The Flow Stopper

Often when starting a shift, I'll find the waiting room packed with patients and several new patients already in rooms waiting to be seen. Sadly, there's no time to chit-chat with the nurses or surf the internet for the latest sports scores. In a situation like that, I've got to hit the ground running. My goal is to disposition and clear out the first few patients as quickly as I can. On a good night, if the stars line up properly, I hope to turn over most of the rooms once or twice before I can even think about slowing down.

With fairly straightforward patients who can communicate well, this is an achievable goal. Tell me your problem and I'll fix it, or I'll find someone who can. That's what I do.

Unfortunately, far too often traffic jams occur. One slow driver in the left lane, a poorly-timed trainwreck, or someone giving grandpa a phenergan will all have the same effect. The laminar flow trickles to a halt, and once it stops it takes a while to get it started again.

These flow stoppers may present in various forms which have been well-described previously on this blog and many others. Any patient who requires an interpreter, any time-consuming procedure, patients who are overly demanding, patients with numerous concerned and annoying relatives, patients who want to be admitted but don't need to be, patients who need to be admitted but don't want to be, patients requiring more than one or two calls to other physicians, and so on.

The challenge is to deal with the traffic jam and resume the previous pace, which is easier said than done (for me anyway).
I sometimes wish I had a REJECT button to use once per shift in a situation that is unnecessarily slowing me down. When Mrs. Jones asks me to talk to her (Pediatric resident) nephew in Iowa to discuss her current condition, I could just press the button and move on to the next patient.

Before I spend a painful 20 minutes on the interpreter phone trying to get a history from Mrs. Xiang, who is almost as deaf as the interpreter, I could just hit REJECT and see three other patients instead.

When I've already arranged an admission for Mr. Stewart's chest pain, and then he wants me to talk to his son's Cardiologist across town and try to transfer him to another facility, I'd be all over that button like I was on Jeopardy and the category was The Human Body.

If grandma's feeling a little bloated because she can't poop, I'd be hitting that button like a fibromyalgia patient on a PCA pump.

Inapsine

In honor of the full moon tonight, I would like to pay tribute to a pharmacological legend. Historically one of the all-time great emergency department drugs, our use of this product has unfortunately been sharply curtailed by the FDA black box warning. While its precise mechanism of action may be unclear, the fact is that this medication is an outstanding treatment for migraine headaches, nausea, agitation, psychosis, and all varieties of annoying drunks. Its most distinguishing feature?

It makes crazy people normal, and it makes normal people crazy.
At least for a little while.

I miss it.

ER Utilization and Plasma TVs

Let's imagine that 60 inch plasma screen TVs were freely distributed to certain members of the population, specifically those who earned less than the federal poverty level and therefore qualified for government assistance in obtaining TVs. Everyone's entitled to a ginormous plasma screen TV aren't they? Well, they should be. This is America, dammit.

Assuming such a scenario was implemented, these unfortunate folks might just come in every other week to get a new one. Why not? They are free, right? Might as well have two in each room. One on each wall, even. There is no limit to the generosity of the American people when it comes to redistributing the labor and wealth of others to the less fortunate. Heck, we'll even load it into the Escalade for them.

Everyone else could buy plasma TV insurance, so that when their current TV stopped working, they could get their next one at a discount (but they still had to pay a rather large copay and deductible). These people, who worked for a living, might just do without a plasma TV for a while, settling perhaps for watching their old (but adequate) tube TV. Even if they did go buy a new one, they probably would be satisfied with just one or two, because they would have to pay a substantial amount of money each time they visited Circuit City.

Now let's say that a federal law required Circuit City to give away plasma screen TVs free of charge to anyone who showed up in the store requesting one, regardless of their ability or inclination to pay for it and regardless of their plasma TV insurance status. Some of these folks would try to pay for their TV anyway, because they are honorable people, but many more would just ignore the bills and stock up on TVs at the expense of the company.

I suggest that if we were to create a plasma screen TV utilization chart, it would look strikingly similar to the CDC ED Utilization Chart.

Imagine that. Human nature is what it is.

Will the working class eventually get tired of subsidizing plasma screen TVs for the less fortunate? Will Circuit City eventually close down? Will the government effectively restrict the production of plasma TVs altogether so that everyone can have a smaller, less technologically-advanced TV? Stay tuned (on your 60 inch plasma).

I'll be watching on my old 36 inch tube TV. As long as it works, that is.

My Princess

OK, now I'm catblogging.

Memories of Internship

A recent patient was admitted for acute renal failure after suffering from a diarrheal illness for over a week. His initial CT scan had suggested the presence of diverticulitis, so he had been treated by his internist with standard antibiotics with resolution of his diarrhea. He had never vomited, but his appetite was poor and he admitted to not drinking enough water. His medications included an ACE inhibitor and a diuretic. As I recall, his BUN was 40 and his creatinine was 3.0.

Were his symptoms caused by an enterotoxigenic form of E. coli, perhaps even the dreaded O157:H7 form? Did the patient's ACE inhibitor and diuretic contribute to the new-onset renal insufficiency? Was there some underlying renal disease that was unmasked by the acute illness? Or perhaps some combination of the above?

These are the sorts of cases that sometimes make me wistful for the days of my internship and my Internal Medicine training. I used to love figuring out interesting conundrums like this. A Mona Lisa smile probably crept across my lips as I enjoyed a brief petit mal event; a sort of transient dreamlike fugue state that took me away from the busy ER for a few moments. Then I was slapped back to reality by a simple question from the admitting intern:

How do you calculate the fractional excretion of sodium in a patient on diuretics?

Hmmm. I can't recall. Why do you need to know that?

My resident and attending will want to know, I'm sure. It will help us decide if the patient is prerenal or not.

So we looked in her little formula book for a while, and we found an equation with tiny little letters that my aged eyes could not read no matter how hard I squinted. To make things worse, we didn't know what the symbols stood for anyway.

"That's why I'm an ER doc now," I said. "I don't have to worry about that stuff anymore. Acute renal failure = admit." I made a satisfied Neanderthal grunting noise for effect.

Well, I won't have to worry about it much longer either. I'm going into Ophthalmology.

Zing!

Minor Laceration Pictures

I can't remember the mechanisms of injury because these pictures are from a while back, but these are examples of various types of simple lacerations that require repair. I'm a fan of steri-strips or Dermabond in many circumstances, but some wounds are more appropriately sutured.


This first laceration was not under tension and was easily closed with steri-strips, a relatively underutilized technique in my opinion. Note the spacing of the strips and the cross-hatched application to keep them secured. Tincture of benzoin is applied to the surrounding skin prior to placement of the strips; the stickiness prevents them from falling off too soon. Be sure to apply the benzoin all the way up to the wound edges to aid in their approximation, but try not to get it into the wound itself, particularly in children. It burns like heck but doesn't harm the wound as far as I know....benzoin is also an antiseptic.


























This arrowhead-shaped laceration was a bit trickier, as it was under tension and therefore tended to gape. A corner stitch was placed first at the tip, then the edges were sutured. I pull all of the knots to one side of the wound to make it look neater.


























Skin tears in the elderly are common, and their fragile skin does not tolerate sutures well. I formerly used steri-strips on these injuries, but now I almost always use Dermabond. I always infiltrate the base of the wound (not the flap) with a little lidocaine with epinephrine to allow me to clean it more aggressively and to reduce the possibility of hematoma formation. This technique is quick, easy, relatively painless, and effective.

Frog of the Day

I'm not cat-blogging. Really.

Just working a lot. And frog-blogging.

American Air Power

I love the soundtracks.

Warthog



Cobra



Cobra gunner

Fecal Disimpaction: Another Unpaid Mandate?

Among the worst possible chief complaints, particularly when falling on the first or last patients of a shift, is the dreaded fecal impaction.

The actual wording takes various forms:

"I think I'm impacted again"

"No BM in one week; bloated"

"Bowels are locked up"

"Pressure in my rectum"

The typical patient is an oldster who was recently started on vicodin; they have the triple threat of the Play-Doh stools which are universally caused by this narcotic, decreased abdominal musculature limiting their ability to bear down, and decreased bowel motility that seems to come with aging. Plus they are probably on 5-10 other medications which contribute to constipation, and they aren't drinking enough liquids. Except for prune juice, which apparently doesn't do shit (so to speak).

Whatever the cause, they have a huge clay-like stool ball that fills their rectum and won't come out naturally. So we have to go in and pull it out. With our hand. Or more commonly, one scooped fingerling at a time, over and over and over again. This is done until they beg us to stop, they start bleeding from the trauma, or we just can't bear it anymore. There are no other endpoints.

As a bonus, they often have lots of liquidy stool that has backed up behind the massive pooball, which not only serves as a lubricant but an air freshener as well. So after several minutes of violating this fragile elderly patient in one of the most horribly unpleasant and embarrassing ways imaginable, causing us to at least wonder if the lingering shit-smell on our clothes is noticeable to our next several patients or our family when we get home, we ultimately have no procedure code with which to bill for this absolutely necessary but maximally unpleasant service (cue shadowfax to come tell us his super-secret $500 billing code for this....PLEASE!)

WTF is up with THAT? I vote we send all such patients to the CMS for the pencil-pushers to disimpact. Then perhaps they might begin to understand the value of this procedure. And to the impacted patients, a request:

Please don't come in at shift change.

Katie Couric's Sputum Production

She didn't like the word "sputum," so she attacked her editor.

Really.

Katie Couric allegedly slapped a "CBS Evening News" editor "over and over and over again" during a tense newsroom confrontation, according to a source quoted by New York magazine, which goes on sale Monday.

"I sort of slapped him around," Couric admitted to the magazine. "I got mad at him and said, 'You can't do this to me. You have to tell me when you're going to use a word like that.' I was aggravated, there's no question about that."

Doctors' Trade Secrets

I got this from a link on SDN. A panel of anonymous physicians of various specialties discusses how they really feel about various medical issues. Sort of like we do on our medical blogs. The question and answer format is nice.

The Sexual Assault Exam

Why is it even done in the ER? I don't get it.

OK, you've been sexually assaulted. I'm sorry to hear that (really). I'll be happy to examine you and make sure you are OK. I'll give you pain medicine for your bruises and sedatives to calm your nerves. I'll suture your lacerations, if any. I'll give you prophylactic antibiotics to lessen your risk of contracting a sexually transmitted disease. I'll give you prophylactic hormones so that you are less likely to become impregnated by your attacker. I'll comfort you with kind, soft-spoken words of sympathy as best I can. I'll give you the telephone numbers of Gynecologists and counselors to follow up with after your emergency room visit. If subpoenaed, I'll even go to court to testify that what I have written in your medical record regarding your history and physical examination is true to the best of my knowledge.

But it's not reasonable to expect me to collect physical evidence from every orifice and crevice of your body or to wade through a lengthy protocol-driven forensic checklist. Or to fill out the seemingly endless pages of forms and anatomical diagrams found in such a "rape kit."

In my opinion, it is my job to stabilize and treat your emergency medical condition. Collection of evidence and detailed completion of medically-unnecessary forms (while sicker patients wait unseen) in order to support an often doubtful and frequently unpursued court case is something altogether different.

I think such examinations are best performed in specialized facilities....not the typical ER. If your ER doesn't have a SANE program, and I suggest that most (if not all) of them shouldn't, then why not refer otherwise uninjured patients to another facility that does offer such a program?

Tell me why I'm wrong.

"Emergency" Management of Elevated INRs

Patients taking Coumadin (warfarin) are occasionally referred to the ER by well-meaning primary care physicians when, as often happens, the INR is noted to be abnormally elevated on routine laboratory surveillance. Other times, elevated INR values are incidentally discovered during emergency department evaluations for unrelated concerns.

This article, impressively discovered by Nurse K (despite the fact that she has never taken the MCAT nor received a medical degree) confirms that adverse outcomes are rare in asymptomatic patients with INR elevations in the 5-9 range, and that the majority of such patients can be managed conservatively.

Bravo, Nurse K. Thanks for educating us.

Emergency Contraception

Should physicians have the right to refuse to prescribe it? Should pharmacists have the right to refuse to fill it?

I say yes, under general principles (although I have personally never refused such a request).

#1 Dinosaur says no. Read the comments for a great discussion.

What say you?

(Of course, since Plan B is OTC now, the discussion is moot. But I still think it's an interesting topic nonetheless)

If You Are Considering Back Surgery

Read this first. Wow.

Treating Over the Phone...

Is not the same as diagnosing over the phone.

This post by Angry Doctor got me thinking about proper management of patients with abnormal laboratory values. KevinMD agrees with AngryDoc that "under no circumstance should physicians diagnose over the phone."

While that blanket statement is debatable, particularly with regards to diagnosis of urinary tract infections in females, I would submit that once one receives a straightforward abnormal laboratory value such as a potassium of 3.3 or an INR of 5, the diagnosis has been made. The only thing left to do is to decide the treatment. MD stands for "make decision," right?

Spare me the long-winded discussions about the importance of differential diagnosis in the assessment of hypokalemia, or the considerations regarding the etiology and potential dangers of overanticoagulation. I'm quite familiar with them, thank you. But you ought to realize that in the ER, the borderline hypokalemic is going to simply get a potassium tablet, and the asymptomatic coagulopath is going to be told to hold his Coumadin today and follow up with you tomorrow for further recommendations.

Can't you do that yourself, or do you really need me to do it for you?

I suspect that the reason some primary care physicians do not want to manage these types of patient issues over the phone is related to the lack of reimbursement for such "hands-off" management under our current system. I'm more than happy to charge your patient hundreds of dollars for doing something that you can't charge anything for. But is that really the right thing to do?

Financially, I understand your concerns. Ethically, I think you should take care of your own patients, like a physician is supposed to do. Put yourself in their place and honestly admit to yourself how you would like to be treated under similar circumstances.