In October 2011, the Centers for Disease Control and Prevention reported a 60% increase in “emergency department visits for sports– and recreation–related traumatic brain injuries, including concussions, among children and adolescents” over the past decade. That’s good news: as the CDC’s press release said, they believe the increase was due in part to “growing awareness among parents and coaches, and the public as a whole, about the need for individuals with a suspected ...
Posts tagged Emergency
An American ER doctor in Tasmania
Beginning work at Launceston General Hospital in Tasmania, orientation really, I noticed a lot of things missing: places to sign my name.For any given patient I’d sign: the completed chart note, perhaps a lab (sorry, pathology) and imaging slip, a prescription form (in triplicate – ok, so that was weird), and a GP letter.I didn’t have to sign (physically or electronically) multiple different "attestations," I didn’t have to generate multiple ...
Physician, don’t heal thyself
A couple of months ago, I was dragging a large suitcase that got hung up on a curb, giving my arm and shoulder a good yank. Over the next few days, my shoulder began to ache a bit. Applying the very reasonable ‘tincture of time’ principle, I rested it a bit, hoping that with time the symptoms would resolve. Two months later, I was getting an MRI and anticipating surgery ...
Physicians must advocate for their patients
Editor's note: Please read Dr. Yang's entire Red Herring series for background prior to reading this post.***The patient really is fine.She returned to the gastroenterology clinic several times for treatments to widen her esophagus. (It’s a neat procedure: The GI doctors insert a small balloon into the esophagus. They gently inflate the balloon to stretch the stricture a few millimeters. With repeated stretching, the esophagus will remain open.) The patient ate ...
It’s time to look critically at the concept of board certification
In 1994 I was thrilled to become certified by the American Board of Emergency Medicine. I had worked very hard. I studied and read, I practiced oral board scenarios and even took an oral board preparatory course. It was, I believed, the pinnacle of my medical education. Indeed, if you counted the ACT, the MCAT, the three part board exams along the way and the in-service exams, it was my ...
MKSAP: 67-year-old man with confusion, agitation, and malignant hypertension
Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.A 67-year-old man is evaluated in the emergency department for confusion and agitation secondary to malignant hypertension. Initial blood pressure is 230/130 mm Hg, and funduscopic examination reveals papilledema.He is admitted to the intensive care unit, and therapy with nitroprusside by continuous infusion is begun; ...
The emergency department in an ACO world
In the era of accountable care, you’ll notice that many hospitals and health systems are already driving towards more collaborative workflow. The integrated delivery network (IDN) is changing significantly, and for the better. But in high-acuity care areas, like the emergency department (ED), the challenge of treating patients more holistically in what is already a fast-paced environment is concerning for physicians evaluating the pay-for-performance model.In today’s ED, patients ...
Patient identity fraud in the emergency department
Almost four years ago now, I left my practice as an emergency medicine physician to enter the business world. However, the medical world isn’t easy to escape. I just couldn’t seem to forget some of the problems I used to face in the emergency department. So, when I had the chance to fix one of them, I took it.The most intractable problem for me was fraud, especially as it related ...
Impersonal care from the new generation of physicians
Historically, American physicians and surgeons were fiercely independent practitioners, who owned their own practices, worked long days and maybe longer nights, made a good income, but saw little of their families. They trained in a male-dominated world in "residency," so named originally because their extended 120 hour/week work schedule demanded them living in dormitory type residence adjacent to the hospital.They developed long-standing professional commitment to their patients that superceded time ...
Medicine introduces us to loss early in life
I recently sat by a man whose young wife was dying. Her cancer was taking her away from her husband and toddler. She was sleeping intermittently as the pain medication we administered did its work. Her husband’s eyes were red from crying and he could barely suppress a sob. He touched her and looked at me. I barely kept my own composure.I wanted to avoid that room and that patient. ...
The new definition for a medical emergency
The recent budget crisis in many state Medicaid programs has led the directors of these health care programs for the poor to cast about for ways to cut their costs, and many have landed on a ‘solution’ that puts lives at risk and undermine the financial viability of an emergency care safety net that is already severely underfunded and overwhelmed. Some 21 states use a variation of the old definition ...
When doctors have to be reminded how to act like human beings
It’s a sad commentary when human beings have to be reminded how to act like human beings, especially when they’re in the helping profession.Loni Hildebrandt was a 29-year old certified nursing assistant who was pregnant with her first baby. Make that two babies because she was pregnant with twins. Hildebrandt considered her pregnancy miraculous because she had infertility and was a diabetic since the age of one. Together, she and ...
Why nursing homes need more doctors on site
The recent New England Journal of Medicine article, highlighting burdensome healthcare transitions in a subset of nursing home patients, is certainly of documentary value. However, for many of us with real-world experience in the nursing home medical care venue, the article certainly falls short of newsworthy. Not even mildly surprising really.Too many of our nation’s nursing home staffs suffer from a lack of onsite MDs for evaluating acute ...
tPA is the standard of care for stroke but with significant risks
Under current guidelines from the American Stroke Association, tissue plasminogen activator (tPA, commonly known as a "clot buster" drug) should be administered within 3-4.5 hours of “last seen normal” – and 1 hour of patient arrival – to potentially ameliorate a new onset stroke. ("Last seen normal" means exactly what it says. A patient who went to bet at 10 PM and awoke with slurred speech at 6 AM was ...
Chest pain is where protocol driven medicine breaks down
On the theme of knowing when and when not to follow the diktats of emergency medicine, one of the greatest challenges for a practicing ER doc is chest pain. Missed MI is still the biggest driver of malpractice costs, and last I hear, ER docs still send home something like 2% of patients who are having MI or unstable angina. Not good. So over the last decade we've gotten all ...
A test of faith during Ramadan
Of all possible times, it happened during Ramadan. The test of faith would be extreme.Azka was the first of four children born to Persian parents in a small town thirty miles outside of Tehran, Iran. Being devout Muslims, her father chose the name Azka in part because it meant “pious”. His wife later revealed to Azka that he also liked how the name rolled off the tongue when spoken in ...
The impact of unnecessary testing and treatment on patients
Ask most patients, and they say their doctor has a good reason for ordering tests and prescribing treatments. Turns out their doctor may secretly disagree. That's the conclusion of a new study. The implications are more than a bit disturbing.Researchers from the Dartmouth Institute for Health Policy conducted a survey of more than six hundred physicians. Forty-two percent of family doctors admitted that patients in their own practice receive too much care - meaning ...
Hospital discharge summaries are a health literacy issue
A couple of years ago, a frail 88 year old Filipino woman came into the emergency department of my hospital complaining of confusion and weakness of her left arm. Her blood sugar level was extraordinarily low, so low that she would have died had she not received immediate treatment.The emergency room doctors treated her by injecting her with sugar, and then called the team of internists on call to admit ...
A hundred shifts in, I have fine tuned my instincts as a physician
I gather my belongings: stained white coat, stethoscope, pen light, black ballpoint. I stuff the last two granola bars into my canvas bag. I glance at the clock on the microwave, which is three minutes fast.Twenty-two minutes until my shift begins. One minute before I will lock the door to my apartment.Precision is critical: ER shifts change fast and blend together, from late nights to early mornings to mid-afternoons. Suns ...
Attending in flight emergencies is part of our Hippocratic Oath
On a recent international flight to London, a passenger required medical assistance. I don’t know if it is the karma of London but this is the second medical emergency on a plane headed to London that I have encountered.I was only a couple rows behind the passenger and could see even before the crew announced the need for a doctor that he needed assistance. I jumped over the woman ...
