30 April 2010

Friday Flashback - Pride Goeth Before the Fall

So says the book of proverbs. You may recall the pride I expressed when I picked up a difficult appendicitis case a couple of months ago. Karma is a real bitch, sometimes, and this week has been payback time. It began in what is for me typical fashion:

It was a classic presentation. A young man, about 19 or so, with 36 hours of anorexia, malaise, low grade fevers, and generalized abdominal pain which subsequently localized to the right lower quadrant. He has a elevated white count, tenderness over McBurney's point, involuntary guarding, and rebound tenderness. Now, as a digression, one drawback of modern technology is that is it nearly impossible to get an appendectomy without a CT scan any more. It used to be that a "negative laparotomy" rate of something like 25% was acceptable. Now any negative laparotomy is viewed in much more negative terms, and the surgeons almost always demand a CT scan before even seeing the patient. So it goes. This was, I thought, one of the few cases which was clear cut enough to justify skipping the CT scan and going straight to the OR. And the surgeon on was one I knew well and who trusted me. I called her up:

"I've got an appy here for you."
"What did the CT scan show?"
"I actually think you may want to just take this one to the OR. I am sure this is an appy. I don't own a hat, but I will go out, buy a hat, and eat it if this is not an appy. I'll get a CT if you like, but I think it'll be a waste of time."
"If you say so, it's good enough for me. I'll come down and see him now."

She examined and interviewed the patient, agreed, and up to the OR he went. An hour later, I got a call from the surgeon. With barely-disguised malicious glee in her voice, she said, "It's time for you to go shopping. What's your hat size?"
It turned out the young man was experiencing a first presentation of inflammatory bowel disease and had terminal ileitis, which is notorious for mimicking appendicitis. (and the surgeon was very nice about it -- we are friends and she too, had been convinced enough to take him to the OR.)

So then the next day when I saw another young man with a classic case of appendicitis, I was more cautious. I told the patient that I was quite sure it was an appy and he would need to go to the OR, but to be certain, he would get the CT scan before I called the surgeon. His CT came back showing epiploic appendagitis, a bizarre and rare, but benign condition which mimics appendicitis but does not require surgery. I have seen it maybe three or four times in my career.

Thoroughly snakebit, I saw yet another "classic" case of appendicitis last night. Once again, it couldn't have been any more obvious, as if from the textbook, in a young male. (It's never straightforward with females. Um, I say that in reference to appendicitis only. Really.) He also got a CT scan, and at this point I was no longer even surprised to have an unusual and rare thing turn up on the CT scan. In this case, it was cecal diverticulitis, which I have never seen before, let alone in a 22 year old (diverticulitis typically occurs in the sigmoid colon and in patients 50-60 years old).

It's almost is if I was living in some Greek tragedy in which the fates were eager to punish me to the crime of hubris, of which I am undoubtably guilty. Enough, already!

If I get a chance, one day I will tell you about the case that truly set me up for this karmic payback. Here it is. I can't argue that I don't deserve it.

Originally Published 26 April 2007

Too Cute

Baby Lion Cubs at the Bronx Zoo

via WaterTiger

29 April 2010

Blue Screen

Funny Animated GIFs - This Seems Accurate

Even androids burst a vein when confronted with the Blue Screen of Death.

Source: SeƱor GIF

28 April 2010

Where romance and medicine collide

A patient was brought in around midnight as a "possible stroke." She was a sixty-something woman who had suddenly become unresponsive.  She and her husband had been making love at the time, and he noticed that she was no longer conscious.  Unable to revive her, he had called 911.

She looked bad -- but it was strange.  She was groggy and semi-coherent, but there was no asymmetry to her neurologic exam.  She was profoundly hypotensive, with blood pressures of 60 to 70 over 30.  Whenever she tried to sit up, she became light-headed and lost consciousness.  Not that we allowed her to sit up!  We had her bed inverted, in the trendelenburg position, and pumping her full of IV fluids we were barely able to bring her blood pressure to acceptable levels.  Eventually we had to put her on inotropes to support her circulatory status.

But not a clue had we about why she was abruptly so sick.  Apparently she had been feeling fine prior to becoming amorous with her husband.  No chest pain and no cardiac abnormalities to suggest a primary heart issue.  No fever or source of infection. No belly pain or signs of bleeding.  No neuro findings.  Just unexplained, severe, persistent hypotension.

Then her husband showed up.  He quite sheepishly admitted what had happened which perfectly explained his wife's situation.

"You see," he hesitantly said in a thick Ukranian accent, "For a long time now I have had trouble getting an erection.  Doctor Sergei said that I could not take the Viagra because of my heart and my nitroglycerin.  But Doctor Sergei is very smart, and he had a solution for me.  I would take one of my nitroglycerin patches and wrap it round the shaft of my penis.  Then I could have an erection and I could have sex again.  This has worked well for us for many years."

I wish I could have seen my own face as this man was telling me this.  It must have been priceless.

"Tonight, after the paramedics left, I needed to clean up before I could come in to the hospital.  I was throwing the wrapper for the nitroglycerin patch into the rubbish and I realized that I did not know where the patch had gotten to.  I think I might have forgotten to take it off, and I think it might have come off inside her."

I had the hardest time suppressing my laughter, but so wretched did the poor old man look that I put on my most consoling face and thanked him for this very important information.  We went back into the room and five minutes later I triumphantly produced the offending patch from her vagina. 

It took a while, but she began a slow, steady improvement from that moment.  We admitted her overnight for observation, and she went home in the morning feeling well.

I don't know that there is a moral to this story, beyond the fact that people will do almost anything to have sex.  I suppose it could be "don't inadvertently insert a nitro patch into your wife's vagina," but that doesn't seem to have as much general applicability. 

27 April 2010

Still more cancers

This is getting spooky now.  Last night's new cancer was a young man whom I diagnosed with lymphoma.  So, counting the others, I'm getting all the systems covered: GI (rectal and pancreas), Pulmonary (lung), Neuro (brain), GU (endometrial), and now Heme (lymphoma).  I worry about how many systems are left, though.  This could take a while to work through them all.

In response to a few questions in the comments, there has been no real pattern to the presentations, or why the diagnosis came ultimately from the ER.  One guy was a curmudgeonly sort who had insurance but just didn't like to see doctors.  One was a very earnest fellow who had been seen by his primary and specialists on multiple occasions without them ever figuring it out.  I suspect they missed it because of his young age, but it was a clean miss.  One was a very complex patient with a whole team of specialists following her, but perhaps each was so focused on their body part that nobody asked the salient question that would have led to a sooner diagnosis.  And a couple were just a new onset problem that probably would never have been picked up until it clinically manifested itself, and when it did, the ER was the appropriate place to work it up.

These cases don't much seem to reflect the larger dysfunction in our health care "system."  Each on its own would be explicable and just bad luck or happenstance.  As a group, they are a little more alarming, but still it's just some very freaky luck.

26 April 2010

iPad X-rayed

An orthopedic doctor in Japan wanted to see what made the iPad tick, so he threw it under an x-ray machine and posted the images to his blog. We guess the good doctor (whose name is Dr. Ambition, according to his blog) wasn't happy with all the teardown photos and videos of the iPad. Or maybe he just wanted to see what happens when you pump it full of radiation. Appropriately enough, the iPad's x-ray was processed with OsiriX DICOM medical imaging software for Mac.

The good news for the iPad is that nothing was broken and, as long as the stool samples come back negative, it seems it can look forward to a long life.

As Seen on TV

Seriously, God, knock it off. KthxBai

I got a bad feeling from the 43 year old man in Bed F.  The triage compliant sounded like one of those bloody "not an emergency but it's more convenient so I'll just use the ER" things that never wind up involving any real pathology:  4 months of abdominal pain and constipation.

I had to suppress my initial snarky instinct "so what makes it an emergency today?"  There were clues that this wasn't a lame nothing presentation.  One funny thing was that this guy had never been to the ER in the last five years.  Odd.  Usually people who come to the ER for something trivial do so repeatedly.  And he was a nice guy -- very normal, with a pleasant wife at the bedside. Also a bad prognostic sign - the bad stuff happens to the nicest people, as a rule. I reviewed the records from clinic and he had been seen multiple times there with no clear diagnosis.  He had been seen by primary care, GI, and even by a spine specialist (due to back pain that seemed associated with the abdominal pain).  The poor man was really hurting, and I commented that he was looking thin.  He reported a thirty pound weight loss, and also some bloody mucous in his stools.  I did a rectal exam and felt a hard, smooth lateral mass.  The patient remembered that the spine guy had mentioned an "enlarged prostate."  Not likely, I thought, unless your prostate is not where it's supposed to be.  I put him in for a CT scan.
Uploaded with plasq's Skitch!
The results did not surprise me.  A rectal mass which was almost certainly rectal cancer, with liver lesions consistent with metastatic spread.  I had the terrible conversation, dropped the bomb on them as gently as I possibly could, and admitted him for the work-up and pain management.

What a day.  Fortunately, it's really really unusual to make a diagnosis like that in the ER.  Maybe once or twice in a year.  I deal with a lot of bad stuff, so it's not unusual for me to have to break bad news, but usually it's the final act, not the opening, where I play my role. 

The next day had a bit of excitement.  A 60 year-old man came in with an acute stroke.  Pretty classic -- sudden onset of left arm paralysis, with some strange seizure-type activity.  The radiologist called me and informed me that the CT showed a right posterior middle cerebral artery stroke with edema.  I called the stroke team and prepared for thrombolysis.  But the neurologist and I were both concerned about the degree of edema (which is typically a late finding) in such an acute event and we decided not to push t-PA.  That was a very good call, it turned out, because the clotbuster drug would have almost certainly induced a lethal hemorrhage in the tumor which happened to be causing his symptoms:
Uploaded with plasq's Skitch!

Then two days later, there was the woman with abdominal pain. I forget why I scanned her, but the result was the same.  Her liver looked like swiss cheese with metastases, and the culprit turned out to be a mass buried in the tail of her pancreas:
Uploaded with plasq's Skitch!

I got to have the "You have cancer" conversation with her, too.  The neurologist had been kind enough to break the news to patient number two above.

By this time, I was feeling pretty snakebit, as you might imagine.  Three cancer diagnoses in three shifts.  Am I cursed?  More precisely, what is it about me that is cursing my patients?  Gruntdoc advised me to simply stop ordering scans.  I was tempted.  But it continues.

The next one was a real tragedy.  37 year old man, with a six year old and a three year old kid at home.  Younger than I am, with kids the same age as mine.  Smoker.  Persistent cough, hemoptysis and weight loss.  The radiologist described his lung cancer as "clover-leaf shaped." It was not a lucky clover, alas.  It too had distant spread.
Uploaded with plasq's Skitch!

That was one of the hardest conversations I have ever had, on par with the time I diagnosed a little girl with neuroblastoma.

And the cavalcade of cancers continued.  I followed these up with a sixty-three year old woman with vaginal bleeding.  She was on coumadin and so it was thought she was over-anticoagulated.  But when her hematocrit got all the way to twenty-three and she fainted, she came to me.  I got the pelvic ultrasound that showed a 4 cm vascular mass in the uterus which is almost certainly endometrial cancer.
Uploaded with plasq's Skitch!
That's all in about, I dunno, a ten-day period.  FIVE new diagnoses of cancer, almost all of them very bad indeed.  It's about three years' worth of cancers for an ER doc.

Really, what the HELL.  This is just not right.  And it's not like most of them required me to be particularly clever or were difficult diagnoses.  I just happened to be the guy on shift when these poor folks came in.  Not that it matters -- sometimes a difficult diagnosis is really satisfying to figure out, but when the diagnosis is cancer there's no pleasure in it and it casts a pall over the entire day.

So I would like to give notice to the heavenly randomizer that I have exceeded the limit of statistically probable diagnoses of cancer for the foreseeable future.  No more, please, or I'm going to have to conclude that you're a malevolent bastard after all.

Thank you for your attention to this matter.

25 April 2010

Chickens for Check-ups

In the annals of "things you probably wished you hadn't said," Sue Lowden, the Republican candidate to replace Nevada Senator Harry Reid, suggested last week that bartering for medical care was a workable substitute for the Affordable Care Act, which she is campaigning to repeal.

Surprisingly, after being called out and roundly mocked for the suggestion, she doubled down on the idea: "You know, before we all started having health care, in the olden days, our grandparents, they would bring a chicken to the doctor. They would say I'll paint your house."

I know that it's hardly fair to pile on someone running for office for a bit of stump-speech dumbassery, but it just needs to be said.  As much as I enjoy a nice chicken sandwich from time to time, barter is not a feasible mode of payment for services any more.  A doctor can't pay his staff, his rent, or his malpractice insurance in chickens. 

A related suggestion was the idea of patients negotiating the price for services directly with their doctors. This also fails the giggle test on a number of levels.  First of all, that is one of the advantages of belonging to an insurance program -- they do the negotiating for you, and because of their size they command much deeper discounts than any individual ever could.  This assumes that a doctor even cares to discuss price with an individual patient.  In the ER I never do, not only because of the circumstances, but because I honestly don't know in advance exactly which of the thousands of codes (and prices) a given patient interaction will result in. 

Moreover, without the protection of insurance, the likelihood that any private individual will be able to afford the cost of an ER visit, let alone a surgery or hospitalization is essentially nil.

It's depressing to realize that there's a substantial likelihood that this dimwit will be the next Senator from Nevada. 

Updated: Also, it was noted that her history includes a malicious indifference to the healthcare needs of those less fortunate than herself:
When Sue Lowden headed the Santa Fe hotel-casino, management forced a group of workers to shift to part-time status and sign away their health care coverage, said a judge who ruled the company violated fair labor practices. 
Nice.  That's a real charmer you're sending to the Senate, Nevada.

23 April 2010

Friday Flashback

Meeting a hero

The triage nurse's note was not encouraging. Something to the effect of "85 year old male, fell, severe low back pain, unable to get out of chair x 3 days." These things are frequently nightmare cases -- either you have someone severely dehydrated and in kidney failure, septic, and terribly sick, probably moribund, or they are uninjured and well but you can't get them out of the ER due to pain, and nobody wants to admit them because there's no "medical indication" for admission and they don't want to deal with a case that medicare refuses payment on. Not the case one would choose to end the shift on, and didn't bode well for getting home on time.

Well, that's why I get paid the big bucks, right? I took a deep breath, squared my shoulders, and headed in. . .

The first thing that greeted me in the room was the strong odor of stale urine. Not a good sign. And the grizzled, unshaven face atop squalid clothing. Expectations met so far. But a pair of keen, bright eyes peered out at me from under bushy eyebrows and a big, albeit toothless, grin. He had been reading a book while waiting for me to come in! A book! After chatting with the fellow for a couple of minutes I determined he was a pleasant, extremely sharp fellow, neither terribly ill nor a complainer. He had never been ill a day in his life (a good recipe for living to 85, it must be said). After concluding the history, I went to examine him and gently picked up his book and put it aside, careful to mark his page with the bookmark. I forget the title of the book, but the bookmark was a large, glossy 4x8 photo which looked like this:"Nice plane," I commented.
"I used to fly it," he responded.
"What? Really? That exact one?"
"No, no, I flew a F model, that one's a G, but you couldn't really tell."
"Wow. What did you do on it?"
"Pilot. 17 missions."

It's hard to explain how he was transformed in my eyes after that. I so wanted to sit down with him and talk about his experiences. I am a pilot, and have nothing but awe for the guys who took off from England, flew these big beasts of aircraft, loaded with tens of thousands of pounds of bombs, across the Channel and over Germany with no navigational systems beyond a compass and a watch, dropped the bombs more or less on target, and returned home. Oh, yeah, and there were people shooting at them the whole time. They were real men.

I try to treat every patient with the same level of courtesy and compassion and all that humanistic bullshit, whether they are homeless scum or the wife of the hospital CEO, and I think I am pretty good at it. But it's pretty rare for me to really truly feel a sense of respect and indebtedness to a patient. In this case, it actually helped make the disposition easier. He turned out to have a couple of compression fractures in his lumbar spine, and despite pain medicine and his best effort, simply couldn't get up and walk. So I called up our hospitalist and began the conversation with: "Hi Jim, I have an interesting guy here. 85 years old with a couple of compression fractures in his back. He actually used to be a B-17 pilot in WWII."
"No shit?" asked the hospitalist.
"Yeah, really. Anyway, he's in pain, so I'm admitting him to you."
"Oh, of course. Send him up."

Good karma. And I got to meet a hero.

Originally posted 22 April 2007

22 April 2010

This makes my head hurt

But it is beautiful:

From Richard Wiseman's blog

Insurance Companies behaving badly, part 27

WellPoint routinely targets breast cancer patients

(REUTERS) One after another, shortly after a diagnosis of breast cancer, each of the women learned that her health insurance had been canceled. First there was Yenny Hsu, who lived and worked in Los Angeles. Later, Robin Beaton, a registered nurse from Texas. And then, most recently, there was Patricia Relling, a successful art gallery owner and interior designer from Louisville, Kentucky.

None of the women knew about the others. But besides their similar narratives, they had something else in common: Their health insurance carriers were subsidiaries of WellPoint, which has 33.7 million policyholders -- more than any other health insurance company in the United States.

The women all paid their premiums on time. Before they fell ill, none had any problems with their insurance. Initially, they believed their policies had been canceled by mistake.

They had no idea that WellPoint was using a computer algorithm that automatically targeted them and every other policyholder recently diagnosed with breast cancer. The software triggered an immediate fraud investigation, as the company searched for some pretext to drop their policies, according to government regulators and investigators.

Once the women were singled out, they say, the insurer then canceled their policies based on either erroneous or flimsy information. WellPoint declined to comment on the women's specific cases without a signed waiver from them, citing privacy laws.

I wish I could say I was surprised, even a little bit.  If this were not such a repeated, systematic pattern of profit protection abuse by insurance companies.  This is why Health Care Reform is a good thing - it will to a great degree curb these abuses.  No regulation can prevent deliberate law-breaking, of course, and enforcement will be key.  But under the new law, rescissions are not permitted except under very clear situations.  Whether the law will actually be enforced adequately remains to be seen.

When I read this stuff, it makes me so angry that I wonder again whether single payer would have been so bad after all...

ACEP Measures the Emperor's Nose

A long time ago, in a faraway and mythical country which we'll call China, everyone wanted to know how long the Emperor's nose was. Of course to look at the Emperor's visage was punishable by death. But so many people were curious, that a group of sages got together to look for a method of finding the answer, and this is what they came up with.

Questionnaires were printed and sent out in bundles to cooperating village chiefs, who distributed them to the peasants. Literacy was at a sufficient level that most were able to complete the single question, which was, of course: "How long do you think the Emperor's nose is?"

When the forms were collected, mathematicians added up all the values, and divided by the number of forms. Thus it was known that the length of the Emperor's nose was 6.734602 cm. The complete set of data was of course preserved, and many years later, with advances in statistical understanding more advanced mathematicians pointed out that fringe values - obviously the product of deranged minds - were distorting the honest opinions of the rest, and by eliminating them and using the very latest numerical modeling techniques, the mathematicians corrected this value to 4.980403 cm. To this day, no-one has produced a better estimate.

I got a survey request today from ACEP.  It asks, over 26 questions, what I, a practicing Emergency Physician, expect will be the outcome of the recently passed health care reform bill.  At first I was eager to complete the survey and have my voice heard.  Then I noticed that the questions, while not exactly biased, seemed more likely to reflect the level of cynicism among physicians rather than an educated projection of the effects of HCR.  Consider this question, which is representative:
Do you think emergency department visits will increase or decrease over the next 6 months as a result of the newly enacted health care reform efforts?
Visits will decrease
Visits will increase
Visits will first increase, then decrease
Visits will first decrease, then increase
Visits will stay the same
Don’t know
Considering that 99% of the meaningful reforms don't take effect until 2014, any physician who answers anything other than "Visits will stay the same" has identified him or herself as someone who is ignorant of the actual provisions of the HCR law.  The survey also asks the standard "temper tantrum" question, whether this law will induce you to quit practicing Emergency Medicine.  Physicians routinely threaten this, which is pretty much the equivalent of "I'll take my ball and go home," sort of brinksmanship.  Note to the media: it's patently a hollow threat, unless you've made so much money that you can retire at a young age, and those guys are usually fat & happy and not exactly being driven out of medicine.  The survey also askes the standard apocalyptic questions -- will all the specialists retire, will there be no more people going into medicine, will all the hospitals close, will there be mass hysteria, cats and dogs living together, human sacrifice and the like.

So while the wording of the questions seems neutral and not overtly biased, the choice of the questions seems explicitly designed to elicit a certain response -- that Emergency Physicians think the whole thing is going to go to hell as a result of Health Care Reform.  Because physicians are a cynical bunch to begin with, frustrated with the administrative demands of our careers, politically right-leaning and because there was such toxic rancor over the HCR law, it's predictable that a significant number of ER doctors are going to just click the "worst case" on all the questions as an expression of their opposition/disappointment.  What is that going to tell us?  Not bloody much.

Once I realized where they were going with this survey, I didn't bother to complete and submit it, and I suspect that response bias will also skew the results pretty far in the anti-reform direction.  Those who are opposed tend to be intense in their opposition and will be pretty eager to say so publicly. Those who supported the reforms are weaker in their support, and especially with such a biased survey are less likely to participate.  Worse, the survey tends to split the "support" response options, whereas the "opposition" choices are unitary:
Do you think the health care reforms will address the critical issues affecting your care of emergency patients, such as boarding and overcrowding?
More will be needed -- but the reforms are a step in the right direction
The reforms don’t do nearly enough
The reforms will ultimately solve boarding and overcrowding
The reforms will worsen conditions for emergency patients
This will effectively magnify the apparent gap between the supporter and opponents of HCR.

So clearly is this survey designed to generate a predetermined result that I'll go ahead and pre-write the press release that ACEP will publicize in a couple of weeks when this study is released at the Leadership Conference:
Emergency Physicians Fear the HCR Law will Reduce Access to Care
Results of a survey of practicing Emergency Physicians (EPs) reveal widespread concerns regarding the impact of the HCR Law.  Fully xx% of EPs expect that overcrowding and boarding will increase as a result of this law, and yy% are concerned that this will reduce access to on-call specialists.  zz% of EPs don't know crap about the law expect ED volumes to increase this year as a result of the reforms. Furthermore, concerns about the physician workforce are raised by the HCR Law as aa% of EPs are considering early retirement due to this reform, and bb% of EPs think this law will discourage students from entering medicine. 
Just plug in the actual numbers from the survey; I expect that they will range 40-60%.  But when you see the result in your mailbox or in the news, don't believe them -- they don't tell you anything except that the Emperor's nose is 4.9804 cm long.

21 April 2010

The Arrogance of Hope

A vignette:

We all stand around the empty gurney in the resuscitation room, expectantly. The tech uncoils the lead wires for the monitor and a nurse prepares her gear for starting an IV. After a minute or two of waiting, it's suddenly showtime. The paramedics arrive in a flurry, a bustling crowd of big, strong men in matching blue t-shirts flanking a gurney with a thin, pale figure on it. One pushes the cart, one trails the head, holding an endotracheal tube in place and ventilating the patient. One performs chest compressions, and another carries the monitor. The lead medic precedes them all, clutching a sheaf of EKG rhythm strips and a metallic clipboard. He breathlessly begins his report:

"63 year-old male, found down and unresponsive. Unknown down time. Initial rhythm was bradycardic at a rate of 25, agonal-looking wide complexes. Intubated and got a pulse back with epi, but lost it again in route." As he speaks, we all swing into action. The patient is slid onto our gurney and CPR is restarted. Another line is started. Blood is drawn and monitor leads are attached. I listen as I begin a primary assessment. I note the lack of hair on the patient's scalp and the marked wasting of the cheekbones, the cachexia of severe illness. I note the waxen color of the skin, pale even for someone in cardiac arrest. I shoot a quick look at the medic: "Do we know any past history?"

He replies, "Yeah." A pause. "Metastatic pancreatic cancer. Been through three rounds of chemo. Family says he's terminal." The entire room comes to a momentary standstill and all eyes turn to the medic. "He's full code," the medic says clearly but with a tone of resignation. Somebody mutters "Son of a bitch!" and CPR resumes.

We run the code for another ten minutes in more or less silence. A pulse is regained and IV drips begun to maintain the vital signs. The entire team is dispirited, but professional, and all the necessary tasks are performed. Finally, the registrar comes in and says "His family is out front, and .... here's his DNR paperwork." Turns out the family members who called 911 were not the ones who knew about his advanced directive. Every member of the team is frustrated and upset. We bring in the family, and allow them to be with their loved one as he passes away.

Later, when the ER is quiet, a two-AM bitch session ensues. One of the reasons we love Emergency Medicine is the opportunity to be there when it counts and to save lives. Codes, even when the outcome is bad, are very much our raison d'etre. We savor them for the adrenaline and for the occasional miraculous result. But there's nothing we hate more than the futile code. They used to call them "slow codes," indicating that the team just went through the motions. And worse than the futile code is the code that should never have happened. That poor man just wanted to die in peace and in the comfort of his home. And because of a mistake (nobody's fault) we brutalized him needlessly in his final hour. "It's a fucking shame, it what it is," one of the nurses bitterly comments.

Interestingly, the consensus among the ER staff is that when it's our time, we want to be let go in peace. There are mordant jokes about having the "No CPR" logo tattooed on our chests once we reach a certain age or diagnosis. That way the ER crew will know not to code us inappropriately. It's always surprised me how consistent ER caregivers are in their desire to be allowed to die a natural death, if death is indeed inevitable and appropriate.

Which is why I found this piece written by an ER doctor interesting, and a little upsetting. It was brought to my attention by Dr Sinclair, who blogs about end-of-life issues at Pallimed. The piece, written by a Dr Boris Veysman, initially published in the journal Health Affairs, was republished in the Washington Post and also appeared on NPR. It's centered around a vignette similar to mine (plus a prolonged self-congratulation over his own cleverness in accomplishing a resuscitation). However, the ER physician takes a very different approach after the DNR order is produced. Key grafs excerpted:

I ask the questions still unanswered. "Is the DNR in effect now? In case of heart arrhythmia, can I give her a shock or more chest compressions? Given the sedation, it won’t hurt." ... Without dialysis, she is doomed by tomorrow. The members of the intensive care unit (ICU) team, having heard about the DNR, are reluctant to treat aggressively. Talking with the family, they are painting a bleak and—to their credit—often realistic picture of what it’s like for someone dying over weeks as organ systems shut down one after another... I’ve resuscitated many patients who died hours later. This case feels different to me. Hopeful. I report my findings to the family. There are times when giving hope is morally and professionally wrong because the hope is false. Today is not that day.

"I think there’s a good chance she is fixable in the short term," I say. ... The family members spend the next two hours in discussion with the primary oncologist, nephrologists, and the ICU team. They decide on comfort care only and no dialysis.

I see the burnout in their eyes. Their will to fight quit weeks ago, after this patient’s minor symptoms from the chemo and cancer were left unaddressed, leaving the impression that her life wasn’t worth living. No amount of hope in my heart can rekindle what has died in theirs.

She is taken off the ventilator and placed on the time-honored morphine drip—a solid choice by the ICU specialist to comfort what comes next. She expires peacefully several hours later from hyperkalemia caused by kidney failure that would have been so easy to treat with dialysis. The best resuscitation of my career turned into my most memorable professional disappointment. It also reminded me that the concept of DNR, however ethically sound and well conceived, can be complex and contentious.

I can appreciate the intent. It's fun to be contrarian and to take on the sacred cows. It's fair to challenge the conventional wisdom that DNR can equal "Do Not Treat." It should not. But the tone of the physician in this case strikes me as highly inappropriate. He clearly has an opinion, as do we all, about what is possible and desirable in a certain clinical situation. That's unavoidable. He understandably is invested in the patient whose life he has extended, at great effort. But Dr Veysman's error here is projecting his own values, his own desires, his own mental status onto the patient and the patient's family. He betrays his bias with the first question he asks -- "Can I give her a shock?" Consider that "Can I?" -- he wants to, he thinks he should, and he is asking for permission. He supports his request with a promise that it won't hurt, which is true. He has crossed the line from an interrogator to an advocate. What he fails to ask is "Should I?" On a broader note, he fails to ask "What would she want us to do?" Rather, he has chosen the course of action which he wants, and he campaigns for this treatment, in spite of the patient's previously expressed desires to the contrary.

Moreover, the author makes some dramatic assumptions about the mental status of the patient and the family, the perceived burden of her disease, and their reasons for making the decision to accept her natural death. He thinks she is not ready to die, but he knows nothing of whether she felt she was ready to die, and whether her reasons were valid. There's even an implication that her situational depression over impending death should have been treated with antidepressants, as if one's looming mortality is a chemical imbalance which must be ameliorated before it can be allowed to come to pass. He has hope, and he takes it as -- literally -- a failure that the family cannot be induced to share that hope.

The conclusion is telling, when he considers his own end-of-life desires: "Only after you made every effort to let me be happy and human, ask me again if my life is worth living. Then, listen, and comply. At that point, if I wish to die, let me die." So presumptuous is Dr Veysman that this patient's family failed to do these things that he pressures them towards aggressive treatment, while he himself wants to be allowed to pass when he determines his time has come! DNR for me but not for thee?

I've had patients & families ask for full measures and I have had them ask to cease efforts when I personally would not have made those choices. Respect for the patient's autonomy demands that I do not argue with them over their decision. There's a fine line between ensuring the decision-makers have enough information to make a truly informed decision and advocating for or against a certain plan of action. Dr Veysman flirts with that line as much as it is possible to do in a semi-fictional vignette with a necessarily incomplete reporting of the difficult conversations that must have taken place.

I'm being a little unfair here, because this really is a complex situation distilled into 2500 words. Were I more charitable, I would assume that Dr Veysman couched his recommendations in more neutral language and displayed more respect for the self-determination of the patient, and for the family's intimate knowledge of her situation. But I have a hard time extending the benefit of the doubt when he is publicly arguing that the signed advance directive should be disregarded if the doctor thinks the family isn't hopeful enough.

So, Dr Veysman, I will be happy to comply with your wishes: should you come into my ER, I will tube you and line you and shock you if that is your wish at that time. I hope that if I come into your ER, that you will honor my requests, that you will not bully my family, and that you will not not subject them to a guilt trip for having, in your eyes, given up.

Give them, and me, that much respect.

This is just wrong

Abandoned Supercars

abandoned cars

Don't look (for the love of god don't look!) if you love cars.

20 April 2010

Lipstick Lesbian

The woman in bed six informed me immediately on my arrival and introduction that she was a lesbian.  I don't know why it mattered, because she was there for a scald injury on her arm, and I hadn't inquired about it.  In fact, I hadn't even begun my history before she made her announcement in a somewhat belligerent tone.  So ... ooookaaay.  I tried not to let this non sequitur throw me too much off my stride and I went through the brief history necessary for a minor injury such as she had.  As an aside, this self-proclaimed lesbian was quite feminine.  She was well-dressed for the hour of the evening and quite pretty in her own sort of way.  Not a butch dyke at all.  She even had a choker of pearls on, along with earrings, lipstick, and well-coiffed hair.

I asked a few questions, though, and was surprised at the frankly aggressive tone of her responses.  Nothing too blatant, nothing that I could call her on, but quite definite.  And her story seemed to not quite add up.  She reported that she had been boiling water and had burnt herself, but the burn was not consistent with a normal scald -- it was a perfect oval on the inner aspect of her right forearm, sharply demarcated.  Water burns leave irregular splash marks.  I commented on that fact, and asked whether she maybe had burnt herself on the pot, a suggestion to which she quickly agreed.  What she was doing boiling water at midnight it did not occur to me to ask.  I noted that she had been in the ER for a similar injury a month ago and asked why she was repeatedly burning herself; she explained that she had MS and was often clumsy.  She was on an MS med, so that seemed to make sense.

Finally I examined the burn.  Again, it was funny.  The skin was a deep red, the sort of color that is associated with deep burns, which are insensate, but she was very tender and wouldn't let me touch it.  The entire burn was the same color, without any variation, and without any blistering.  It's really odd not to see a single blister on a wound that looks so angry.

I wandered out of the room to chew it over, and I ordered some wound care and a dressing to be applied.  The nurse, Lisa, came out and informed me that the patient had refused wound care; said she had cleaned it herself at home.  She wanted pain medicines, though.  I commented that it was a funny-looking burn.  Lisa agreed with me and smiled.  "Yes doctor, it is a funny burn.  She's a pretty lady, too, isn't she?"

"Well, I guess so, why do you mention it?" I responded, wondering what Lisa was getting at.

"I was just noticing how nicely she was dressed up.  And her make-up.  Especially the lipstick.  Now that I think of it, isn't it funny that her lipstick looks the exact same shade of red as her burn?  Weird."  And she sashayed off.

I'm told that my expression at that moment was priceless.  I went back into the room and once again the patient refused to let me touch her wound.  I distracted her for moment and dragged an alcohol swab across the "burn" and, of course, the pigment came right off, revealing normal, healthy skin underneath.

I don't know how I didn't see it myself; I must need to get my bullshit detector recalibrated.  The patient received a stern talking-to and eloped from the ER shortly thereafter.  I got the deep satisfaction of entering a discharge diagnosis of "Malingering," which I rarely use except in bullet-proof cases.

And I think I owe Lisa a cup of her favorite coffee.

19 April 2010

Photos not from Mordor

But from Iceland's erupting volcano.  Too cool.  The Big Picture, as always, has the scoop.

If Peter Jackson ever remakes Lord of the Rings, this would look pretty damn cool for Mount Doom.

Small Worlds

Cool video.  Not miniatures -- it's real.  He uses a technique called tilt-shift.

Small Worlds - Preview. from Keith Loutit on Vimeo.

16 April 2010

Friday Flashback

Oh, what the hell. It's fresh in my mind after the last post and I can never resist telling one of my favorite stories. And you will see why I deserved my comeuppance.

A couple of years ago I came in to the evening shift and took sign out from my partner who was going off-shift. There was one case signed over which made my eyebrows go up a bit. I was a woman, early middle-aged, who had a story which weakly suggested appendicitis: right lower quadrant pain, no rebound, mild tenderness on exam. They got a CT scan on her and the radiologist did not think it was an appy, but was a little uncertain. So he consulted with one of his colleagues who had suggested (for reasons which to this day are beyond me) that the CT scan be repeated with the patient in the left lateral decubitus position (picture). I had never heard of such a thing, but I'm not a radiologist. Then the second CT scan was also indeterminate. So they decided to get another CT scan, in the right lateral decubitus position. The results of this CT were pending when I took over the case. My partner wryly informed me that his suspicion was kind of low anyway, so once the radiologists quit screwing around and decided this CT also was negative, the patient could go home with a diagnosis of "Abdominal pain, uncertain cause" and the standard precautions.

Sure enough, an hour or so later, I got the final results which were negative for evidence of acute appendicitis.

So I went in to tell her about the diagnosis and plan. She was a little anxious about the uncertainty, but I reassured her and went to re-examine her in a rather cursory, desultory fashion. Her abdomen was modestly obese and soft, and she did not even wince as I palpated deeply in the right lower quadrant. Idiots, I muttered to myself, all this fuss and not even pain on exam. I let go and stepped back, and as I let go, she gasped in sudden pain and sat up bolt upright. Okay, that was unexpected, I thought. Something just happened. I examined her again, a little more carefully, and again, though she really had no pain when I pushed on her belly, she had classic and severe rebound tenderness.

I hate it when this happens with a sign-out. Supposed to be a simple discharge, and now I have to look at the chart and re-think the whole thing. Hmm. She does have an elevated white count, and she has been in the ER eight hours getting her scans, so that's long enough for the rebound pain to have evolved -- you classically want a twelve-hour serial exam to rule out an appy, and eight is getting pretty near there. It was getting close to midnight, and I called the surgeon, who was a nice guy and a reasonable fellow, but unsurprisingly skeptical.

"So Brad, I have a lady here with an unusual presentation of appendicitis."
"Okay, what did her cat scan show?"
"Well, that's the funny part. She had three of them, one supine and bilateral decubitus CTs."
"Are you kidding me? That's insane. What did they show?"
"Well, they were all negative. But she's been here for 8 hours and clinically she has an appy on exam."
"Now I know you are kidding me. Three negative CT scans and you think she has an appy? You're on drugs. Send her home."
"Brad, I know it sounds bad, but really, you have got to see this lady."
"Fine, send her home and I'll see her first thing in the morning in my office."
"Brad, I can do that, but I don't recommend it. She'll have ruptured by then."
"You're killing me. Can you just admit her to me and I'll see her in a few hours on the floor?"
"I can do that if you prefer, but you'll just be taking out her appendix at four AM."
"Oh God. Fine. Send her up to the OR then." [click]

A couple of hours later I got a phone call from the surgeon.

"You know, I was really pissed at you for sending me that stupid case. And the thing that really pissed me off when I opened her abdomen and saw her black, necrotic appendix lying there, was the realization that the next time you call me with some stupid consult in the middle of the night, I am going to have to take you seriously and listen to what you have to say."

I should say that we have some really great surgeons and have a great relationship with them. I portray them as gruff but they are not in any way unpleasant or jerks, so don't read it that way.

I was very proud of my cojones that day, calling the diagnosis in contradiction of not one but three scans. I strutted around for quite a while after that. Which, as I said, is why I undoubtedly deserved my karmic comeuppance.

Originally posted 26 April 2007

14 April 2010


Intueri has it.

Go read.  Really.  I'll wait.  Go read that and come back here, because I have something to say too.

She writes beautifully, and it's a hard read.  I almost stopped before I finished it, and I did flinch more than once.

This man was in my ER today, or at least someone very like him.  He was rolled onto a hallway gurney, given a cursory inspection, and left to sleep it off before being given the bum's rush out when he became more sober and obnoxious. 

He was viewed by the staff as an irritation, a burden, an annoyance.  Smelly, dirty and creepy.  Scaring the children as they walked by to their rooms. Nurses were short-tempered and brusque to him, and the doctors avoided him as much as possible.  They were probably angry at him for showing up, and for doing this to himself.  He was as thoroughly dehumanized as he is when he lay in the gutter.

It's easy to view these folks though the judging filter.  It's their own damn fault.  We've sobered them up and put them through detox so many times and they just come back again and again.  Why should I have compassion for someone who is trying so hard to destroy himself?  Indeed, it's hard to bring yourself to have compassion for them, and systematically we fail to provide that caring element to our patients.

But it's not just the bums, though they're the most obvious victims of compassion failure on the part of the ER caregivers.  There are patients for whom it's easy to feel compassion -- the children, the dying, the innocent victims of some terrible disease, the ones in acute pain from some accident or sudden illness.  They're suffering and since it's not their fault we don't judge them, but simply feel for them.

But the guy with COPD who refuses to stop smoking?  The unemployed mom whose teeth are rotten and can't afford a dentist (though she does have a cell phone and cigarettes)?  The fat guy with diabetes, hypertension and a stroke as a result?  The chronic migraneur who everybody suspects is just addicted to narcotics?  How much compassion do they get?  How much do we judge them and find them wanting?  It's hard to muster the emotional energy to get past the self-inflicted elements of their illnesses, and it's so easy to slip into contempt for their weakness and frailties.

I see it in my co-workers, and I am as guilty as any of them.  And I see it in the writings of my Emergency Department colleagues in the medical blogs and comments.  On the net, behind the veil of anonymity, people are more willing to express their darker sides, and the intensity of the contempt and the venom directed towards our patients can be disturbing.   (If I delve too far into my own archives, I might find some expressions of which I am not entirely proud.)

So how do we avoid falling into the trap of judgment and contempt?  I think Maria nails it: "What if you remembered how much he laughed when you cycled with him through the park?"  By which she means, what if you could identify with him?  What if you were him, or someone you loved were?  I see these poor souls and I remember that once they were seven years old, like my older son, and their whole lives were ahead of them, full of promise.  And I try to see them as they were when they were seven.  That works for me.  Your mileage may vary.  I also try to remember that my children's lives could easily go wrong and if any of them are someday in the ER, broken and suffering, someone will remember that I loved them and treat them with compassion.

More humbling, I try to remember that physicians are prone to substance abuse, and that I have seen former professionals in the ER, victims of their own self-destruction, and I think, "There but for the grace of god go I." 

There are exceptions to the epidemic of compassion failure.  On the net there are people like Intueri, Dr Charles, and StorytellER Doc (to name a few) who strive to capture the human beings behind the cases.  In my ER there are nurses who will often go above and beyond the call of duty to help someone.  And there are even some docs who manage to approach each patient with respect and a smile.  I may not be one of them, but it's good to have role models who can remind me to refill the old compassion well every once in a while.

13 April 2010

A thing of beauty

demotivational posters

Because even hippie liberal peaceniks still love guns and things that explode.

The Empty Charade of Continuous Certification

Kevin wrote today about his impending recertification in Internal Medicine, and as a coincidence, today I took three of the exams needed for my re-certification in Emergency Medicine.  Great minds think alike and fools seldom differ, and Kevin and I seem to be in agreement that the Maintenance of Certification (MoC) project is badly misguided and poorly implemented.  And, Kevin, just you wait, because ABIM is not yet as deep into the MoC morass as ABEM is, and it's going to be getting worse before it gets better. 

For the non-medicos, the way things used to work was that you graduated medical school, maybe (or maybe not) got some specialty training, got your license, and you could hang out your shingle as a physician.  For those who completed a residency or fellowship, they could take a test given by a member body of the American Board of Medical Specialties, and if they passed, they could advertise themselves as "Board Certified" in a given field or specialty.  Board Certification was supposed to represent a higher level of quality, and studies supported the idea that board certified docs did provide better care.  Over time, board certification evolved into a more or less obligatory merit badge for practice at most hospitals.

In Emergency Medicine, you have to recertify every ten years; the recert exam is a slightly shortened version of the initial certification exam. Apparently in some specialties you used to be able to get lifelong certification but that is no longer the case.  

In recent years, the ABMS has decided that a once-a-decade test was not good enough, and implemented the Continuous Certification program.  For ER docs, this has manifested as a series of obnoxious, poorly written annual exams called the LLSA.  The idea was that they would give you a couple dozen important articles from each year and test you on them to make sure you were staying abreast of developments in the field.  Sounds good, but in practice it's really annoying.  First of all, it's open book, which ought to make Kevin happy, but the questions on the exams are not generally reflective of the critical points in the literature.  They are more commonly picky detail questions to force you to go back through the articles to find the trivia point that is referenced.  (Pro tip for test-takers: get the articles in PDF and do a keyword search and you don't have to read the articles at all!)  Worse, the questions on the EM tests do not appear to have been written by professional test-writers.  They are ambiguous, often with multiple possible "correct" answers, forcing you to infer what the examiners were looking for -- the old "guess what I'm thinking" game.  That's fine for oral teaching rounds, but poor form in an exam.

The whole experience is quite worthless.  I banged out three exams today, in about two hours. I scored 100%, 95% and 100%. And I didn't learn a damn thing.  I hasten to add that this is not because I am so damned brilliant, but because the concept and execution are fatally flawed.

Though I am, you know, pretty damned brilliant, too.  Just saying.

The next step is going to be worse.  An "Assessment of Practice Performance" and "Performance Improvement." In this, you will have to choose a diagnosis or presenting complaint, review charts, confess your sins find deficiencies and develop a performance improvement plan.  Then you do a prospective review and see if you are now sin-free performing better.  Sounds like a lot of busy work for very little benefit.  Also, it appears that "Patient feedback" is going to be involved somehow.  To my cynical ear it sounds like Press-Ganey will be involved in my future recertifications.  Great.

Now I should be clear on this: it actually sounds like the ABEM is trying to come up with MoC requirements which are more or less painless for ER docs to meet.  The Practice Performance description explicitly suggests that groups can just rubber-stamp their existing quality committee work, more or less, and have it count.  For that matter, the LLSA exams are also allowed to be taken in groups and are designed to be easy.  I appreciate that.  But by devising these shortcuts, ABEM is entirely undermining the point of the MoC project and revealing it to be an empty activity, a merit-badge to be earned, but not a learning experience.  

Which makes it a horrendous waste of physician time and energy. 

Most of my irritation is directed at ABEM, but it's important to understand that this ABEM is just the messenger here.  It's the ABMS that has foisted this obligation onto us.  Looking at the ABMS roadmap for MoC, it's a muddle, and looking highly painful: 

The Six Core Competencies

  • Patient Care-Provide care that is compassionate, appropriate and effective.... (this sounds bland enough)

  • Medical Knowledge-Demonstrate knowledge about established and evolving .... (standard fare)

  • Interpersonal and Communication Skills-Demonstrate skills that result in effective information exchange and teaming with patients, their families and professional associates (e.g. fostering a therapeutic relationship that is ethically sounds, uses effective listening skills with non-verbal and verbal communication; working as both a team member and at times as a leader). (Oh Jeebus, are you kidding me?)

  • Professionalism-Demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles and sensitivity to diverse patient populations. (What the hell does this even mean? And how will you test for it?)

  • Systems-based Practice-Demonstrate awareness of and responsibility to larger context and systems of healthcare. Be able to call on system resources to provide optimal care (OK, now I know you are joking.  Even you don't know what this means.)

  • Practice-based Learning and Improvement-Able to investigate and evaluate their patient care practices.... (Obligatory self-flagellation)
Blech. What a godawful product of committee-think.  These are all fine ideas, by the way, commendable and appropriate to be included in medical education.  What they are not, is testable.  Not in any meaningful way.  Remember, one defining characteristic of a test is that there is measurement, a standard to be met and a possibility of failure.  The vague buzzword-fest above is unsurprisingly resistant to objective measurement.  And if the Boards do not have the gumption to fail physicians who cannot, say, demonstrate fostering of a therapeutic relationship, if it's a test where everybody passes, then it really isn't a test, is it?  And if they are not measuring quality, then what value are these charades providing to patients?

I do think that it's a good idea for doctors to stay current -- on the evolution of the science of healthcare as well as the ancillary skills and topics.  I also think it's a good thing to have to recertify every so often, and a knowledge-based test seems like a fine method.  If, as Kevin suggested, it were open book and designed to induce physicians to integrate dynamic information sources into the testing, that would be better.  I also think it's a good idea for the house of medicine to produce a reasonable mechanism to ensure maintenance of skills before somebody else does it for us.

But this confused, pointless hollow time-waste of a process should be trashed and rebuilt from the ground up.

12 April 2010

So when is "Late April" anyway?

iPad - Unboxing Video from Brian Stark on Vimeo.

I just can't wait. It's killing me.

(Late April is when the 3G iPad, the one I ordered, is scheduled to ship.)

The role of MLPs and consultants

In the comments to my "dealing with consultants" post, Seattle Plastic Surgery on Lake Union commented:
When consulting a specialist, its polite to have the ED physician speak directly with the on-call doc. PAs and other mid-levels can be quite good, but many really miss the mark. Certainly, in an academic ED, this system works differently, but the Harborview trauma-doc days are over. Asking a sleepy doc at home to come in to see a patient should be a doc2doc discussion.
This raises an interesting issue I commonly deal with.  First of all, in a limited context, SPSOLU is entirely right: if it's a patient I have personally seen and treated, of course I should make the call.  It should not be delegated to a nurse or any other practitioner.  That's a fundamental courtesy and also a practical necessity.

But I don't think that was the central point from SPSOLU.  He or she specifically criticized the use of "PAs and other midlevels," presumably meaning ARNP's.    These are Physician Assistants and Nurse Practitioners, for those not familiar with the terms.  In our state and our ER, these mid-level providers (MLPs) are licensed as "independent practitioners" and function autonomously.  They have a scope of practice of complaints and conditions which they are authorized to care for, and they work in an environment, Fast Track, which is supposed to ensure that their patients are appropriate for their skill set.  In our ER, 95% of patients seen by PAs are never seen by a doctor, and we are not required to review or sign their charts.  (Many states and ERs operate differently.)

The tension arises when a PA calls a consultant and the consultant is offended that it's not a "doctor" calling directly. 

The fact is that a MLP is not a physician, and they should be aware of the limits of their abilities.  On the other hand, it can be hard for consultants who do not regularly work with MLPs to respect them for the competencies they do have.

For example, if you consider a plastics consult.  The average PA at our facility will suture over 200 lacerations per year, based on our coding data.  The average physician will suture fewer than 50.  It's true that we tend to do the harder ones, and that we have operative training that would allow us to better recognize what can and cannot be done in the ED.  So there is a difference in quality.  Still, when one of my experienced PAs tells me that a laceration, for whatever technical reason, needs a plastic surgeon to repair it, so long as they can explain the reason to me clearly, I have no problem with that PA calling the surgeon directly.  More to SPSOLU's point, were I to make the call to the surgeon in the place of the PA, it's not clear to me that I would be adding anything of value to the patient's care by my involvement.

Truth be told, this is more of an issue for us with orthopedics and ENT.  Our plastics guys tend to be pretty good.  But it's routine for the ortho/ENT guys to leave irritated voice mails for our director, complaining about the indignity of the fact that they were called by a mere PA.  And you go back to look at the chart and it was something ultra-appropriate, like an intra-articular distal radius fracture.  What do you need an MD for in that case?

None of this is to defend dumb consults.  PAs who call inappropriate consults should be educated (ideally prospectively, or on the spot if needed), and PAs should have access to a doc to gut-check borderline or uncertain cases.  If it's a particularly challenging or unusual case, then indeed the physician should be involved and probably make the call.  However, I would also hope that a professional consultant, receiving an appropriate consult from a MLP who can reasonably articulate the necessity of their involvement, would have the reciprocal courtesy to respect the PA or NP for their expertise and experience.

10 April 2010

A Brief Dramatic Scene

The Setting: a large open-air ER ward. All beds are empty except for one, upon which a Patient lies in moderate discomfort.
Enter: A Doctor, a Nurse, and a Tech. They attend to the patient. Nurse begins to start an IV, Tech affixes monitor wires, Doctor reviews the chart.

Doctor: Sir, I see from the chart that you are having some abdominal pain. When did this pain first start?

Patient (in a very matter-of-fact tone): I think the pain started sometime after I finished eating that gallon of peanut butter.

(Doctor responds with a blank stare, queries Nurse and Tech with a glance. They maintain carefully neutral facial expressions.)

Doctor (to Patient): I really don't know what to say to that.

(Nurse and Tech double over with poorly-muffled laughter.  An awkward silence follows.)


09 April 2010

Friday Flashback

Advice for Emergency Medicine Interns

I thought I would steal a page from the sadly departed but still remembered Barbados Butterfly, and give some sage advice to those still in training.

I will pause a moment here for those who personally know me to recover from their shock and horror at the notion of someone like me providing anything approximating “sage advice.” They may need to clean the coffee off their monitors. . .

There, all better now? Off we go, then.

How to deal with consultants:
The last couple of posts involved exchanges in which I presented an uncommon or hysterically improbable set of facts to a surgical colleague, and they took the case as presented. Charitydoc alluded to a similar experience in the comments. This sort of thing pretty much never happened in my training. For one, the ED and surgeons regarded one another as natural enemies. Also, more than half the time you didn’t really know the person on the other end of the phone. I have been in private practice now for about seven years. There are a number of critical differences between training and private practice. One is that you tend to work with and refer to the same individuals over a prolonged time, rather than the rotating groups of short-time consultants you get in academic institutions. You build relationships, view one another as colleagues and (gasp) friends, and develop a history with your consultants – be they hospitalists, surgeons, what-have-you. They come to know you, and hopefully trust you, and their response to your requests is predicated on their opinion of you. I cannot emphasize this point enough:

Credibility is the sole currency you have in this relationship. Hoard it carefully and spend it wisely.

You, as an ER doc, have one and only one job: to keep your patients alive long enough for them to become someone else’s problem. To accomplish this end, you are entirely dependent on the good graces of your consultants. I have many times watched my partners, especially some of the junior ones, chase their tail for hours trying to get a patient admitted, because they couldn’t get their consultant to bite on their presentation.

This my patented recipe for success:

1. Never call without first knowing exactly what it is that you want. If you call with a wishy-washy “do you think that you should get out of bed and do a lot of unpleasant work?” then human nature dictates that in many cases the consultant will seek out the easiest solution, which may not be appropriate, since you have seen the patient and they have not. They may well embarrass you by asking irritably “Well, you’ve seen them, what do you think I should do?” It’s quite deflating to have no ready answer to that question. Know in advance what the desired outcome of the conversation will be.

2. Be direct when presenting on the phone. The consultant doesn’t want to chat, especially if it’s after midnight. The FIRST thing they think when their pager goes off is “Oh, shit, it’s the ER; what the hell do they want?” So answer that question first: “Hi Dr Jones, I’m sorry to bother you but I have a patient for you to admit/consult in the ED/take to the OR/see in the office/give advice on.” Don’t make them wonder; if they know where you are going from sentence one, they can prepare a response as you talk and are much less annoyed than they would be by a rambling presentation.

3. Make a compelling sales pitch. You are calling them because you have already decided that you need something from them. (See #1) You need to convince them that what you need is in fact reasonable. I begin with the diagnosis, present the supporting facts in an order designed to logically lead to the conclusion I have already reached, then reiterate the diagnosis and required action. Don’t present a rambling review of systems, and don’t lead with the chief complaint or narrative history. We love to “tell the story” but at 2AM with a sleepy surgeon on the phone, he or she does not care about the story. Just make the sale and convince them as succinctly as possible. Three sentences is as long as this should take:

“I have a patient with Pneumonia. 66 y/o, fever and cough. 
Needs to be admitted because the O2 is 88%.”

4. Never lie or shade the truth. They will find out. If there are facts counter to your working diagnosis or proposed plan, you must acknowledge them up front. It’s tempting to try to pull a fast one, especially on those borderline cases – just get the internist to agree to admit and send the patient on up, right? Wrong. You may or may not get an earful from their department director later, but even worse, the next time you try to admit to them, they’re not going to believe a word you say, and you’re fucked, me boyo. In some cases you need to be very up front. I frequently begin the conversation with “I am sorry but this is a social admission, and it is necessary because…” or “I do not know what is wrong with this patient but they need to be admitted because…” The nice thing about this is not just that you don’t have to contort yourself to make a medical case out of it, but you get a reputation for not trying to put lipstick on the pig, which pays dividends when you have the more genuine medical admissions.

5. Don’t shoot yourself in the foot. If you start off your presentation with the adverse facts, you are making it hard to convince your consultant. Start with the case FOR your diagnosis and plan, then acknowledge the countervailing facts. When possible, do so linked to an immediate explanation why those facts do not negate your overall impression. Be assertive and speak in short declarative sentences. If they hear uncertainty or ambivalence in your voice, they will pounce and you are lost.

6. Anticipate and pre-empt obstacles. It’s no secret that some consultants are hesitant to see/accept an ER patient until they have been fully worked up. You want to get them upstairs as quickly as possible. Figure out what the roadblocks may be, address them in your presentation, and have an answer for the objection before it is even uttered. Examples:

  • Blocker: Have you ruled out PE? Preempt with: I considered PE, but they are not tachycardic and have no risk factors (blah blah) and so my clinical concern is low.
  • Blocker: Altered mental status? What about an LP? Preemption: I think meningitis is unlikely because of (insert clinical reasoning), so I did not do an LP. After you have seen the patient I am sure you will agree with me.
  • Blocker: Did you order (insert reasonable but obscure and time-consuming test)? Preemption: Yes (as I write it on the admitting order sheet) and it should be resulted by the time you see the patient on the floor.
  • Blocker: Can you hold the patient in the ED until (sometime in the future)? Preemption: I have ordered tests X, Y and Z, but the patient is stable and I have 40 patients in the waiting room, so with your permission I will write holding orders, and you can see him on the floor.
  • Other popular ones are “Is the patient stable enough for the floor/sick enough for the ICU/well enough to go home?” (Often all of the above amusingly applied to the same patient) Or “shouldn’t this be admitted to (some other specialist)?” If you can anticipate the concern and address it in advance, you are much more likely to move the patient out of the ED in a timely manner.
7. Be reasonable. Don’t try to admit an abdominal pain to medicine without a CT (or surgical consult, as appropriate). If there is reasonable concern for PE, rule it out or at least get the process started before you make the call. Sometimes the specialists know more than you do (really!) and may legitimately have an alternative strategy which may be effective. Listen to them.

8. Close the deal. Once you and the consultant have agreed upon a plan, be very concrete in defining the next step. “I will write holding orders and you can see them in the morning,” “I will see you in the ER shortly,” “I will send the patient to the cath lab/OR/ICU and you will meet them there.”

9. Be pleasant. Get to know their names, chat and joke as the situation and time of day allow. Social niceties lubricate and facilitate these interactions. You may even become friends(!).

10. Become involved in your hospital medical staff. The better your consultants know you, the more credibility and trust you will accrue. Many docs view the ER docs as itinerant locker-docs and glorified paramedics. When they work with you on the medical staff, they are much more likely to view you as a valued colleague. What’s more, they are much less likely to be a dick to you over the phone when they know that you will sit next to them at the X Meeting tomorrow. And if they know that you will be reviewing their credentials the next time their appointment comes up for renewal…

I had a nice interaction with a hospital internist recently. I had a really borderline case where there was no clear indication for admission, and I apologized for that as I presented it to the hospitalist (who was a notorious blocker). She responded, “That’s OK. We don’t mind because with you we know that you’re not going to admit for a stupid reason, and when we see the patient on the floor they will be exactly as billed.”

I felt really good about that.

Originally published 30 April 2007