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Archive for September, 2010

Scientific Assembly Day 2

Thursday, September 30th, 2010

Still can’t get the pictures to post correctly from my portable netbook. Will have to wait until I get home and then add pictures to the post.

The Wellness Center is probably worth the cost of conference registration by itself. Screening blood tests, burnout assessment, flu shot and dTAP booster all for $20. I’m not doing the damn body fat testing any more. They said that my body fat went from 4% last year to 8% this year. I think their machine is broken.

I was fortunate to get a deal at the 24 hour store in the hotel. A bottle of Gatorade and a banana were “on sale” for $6 – according to the cashier.

I get texts throughout the day from my kids which is nice. The only thing is that the content of the texts has changed. When I got here, they were some iteration of “we love you and miss you dad.” Now they have changed over to “what did you get us?”

So I walked around the exhibits groveling for beach balls, flash lights, and back packs. It used to be grown men in suits fighting over pens. Now it’s deteriorated into grown men in suits fighting over foam rubber models of the Statue of Liberty.

I stopped back at the Boehringer Ingelheim exhibit looking for their sign about people who were not allowed to eat the root beer floats being given to the attendees. The big sign was gone, but there was a smaller sign telling people from Colorado, Massachusetts, Minnesota, and Vermont to get lost. Took a picture of it that I will post when I get home.

The ultrasound courses are outstanding. Went to two of them today. Very impressed.

Organization is another issue. In the hallways between exhibits, it is like New Years Eve in Time’s Square. Wall to wall people who can’t move anywhere.

Got a chance to walk along Las Vegas Boulevard this evening and take pictures. Definitely an interesting experience. I got propositioned several times. I walked through about 8-10 gauntlets of people wearing T-shirts guaranteeing a girl in my room in 20 minutes who were flicking cards on their hands and then trying to get you to take the cards. I took a few for souvenirs. Then I started walking by them flicking the cards on my hands and trying to get them to take them back. Got some strange looks. I also started videoing the gauntlets as I walked down the street. That got me some curses, but kept them away when they saw the camera.

There were a lot of street performers along the way. Some were pretty good, some were tone deaf. Most were entertaining. Except the strange guy wearing a clown mask sitting on a tricycle and ringing the tricycle bell. Yeah, bud, that makes me want to whip out my wallet to give you some money.

It’s 2:30 AM Las Vegas time which is 4:30 AM Central time. I just got back to the hotel. But it is nice when you leave Las Vegas with more money than you brought to Las Vegas. Craps tables were good to everyone I was with. One doc’s wife had a 20 minute roll. That roll substantially increased the $50 I put on the table.

Thanks to Ramona for letting us know about GruntDoc’s tweeting frenzy about the Scientific Assembly.

Only have about 5 hours until the next lecture starts and about 12 hours until I’m on my way back home.

Scientific Assembly Day 1

Wednesday, September 29th, 2010

At the ACEP Scientific Assembly for day 1 of the event in Las Vegas. It is the most attended Scientific Assembly in the history of the College.

Lots of good lectures. The faculty here is top-notch.

I kept a pad with me and took notes as the day progressed. Things I jotted down are below.

Temperature is 105 degrees outside. If what happens in Vegas stays in Vegas, that’s a good thing. Keep the weather. And don’t even go there about the “dry heat” thing. If you stick your head inside of a dryer, that’s dry heat, too. Doesn’t make the air any less hot, does it?

The hotel – Mandalay Bay – is literally bigger than my home town. It takes me 10-15 minutes to walk to the conference rooms walking at a brisk pace – well, except when going by the windows overlooking the swimming pool – but it’s still a damn big hotel.

Worked out in the hotel gym and, on the way back, sat down to play slots. Put in $20 on a 25 cent machine. Won maybe twelve cents out of the first 20 spins. A husband and wife sat down at the two machines next to me. Husband wins $300 in first 2 minutes, wife wins $100 2 minutes after that. I just sat there with my jaw on the floor. Should have just handed them my twenty and walked away. I’d have been a lot less ticked. Then I checked my biorhythms on the smart phone – emotional and intellectual are both at their low points for the next two days. I’m staying the hell away from the craps tables.

Was at a lecture about pediatric sedation. The lecturer discussed sedation for reducing fractures and noted the following: “Hey when the orthopedists learned how to spell ‘ketamine’, it was a milestone. They could get to the gym an hour earlier each day.”

Seven dollar draft beers – I thought that was only in New York City. But it was at a bar in which you were given a parka so that you could drink in 5 degree below zero atmosphere. Don’t know which is worse – being too hot, being too cold, having to wear a fleece, or being fleeced.

Overheard a story about William Shakespeare: They recently opened his tomb and found that he was inside erasing all of the things he had ever written. When they asked him what he was doing, he replied “Decomposing.”

Tonight, we had an EM blogger summit with GruntDoc, Shadowfax, Graham Walker, and Nick Genes. Lots of fun stories and laughs. Also got to meet Mrs. GruntDoc who is going to do a guest post on this blog about some spice cabinet issue she had with her hubby. More on that later. Don’t even bother asking any of the other bloggers what I look like. I was wearing a carefully crafted disguise.

Will try to add pictures with tomorrow’s post. Currently having an equipment malfunction.

If you’re in Vegas, stop by the EP Monthly display in the 1900 section and say “Hi”.

Thank God

Monday, September 27th, 2010

As I walked into the ED for my shift, the nursing supervisor was fumbling with a syringe attempting to get medication out of a small vial.

“Ummmm. Looks like you need to adjust your bifocals,” I quipped. We have a running joke about who is older and bust on each other about our ages every chance we get.

When she turned around, the look she gave me signaled that it was no time to joke. Tears were running down her cheeks.

“What’s …?” She cut me off.

“Thank God you’re here. Get into Room 7 now.”

When patients are really sick, it has been said by people much smarter than me that your worth as a physician can be judged by how people invoke deities. There are the “Oh God” docs and there are the “Thank God” docs. Being classified in the latter category by a nurse whom I admire is a compliment, but it also meant that there was something very bad behind the curtain across the hall.

I set down my bag, unzipped it, and searched around for my stethoscope. The nursing supervisor grabbed my shirt and pulled me toward the room. “Use mine,” she said.

She threw open the curtains and it took me a second to size everything that was going on. Despite the commotion, it was eerily quiet. In one corner, a middle aged man and his wife were sitting holding each other’s hands. Both were crying. An ambulance stretcher was pushed to the side of the room. EMTs were trying to start an IV on one arm. Two nurses were working on getting an IV in the other arm. At the head of the bed was the respiratory therapist. He had a brow full of sweat and kept wiping his forehead with his arm as he worked the Ambu bag. He told the doc who had her stethoscope on the patient’s chest “I’m barely able to get any air into her lungs.”

Laying on the bed was the limp body of a 13 year old girl. Her color was between dusky and blue.

“What’s going on?” I asked.

“Bad asthma. She just stopped breathing on the way to the hospital,” said one of the EMTs.

“We can’t tube her because her jaw is clenched down and we are having trouble bagging her because she’s so tight,” the other doc explained further.

She was from an outlying area, so her transport to the hospital took 25 minutes. She was in respiratory distress when EMTs arrived, so there was at least 30 minutes of ineffective respirations.

“What has she gotten so far?” I asked.

“Nothing, we can’t get a line,” said one of the nurses.

I grabbed the nursing supervisor. “You need to go get epi NOW.”

She walked out of the room and said over her shoulder “I was doing that when you walked in.”

I watched the respiratory therapist try to ventilate the patient. The problem wasn’t that her lungs weren’t getting enough air, the problem was that her lungs were full of air and the airways were so constricted that the air couldn’t get back out.

I went to the side of the bed and started squeezing the patient’s chest between ventilations to force the air back out.

“IV in!” Announced one of the nurses.

Medications started pouring into the IV line – to improve the patient’s asthma, to sedate her, and to paralyze her muscles so that we could put her on a ventilator.

I looked up at the respiratory tech. Sweat was forming a triangular wet spot down the front of his shirt.

I prepared to insert a breathing tube and pressed down on the patient’s jaw to insert the laryngoscope blade. Her mouth filled with vomit.

Dammit.

We lowered the head of the bed so that the vomit would pool in her mouth and then suctioned her. Her oxygen saturation started to drop. We Ambu bagged her again. More vomit filled the mask.

Dammit.

We suctioned her again.

“Do you want me to call anesthesia?” asked the nursing supervisor.

“No. I can do this.”

“Are you sure?”

“Yes. She just needs to stop vomiting.” The tone of the beeps on the oxygen monitor became lower and lower – meaning that the patient’s oxygen level was getting lower and lower. Now I could feel the sweat building on my forehead.

With some additional suction, the airway was clear and I got the tube in place.

The beeps on the oxygen monitor began to rise in tone. Everyone in the room breathed a sigh of relief … including me.

As the respiratory tech taped the tube into place, a few drips of his sweat dripped onto the bed. I looked over at him. His whole shirt was soaked. He looked like he had just walked out of a sauna.

The secretary came into the room and handed me results from a blood gas. The pH was 6.7 and the pCO2 was greater than 100. Not encouraging.

The patient’s parents looked up at me. I tried to be upbeat. With a half smile I softly said “She’s doing better now.”  On the inside, I wasn’t so encouraged. With her prolonged down time and that ABG, I wondered whether she would ever wake up.

We arranged transport to the regional Children’s Hospital pediatric ICU and within a half hour she was lifting off of our helipad. By the time she left, the sedation and paralytics we gave her would have worn off, but the patient still wasn’t moving.

All I kept thinking about was that this could very easily have been one of my daughter’s classmates – or even my daughter – who was only a year older than the patient. I had to stifle the urge to call home just to make sure that everyone was OK. It was 12:30 AM and giving myself peace of mind would only have created a whole lot of angst with my family.

About three hours later, we get a phone call from the Children’s Hospital. The physician wanted to give me an update about our patient. By that time it was almost 4:00 AM. The physician on the other end of the line sounded exhausted.

“The transfer that you sent over here …” During that small pause that followed I could already feel my face getting flushed. For some reason I suddenly had this overwhelming sense of grief.

“Yeah …?”

“She’s already awake and trying to pull the tube out. Looks like you guys saved her life.”

All I could muster were the words …

“Thank God.”

Press Ganey Article

Friday, September 24th, 2010

Remember that survey that we did last fall about Patient SatisFICTION?

Two of the editors at EP Monthly finally used some of the survey results to create an article about Press Ganey.

Interesting reading …

2+2=7? Seven things you may not know about Press Ganey Statistics

Healthcare Update — 09-23-2010

Thursday, September 23rd, 2010

Bitten, shot, spat on. A day in the life of a health care worker. Hospitals would be wise to start taking the safety of their employees more seriously. I guarantee that this issue will come to a head in the near future – probably literally and figuratively.

Speaking of health care workers being shot … doctor tells patient and son about patient’s medical condition. Son then becomes upset, pulls out gun, shoots doctor, mother, and himself. Additional stories here and here.

After news of the shooting was published, this eloquent letter to the editor of a Baltimore newspaper emphasized why violence against physicians is escalating. “Stressed patients don’t see doctors as allies; rather as people to fight, manipulate or blame.” “We now seem to be living in a country where death is no longer natural; instead it’s a doctor’s mistake.” If you want some clear insight about why medical care in this country is deteriorating, you have to read this letter.

Lawyer mess up screws injured client. An anomaly, I’m sure. Nevertheless, it’s about time to push for legal care reform.

Annals of Socialized Medicine. A look at care in countries that provide socialized care.

How much is a lack of foreskin worth? Parents sue when baby is inappropriately circumcised after consent form is misread.

Patient gets nothing at trial after allegedly informing doctors of an allergy to morphine and then going into a “psychosis” when given morphine during his hospitalization.

Family sues for “cruel and discriminatory” treatment of man who died in his wheelchair while waiting 34 hours in a Canadian emergency department.

When you need 80 primary care doctors for every 100,000 people and you only have 36 doctors for every 100,000 people, what happens? Hospital emergency department visits increase between 12% and 54%. One California urgent care clinic in the article had an increase in patient volumes of 250%. Oh, and if you don’t want to wait, you can pay 25 bucks to reserve an emergency department appointment at Loma Linda University Medical Center. If you don’t have the $25, you wait in line like everyone else.

If you can’t repeal Obamacare, defund it. So say the Tea Partiers.

Another article showing why it is always necessary to get an itemized copy of your medical bills and to question any charges that don’t seem legitimate. A CT scan of the head for $5,874, $457 for drops that cost about $2/day, and a baby aspirin for $4.07. Yowza.

The IRS May Owe You Money

Wednesday, September 22nd, 2010

Several medical schools and universities sued the IRS for taking FICA taxes out of resident paychecks. The theory was that a “student exception” to tax laws also applied to residents and interns. As of 2005, the IRS changed the tax laws to close this loophole.

The IRS recently accepted the position that FICA taxes should not have been taken from intern and resident paychecks prior to 2005 and is now in the process of submitting refunds to the hospitals and residents who made claims.

If you were a resident before 2005, you may be entitled to a refund of any FICA taxes that you paid, in addition to statutory interest. Check with your training program to see whether it filed a claim on your behalf. I have heard through other docs that training programs will need to submit finalized claims in the near future, so act sooner rather than later if this situation may apply to you.

If your training program did not file a claim on your behalf, you may be out of luck since the statute of limitations has passed for filing such claims. Talk with your tax professional.

More answers to questions about this refund are here: http://www.irs.gov/charities/article/0,,id=219547,00.html

Any tax gurus out there? Since the statute of limitations has passed on the ability for an individual to claim these refunds and interest, can that money now be written off by individual taxpayers as an uncollectable debt?

Best States to Practice Medicine

Tuesday, September 21st, 2010

Physicians Practice Magazine just came out with a list of the Best States to Practice for 2010.

The article looked at things such as cost of living, state income tax, malpractice premiums, number of physicians per capita and number of disciplinary actions per 1000 physicians, then graded each state in each category as a “green,” “yellow,” or “red.”

Weren’t any states that were all “green,” but Alabama, Alaska, Kansas, South Dakota, Texas, and Tennessee came closest.

Worst states? New York leads the pack. DC, Hawaii, Rhode Island, and Vermont have multiple categories in the red as well.

What’s The Standard of Care for Strokes?

Tuesday, September 21st, 2010

EP Monthly has taken a new twist on its Standard of Care Project.

This month, the editors published a statement regarding whether use of thrombolytics is the standard of care for a stroke. They’re asking emergency physicians who agree with the statement to log in and cast their vote.

The theory behind the project is that if several thousand emergency physicians agree that the standard of care does not require that thrombolytics be given for an acute stroke, those statistics can be published and used as evidence at a trial.

The whole concept is in its early stages, but if you’re interested, go to the home page for the project:

http://www.epmonthly.com/soc/

Medications and Side Effects

Monday, September 20th, 2010

I went to visit a friend in our hospital after he had abdominal surgery.

He was having pain, so his doctors put him on a morphine pump. The way that a morphine pump works is that the doctor determines the dose of medicine and the lockout period. For example, typical pump settings may be a 2 mg dose with a lockout of 15 minutes, meaning that if the patient pushes the button to receive a dose of pain medication, he will get 2 mg of morphine. Then, no matter how many times he pushes the button after that initial dose, the machine will not give him another dose until 15 minutes have passed. The maximum dose of morphine that the patient could receive in an hour would be 2 mg x 4 doses in 60 minutes or 8 mg in an hour.

My friend told me about how one of his co-workers came to visit him and was sitting in the chair in front of the bed. While they were talking, my friend pressed the button for the morphine pump. His co-worker asked him what the button was for. My friend told him and his co-worker looked a little concerned that a patient could give himself his own dose of medication.

Then my friend took that as a cue to keep pressing the button. “Naw, it’s OK. I have a lot of pain, so this stuff makes me feel better. Besides, I haven’t stopped breathing … yet.”

Every 15 seconds or so, he’d push the button several times. His co-worker became more and more uncomfortable.

Then he started slurring his words and acting sleepy.

His co-worker started getting anxious. “DUDE! Stop pressing the button! You’re freaking me out with all that medicine.”

My friend hung his head down and sat there for a few seconds, then opened his eyes and started laughing, which made his co-worker a little upset with him.

We laughed a little more about other stories and then I got ready to go.

As I was leaving, I went out in the hall and said loudly “this man needs a STAT enema … NOW!” After all – all that morphine does tend to constipate a patient. The unit secretary smiled at me and no one else seemed to be paying attention. I turned around to my friend and made a squeezing motion with my hand, then waved goodbye.

By the time I reached the parking lot, his wife had sent me a text message saying that the patient’s nurse went into the room with an enema shortly after I left – thinking I was serious.

I was going to call back to the nurse’s station and ask if my friend got his enema yet, but figured that would give him even more of an impetus to get even with me.

The Power of Suggestion

Saturday, September 18th, 2010

A couple of weeks ago, I got to work and the first three patients in the rack waiting to be seen were a child with a rash, a young lady with a toothache, and a patient who had been to our emergency department many times in the past for chronic low back pain.

I did my best impression of Al Delvecchio from Happy Days.

“Ahhhh yep yep yep yep yep yep yep. It isn’t a day in the emergency department without a rash, a back pain, and a toothache.”

We are now up to eight consecutive shifts I have worked in which there has been at least one patient with a rash, with back pain, and with a toothache. In fact, it has become a mission of everyone working in the emergency department during my shifts to ask every patient – regardless of their chief complaint – whether they have had a rash, a toothache or back pain.

Apparently the whole suggestion thing only works under limited circumstances, though. I tried saying

“Ahhhh yep yep yep yep yep yep yep. It isn’t a day in the emergency department without winning the lottery.”

Nothing.

Dang.

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