June 13, 2006
MedBlogs Grand Rounds 2:38
It's that time: The Haversian Canal: Grand Rounds Vol 2 No 38
Of 42 entries from 39 authors, 25 met the criteria I put forward in my call for submissions. Of my original categories, two gathered no enteries that meaningfully fit the categories: Case studies and ethics. My explicit goal was the 30 best articles from 30 authors. My aim was to motivate the authors, as a whole, to stretch a little further. Was it successful?Another good group of links. Should keep you occupied for the whole morning.
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AMA recruiting gimmick
Today in the mail came a big envelope, and a full-page flyer trumpeting "AMA membership for 1/2 price". It's a nice ad, with a cute kid and a caring doc.
The devil is in the details: Yes, it's half-price membership, because it's for a half-year of membership.
AMA: Not a member since 1998. Not likely to be, at this rate.
01:00 AM Amusements, Medicine | Permalink | Comments (3) | TrackBacks (0)
June 12, 2006
Cheerful Oncologist has moved
Well, now. A couple of days ago it was Dr. Charles, and now The Cheerful Oncologist has moved over to ScienceBlogs.
http://www.scienceblogs.com/thecheerfuloncologist/
They must be giving away free pens over there at ScienceBlogs ...
via Kevin, MD
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Too relaxed to rant
This is an odd turn of events: I'm still too relaxed to rant, to get the bile flowing, etc.
Blame it on the vacation, but I cannot get worked up about anything (and there've been some things happen that would normally make me nuts: at the part-time gig I had a shift wherein the hospital didn't have five (5) medications I requested on one shift. ! )
This too shall pass, but it's nice while it lasts.
I've been busy preparing for another lecture, about neck trauma this time, that I'm giving Tuesday (I think, I need to call somebody...). It's a topic that nearly any one facet could make an hour lecture, and I'm giving an overview in 45 minutes. Only about 65 slides, though, and for once I'm finished more than 24 hours ahead of the deadline.
The old me will be back, too soon.
02:08 AM Amusements | Permalink | Comments (0) | TrackBacks (0)
June 11, 2006
Dr. Charles has moved
His new address:
http://scienceblogs.com/drcharles/
Please make a note of it.
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June 10, 2006
Brazos County SO has a sense of humor
Hat tip to Bert for the photo.
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June 09, 2006
How docs can be our own worst enemies
I have a relative who had an urgent gallbladder removal recently, and he's doing well, thanks.
However, we've been having some email exchanges about his workup, and specifically a trip to the ED that didn't diagnose GB dz. (Patient presented with lower abd pain, N/V; presumably had labs done, though he doesn't know the results, and had a CT to r/o appy. No appy by CT).
So, he went home, felt better for a week, then worse again, and went to his PCP. This is where it's so easy to look smart by subtly (or non-subtly) saying 'well, the answer is "x", and they missed the boat by not finding it'. For instance, from an email (excerpt):
...he said I was showing classic symptoms of a bad gall bladder. When he pulled up the results of my CT scan on his computer, he said the results clearly backed that up. He even questioned why the ER doc would not have ordered an ultrasound after seeing the same results. At any rate, he sent me to a surgeon right away. The surgeon agreed with the diagnosis and ordered an ultrasound,...
(emphasis mine).
Now the seed has been planted, and it germinates in law offices with predictable results. (He's not going to sue, but now a lot of doubt has been planted in his mind). It's the kind of doubt that makes people go from ED to ED for a 'second opinion'.
I am NOT advocating a code of silence or anything nefarious, but we ALL need to remember that second-guessing and criticism of other docs is neither constructive nor smart. I have had complaints in the past, generated when the patient followed up with their doctor who (allegedly) tells the patient 'you should have had 'x test', and that ER doc completely missed it by not ordering one', resulting in a letter complaining about their care, etc.
So, let's just save our snide critiques for the politicians, okay?
09:40 AM Medicine | Permalink | Comments (16) | TrackBacks (0)
June 08, 2006
I'm Back!
And, I need a vacation to rest up from my vacation...
That's not going to happen, alas, as I start work again tomorrow morning. (Yes, I know, if you take that many days off you're going to work more frequently to make them up, but that doesn't make it more fun).
Big, big thanks to Nick from Blogborygmi and Symtym for keeping the place occupied and lively during my absence. Much better work than I do, and unfortunately now the bar has been raised a bit too high. Lower your expectations, everyone.
Really, I had as much fun as possible with my clothes on, and it was a Disney vacation, so they stayed on. Hopefully in a few days I'll do the internet version of '1000 slides of my vacation in only 4 1/2 hours'.
Now to unpack and do some a lot of laundry.
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June 07, 2006
Big Love for Academic Emergency Medicine
I was pleased when I opened my mailbox today, and the new Academic Emergency Medicine burst out. It's really a treat, on par with my subscription to the New Yorker. Why? Because AEM really expands my concept of what research, and emergency medicine, can be. I'm not kidding, and I'm not damning by faint praise (and EM is too small a community for me to get away with it, if I were).
The first article that caught my eye was entitled, Laser-assisted Anesthesia Reduces the Pain of Venous Cannulation in Children and Adults. Now, over the past year I've become pretty good at starting IV's, I'm starting to incorporate ultrasound guidance on some tricky, urgent cases. But I've never really focused on minimizing pain, as my patients can attest. In the OR I've seen the anesthesia residents sometimes use lidocaine (and I certainly give it before a spinal tap) but I had no idea lasers were an option. Apparently, using a handheld laser over the planned IV site will ablate th topmost layer of skin, allowing transdermal anesthetics to seep though. Patients reported less pain in a randomized controlled trial (the patients and researchers were also blinded, though it's not clear whether it was by design protocol, or from the power of the lasers).
Anyway, the next time I see an administrator strolling through the ED, I'm going to ask for a handheld laser. The evidence supports it, patients love it, and I've always, always wanted a laser gun.
Another eye-catching study was called, Single Question about Drunkenness to Detect College Students at Risk for Injury. The question was, "Hey, buddy, want to go grab a drink?"
Ha! No. I kid. The question was "In a typical week, how many days do you get drunk?" Any answer greater than or equal to "1" was associated with a fivefold increase in EtOH-related injury, a more than twofold increase in falls requiring medical treatment, and a more than twofold increase in being sexually assaulted. It's a better marker than binge drinking, or anything else out there. The study was limited to ten North Carolina colleges -- we'll see if it's generalizable beyond that. But the ED is a great place to make an intervention in a young college kid's life, and this one question is a heck of a start.
It's not all great in this month's AEM -- I was a little disappointed that Childhood Injuries Caused by Falling Televisions didn't contain any blockbuster revelations (did you know there's no ICD-9 code for falling televisions? for shame!) but on the whole this journal kind of inspires me. Anyone else out there a fan of AEM?
--Nick
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June 06, 2006
MedBlogs Grand Rounds 2:37
What would GruntDoc do today? Why, link to this week's Grand Rounds, and give an excerpt!
Not until the last moment did I realize that my Grand Rounds falls on a day of apocalyptic significance, celebrated by some. My hope is that TMBN's new ideas will not cause the end of the world and instead bring us "Hell of a Grand Rounds"!
Amen to that. Tune into the Medical Blog Network's edition of Grand Rounds, and see what everyone in the medical blogosphere is talking about. My interview with Dmitriy Kruglyak is available on Medscape (registration required).
-- Nick
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June 04, 2006
Bring It On
Hello, GruntDoc readers! This is my first guest-blogging stint, but I'm a big fan in general of neighborly community behavior. We have friends pick up the mail for you when you're away, maybe feed the cat, so why not maintain the online presence, as well?
Especially when the online presence is that of GruntDoc, who's been a dedicated supporter of medical blogging in all its forms, including Grand Rounds (he is a three-time host, I interviewed him once for Medscape). GruntDoc has also been a source of tips and commentary to MedGadget, another blog I contribute to (in fact, when we got the tip about this cricothryroidotomy keychain, I immediately thought of him).
GruntDoc encouraged me to rant during my stint here -- I think he's trying to keep things lively, or maybe he knows how much I have to reign it in usually, as an intern blogging under my real name.
I'm not sure this is a rant, but I do want to address Symtym's assertions on what's really an emergency. He quotes a figure I've heard, and verified -- 100 million visits to US Emergency Departments each year (I'm getting numbers from Richardson AEM Vol 40, p 388).
100 million A huge number, to be sure, especially given the US population of 300 million. So it's easy to say we're in crisis now, everything is an emergency, forces have conspired to make people think they should use the ED for hangnails and stuffy noses. right? guess Well, guess how many visits were logged fifteen years ago: 90 million.
OK, now maybe there was wild misuse of emergency services in the early 90's, too (I wouldn't really know, I was in high school). It seems, though, that the problem isn't that there are more people using ED's inappropriately, or at least, this isn't a terribly new issue. Rather, it's that there are fewer ED's around, so we're all feeling the crunch more.
As for those 100 million visits, does that really mean that one third of all americans go to the ER each year? Of course not. Me and my two friends sure don't, least not yet this year. Meanwhile, I can personanly vouch that some of our "regulars" chronic homeless alcoholics use the ED 100 times a year. How big a problem is this? I've blogged about it before, it's a big problem and accounts for a substantial fraction of ED expenditures.
What about all the 70-year old diabetic hypertensives with chest pain? They come in every three or four months with disturbing symptoms. The 80-year olds who feel week and dizzy, maybe they blacked out for a second. These are real complaints, real emergencies, they need workup, every time.
As for the hangnails, the inappropriate use of ED services, it's actually notoriously hard to calculate how many are seen inappropriately. People have tried (Richardson, again -- maybe I've worked with her, once or twice). The bottom line is, it's hard to measure inappropriate ED use, and efforts to deny care to non-emergent situations may end up costing more, and/ or causing bad outcomes. Researchers try to quantify it, but existing denial of care methods just don't seem to be worth it, and the estimated savings may be exaggerated as well.
You can blame "themes of entitlement" and whatnot, and I've found doing so provides some comfort when you're stressed and feeling put-upon by those few demanding, unappreciative patients. But, when you really look at it, it's hard to blame the patients.
And, you know, as an intern, I'm going to get paid the same living wage whether I see a dozen patients a shift, or two dozen. But I keep trying to move quickly, providing good care and pleasant bedside manner, because I want to see as much as I can, and I'd like patients to get a favorable impression of our hospital and ED. If they end up realizing that we, in the ED, can provide services faster and more completely than if they just showed up unscheduled to their primary care doc, well, good for us.
Look, I'm not trying to debate ED access or government incentives to waste -- that argument sprouts up every few weeks on the blogosphere and there's already a good iteration / continuation in progress over at Grahamazon. I'm just trying to, well, figure out the right mindset and perspective to approach my job, and avoid becoming as jaded, down the road, as some others appear to have become.
-- Nick
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June 02, 2006
Incentivized Behavior
To answer the question ("Hey you in the ER! Is this really an emergency?")—of course not! Historically the utilization of the "ER" runs 35% of the US population, or roughly (and presently) 100M annually. We lives in an exceedingly dangerous and ill society if we believe that one-third of our society has a "true" emergency requiring the services of an "ER" every year. Additionally, in many urban settings, 25% of ER volumes are brought to the ERs by ambulances. Again, we live in a very dangerous and ill society if we believe that one-twelfth of our society is so impaired that an ambulance is required every year.
For many reasons, the ER is the US healthcare system's equivalent to fast-food. Similarly, the ambulance, often referred to as a cabulance—is just a form of door-to-door public service. Addicting? Essential? Fundamental? A right? A waste? Why? All very fair observations and questions, and I believe all come down to what we have incentivized in our society, directly and indirectly.
For those that utilize the ER and truly perceive every pain, malady and bodily dysphoria (theirs or those they decide for) to be true emergencies it is hard to fault that as inappropriate. I consider that appropriate "overreads" for a kind society and related to all the PSAs that promote self-awareness of healthcare issues. They get an "A" for intent, but only a "C" for excution—but reasonable, when we want a system that should be based on sensitivity trumping specificity.
If you consider all governmental funding sources for healthcare equivalent to a zero-sum game, then I believe it is easy to understand why both the feds and the states are increasing the pressures on the Medicaid programs. It has nothing to do with state surpluses, because the feds and the states share equally in the Medicaid yoke. But (IMHO) has everything to do with where governmentally-derived healthcare spending will need to go—Medicare, boomers, and healthcare information (broadly construed). We are fast coming upon a true constituency-based phenomenon, the largest, single, and united constituency group the US has ever seen begins this year—those residing in both the Medicare and boomer demographics. Contrast that with the diverse constitutency groups composing the Medicaid demographics coupled with the strong negative stereotypes of Welfare, the poor, the immigrant, the illegal, etc. Funding Medicare will always be more politically acceptable over funding Medicaid. Granted the states are not responsible for Medicare funding, but they are responsible for the state and locally employed boomers (and dependents) that will be retiring and utilizing their state/locally funded healthcare.
In California, the Medi-Cal receipents have been placed into managed care Medi-Cal programs that at least in my area (Sacramento) has had four major problems. First, managed care has driven so many providers out of the area there exists long waiting times for any forms of health services. This creates a collateral pressure on the ERs—"managed Medi-Cal" just can't be seen in a timely manner. Second, because of the inability for them to be seen in a timely manner their health problems are more complicated and more advanced—which snowballs even more ER utilizations.
Third, those not able to get into the managed Medi-Cal programs are pretty much disenfranchised from all providers, because almost all providers are aligned with existing managed plans—there are very few providers that will pickup "straight Medi-Cal." This constitutes another collaterally pressured group of Medi-Cal receipents into the ERs.
Fourth, a catagory of Medi-Cal called "emergency Medi-Cal," which was created to provide Medi-Cal coverage for emergency conditions. Whether intentional or not, it is widely perceived that "emergency Medi-Cal" is not for "emergency" as a condition but for "emergency" as a venue. The ER becomes the venue for all Medi-Cal services under this misinterpretation. A very typical dialog with members in this category of Medi-Cal starts with "I have my emergency Medi-Cal and I want…."
What would be the effect of limiting Medi-Cal funding in California—immediate proportional and incremental increases in ER volumes for true emergent needs, for those further disenfranchised from primary care providers, and for those that already believe "the system owes them." For good and bad reasons, Medicaid programs have incentivized behaviors and expectations over time. Changes in "who is covered" and "what is covered" without credible alternatives and potent counter-incentives will just drive-up ER utilizations.
There is a profound misunderstanding in the US about "Emergency Room," it is an oxymoron, because utilization of the ER for everything other than a true emergency has been pervasively incentivized.† We have created a near-entitlement in the form of Medicaid and we have created a general expectation that any medical condition may be addressed in an ER.
† Aside, when I first started my EM practice I was very incensed at parents on Medi-Cal who would bring their febrile child to the ER to get a prescription for APAP and had a pack of cigarettes sticking out of their shirt-pocket or purse. Over the years, I've come to have two reflections on the matter, first, I can't affect social and healthcare policy in the ER at 3 AM (the hair trying to wag the tail that wags the dog); and second, not writing the prescription only causes the child to suffer.
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June 01, 2006
Glog Potpourri
Glogging while the cat's away…
This post will be more like an emergency medicine (EM) potpourri sort of along the lines of "why are fire engines red?" You know random associations…
First, I've got to get use to the Movable Type interface again—I haven't used a WYSIWYG editor since my blogging infancy, circa 4.04. I have the same version over at symtym, but it is just for looking at the "nuts and bolts." So turn off the WYSIWYG editor and use my much preferred AR markup in XHTML.
Second, I try to collect EM relevant abbreviations/phrases/terms—we have a vast wealth of colloquialisms with bad pronunciation, grammar and spelling mixed in. Humor is always a good place to start this "guesting" relationship. Old favorites and a few new ones in no particular order, with commentary (of course):
- ground level fall: no one can fall from the ground to the ground
- mechanical fall: well of course it is mechanical, the only alternative is virtual
- GCS 16: one that calculates his/her own score
- 5–point restraints: leathers and a foley
- male bed: has a fifth wheel
- my child has whelps: are they house broken?
- I'm passing clogs: I like Bastad Monet in a 43
- penis: OK (actual triage complaint)
- vag spots: thousands of exams, but never seen a spotted one…
- WAD: weak and dizzy; see WAD panel
- WAD II: weak and dizzy and needs a CT
- DFO: done fall out, see #1
- AEIOU: acute ethnic illness otherwise unknown
- VM: vowel movement
- DBI: "dirt ball index," calculated from the BAL × BSA (in tattoos) ÷ by the number of remaining teeth
Enough of that PC stuff…
Third, Press Ganey revving the engine while in park.
'Patient' says it all | USAT | 5.31.06
…
The average length of stay in U.S. emergency rooms is 3.7 hours, or 222 minutes. The state-by-state look at emergency department waiting times was conducted by Press Ganey Associates, which measures patient satisfaction for 35% of the nation's hospitals.
The report on emergency-room times is based on about 1.5 million patient questionnaires filled out in 2005. And it shows wide state-to-state variations in the time between entering the hospital's emergency department and being admitted or sent home.
Iowa (138.3 minutes) and Nebraska (146.1 minutes) had the shortest emergency-room stays, while Maryland (246.9 minutes), and Arizona (297.3 minutes) had the longest.
…
Press Ganey measures the perception of performance (subjective), which is the surrogate for actual performance (objective, if all biases can be truly identified and controlled) and even farther removed from production. If we desire the countries EDs to function like public safety (which is often the expectation)—then they must have a production model akin to public safety. There are worlds of differences between an average response and a percentile response. Take a typical marking ploy for hospitals, stating an average door-to-doctor time in the ER that averages 30 minutes, 50% will see the doctor in greater than 30 minutes (normal distribution). Contrast that with a paramedic ambulance provider that has a contractual requirement to provide an ambulance to the scene within 8 minutes 90% of the time (normal curve skewed markedly to the left). Such a degree of production (moving the whole curve to the left on the time axis) requires tremendous additional cost and infrastructure. Skewing the production to the left (moving the "hump") will require even more cost and infrastructure. Anyone involved in a high performance EMS systems knows that all components must be at peaking staffing—i.e., to wax biochemical, we're dealing with zero-order reactions, where production is constant and continuous. This can be achieved in EMS with 90% reliability, but healthcare and the payers have no such commitment or public mandate.
- Normal distribution curve
- Percentile distribution curve
- Comparison of normal-percentile distribution curves
Press Ganey gets to rev the engine—and gets paid very well for doing it. It has very little to do with quality or the offering of credible solutions, but everything to do with the promotion of competition amongst healthcare entities.
Well not to be accused of maundering, that's enough meandering.
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May 31, 2006
Vacation, and a Guest Host Introduction
I'm taking a vacation. A real one. I'm not taking a computer, won't be checking my email, etc.
Now, just because I'm relaxing in the sun doesn't mean I've abandoned you, gentle reader. Three Emergency Medicine colleagues have volunteered to occasionally post here, to keep the place interesting. No restrictions have been placed on their posts, so this could be fun.
The pinch-hitters, in no particular order:
Symtym, a BC EM doc in California.
Blogborygmi (Nick Genes), by an EM resident in New York City.
Dr. Mark Plaster of EP Monthly, the only one who's not a 'blogger' but is a terrific writer.
I thank them for stepping into the void, and hope this works for all of us. See you in a week!
06:00 PM Announcements | Permalink | Comments (3) | TrackBacks (1)
Homeowner tales
I did a home improvement project the other day. It required three different materials, in different quantities.
And, I didn't have to go to Lowe's once. That felt very odd. I'm used to having to go at least once to get supplies, but I had enough leftovers that a trip for more was unnecessary.
It did make the project go very quickly, which was nice. But I've resolved to go to Lowes today, to restore balance and order to the panet.
09:36 AM Amusements, Family | Permalink | Comments (5) | TrackBacks (0)
