Should a consultant pass through the ED to see what's up?

A couple of weeks ago, this tweet appeared.

I could relate to it for two reasons. One, I lived in New York City in 1975, and here is the other.

Early in my career, I thought it was a good idea when leaving the hospital at night to exit via the emergency department to see if there were any potential surgery cases brewing. I was hoping to avoid going all the way home, getting paged to the ED, and having to go right back to the hospital. I soon learned to stop that practice because it was similar to poking a skunk.

Less crowded EDs = less waiting & "big data" isn't so big

Two recent papers caught my eye. As usual, I will preface my critiques with a disclaimer that I have never written a Nobel Prize-winning paper myself.

The first paper, “Emergency department ‘undercrowding’ is associated with decreased waiting times” appeared online in the journal Emergency Medicine Australasia.

The authors looked at emergency department patient numbers and waiting times before and after a nearby tertiary care hospital opened a new emergency department.

Their main finding was that after the new ED opened, their ED saw 28% fewer patients with a concomitant decrease in patient waiting times of 15 minutes from 26 to 11 minutes with p < 0.001, a significant difference.

They concluded, “Wait times are strongly associated with patient presentation numbers.” Furthermore, “Controlling demand may benefit patient processing, flow, and patient perceptions of level of care.”

"Code Black" is still on TV. Did it get any better?

Despite some recent ratings problems, the TV show "Code Black" somehow remains on the air. It has lost viewers after five of the last seven episodes including a whopping 23.8% drop in the all-important 18-49 year-old demographic after the 2/17/16 installment.

It's still viable because of fans like Sharon who said on the ratings website: "The best medical show on. I have been in the medical profession 30 years and it depicts the most true to life situations of any of the medical shows I have watched. Love the show." Sharon must work on the psych floor.

I decided to take another look at it. Having seen the 2/17/16 episode, my opinion hasn't changed. Here's why.

Code Black Part II: "It gets worse"

Last week, I reviewed the premier of the new medical television series "Code Black" and pointed out several flawed or impossible scenarios. I didn't think I'd watch another episode.

But I was alerted to a rather shocking error on last week's installment. I had to see it for myself.

On this typically chaotic day in the emergency department, a young woman was brought in after a car crash which occurred while she was in her way to the ED because of abdominal pain. A CT scan of her abdomen and pelvis was negative, but her serum lactate level was elevated. They then decided to examine her abdomen and noted tenderness. A bedside ultrasound done in the ED revealed a left ovarian torsion (twisting of the blood supply to the ovary which if not rapidly corrected, could cause irreversible damage). The patient had already had her right ovary removed. Further heightening the drama was that her husband died of lymphoma but had banked his sperm, and the patient wanted to have his baby.

She needed immediate surgery, but all of the hospital's operating rooms were busy. As the window of opportunity to correct the problem was closing, an operating room opened up. But alas, there was not a single gynecologist or surgeon available to do the case. According to the back story about Dr. Neil Hudson, he's a fully trained surgeon who decided to work in emergency medicine. One of the new ED residents begged Dr. Hudson to do the case, and he resisted for a while until it was almost too late.

“Code Black” should be pronounced dead

A new television series called “Code Black” debuted last night on CBS. The show’s name supposedly means the emergency department has too many patients and not enough staff. In my over 40 years in medicine, I’ve seen many busy, understaffed EDs but never heard anyone call it a "Code Black."

There is the usual array of standard medical characters—the inexperienced new residents on their first day at work, the savvy nurses, and the cocky, overconfident attendings. This one has a few twists. The world-weary head nurse is a Hispanic man, and the headstrong know-it-all attending is a woman, Dr. Leanne Rorish. She has early conflict with the handsome, more cautious Dr. Neal Hudson, but I see romance in the future should this show manage to stay on the air.

It takes 5 people to push an empty gurney at Angels Memorial

The show started off with a gunshot wound to the neck that the docs had to retrieve from a car which had been abandoned in the hospital parking lot. Although no one had been putting pressure on the damaged carotid artery for an undetermined period of time and blood was visibly spurting out of the wound, the patient pulled through the resuscitation thanks to Dr. Rorish who replaced all his blood with cold IV fluid. She spiced up the resuscitation by asking the new residents questions about what she was doing.

Aortic dissection leads to man's death in the ED: His wife's perspective

A woman wrote to me about the day her husband died. I have edited her email for length and clarity and changed some insignificant details to protect her anonymity as she requested.

Joe passed away outside in the parking lot while they were getting on a helicopter for transport to a hospital equipped to do his surgery.

He had presented to the ED in terrible pain with lots of thrashing and writhing. His right hand was very cold. His right arm tingled to the point of hurting bad. The vision in his right eye was cloudy, and his hearing was muffled on the right. This was in addition to being very pale and diaphoretic upon admission. This is when I felt a dissecting aorta should have been suspected.

I don’t recall the vitals in the beginning, but they were changing and his blood pressure was dropping very fast. As soon as they finished the EKG-in the first 5 minutes of the visit, I asked the doctor about John Ritter's death [the actor died of a dissecting thoracic aneurysm in 2003]. First I asked if he could check for the condition that caused John Ritter's death. I called it an abdominal aortic aneurysm. The doc corrected me and said that it wasn’t an AAA it was a dissected aorta. I said OK, then check for that. This was 1 hour before the CT scan that led to his diagnosis.

More bizarre tales from "The Night Shift" ED

Much to my surprise, a medical TV show called "The Night Shift" is still on the air. It's about an emergency department the likes of which you or I have never seen. When it debuted back in May, I wrote a scathing review.

An emergency medicine physician, Nick Genes, has been blogging about the show, and his post about last week's episode caught my eye. So many outlandish things happened that I had to see it for myself. [link here]

Nick's review was so comprehensive and on the money that I won't try to top it. I'll leave out the flashbacks to one ED doc's time in Afghanistan, the chemical plant explosion, and the stripper who gave an intern a lap dance in an ED storage room and focus on the surgical cases.

A 16-year-old girl was brought in because of shortness of breath which turned out to be due to a fork lodged in her larynx. It was removed by the emergency physician who also made the diagnosis of bulimia. The parents refused to let the girl be admitted, so she swallowed a scalpel and vomited a large amount of blood.

At this point, most ED docs would ask for a surgery consult, but not those who work on television. Here the head ED doc and the intern performed a laparotomy in the ED, opened the stomach, and retrieved the scalpel.

As you can see, the rules are a bit more relaxed in the ED. No one is wearing a cap or mask, but at least they've all donned gloves and protective eyewear.

Another crisis arose, and the ED chief had to leave. On her way out she said, "Close her up. Run in another two units. And move her up to the OR." We are left to wonder whether the injury that caused the massive bleeding was dealt with and why she was being taken to the OR after the procedure was over? The ED docs on the show never seem to do any charting or paperwork so maybe they needed a surgeon to write the postoperative orders.

Not to be outdone, two other ED doctors diagnosed internal bleeding in a plane crash victim whom they had rescued after they were lowered from a helicopter. As they were taking him to the operating room [I'm not sure why since there are apparently no surgeons in this hospital and major surgery is done in the ED every day], they decided to stop for a CT scan. They were accosted by a man claiming to be a DEA agent, but who really was a drug dealer.

He wanted to talk to the patient who had been carrying a large amount of drugs. When he was rebuffed, he killed the CT tech and took the doctors hostage. In an effort to keep the patient alive, they intubated the patient without a laryngoscope by jury-rigging some IV tubing to a handy light source and performed a laparotomy without retractors and instruments in the CT suite. The patient died. The bad guy was subdued by a SWAT team, but not before he shot one of the docs in the abdomen.

Whether a surgeon will be consulted and how the wounded doc fares will be revealed during the exciting season finale tonight.

I can't wait.

My grandson survives a visit to the ED

Last weekend, my 16-month-old grandson was at a backyard barbecue with his parents. He had been eating some potato chips when he suddenly stopped breathing and turned blue.

Having had CPR training, my son started rescue breathing and suspecting aspiration, performed toddler airway clearance maneuvers. No obstruction was found. The child slowly awakened but was very drowsy.

Because of the concern for aspiration, an ambulance was called and the child was taken to the nearest hospital.

My son called and told me what happened. My wife and I drove to the hospital, which was 15 minutes from my home, but not one where I knew any staff.

By the time we arrived, child had been in the ED for about 10 minutes. Two nurses were trying to start an IV in his chubby arm, he was crying loudly. We took that to be a very good sign. He had already been examined by a doctor.

After successfully starting the IV, the nurses secured it and calmed down my daughter-in-law. She asked where she could buy a bottle of water. One of the nurses said not to bother and brought her a glass of ice water.

The nurses were gentle and professional, so much so that my wife, who is a former ED nurse, didn't mention that fact until nearly 5 minutes after we got there.

The initial vital signs taken were remarkable for a temperature of 104° F, prompting the emergency physician to suggest that the child probably had suffered a febrile seizure. He ordered a chest x-ray because of the history of possible aspiration.

The boy stopped crying and began to watch a cartoon on his father's iPhone. Soon he was smiling and laughing.

The x-ray was negative, and the fever came down with ibuprofen. I resisted the strong urge to point out that lowering a child's temperature has never been shown to prevent a febrile seizure.

We were all relieved that he was okay.

If you were expecting a tale of mistakes, sloppy nurses, and arrogant doctors, I am sorry to disappoint you.

Several essays, blog posts, and media articles about poor care received by doctors or their family members have recently appeared.

This is not one of them.

PS: The nurses complimented us for not trying to run the show.

Is ultrasonography overrated? A radiologist thinks so

In response to an article in the New England Journal of Medicine that discussed whether bedside ultrasonography (US) should be taught to medical students, radiologist Dr. Saurabh Jha recommended that clinicians do a proper history and physical instead of point-of-care ultrasound.

His post appeared on the KevinMD website.

As if a radiologist advising doctors to do an H&P wasn't shocking enough, Dr. Jha then confessed that he thinks "ultrasound images look like a satellite picture of a snow blizzard."

He worried that rather than finding hidden pathology, indiscriminate use of US by inexperienced physicians will simply lead to more and more testing.

Even seasoned radiologists tend to overcall abnormalities on US said Dr. Jha. This leads to increased use of other imaging studies, most of which turn out to be normal. Using US to avoid the risks of ionizing radiation often results in patients having CT scans anyway.

In the comments section of the post, Dr. Jha emphasized that he was talking about situations where the pretest probability of finding something wrong is very low. Directed US based on clinical indications is obviously of value.

Emergency medicine physicians who

Photo via Dr. Ryan Radecki (@emlitofnote)

commented listed several instances which bedside US can be useful such as in identifying pericardial effusions and fluid or blood in the abdomen of trauma patients.

Ultrasound is clearly the test of choice for right upper quadrant abdominal pain. There is nothing better for identifying gallstones, but thickening of the gallbladder wall and fluid surrounding the gallbladder are best seen with US done in the radiology department.

Probing all body cavities with a transducer for no specific indications is another matter.

Is there still a role for a good history and physical examination in modern medicine? Yes.

Is US a useful test? Yes, in the proper context, it can be very helpful.

Should every medical student be taught how to do bedside US? I don't think so. A course is just the beginning. Learning how to perform US requires a lot of repetitions. Many medical specialists will never use it.

I agree with Dr. Jha that the time should be used to "Teach them to organize their thoughts coherently."

What's your opinion?

Note: These folks also tweeted the photo.@EM_Educator @MDaware @EBMGoneWild @choo_ek

Why I am I so grumpy?

Patient information and situations have been slightly altered for privacy reasons, but the essence of the stories is true.

A middle-aged woman was admitted to the medical service for symptoms of alcohol withdrawal. Her liver function tests were abnormal. Despite the fact that she had no abdominal pain, an ultrasound was ordered and showed a gallstone. The cognitive doctor called me and said he didn't think the gallstones were significant but would like me to see the patient and confirm his feeling. Asymptomatic gallstones do not require surgical intervention. Why can’t a cognitive doctor deal with this himself?

An emergency physician had a woman in the ED who had fallen down some steps and fractured her right humerus, clavicle and a rib. There was no history of loss of consciousness. Her total body CT scans were otherwise negative. He consulted me to "clear" her regarding possible other injuries before deciding on her disposition. Are ED MDs capable of assessing and "clearing" trauma patients or not?

A man was admitted to the medical service with gallstone pancreatitis. [Whether such patients should be admitted to medicine or surgery will be the subject of another discussion.] I was called for a consult at 2:00 a.m. Think about it. How likely was it that I was going to operate on this patient in the middle of the night? Hint: Not very.

The answering service of a surgeon I was covering for called me at 5:00 on a Sunday morning to tell me that a woman had called to say her husband, who had undergone surgery a few weeks before, was having pain. I called the number I was given, and the call went straight to voice mail. Through clenched teeth, I left a message stating I was returning her call and that if she wanted to talk to me she should leave her phone on and call the service back. When she called back a while later, I learned that the pain had been going on for more than 24 hours. Why couldn’t they have waited two more hours to call? And how about leaving the phone on to receive the call-back?

A patient of another surgeon I was covering for called me at 6:00 p.m. on a Friday to tell me he had just run out of pain medication. Wouldn’t it make more sense to call the doctor for a refill when one was down to say, two or three pills? By the way, this happens all too frequently. It always makes me suspicious that the patient is drug-seeking. They get just enough pills to last the weekend.

I was called to the ED to see a morbidly obese woman with an incarcerated ventral hernia. While taking a history, I learned that she had diabetes, hypertension, asthma, sleep apnea, hypercholesterolemia, arthritis, atrial fibrillation and was taking prednisone and Coumadin, as well as 15 other medications. Her primary care physician, all of her specialists and the surgeon who had performed all of her previous operations practiced at another hospital. Why did she come to my hospital? She said she knew she wouldn’t be kept waiting as long in our ED.

Horace Greeley: “Common sense is uncommon.”
Skeptical Scalpel: “Common sense cannot be taught.”

Washington State Medicaid will no longer pay for “unnecessary” ED visits

By now you must have heard the news that as of April 1, Medicaid in Washington State will no longer reimburse hospitals for care of what Medicaid deems unnecessary ED visits. [The Seattle Times report is here.] The problem, of course, is that many times the perceived lack of necessity can only be determined after the patient has been worked up. Even a patient brought in by ambulance will not be covered if it turns out that his illness is not a true emergency as defined by the rules. And hospitals will not be allowed to bill the patients. The unnecessary visits list includes illnesses like hypoglycemic coma and asthma attacks. Unstable vital signs do not matter if the visit is eventually found to be unnecessary.

Hospitals and ED docs in Washington have vociferously objected to this patently stupid plan but so far the state’s Medicaid boss [a doctor] is standing firm.

In addition to the obvious problem of not knowing whether a patient is sick or not before he is examined, what is an ED doc supposed to do if an ambulance brings in a Medicaid patient with a cold? Should the patient be refused entry into the ED?

That probably would not be wise because of a federal law known as EMTALA [Emergency Medical Treatment and Labor Act]. From the website EMTALA.com: “EMTALA requires most hospitals to provide an examination and needed stabilizing treatment, without consideration of insurance coverage or ability to pay, when a patient presents to an emergency room for attention to an emergency medical condition.”

What happens if EMTALA is violated? “A hospital which negligently violates the statute may be subject to a civil money penalty (i.e., a fine, but without criminal implications) of up to $50,000 per violation. If the hospital has fewer than 100 beds, the maximum penalty is $25,000 per violation.”

Anyone who works in a hospital knows that EDs are being inundated with patients who don’t really have emergencies, but shifting the blame and cost to the hospitals and EDs is not the answer.

Like many issues today, personal responsibility is no longer expected or required. The Medicaid card is the “everything” card. Get one and you’re all set. I worked in a city hospital for several years. The Medicaid patients had absolutely no interest in controlling costs. They knew that if they went to an ED, they had to be examined and treated.

Assuming that there are enough primary care doctors, accountable care organizations or “medical homes” in the State of Washington to accommodate the no longer ED-bound Medicaid population [a factor that apparently no one has brought up], wouldn’t it make more sense to shift the responsibility of deciding whether they should go to an ED to the patients themselves?

But that would require some restrictions on the “everything” card. I doubt that any politician or bureaucrat would have the balls to even suggest, much less implement, such a policy.