John Mandrola, an electrophysiologist, is cautiously supportive of this transition, but poses the unsettled question of whether this is good or bad for patients.
To some degree, it's a clear win for patients. A well-rested surgeon performs better. An ER doc who is suffering from burnout is not the one you want treating your child. An internist who retires at age 50 because the office life is too demanding represents "brain drain" as the most experienced and valuable docs flee the workforce.
The surgical and procedural-based specialists seem to have the most resistance to this change, and they do have some valid points. There is a correlation between how many times you do a procedure and how well you do it. You can learn to do a lap chole in residency, but you may not be really good at them until you have done a few hundred in the first few years of your practice. Further, surgeons have a different relationship with their patients, usually shorter duration but much more intense. This makes it harder to place boundaries on intrusion of their practice into their personal lives.
However, these hurdles are logistical barriers which can be overcome, at least in part. The use of trained and experienced physician extenders can greatly streamline the non-operative elements of care and allow the surgeon to focus his or her time where it carries the most value: in the OR and at the bedside.
The greater question of whether this is good for patients relates to the the looming physician shortage. If physicians, as a group, are cutting back on their time at work, this will require a larger workforce to deliver the same amount of care. There are some efficiencies that can be gained, especially through the use of PAs and NPs, which may mitigate the matter. However, it's hard to escape the conclusion that the trend towards a firmer life-work boundary for doctors will exacerbate the physician shortage.
I don't think that's an argument against greater work-life balance in medicine. That's still good policy. The consequences need to be acknowledged and addressed, and it's worrisome because little is being done to address the physician shortage in the first place. But it doesn't change the fact that the ability of doctors to have stable and fulfilling extraprofessional lives is good for both doctors and the patients we serve.
And in any case, the argument of whether this is a good thing or a bad thing is about as important as a debate over the tides. It's happening, as the result of thousands of individual docs all making the same personal choices, and it's very unlikely to change. So we had best recognize it and make plans to deal with it.
Posted by shadowfax at 12:07 PM
08 November 2011
There's technically no difference between "I almost sent home that baby with bacterial meningitis" and "I made a tricky diagnosis of a life-threatening case of bacterial meningitis." The facts of the case are the same. One statement expresses justifiable pride in a job well done. The other emphasizes how close you can come to utter disaster without ever knowing it.
Apropos of nothing, I think I'll buy a lottery ticket today.
Posted by shadowfax at 12:48 PM