Movin' Meat

A better way to think about Altered Mental Status

2016-02-09T01:08:00.003-08:00

I recently had occasion to prepare a talk on the various causes of Altered Mental Status. As it happens, EM:RAP had a nice Continuous Core Content segment recently on the same topic. (Don't listen to EM:RAP? You should. Want to try it for free? Rob Orman of ERCast has an offer for a three month free trial. Use the code ERTHANKS.)* They used a practical case-based format to structure the approach, which I like, but also fell back on the old mnemonic of AEIOU TIPS. God I hate that mnemonic. It's so haphazard and utterly disorganized: just like the typical approach to AMS.

A — Alcohol/Acidosis (not the same thing or in any way logically connected)

E — Endocrine/Epilepsy/Electrolytes/Encephalopathy (E is a common letter?)

I — Infection or maybe Ingestion who the hell knows nobody agrees

O — Opiates, Overdose (sorta the same thing but ehhh)

U — Uremia (not likely but something's gotta start with U)

T — Trauma (garbage pail)

I — Insulin (huh?)

P — Poisoning/Psychosis

S — Stroke/Seizure/syncope (wait syncope doesn't, and wasn't epilepsy already covered?)

This is just terrible. Too many things thrown into too few headers with absolutely no logical connection between any of them and criminally incomplete to boot. Bad for learners, and pretty useless for recall too. My approach was to ask myself, well, AMS basically means the brain's not working right, right? Let's group the causes of AMS by the mechanism by which they make the brain not work right. So that's what I did. It is offered here for your perusal and amusement and maybe even use.

Things your brain needs to live and function

↓ Oxygen/Glucose (fix these immediately)

Things that squish the brain

Blood where it should not be: Subdural, Epidural, Intracerebral, Subarachnoid
Blood that has clotted where it should not: Dural Sinus Thrombosis
Masses and tumors
Obstructive Hydrocephalus
Edema: Traumatic, posthypoxic, hypertensive, vasogenic, PRES

Bad things living in the brain

Meningitis
Encephalitis: viral, inflammatory, autoimmune
Abscesses
Syphilis/Amebas/Cysts

Primary brain not workings

Acute Ischemic Stroke
Concussion/Diffuse Axonal Injury
Seizure, Status epilepticus (may not be convulsive), post-ictal state
Migraine
Degenerative conditions: MS, Parkinson’s, TBI, Dementias sundry

BONUS POINTS for this plus another cause

Delirium and Encephalopathies and Various Failures of Homeostasis

Sepsis and other shock states (hypoperfusion)
Systemic infection without sepsis
Fever, Hyperthermia and Hypothermia
Dehydration, ↑Na, ↑Glucose (HONK and/or DKA)
↑/↓ Ca, ↓Na, ↑/↓K
↑/↓ Thyroid, Adrenal Crisis

Bad Things in the Blood

EtOH (rare)
Endogenous bad things

↑CO2, Uremia, Ammonia

Medicines that can mess you up when used as intended

Opiates, benzodiazepines, imidazopyridines (ambien et al)

Medicines that will mess you up when you get too much of them

Lithium, Tricyclics, Anticonvulsants, Antihistamines, Salicylates

Things that you are not allowed to have in your blood because it is a crime

Meth, cocaine, heroin, MaryJane, GHB, ketamine, spice, bath salts, etc etc.

Things that you are not supposed to have in your blood because they are poison

Carbon monoxide, cyanide, pesticides, other alcohols, hydrocarbons and solvents, etc etc

Unique weird reactions to things:

Alcohol Withdrawal, Neuroleptic Malignant Syndrome, Serotonin Syndrome, Agitated Delirium, Wernicke's

Maybe You’re Just Crazy?

Conversion Disorder
Psychosis/Mania
Malingering
These are last on the list for a reason

This is by no means an exhaustive list (I get exhausted just thinking about all the bad things in the blood) but rather a mode of thinking about the potential causes for a patient with AMS. Also, the astute reader will note that it is neither sorted by frequency nor by approach to workup (though that would be fun to categorize. "Things you will see on CT"; "Things you will diagnose when the hospitalist forces you to do an LP"; "Things that will require a Neuro consult" etc.) Enjoy, and remember, no matter what, always check the fecking glucose.

*I'm not getting paid by EM:RAP. But I will probably make Rob buy the first round the next time we are both at the same conference.

Happy SGR Repeal Day

2015-04-15T12:35:00.000-07:00

Yeah, it happened. The SGR is finally dead. Hooray! Sort of.

I mean, it's great and all that — we'll no longer have the annual threat of a massive payment cut from a poorly crafted piece of legislation from the 1990s; we'll no longer have to endure the annual ritual of last-minute legislative theatrics to avert the yearly cuts, we'll no longer have to waste our lobbying time and effort to make sure those cuts were never allowed to go into effect.

But let's not pretend this was in any way a win for physicians.

The replacement for the SGR, in the "Medicare and CHIP Reauthorization Act of 2015" (MACRA - get to know that acronym!) is that physician reimbursement is low locked into a long-term deflationary schedule. The Medicare Professional Fee Schedule will now post annual increases of 0.5% from 2015-2020 and 0% from 2020-2026. Even assuming this extended period of unnaturally low inflation continues for the next decade, that still amounts to a compounding negative real payment update every year. This may not be a terrible deal for, say, emergency physicians. I may not like it but my practice is very low overhead, and I can absorb a small negative hit to my income.

But for practices with meaningful overhead — rent, salaries and benefits for non-physician staffing, IT, equipment — this is really bad. Those costs are going to continue to rise, some well in excess of the general inflation rate. And that is going to continue to squeeze the viability out of general office-based practices, a trend that is already a decade old. It's worth re-emphasizing that many private payers track medicare fee schedules, so these reductions will ripplae across markets.

And let's not forget all the other crap that got piled into this bill while nobody was looking. The pay-for-performance program will now put an amount of physician income of 4%, rising to 9%, at risk for physicians and groups not meeting the as-yet-undefined performance metrics.

The performance metrics will, however, more or less require use of an EHR and are written in such a way that participation in the much-maligned ABMS Maintenance of Certification program is almost obligatory. There are also extensions of requirements for "Meaningful Use" of an EHR which I admit I am not an expert on but also seems to draw much ire from physicians.

It's a testament to how desperate the AMA and all the other organizations within the house of medicine were to get rid of the SGR, that there was not a single objection voiced to, well, to any provision of MACRA. We were prepared to accept anything, no matter how bad, to get rid of the SGR. Mission accomplished.

It's a bad deal. It's better than the alternative and probably the best deal possible from this Congress and in this budgetary environment, but we should not be too giddy about it, or pretend it's anything more than it is. The SGR is dead and the campaign to fix MACRA will begin, oh, any time now.

In Defense of the Hyperangulated Blade

2015-02-04T14:19:00.000-08:00

Let me begin, as is my wont, with a story. Let's say, for the sake of discussion, that I was moonlighting at Janus General Hospital. I had a patient signed out to me by my partner: a young patient with COPD, influenza, and pneumonia. He was on BiPAP and supposedly stable waiting for an ICU bed. Murphy's law being what it is, immediately after my partner left, the patient deteriorated and clearly was going to require intubation. He had all the predictors of being a tough tube, so I made sure to have my back-up plans articulated and ready to go.

My go-to technique for quite a few years is video laryngoscopy (VL) with the hyperangulated blade of the GlideScope. My back-up is direct laryngoscopy (DL) and my ace-in-the-hole is the gum bougie. I'm not a huge fan of fancy tricks like awake intubation (too much work, and I'm lazy) and in any event, this guy was too sick for that. Since this was a daunting airway I made sure to have all the stuff ready to go, including our quick cric tray.

I couldn't get the tube with the GlideScope. While I had a nice view of the larynx, there were frothy secretions welling up through the cords so quickly that between the time I suctioned and tried to place the tube, I lost my view. Faced with crashing sats, I tried to bag him back up, but couldn't ventilate. I got his sats from 50% all the way up to … 75%, and he clearly wasn't going higher. So I had my partner prepping the neck while I went back to the old stand-by, DL, and I was able to snake the bougie in through the foam and successfully passed the tube (much to the disappointment of my partner, who was kind of excited at the prospect of doing a live cric). Here endeth the story.

Now I share this to highlight a couple of points regarding airways. I could make the point regarding the importance of having your back-up plans ready and practiced and not being afraid to progress to a surgical airway, but that point has been made at great length and far more articulately by others. It is a good illustration of the principle, though.

I'm more interested in comparing the relative benefits of VL vs DL and particularly the geometry of the blades.

I admit to being disappointed in seeing the cognoscenti of airway masters coalescing around the position that VL is at best, a necessary evil, and that if it must be tolerated, it should be performed with a standard geometry blade. The C-MAC device, which has a Macintosh-style blade with an attached screen, seems to be the device of choice. (For the record, I have not been paid by either device maker but am more than willing to accept bribes, if any are on the offering.) They make a good argument that the C-MAC is better because it helps develop/preserve the DL skill-set, is its own built-in back-up with no need to change devices, and for attendings allows good supervision of trainees. I agree with all these points.

From my perspective, though, I still favor the GlideScope, which differs from the C-MAC in that it has a hyperangulated blade. (There may well be other brands out there with similar shapes, but I’m not as familiar with them.) And despite the failed airway above (my first ever failed airway in hundreds of cases with this tool), the GlideScope remains my first-line intubating approach in most if not all cases.

A couple of important caveats: I had been intubating with DL for many many years before I ever touched a Glidescope. DL is the ultimate and necessary skill that must be completely mastered before moving on to the hyperangulated blade. For trainees: stick with DL till you've done a few hundred. This is a varsity level device. For occasional intubators it might be a good idea to stick with DL to keep the skills sharp.

I, however, am in none of those categories. I have intubated hundreds if not thousands of people over the years, am highly comfortable with my DL skills, and I continue to intubate pretty frequently. And here’s why I will continue to use my GlideScope until they pry it from my cold, dead hands:

It is a better tool that is easier to use & harder to mess up.

There. I said it. I am, as I said, very lazy, and I will always choose the easy and reliable tool over the dodgy tool which requires a lot of effort to use correctly.

This is why I believe it to be so: when I perform DL, I need to establish a direct line of sight with the larynx. Unfortunately, mother nature thoughtlessly designed the human anatomy so that there are lots of fleshy bits between my eye and your vocal cords. There are lips, teeth, the tongue, the glottis, the salivary glands, and all the redundant fat, muscles and soft tissues of the sublingual space. If I want to establish that direct line of sight, I have to get your head & neck in perfect positions, put the tip of my blade in precisely the right spot, seated in the vallecula, and then lift, sometimes with quite a lot of force, and then I have to hold the blade in place and sort of squint to see way the hell down there for the cords. Blade a little too shallow or too deep? U NO SEE CORDS! Blade slightly off midline with tongue oozing around it? NO CORDS FOR YOU. And the motor skill to lift just the right way is tricky. Rotate the blade and not only do you not see cords, you break teeth. You have to lift up and forward just a bit, and if it’s not quite right, you have to apply ~~cricoid pressure~~ bimanual manipulation to see your target.

This does not look comfortable

I can do it. I’m pretty good at it, still. But there’s a lot of room for error, and sometimes it’s really freaking hard. Even as an experienced intubator, there are times that I am sweating bullets or feeling like I dodged a bullet when I succeed on a tough tube. Because you are fighting the anatomy, and the anatomy is set against you.

But the GlideScope, well, it’s designed so that with no manipulation of the native anatomy, it will drop directly into the necessary position and provide a beautiful view of the larynx. Every damn time. No lifting. No squinting. No fiddling. And if the fleshy bits (excuse the technical anatomic jargon) are still in the way, I don’t care. I can still see my target. It's even forgiving of less than optimal patient positioning. With the GlideScope all the airways are easy, because your tool is designed to work with, not against, the anatomy. That’s the beauty of the hyperangulated blade, and that’s why it has been so widely adopted. You don't need to manipulate the anatomy to see your target, and reducing that step reduces the possibility of error and a failed airway, or at least relieves the cognitive workload of the procedure. It’s rare that I ever have to take a second look, and it seems like every tube slides in effortlessly. And reducing the cognitive workload, reducing provider stress, is not a small benefit when you are dealing with a critically ill patient. If I don’t have to sweat the tube, I can better dedicate myself to management of the patient’s overall condition.

It just fits!

Yes, VL has its limitations. I didn’t say it was perfect. Secretions, blood and gastric contents can confound any intubation, particularly video. Electronics are fallible. Back-ups are necessary and you need to be able to use them. And the use of VL and the hyperangulated blade is a different skill set. Since you can’t see the larynx directly, you need a decent spacial understanding of where you are blindly shoving the blade/tube and the degree of force (or lack thereof) that is safe to use. That only comes with experience and attention to the differences between DL and the hyperangulated blade. It's kind of like tying your shoes in the dark - not exactly tricky, but you do need to be able to visualize what your hands are doing without seeing them directly. But after performing many many intubations with both types of device, I feel that intubations with the GlideScope are easier and less fraught with error.

The airplanes at my flying club are equipped with really cool GPS-linked 3-axis autopilots. But when I was learning to fly, we focused exclusively on basic stick-and-rudder skills, and never touched the autopilot. As I got more advanced, however, we began to use the autopilot more and more. Finally, by the time I was IFR certified, I could take off, turn on the autopilot, fly the entire trip and a linked approach on it, and turn it off just as I began the landing flare.

I see this as highly analogous to the DL-vs-GlideScope debate. You still need your basic airmanship skills. Without those, you die. But the autopilot is a tool which, correctly used, is more reliable than you are at keeping your wings level and frees up your mind and attention for other critical tasks and therefore should be used as much as possible. For those who are more comfortable with DL or VL with a standard geometry blade, I am not saying that there is any evidence-based benefit to GlideScope or that there is clear superiority - keep doing what you're doing if it works for you. This is a personal preference based on my own skill set and how I have found these tools to work. But, contra the growing consensus that VL-with-a-standard geometry-blade is the way to go, I would suggest that outside of the training environment, there are distinct advantages to the GlideScope and would not relegate it to an afterthought among the modalities of airway management.

On Call

2014-07-07T01:00:00.000-07:00

Every ER has its call roster, that sacred list of oracles, laying out who we can call when our patients need some service that we cannot provide. If I need a cardiologist, or a neurosurgeon or even a dermatologist for some acute emergency condition, all I need to do is ring up the operator and tell them, “This is the ER doc, I need [insert name of specialty here].” And like magic, ten minutes later, I’m talking to the local expert in whatever the patient has.

Fun fact: in the last month, I have consulted both physiatry and rheumatology from the ER.

So I was a little surprised recently when I had a patient with a nine-millimeter proximal infected ureteral stone and I called the operator to get me urology, only to be told, “There’s nobody on call for urology.” Huh? I pulled the call roster from the wall and scanned it:

Urology - No Coverage
Opthalmology - No Coverage
ENT - No Coverage
Plastics - No Coverage

Wow. That’s a lot of specialties that we don’t have access to. For the record, we are not some little 40-bed rural hospital. We are a 100,000 visit facility that styles itself a “regional medical center” and accepts transfers from a large catchment area. And evidently there are multiple services we no longer offer, at least not in the evening and at other inconvenient times.

Why is this? Because these local specialists have decided, as individual groups, that ER work is taxing, difficult, low-paying and high-risk. (Tell me about it.) And one by one, they have decided to quit. They just said, “Nope, not covering the ER any more.” And our hospital is not the only one facing this problem. It is, in fact, probably the biggest challenge facing emergency medicine nationwide.

Now I get it. I die a little inside when I have to call in a board-certified urologist at 0300 to put in a foley on some poor 87-year-old in urinary retention, after all my nurses and I fail to get it in. I really hate inconveniencing them, especially when it’s something that I maybe should have been able to handle myself. But that’s the life of an ER doc and I am pretty inured to it by this time. (Maybe I’m all the way dead inside?)

Which is why I was kinda incensed by the recent post over at Kevin’s site: Should Doctors be paid overtime for taking call?

The cardiologist writing that post painted a beautiful picture of how much call sucks, and I get it. I know the absence of call played into my decision to pursue Emergency Medicine as a career. But the question posed, in the context of the current situation, feels almost like blackmail: “Pay me or I’m gone, too.”

The history here is that being on call has pretty much always been a service that is part of the practice of medicine. No matter your specialty, if your patient got sick at night, you would be called in to deal with it. As the number of patients without established doctors grew, most hospitals had “no-doc” coverage rotating for unassigned patients. When you are on call, you don’t get paid for phone calls, but you do get paid if you have to come in and see or admit a patient (presuming they have insurance). In the old days call may have been a practice-growing revenue stream, but for a long time now it’s been a poorly-reimbursed time suck for most specialists.

A growing trend we are seeing nationally is for specialists to demand — and receive — reimbursement from the hospital just to be on call. Our hospital being a ~~skinflint catholic shop~~ responsible steward of resources told the specialists to pound sand, which led to their absenting themselves from the medical staff and call roster. But many hospitals, especially those in highly competitive markets, have started to pony up and pay docs to take call.

The math of this is really challenging. Once you are paying one group to be on call, it’s hard to justify not paying all of them. The most demanding, in my understanding, have been ENT, Hand, Neurosurgery, Optho, Plastics and Urology. The going rate seems to be about $1,000 per night, though YMMV. Ironically, these are among the least-consulted and highest-paying surgical subspecialties, which further creates an unseemly impression of physician greed. But if you meet their extortionate demands, that winds up costing the hospital $6,000 a day, 365 days a year, or about $2.2 million annually, assuming all the other specialists don’t pile on with their own demands. That’s for nothing, mind you: for being “available” without doing any work. No calls? You still bank nearly as much as I did for a busy shift of seeing patients.

And there is a tendency to see the hospital as the font of endless dollars, but hospitals are in rough shape. Their typical profit margin is in the 2-4% range, frequently dropping to zero or negative when the economy dips a bit, and under relentless pressure from medicare and insurers to accept lower reimbursements. While it’s tempting to look at the gross revenue and assume that of that $50-100 million, "surely the hospital can afford to pay to keep me on call,” in reality that is not the case.

The grim reality is this: we pay more than any other society for health care (and get less for it). There is no new money coming into the system; quite the opposite. When specialists demand extra money for a service that they have previously provided not for free but based on only professional reimbursement, that’s going to pull resources from somewhere else. Maybe it’ll be fewer ER nurses. Maybe it’ll be fewer staffed inpatient beds. It’s going to come out of the budget somewhere.

Which is why I am kind of glad our facility held firm in the face of the extortion of the surgical specialists. These guys all make ~$300K a year. I feel that if I (also well paid) have to see folks at 3am as part of my gig, they should too, and not command some premium for the service.

Am I bitter? Yes, a little. But much of that comes from the fact that I see the consequences of the specialists who opt out of call. I feel like they are still really well paid and are shirking their duty to the community and to the patients. That patient with the kidney stone? I had to transfer him out of our gleaming $500 million hospital to the county facility where a resident could take care of him. His care suffered because of the greed and entitlement of the local specialists; this wasn’t the first or last time I will encounter this problem. I don’t like seeing patients used as pawns, and I get a little enraged when local doctors jeopardize patient care over economic concerns. As I see more and more physician practices being bought by hospitals, in part to secure their call networks, I see these guys digging their own graves.

So, no, I don't favor paying specialists for being on call. Suck it up, guys, and do the right thing for your patients. Structure your practices to make call suck a little less, maybe. I empathize. When I'm sitting in a mostly empty ER at 4AM, I'm not getting paid either. But overall, we both make enough to have pretty good lives and still not opt out of caring for those who are unlucky enough to get sick at inconvenient times.

Pain and Suffering in the ER

2014-06-16T10:23:00.000-07:00

I took a recent family trip Down Under and had the good fortune to be in Australia's Gold Coast at the same time as the SMACCGold Conference. (Well, it wasn't entirely a coincidence.) I was happy to get to make it there one day and it was a great experience. I got to meet uber-tweeter and stalker Minh LeCong, organizer and LITFL dude Chris Nickson, St Emlyn's own Simon Carly, the Irish EM blogger Andy Neill, Kangaroo Island doc Tim, and many, many more. I had an extended conversation with Karel Habig of Sydney HEMS under the misapprehension that he was Cliff Reid. (Did I mention the open bar?) Sorry about that!

I haven't the time to do a full write up now, except to note that this was the only conference I've ever seen where there was an open bar in the exhibitors' center ... at 9AM. Because 'Straya.

I love the SMACC guys and I love the SMACC ethos. One of the cool things about it is that they put their talks online, freely available, as part of the FOAMed (Free Open Access Medical Education) concept. So if you missed it, you can enjoy the full conference after the fact. Most of the talks are short, usually less than 30 minutes, and they have a rather different focus than that which you will find in more traditional academic EM.

The talk that I most enjoyed, was this one, by St. Emlyn's co-blogger Iain Beardsell. It's a bit of a head fake, and not the topic one would have expected to emerge as the show-stopper, but it sure was for me. You can watch it here:

Iain Beardsell - Pain and Suffering in the ED from Social Media and Critical Care on Vimeo.

You can see most of the talks on Vimeo where they are posted in full video format, or download them as iTunes audio podcasts to listen to them on your way to the ER. The opening ceremony ... a surreal experience ... is truly not to be missed.

Best of all – SMACC is coming to the US next year, of all places, to my hometown, Chicago. The dates are June 23-26, so be sure to be there!

Someone is WRONG on the internet! (Hospital admission edition)

2014-06-07T16:09:00.002-07:00

The grandiosely-named "MD Whistleblower," recently wrote a post, reblogged at KevinMD, entitled "Why the ER admits too many patients."

I will begin with the time-honored ad hominem attack, since I am aware of all internet traditions. "Whistleblower MD"? Really? That's so cute. You see, as a whistleblower, he is a genuine hero, someone who is willing to expose himself and his career to enormous personal risk in his unrelenting search for truth. Unlike the rest of us, who are just random jerks on the internet with a bunch of opinions. He's a truth-seeker, so his opinions should be given special weight and are clearly objective, unbiased, pure Truth. Or maybe he's just another opinionated jerk like the rest of us, and in this case, a spectacularly ill-informed one.

Having said that, I would like to explain why he is wrong, in all the myriad ways, in his contention that emergency physicians (EPs) admit too many patients because of improper motivations. Note that I am not going to argue that EPs don't admit too many patients - that's a legitimate discussion to have and there may be some merit to the case, though the pendulum is clearly swinging against the trend of excess admissions.

The Whistleblower, a gastroenterologist named Dr Michael Kirsch, alleges that EPs admit patients who do not have a need for inpatient care for the following reasons:

EPs are incentivized monetarily for admitting patients.
Hospitals pressure EPs to inappropriately admit patients.
EPs admit to minimize malpractice risk.

The third point, I will agree, has some merit, so we will leave that alone. The first two, however, are profoundly ignorant to the realities of the actual practice and economics of acute hospital medicine (from all perspectives - those of the EP, the hospitalists who do the admitting, and the hospitals themselves).

First of all, remember that a substantial majority of EPs are not employed by the hospital, and receive their sole reimbursement from the patient's insurer, for the professional service bill. This means that whether I admit the patient or send them home, presuming that I did some sort of work-up and considered complex data and potentially risky diagnoses, I've got a level 5 chart on my hands. Nothing more is to be gained for the physician if the patient is admitted. Not. One. Penny.

In fact, admitting the patient will likely decrease my net productivity and thereby, compensation, and certainly generates more work and makes my job a ton harder. Bear in mind that Whistleblower MD stipulated that we are talking about patients who do not meet inpatient criteria.

So if I want to get this borderline patient admitted, I have to get a skeptical hospitalist to agree to accept the admission. They know full well when I'm slinging them a line of BS, and if I try to elide the truth to get the patient admitted, my credibility with them the next time I try to admit a borderline patient is shot. So I need to be honest that it's a BS admission - whether it's a social admit, or an observation admit, or someone who just doesn't look right. Hospitalists are under extreme pressure from hospitals not to admit patients like this (more on that in a moment) and they also tend to be overworked and disinclined to admit another patient if the patient doesn't need it. So most hospitalists are going to try to block this admit, or make me do some extra work to try to get the patient home, or if nothing else subject me to a withering cross-examination that takes away from time I could be using to see another patient and making more money.

Then, let's say I get the patient admitted. Great. I win, right? Well, if I work in some sort of utopian ER where admitted patients go directly to the floor and become someone else's problem, yes. In the real world, unfortunately, admitted patients tend to board in the ER for many hours, sometimes many many hours, often on hallway gurneys. So this admitted patient, who could have gone home, is now going to squat in one of my beds for hours, congesting the ER, consuming nursing resources and preventing me from seeing patients languishing in the waiting room. To be clear: excessive admissions, as an EP, cost me money.

Now what about the hospitals? Are they going to be pressuring EPs to admit more, or even, as Whistleblower hints, improperly financially incentivizing admissions?

Again, to even suggest such a thing reveals a disconnect from reality that only a specialist who hasn't practiced acute care medicine in a decade could possess.

See, Medicare decided some years ago that inpatient care was costing too damn much. So they decided that they were going to get really aggressive about reviewing admitted cases, and then, retrospectively, denying payment for patients who were incorrectly admitted as inpatients when only observation care was indicated. Observation care reimburses the hospital only about one-sixth the amount that inpatient care does. They've gone through some contortions to try to clarify what they mean, including redefining the criteria for inpatient care and issuing the infamous two-midnight rule. So rather than pressuring EPs to admit more, the hospital administrators and utilization review folks have become intensely focused on reducing preventable admissions, and correctly categorizing observation admits as such. Hospitalists are generally the most sensitive to the hospital's concerns on this front and tend to act as a first line of defense in trying to keep the marginal admits out of the hospital.

Then you consider RAC audits. These bounty-hunting contractors are empowered to examine hospital records and retroactively recoup improper payments years after the fact. This year, RAC audits are expected to result in hospitals having to return over $3 billion to the government. Oh, and hospitals face penalties for re-admitting patients to the hospital within 30 days. Oh yeah, and medicare general medical admits generally have a flat to negative contribution to the hospital's profit margin.

So, um, no, hospitals are hardly pressuring EPs to admit to keep the wards full.

Finally, the real evidence that Dr Kirsch couldn't find his ass with both hands and an ass-finding device is the ignorance of the real revolution in ED care over the recent years: the proliferation of new treatments and decision-making tools which have allowed EPs to treat formerly admitted patients as outpatients. Consider just a few that occur to me off the top of my head:

The PORT Score for pneumonia
The San Francisco Syncope rule
Low molecular weight heparin for DVT
Low risk criteria and rapid rule out protocols for chest pain
The ABCD2 score for TIA
Early cardioversion for new onset Atrial Fibrillation
Low risk criteria for PE and a nascent move towards outpatient treatment

And many more. While the valiant Whistleblower derides EPs for admitting tummyaches, the truth is that EPs are treating more and more people with formerly inpatient diagnoses as outpatients and saving the healthcare system countless dollars. We are not perfect: there are patients whose clinical need is genuinely indeterminate from the ER, and there are some indecisive or anxious docs who admit more than is strictly necessary. If Dr Kirsch wants to inform himself on the facts and make policy suggestions to improve care, his voice would be welcome. On the other hand, if he just wants to make ignorant insinuations towards the improper financially-driven motivation of an entire specialty, perhaps he would be better advised to stick to performing $6000 screening colonoscopies.

(hat tip to Whitecoat for flagging this egregious post. If you haven't it, you may wish to check out his own snark-filled rebuttal.)

This week in Children and Gunfire

2013-07-24T16:42:00.002-07:00

Horrific:

Gone Electric

2013-04-12T21:14:00.000-07:00

Haven't written much in a while, but thought I'd throw in an off-topic post, just for the heck of it. A couple of months ago, I made a major change in my life: I traded in my old car, a 2004 BMW 530i and I went and got a Tesla Model S

Yep, I'm a proud member of what's been described as the "world's more expensive beta test."

I've had it now for almost exactly two months, and I thought I'd share my observations.

First of all: cost. Yes, it's an expensive car. No denying that. However, it's not quite as crazy expensive as the sticker price makes it seem. My default plan was to replace my old BMW with a new one, probably the 550. The Tesla actually specs out about the same in the cost department. There's 10% sales tax on the BMW, but my state has no tax on electric cars, and there's a $7500 federal tax credit, which helps narrow the gap quite a bit. Then, depending on the assumptions you make, the cost of fuel should actually make the Tesla cheaper over time than the BMW. I figure that over 100,000 miles (I put 130K on my old one), I'll spend about $22,000 on gas for the BMW. Electricity costs for the Tesla over the same time period should be about 10% of that figure, which could in theory make the Tesla substantially cheaper. A lot depends on the big unknown of the battery life. The one I got is warrantied to 100k miles, but the replacement cost and whether I should lay away costs towards a replacement at 100k miles is unclear. On the other hand, Tesla maintenance should be near zero. It has so few moving parts - pretty much brakes, tires and running gear; contrast that with replacing the clutch on my BMW which was over $3000. Just looking at cost of propulsion, so far I'm averaging about $0.028 per mile, compared to about $0.25 with the BMW.

It's a pretty car. It's got a rear-focused profile which reminds me of the Jaguar XK8. I happened to get mine in something approximating a Jaguar green, which looks lovely in the sunlight but alas looks black in gray light (so in the cloudy Pac NW, it mostly looks black). The front styling looks a little like an Aston Martin, but the LED "eyebrow" lights around the headlights are distinctive and unique.

I also like the layout. There's no engine, so the front hood hides a medium-sized trunk. I can carry my emergency supplies plus a suitcase or gym bag or groceries or lawn chairs, but it wouldn't handle a golf bag. The back is a hatch design and since I have 4 kids I got the jump seats:

The girls are sitting directly on top of the drive train, which is shockingly small. There are no gears to speak of, and no transmission. The engine revs from 0-30,000 RPM or something ludicrous like that, and is directly mated to the rear wheels.

The interior is outfitted to match the price, easily comparable to the BMWs and Mercedes of my experience. Certainly consistent with a luxury car's expectation. I think I detect a little roughness in the fit & finish -- a little buzz from the inexact fit of the air vents, maybe. Nothing major. More puzzling is the spartan approach to storage and utility. The cupholders (there are only 2) are small and oddly placed behind the driver, and there is only one very small shelf useful for holding, say, a cell phone or some sunglasses or other doo-dads. Other than the glove compartment, there are no other storage compartments anywhere in the car. There is a lovely flat space in between the front seats (no drive train to create a floor hump) and I can toss my ipad or my wife's purse there. But it's not the same.

The center console is a bright, sharp LCD:

The center number is your speed, and the left blue bar is an analog display of your speed. The right yellow bar is your instant power usage. Yellow means you are discharging the battery, and green means you are regenerating it. You can configure the side panels to show what you want; I have media on the left and energy stats on the right. In the right corner is a Lego figure my son made a few years back, which is the totem of my car. When you're in navigation mode, on the left is a perspective-style view of where you're to go, which is pretty intuitive and easy to follow without taking your eyes too far from the road. The center green bar is battery status and ideal range in miles. The display, as a whole, is exquisite. I'm super impressed with the design and the care that went into it and how easy it is to use.

The big display in the center console has gotten a lot of press. It's a multifunction display which is very familiar to those of us with aviation backgrounds! It's also bright and sharp, but placed such that when you use it, your eyes are well off of the road. One very cool thing is that the rear view camera can be used while driving and supplants the rear view mirror to a large degree. The view out the rear hatch is not that great, so the fish-eye lens actually give better rear and blind spot awareness. The camera is super sharp and bright (it was raining when the above pic was taken, so it's a bit blurry). I leave it on most of the time. Below is the nav, which is powered by Google maps. You can swap out various functions or make them full screen. The media lets you choose between radio, internet radio, satellite (if you pay for it) or your local media, such as an iPhone or flash drive. The energy function lets you monitor your power usage and efficiency and is super addictive. I usually wind up trying to beat my "high score" for a given route. But that requires you to drive slow, so I turned it off. There is a browser window, which you CAN use while driving, if you're reckless enough. Fortunately (?) it's super slow, both the 3G internet and the browser itself, such that it is essentially useless, so there's little temptation there. Supposedly there's a 4G and wifi option in the works, which would make it more useful, but so far there's little risk of driving and surfing. Data is free for now, but we will probably have to pay up in the future. The phone app syncs your contacts, if you have a smartphone, and makes it super easy to call or navigate to anyone in your phone book. And unlike ANY other car I have ever used, the voice control functionality is actually pretty useful. As for the stereo:

It goes to eleven.

The driving experience is pretty damn awesome. It's been said over and over again, but the acceleration of this thing is just sick. It's hard to describe what "instant" throttle response really feels like till you've experienced it. I've driven some really fast cars in my time and this car is quicker to respond to drive input than any I've experienced. The Porsche 911 does have more acceleration, but only by a bit, and even then it has the ups and downs of its power curve, while the Tesla has maximum torque from the moment you stab at the right pedal till you let off. While it's impressive off the line, it's almost more impressive when you're doing 40 and can still fling your head back against the rest as you punch it to 60. I've had it as high as 110, and it still felt like it had plenty to give, though it's electronically limited to 125 mph.

Also unusual is the braking: you rarely touch the brake pedal. The moment you let up off the throttle, very strong regenerative braking begins, recharging the battery. You are actually thrown forward slightly if you let off the throttle at speed, and the brake lights come on. (They are controlled not by the brake pedal but by an accelerometer.) For someone used to a manual, it's you need to relearn how to drive, slightly. This car does not coast.

The handling is good. This is in fact a very heavy car (4700 lbs curb weight) and it does feel that way when cornering and stopping. It takes corners very well and is more than competent at high speed. I am a bit spoiled from the stiff handling of my BMW, which I miss. The suspension and ride of the Tesla are distinctly softer, if perhaps more comfortable.

One other odd experience is that you never turn the car on -- or off. You walk up with the key (which is shaped like a little matchbook Tesla) in your pocket. The door handles extend as you approach, you sit down, put it in drive, and go. No ignition, no parking brake, no "on" button, you just go. And when you get to your destination, you just put it in park, get up and walk away. It knows you have left, and applies the brake, locks the doors, and powers down. I'm always feeling like I have forgotten a step.

Charging has been a non-issue so far. I had a standard 220-volt outlet (like a dryer outlet) put in my garage and I just plug the car in every night before I go to bed, as I do my cell phone. There are charging stations all over Puget Sound, but since I've 200-300 miles to play with I've never needed to charge outside of my garage. I get about 30 miles of charge per hour, so I can pretty much completely recharge overnight, even if fully drained. You can also set the car to charge during off-peak periods, when electricity is cheaper.

The rated range is 240 miles, and the ideal range is 300 miles. My experience is that I can count on the 240 miles pretty reliably. In order to get the ideal range, I'd need to drive a lot slower and also live somewhere flat, since hills really eat up the charge. But as I live at the top of a 7% grade, I accept that I will never get the ideal range. I can do road trips, but it takes a bit of planning to make sure that you can get there and that there are charging stations en route in case you need it. There are a number of good apps that tell you where to find charging stations, what sort they are, and whether they are free or charge (about 50/50, it seems).

On the subject of apps, there is a Tesla app for the iPhone. Its main use, as far as I can tell, is to allow me to preheat the car at 2AM when I'm getting ready to leave the ER. It's nice to come out to a cozy preheated vehicle. It can also be useful for finding your car in a parking lot, or checking the state of charge. But it doesn't do much else.

Overall, I love it. I love the fact that I never have to fill it with gas. That was a chore that I always hated and tended to make me late for work -- even later than is my norm. Now I've gone 2500 miles without setting foot at a gas station, which is pure heaven. Yeah, it's green, especially in the NW where almost all our energy is hydro. But that's not why I wanted this car. Frankly, I would still love it if it ran on ground-up puppy dogs. I'm not in this for moral superiority. I've done too many terrible, terrible things to claim that mantle. I love it because it's a hoot to drive, and because it's the coolest damn gadget I've ever seen: the über-gadget, if you will. And I am all about the gadgets.

Mayor Bloomberg and Narcotics

2013-01-15T11:39:00.002-08:00

I may be just a bit late in commenting on this, but last week (which was like ten years ago in Internet time) there was a bit of hue and cry regarding Mayor Bloomberg's report on the matter of prescription drug abuse and restrictions on new prescriptions for painkillers through the Emergency Department.

Initially, I was concerned. I completely agree with the comment from the linked article: “Here is my problem with legislative medicine,” said Dr. Alex Rosenau, president-elect of the American College of Emergency Physicians... “It prevents me from being a professional and using my judgment.” The verbiage used regarding the new rules was worrisome: restricted sharply... city policy ... will not be dispensed ... regulatory authority to impose, and the like.

I'm like most doctors in that even when I agree with the purpose of proposed rules, I quite object to interference in how I practice, to "the government coming between you and your doctor" as it was so memorably put in the past. And given that Bloomberg is getting something of a reputation for being a little dictator I was all ready to get my pitchfork and torches and head down to join the mob.

While I was getting my outrage machine up to operating temperature, I took a moment to read the official press release and the actual source document (PDF), though, and one word in the very first paragraph, notably absent from the press coverage of the proposal, jumped out at me:

VOLUNTARY

Well, that's a horse of a different color, isn't it? Doctors and hospitals are encouraged but not obligated to follow the new guidelines, and in individual cases, the doctor can freely exercise his or her judgement. I'm good with that. So what about the meat of the policy?

Key points that jumped out at me:

A new/improved database for tracking narcotic prescriptions and making it available to prescribing doctors.
Not prescribing more than a 3-day supply of most narcotics, and not at all prescribing oxycontin, fentanyl or methadone through the ER, and not refilling these meds
All narcotics to be electronically prescribed (to limit forged prescriptions)
Changing the defaults on EMRs to have lower amounts of tablets dispensed.

Frankly, these all seem reasonable, as long as physician discretion is preserved. If someone has a long-bone fracture and won't be into see ortho for a week, well then a week's worth of pain meds is reasonable, for example. In our state, we put forth some very similar guidelines in our "Seven best Practices" for reducing ER overuse and abuse.

The "guidelines" are particularly useful for a practicing doc in that it gives you permission to say "no." Currently, if I see a patient whom I suspect is "working me" for narcotics, but I don't have clear evidence to support that suspicion, I am in a bit of a bind. In such cases, there's no objective evidence of disease — back pain, neuropathy, etc — but that doesn't mean there isn't real pain. If I say no, I run the risk of patient complaints and a letter from the CEO. If I say yes, I then get bogged down in negotiations over how much and what drug. The guidelines offer a compromise: a limited supply of less potent meds. If the patient ups the ante or tries to demand more, I can point to the guidelines and explain that we have a policy, that it's not personal or judgmental, but is simply our "best practice." Even better is that there are clear guidelines against refills and treating of chronic non-cancer pain in the ER. All this is meant to give doctors faced with a demand for narcotics the institutional backing to say no, and tacitly recognizes the fact that doctors have been complicit in creating the problem through excessive opiate use.

I note that endorsing the proposal in NYC was the New York chapter of ACEP, which is also heartening. The problem of ER abuse and prescription narcotic addiction/diversion is a real issue, and it is growing. We, as ER physicians, need to take ownership of the problem, as much as we can, and take leadership in developing measures to mitigate the problem. If we don't, then it is predictable that someone else, likely state governments, will come in and impose solutions on us -- and those "solutions" are likely to be heavy-handed, draconian, and probably ineffective.

So. from what I can tell, New York's approach seems very well-reasoned and hopefully pretty effective. I am also encouraged by an addendum that several private hospitals in the NYC area have announced that they are also going to follow these guidelines (which properly only apply to city-owned hospitals). I'm also particularly pleased that the process we went through in our state has begun to be used as a model for other states to follow!

Apparently I'm a pimp

2013-01-14T05:00:00.000-08:00

I actually have no interest in responding to this. I decided some time ago that life is too damn short to waste it arguing with assholes on the internet. I've stuck to that reasonably well, and been happier for it. But since I have been personally named I suppose I should give it a perfunctory response. That's all it deserves.

I wouldn't bother at all, in fact, if it weren't for the steaming mass of ad hominem attacks piled on top of it. But that's his style: he uses strawman arguments and personal insults to obscure fuzzy thinking. Apparently, in the minds of the free-market, anti-government zealots out there, if I support expanded government funding and regulation of health care insurance, which I long have and still do, then I may never ever criticize or disagree with anything the government does.

That's the mindset of an ideologue: purity above all else. You are for the government or you are for the private market. It’s an either-or, absolutist position. You cannot logically have a nuanced view or a pragmatic approach: that’s unpossible!

Clearly, there’s no point in discussing anything with this sort of person, so I won’t bother. But I will make one point — just one point — in rebuttal. The worst abuses I have encountered, thus far, have been by private, not governmental actors. Contracted Medicare carriers and insurance companies have been far more aggressive in trying to exploit the logical catch-22 in the medical necessity rules. For those who say they fear the government intruding into medical care, I agree it’s a fair point. But given their financial incentives and lack of ethics, I will always fear the private insurers even more.

Canadians can be funny

2013-01-13T11:24:00.001-08:00

Who knew?

By Bowser and Blue

Merry Christmas!

2012-12-25T00:06:00.001-08:00

From one godless atheist to your family. Hoping it's a great holiday for all of you.

Tis the Season

2012-12-16T16:07:00.001-08:00

Grew up in a very big Irish Family in Chicago, and this pretty well encapsulates my experience of the holidays growing up:

My cousin Tom and I were the nephews designated Mischief and Mayhem...

(Only) human

2012-12-12T05:00:00.000-08:00

Chatting with some med students, a good question was raised: how do we, as doctors, deal with the emotional baggage we encounter in our profession? It's high stress, we see disturbing things, and sometimes we make mistakes that can result in harm to patients. The pressure and responsibility can be very hard to handle.

These stresses, if unmanaged or poorly managed, can carry severe consequences for physicians. Burnout is rampant among docs (and trainees, too). Doctors have high rates of divorce, substance abuse and have the highest suicide rate of any profession.

A normal day at my job is hard: I'm running nonstop for 8-12 hours, I'm constantly interrupted, I have patients making demands of my attention and empathy, I'm saturated with information and need to make rapid decision without adequate information, and I know that if I make an error or miss some important piece of information, the human, professional and financial consequences can be disastrous. It's a pressure cooker.

And that's a day where things go well. A bad day can be very bad indeed. Sometimes it's just the emotional strain of dealing with particularly difficult patients. Maybe you go through a run of giving out terrible diagnoses. Maybe you deal with the death of a child. Or a patient who pulls at your heartstrings in some unique and personal way. Maybe someone dies on you unexpectedly. Worse, maybe someone dies on you and you're not sure if it was your fault or not. Perhaps you know you made an error, and that you're going to have to face accountability for it.

These are the days that drive physicians over the edge. I've had them, and I remember them so vividly even years later. There was the one lady with a gallbladder attack on Thanksgiving, many years ago. She had classic signs and I saw gallstones on my bedside ultrasound. She crashed and died right in front of me from a ruptured thoraco-abdominal aortic aneurysm. Her abdominal aorta had looked normal on my scan; the aneurysm was in the chest and ruptured into the thorax, which is very unusual. That didn't make it any easier to go home and sleep that night.

So I guess my take on the question is not how do we deal with the psychological stress but how should we? I am not an expert, but here are my thoughts.

The first step, which most practicing professionals have already accomplished, is to learn what is called "professional detachment." This is an unnatural skill in which you must suppress your innate sympathy for the suffering experienced by a fellow human being, pain which you may be personally inflicting. The first time you stick someone with a needle, it's probably as traumatic for you as for the patient. More advanced applications involve you ignoring someone's pain or personal tragedy while trying to figure out the hidden life threat. This is a necessary skill if you are to function in the medical environment.

Another way to think of the same skill is to maintain a sense of distance. Remember, an older teaching physician once told me, the patient is the one with the disease. This helps you remember that the patient's condition is not your doing (usually) and their outcome, if negative, is the result of their disease and not necessarily a reflection on your care.

While this detachment is useful and necessary, it can be maladaptive if taken to extremes. First of all, as a physician you do need to express empathy and compassion. It's part of the job. But the emotional demands will be overwhelming if not governed in some fashion; we have limited capacity for caring. My solution is to dole out my compassion and empathy in measured doses, as appropriate to the case and my own mental state. This is not a license to be callous and uncaring in other cases, but rather to be polite, professional and reserved, emotionally.

Furthermore, you need to understand that the professional reserve does not equate to repression of emotion. You suppress it, in the moment, set it aside to get the job done, but that doesn't mean it never happened. For minor stuff it probably is okay to suppress it & forget it. But the bad things — they won't go away on their own, but will fester and bubble up at the most inopportune moments. You need to take some time, when appropriate, to unpack the experience and re-live the emotions to deal with them. Maybe it will be just turning the case over in your head the next day. Maybe it needs to be more immediate. We've sent docs home after bad pediatric arrests when it was clear they were so upset they needed some time. It's essential, in any case, to explore the disturbing feelings so you can come to a resolution and move on.

Many institutions will have formal critical incident debriefings for the entire team, for particularly awful events. While this doesn't need to be performed formally for routine events, it's a good idea to informally debrief with a trusted partner, superior or mentor. Talk through the case, review the medicine and the science, review your actions and outcomes, and your emotional response to the situation. It is helpful to do this with someone you respect, so he or she can give you valuable feedback. This can be over coffee or a beer or three; possibly better that way.

There can be a lot of shame involved when there was a bad case, even when well-handled, but especially so when you know that you made an error or may have. A lot of docs like to bury these as deep as possible. But these in particular are helpful to talk about, and the more publicly the better. This is not easy, but can be invaluable. We instinctively shy away from openly talking about our mistakes, but when you do you will probably receive a lot of support from your colleagues, many of whom have done the same or understand that "there but for the grace of god go I." An additional benefit is that your mistakes may have been due to a system error or a cognitive bias and by reframing the discussion in an educational light, by seeking out the root causes, you can improve the quality of your own care and that of your partners.

Keep a sense of perspective, and try to stay positive. When the job is really getting you down, take a break, go out to the ambulance bay, take a few deep breaths and try to remember the big picture. We have a great job. It's a privilege and an honor to be allowed to care for patients. We can sometimes make a huge difference in people's lives. We have respect and status in society, and are quite well paid for it. Many people would give their right arm to be where you are. Yes, seeing the 10th drug seeker of your shift is a drag, but damn, it's still better than sitting at a desk and moving numbers from column A to column B.

Sublimation is a defense technique that is particularly valuable in the ER. It is a form of displacement where the negative feelings are transformed into something positive, or at least more-or-less acceptable. The most common form it takes is "gallows humor." Tragedy and comedy are deeply linked, and a morbid witticism can provide a lot of relief of the emotional tension that builds up in a clinical setting. Others may channel these feelings into art or literature. To each their own. If this is not your thing, find an outlet. I practice karate, and there's nothing like pounding the hell out of the heavy bag — or a white belt —after a bad day.

Finally, and possibly most importantly, when you know you screwed up, when you know there was an error that harmed or may have harmed a patient: forgive yourself. You are human, as are we all, and we make mistakes. Take the time to understand it, do your best to learn from it, and forgive yourself. Let go of it, file it away, and move on. If you don't or can't, self-doubt and self-hate will paralyze you and in the end it will sink you.

One last thing: if you are really having trouble, get professional help. If you're self-medicating, or if you are bringing work home to the point it's affecting your family, be humble and realize that doctors can benefit as much as (or more than) any other patient from psychological counseling and support. Many hospitals have a confidential Physician Assistance Program, staffed by professional counselors trained to deal with the issues doctors struggle with. I've seen doctors torpedo their careers with behavior and substance issues, and I've seen programs like these successfully rehabilitate physicians who were in a downward spiral. Check with your medical staff office and use the resources that they offer.

What malpractice looks like

2012-11-30T13:06:00.001-08:00

I review a lot of cases in my professional life. Some of them are just ones that our QA group comes across in our practice. Some are cases related to our liability policy. Some are cases I'm sent for review, or educational cases I present. We see a lot of cases which could have been done better, or in which the documentation is imperfect (or even downright bad). But, fortunately, most of the cases that pass across my desk are within the standard of care.

We get into a lot of arguments over when care provided (or documented) falls below the "standard of care." This term is widely misunderstood, especially in academic circles, and this causes a lot of controversy. Many docs interpret the "standard of care" to mean "best practice." So any care that deviates from best practice, they contend, is prima facie a failure to meet the standard of care (and hence, malpractice). Unfortunately, this is the interpretation that plaintiff's experts also prefer to embrace! However, it's important to understand that "standard of care" is a legal term with a clear definition that is much more expansive: the level at which an ordinary, prudent professional having the same training would practice under the same or similar circumstances. So the standard of care is not only not perfect care, it is not even average care, because by definition that would imply that 50% of care is below the standard.

This is a pretty low bar, actually. As I explain to our docs and trainees, you are allowed to be wrong. You are allowed to make errors. You are not allowed to be negligent. There is a difference. This is all, of course, limited to the abstract world of theory and pre-trial evaluation. Actual juries have notoriously variable determinations as to the standard of care. But when reviewing cases in advance, deciding which to defend, or what you would testify in favor of, it's a good guideline.

The cases I review tend (obviously) to involve bad outcomes, and generally present with varying degrees of imperfection, but it's pretty rare for me to see a case and stone cold identify it as malpractice. Part of this is because most docs are not, in fact, negligent, and part may be because I have a bias towards the defendant physicians. Most of the deficiencies I see generally involved a diagnostic error, or a minor lapse that probably did not impact the outcome of the case, or simply poor supportive documentation of the thought processes that drove the decision-making the way it went.

Sometimes, though, there is a case that you review and immediately reach for your checkbook.

This is an example of one such case.

A 19-year old male presented to the ER with a fever and headache. He was generally well-appearing, though febrile and tachycardic and as ill-appearing as a young person with the flu typically appears. He had no focal symptoms to suggest a source for the fever (i.e. no cough or sore throat, etc), just generalized fatigue and bodyaches. He was alert with a totally normal neurologic exam. He had no meningismus; his neck was described as supple on two separate exams. He was given 2 liters of IV fluids and tylenol after which his vital signs normalized and he felt much better. He was re-examined twice and demonstrated improvement on both exams, which were well documented and timed. Nursing notes agreed that the patient was much improved. The doc, a conscientious and compulsive sort, did a fairly thorough work-up. Chest x-ray was normal, as was bloodwork, with the exception of a WBC 11,000, just at the upper limit of normal. Influenza swab was negative. Blood cultures were sent, but antibiotics were not given. Because of the severity of the headache, he also did a spinal tap, which was normal. The patient was discharged home in the care of his parents with instructions to follow up with his doctor the next day for a recheck if he wasn't feeling better, and a voicemail was left with the PCP to ensure access to follow-up care. The discharge diagnosis was "Fever, uncertain source; possible viral syndrome."

So... before reading on, do you see any inadequacies in this case? I don't. If anything, the case was more aggressively worked up than was indicated, and for sure more workup was done than I would have, generally.

Except for one thing. The doctor documented a "normal" spinal tap when in fact the lab reported 110 WBCs, mostly neutrophils. This indicates that the patient had meningitis, quite probably bacterial.

More baffling, the doctor knew about this. The lab called the charge RN, and the charge RN notified the doctor, who added on CSF PCR studies for viral pathogens.

And yet he discharged the patient. Didn't call the diagnosis meningitis. Didn't tell him there was a possibility of serious illness. I have no clue why. It's baffling.

Now it's really easy to bash him as incompetent and dangerous, but I know this guy well. He's an MD/PhD who is double boarded in EM and critical care. He's smart as hell, and generally a great and conscientious physician. We don't know what happened here. Of course this case went on to the predictable bad outcome. The doc does not remember the case, so he can't really explain or defend it either. One can only presume that it was busy and he got confused or distracted, maybe had the discharge teed up and ready to go, expecting the negative LP results, and failed to change course on getting the results. It is, in any event, as clear-cut a case of a medical error as I can ever recall seeing. Most of us will never see such a case, unless you're doing expert review.

Now ask yourself, if he had not done the LP, the outcome would have been the same, and the allegation of negligence would still have been there: Fever and headache — how can you justify not doing the LP? If you've been in the trenches, though, you know that everyone with the flu also has a headache. It's part of the febrile syndrome. But the decision whether or not to LP is a judgement call. you can make a wrong judgement without being negligent. I would not have done the LP, based on the case as presented. I'd have been wrong, but in such a case that decision would have been well within the standard of care.

This is also a trend that I see when reviewing series of closed cases where the doctor lost in court or settled. Sure, there are cases where the care was fine but it settled because of a sympathetic plaintiff, or where a jury miscarried justice. But remember that the odds that a physician will prevail in a malpractice case is about five to one. We almost always win. When we lose, more often than not, there was a "WTF?" moment when you review the doctor's actions. It makes it really hard to present these cases for educational purposes: the docs reviewing the case can't put themselves in the position of making such an egregious error. The only possible conclusion is that the doctor who screwed up was an idiot or lazy or a "bad doctor." It's not true, though. There are bad doctors out there, but there are many more good ones. Of the good ones, we are all human and we all are subject to cognitive biases and errors, no matter how smart we are. And ER docs all bear the burden of a distracting environment with systems prone to error (hand-offs, triage cuing, overcrowding), working night shifts, seeing patients who may not be able to tell us what's going on. A set-up for errors.

In the last decade I have cared for about 15,000 patients, and I am sure that I have made an error just like this. I must have been lucky, since mine didn't blow up in my face. Maybe I caught it, or a nurse did, or it was for a less lethal condition. If you're honest with yourself, know that you will make errors like this, too.

So bear this in mind, when you think about "malpractice" and the "standard of care." Negligence, when you see it, is usually not debatable; it's obvious and flagrant. If there's a reasonable case to be made that the care provided was within the standard, it probably was an ordinary error or a mistake of judgement. This is not to say you will win in court! But perhaps you can think of it like pornography, in the words of Justice Potter Stewart, "I know it when I see it."

Vindication

2012-11-27T05:30:00.000-08:00

I love, it, I really love it, when one of my strongly-held prejudices is borne out by actual, you know, facts and science.

For years, I have been arguing against the practice of performing a routine lumbar puncture (aka LP or spinal tap) in patients with the "worst headache of their life." This is done after a CT scan of the brain, typically, to look for a subarachnoid hemorrhage (SAH). The SAH is feared because in some cases they represent a leaking aneurysm which is at risk of bursting, often with devastating or lethal consequences.

The need to do the LP is one of the sacred cows of Emergency Medicine, written in stone, and has been for longer than I have been practicing. The reason is that SAH is dangerous, the CT scan is imperfectly sensitive for SAH whereas LP is highly sensitive (in fact, the "gold standard") and relatively easy and safe to do. This was perhaps more true long ago when the resolution of a CT scan was lower than it is with modern machines, but the dogma remains. There is, however, a huge variation in actual practice out there. Many docs seem to do very few LPs for headaches, and some seem to LP everybody. I performed a unscientific survey of ER docs on twitter and found that about half "always" still do the LP or are strongly inclined to do it routinely. Some were, in fact, required by their employer to do the LP!

Now my experience over the years was that the LP seemed to be a horrific waste of time. It was traumatic for the patient, consumed a lot of ER resources, and never ever showed anything. Twice -- twice! -- in a decade I spotted the unicorn and had a genuine negative CT followed by a positive LP. In both cases, the patient went on to have negative angiograms, so either the LP was a false positive or they were non-aneurysmal bleeds (which, as it happens, do not require treatment).

So I dug into our data. Pulling a year's worth of cases, I found that we had about 2,800 headaches present annually, slightly under 3% of all of our visits. 18 of those were subsequently diagnosed as SAH, for a prevalence of about 0.6% within all-comers of headaches. But that's not entirely fair, since over half of the headaches were either migraine type headaches or other chronic/recurrent headaches, and these folks are not those for whom we are highly suspicious of SAH. Of the headache patients, about 900 had CT scans ordered. While I might argue that not all of those truly needed a CT, and certainly not all would have gotten one in other countries, for this discussion it's reasonable to use that as an index of how many headache patients we had for whom our doctors were worried about SAH. So we have about a 2% prevalence of disease in our "acute" headache population (18/900). The traditional data was that CT was about 90% sensitive for SAH, so the negative predictive value of a CT is very good -- somewhere well north of 99% likelihood that the patient does not have SAH. Now you can play with the numbers and tighten it up a bit by more rigorously screening out headaches that are not "worst ever" and not sudden onset, but even if you get to a pretest prevalence of 10%, which would be quite high, the NPV is still very good, certainly better than we can rule out other serious diseases like PE or unstable angina.

But this was very rough math from a single practice with small numbers. So it is not exactly something I was able to endorse as a standard of care. Just contextual information I could offer a patient guiding them whether or not to accept the LP I was offering. Most declined, but some preferred the assurance that the gold standard test offers.

I've been quite pleased, though, to see more and more new and more rigorous data emerge on the topic. It seems, ever so slowly, the tide of opinion is turning against the routine LP. First David Newman over at SMART EM did a great deep dive on the topic, showing that for LP, the Number Needed to Treat is somewhere around 500, which means that you'll do a lot of LPs to find a single SAH in a patient for whom it will make a difference. (Updated podcast on SAH here - worth listening to!) Then there was the Perry article in the BMJ last year which showed that the sensitivity of early CT is very very good, perhaps as high as 100% for SAH. Then there was this August 2012 article in the highly influential journal, Stroke, authored by none other than Dr. Jonathan Edlow:

Diagnosis of Subarachnoid Hemorrhage : Time to Change the Guidelines?[...] Given this analysis, we believe that practice should change. Neurologically intact patients who present with thunderclap headache and undergo CT scan within 6 hours of symptom onset no longer need an LP to exclude SAH if the CT scan is negative.

This is the same Dr Edlow who was lead author on the ACEP clinical policy, only 4 years ago, which did recommend routine LPs! (Link: PDF) The times, they are a-changin'!

So I feel comfortable claiming victory here. I was right all along and shame on you for ever doubting me.

(insert nuanced discussion here about shared decision-making with patients and the need to assess each patient as an individual.)

This is what it takes to get published nowadays

2012-11-26T09:53:00.000-08:00

For Pete's sake. This popped up in my newsfeed today, with multiple lay media citations:

Pediatric Inflatable Bouncer–Related Injuries in the United States, 1990–2010

METHODS: Records were analyzed from the National Electronic Injury Surveillance System for patients ≤17 years old treated in US emergency departments (EDs) for inflatable bouncer–related injuries from 1990 to 2010.

RESULTS: An estimated 64 657 (95% confidence interval [CI]: 32 420–96 893) children ≤17 years of age with inflatable bouncer–related injuries were treated in US EDs from 1990 to 2010. From 1995 to 2010, there was a statistically significant 15-fold increase in the number and rate of these injuries, with an average annual rate of 5.28 injuries per 100 000 US children [...] Most injuries were fractures (27.5%) and strains or sprains (27.3%), and most injuries occurred to the lower (32.9%) or upper (29.7%) extremities.

CONCLUSIONS: The number and rate of pediatric inflatable bouncer–related injuries have increased rapidly in recent years. This increase, along with similarities to trampoline-related injuries, underscores the need for guidelines for safer bouncer usage and improvements in bouncer design to prevent these injuries among children.

Sweet Jesus on a pogo stick. So you mine a database for some trivial but catchy mechanism of injury and slap a ramshackle statisical analysis on it (somewhere between 30K-100K injuries? that confidence interval is as wide as a barn door) and presto blammo you're in Pediatrics and USA Today and on CNN solemnly intoning on the dangers of letting your kids go to Jump Planet.

Is this where we are as a society? Have we run out of actual public health concerns that we find this sort of minutia worth researching? Or are car crashes and gun accidents and drug overdoses gotten too boring to publish and report on? Or, I suspect, is the culture of academia so degenerate that the mandate of "publish or perish" overwhelms common-sense judgement in deciding whether a topic is publication-worthy? Yup, that's it. Bring on the trivia!

Next thing you know they will be warning you of the dangers of tripping over your pets. Oh, wait. They already did that study.

That meteor can't get here soon enough.

EDIT: Great minds etc etc etc

Be careful out there

2012-11-22T15:33:00.000-08:00

Cute little PSA -- Dumb ways to die

On objectivity

2012-11-21T19:24:00.002-08:00

Now, I'm not a radiologist, oncologist or an epidemiologist. So I am not claiming any expert opinion of the science, but I was not surprised to see yet another major article released regarding the value of early detection of breast cancer via screening mammography -- it tends to detect a lot more early cancers, but doesn't seem to reduce the number of advanced cancers.

From today's NEJM:

The introduction of screening mammography in the United States has been associated with a doubling in the number of cases of early-stage breast cancer that are detected each year, from 112 to 234 cases per 100,000 women — an absolute increase of 122 cases per 100,000 women. Concomitantly, the rate at which women present with late-stage cancer has decreased by 8%, from 102 to 94 cases per 100,000 women — an absolute decrease of 8 cases per 100,000 women. With the assumption of a constant underlying disease burden, only 8 of the 122 additional early-stage cancers diagnosed were expected to progress to advanced disease. ... breast cancer was overdiagnosed (i.e., tumors were detected on screening that would never have led to clinical symptoms) in 1.3 million U.S. women in the past 30 years. We estimated that in 2008, breast cancer was overdiagnosed in more than 70,000 women; this accounted for 31% of all breast cancers diagnosed.

This is not a new finding at all. Numerous previous studies have been published questioning the value of rountine mammography screening in younger women, and a major controversy was ignited a few years ago when the experts at the USPSTF finally recommended that women under the age of 50 not be routinely screened by mammograms.

As I disclaim above, I do not have a vested interest or a strong opinion on this, though I do have a bias towards accepting the conclusion as the body of science accumulates. But one thing that I noted in the media coverage of this newest study was this statement which was almost universally cited:

The American College of Radiology issued a statement saying the report was "deeply flawed and misleading"

While I understand that journalists should try to present both sides of an issue, especially one which is so controversial and emotionally charged, maybe an organization which has such a strong, vested, economic interest in the value of mammography might not be the most credible source to turn to for an expert opinion? As Upton Sinclair famously said, "It is difficult to get a man to understand something, when his salary depends upon his not understanding it!"

Discharge a PE? that's crazy talk!

2012-11-21T12:49:00.001-08:00

So I recently sent home a patient with a Pulmonary Embolism (PE) for the first time. Or perhaps I should say that that it was the first time I've knowingly sent home a patient with a PE, but that's neither here nor there.

This was an unusual case, to be sure. The patient was young and healthy, a triathlete in exceptional condition. He had had arthroscopic surgery on his left knee about a month ago, and a few days after that developed this sharp pleuritic left chest pain. The pain was quite severe, but he ignored it for about three weeks until finally, since it wasn't going away he presented to his doctor, who diagnosed the PE on CT and sent him to me for treatment.

The PE was small but not tiny, segmental as I recall. He otherwise looked great, with no tachycardia or shortness of breath. Functionally, he was doing great. He wasn't back to running yet, but he was cycling and swimming and performing at about his usual level. So I guess that made him functionally "well-preserved." Given that he had symptoms for over three weeks, I guess that qualified him as stable, so we started him on low molecular weight heparin (LMWH) and sent him home.

And I suspect that this is where we are going in the future - outpatient management of stable PE patients.

I threw out the question on twitter at 2AM, and woke to find a vigorous conversation ongoing on the topic among ER physicians on three continents, including one principle investigator of a major trial on the topic. Twitter is awesome. You can read the conversation, in part, here on Storify. Michelle Lin over at Academic Life in Emergency Medicine put together a PV Card on the topic and received some more feedback.The consensus was that most non-US ER docs have already or are beginning to embrace the concept of risk stratifying and discharging some PE patients, while the US practice has not moved much and is deeply skeptical of the idea.

Can we safely send home some PE Patients?

There are many patients with PEs who are clearly ill. They're easy to spot if you've a smidgen of clinical judgement - they're dyspneic, tachycardia, hypoxic, hypotensive, etc. There is a nicely validated scoring system to sort out those who are more likely to have a bad outcome, and presumably, these folks are the ones who would benefit from hospitalization. But, of the well-appearing PEs with lower risk, the risk is still not zero. There are some people who present with small clots who will proceed to have recurrent embolic events and die. We've all seen it. Is it possible to quantify how commonly that happens? More importantly, is it possible to predict which of the well-seeming patients are more likely to have these bad outcomes?

There is some research out there to support a selective approach to outpatient management of PEs. There was this study which supported the safety of early discharge. More recently there is the Hestia trial which was a prospective study supporting the safety of outpatient treatment, and one unblinded randomized controlled trial of outpatient treatment which also supported outpatient management. If you haven't, I would strongly encourage you to listen to Rob Orman's ERCast podcast on this topic.

I would also add that the value of inpatient treatment as currently practiced seems limited. The well-appearing PEs in the US tend to get a very brief inpatient stay, less than 24 hours, which I suppose might screen for stability but I'm not sure there's any evidence to support the utility of the brief admission. Talking with some european docs, not only is outpatient management common over there (in some countries), it can take 3 days to get a CT-PA, so in many cases they are discharging suspected PEs on LMWH until they get their study, and if it's positive then they get admitted. (Which makes no sense at all, but there you have it.)

The signs seem pretty clear: low-risk patients, as judged by an objective risk stratification score like PESI plus some good old-fashioned clinical judgement (size and location of clot, total clot burden, risk indicators maybe not built into PESI) probably will allow us to safely discharge patients with PE. But can we get there? I'm not sure. The culture of the ER, especially with a perceived high-mortality diagnosis like PE, is highly risk-averse. Merely mentioning the notion elicits gasps of horror from my colleagues, and mutters of "over my cold, dead body." A further, and larger, obstacle to changing practice is our zero-risk-tolerance, highly litigious medical environment. Who wants to be the first ER doc sued for sending home a PE? Plaintiffs' experts will be lining up around the block to testify against you.

And this is a problem. We know that some people with PE will suffer recurrent embolic events despite anticoagulation, though it's a small number. Being hospitalized will not prevent the recurrent embolization, though it may provide earlier detection and therapy. Since we do not know in advance among the low-risk group who will suffer recurrent emboli, it's a catch-22. You can admit them all, a very large number of patients, to detect a very rare complication, or send them home with the risk that when a complication does happen, you are ar risk for being "blamed" for the decision to discharge.

I think we are not ready for prime time here, but it's coming. US docs will demand better data before warming to the notion. Strong institutional support will be needed from hospitals, meaning defined care protocols supporting the practice, in order to convince skittish doctors that they have the backing of the facility in the event of a bad outcome.

You've been warned.

The Catch-22 of documentation fraud

2012-11-15T05:30:00.000-08:00

I just wanted to expand on something I wrote yesterday, which relates to my other sort-of-recent post on upcoding. I wrote, about scribes and compliance:

Knowing that the scribe cannot document a complete ROS unless I actually did that ROS, I am more compulsive about making sure I hit all ten systems. (Even when it's not clinically relevant. Such is the Kafkaesque world we live in.) And I make sure to do a full exam where before I may have elided over a few systems. This is, of course, only for cases where the complexity of the case will justify a service level requiring the complete H&P.

This hits at the heart of the upcoding debate. Remember this front-page article in the New York Times from six weeks ago, in which the increased billing levels of ER doctors is asserted as prima facie evidence of fraud and abuse, and the follow-up in which the powers that be asserted their intent to reclaim these hundreds of millions of dollars in "inappropriate payments." We are not looking at a hypothetical threat here, and the financial risk to care providers is enormous.

The rules, for those not familiar with them (and who the hell would be reading a blog post about medical coding if you weren't?) are that to bill at a level 5, which is the highest ordinary level of service in the ER, the physician must document the following:

An extended history
A complete review of systems
A comprehensive exam
High complexity medical decision-making

In order to quality for a level 5, all of these must be met, but the sine qua non is the medical decision-making (MDM). This is, in fact, the ultimate driver of the visit level. MDM consists of three components: the number of diagnostic options (i.e. your differential), the amount of data you must review (i.e. tests, re-examinations) and the risk inherent in the presenting problem. If the MDM isn't met, no matter how nicely documented the rest of the chart is, a high service level may not be justified. To put it another way, an ankle sprain, no matter how thoroughly documented, is still just an ankle sprain.

Previously, it was common to have cases "downcoded" when a doctor had a high-complexity MDM but slipped up on the other items, most commonly on the ROS. Over the years, physicians have gotten better educated about the system and more sophisticated at making sure the ROS and other requirements have been met so that the billing level can, appropriately, be determined by the MDM.

This rankles. Always has. When I see a patient with chest pain and a heart attack, in order to get paid appropriately I have to ask a bunch of completely irrelevant questions about unrelated systems: do you have burning when you urinate? Do you have any rashes? Nobody would argue that the complexity and risk don't justify the level 5, but I have to document a bunch of medically unnecessary trivia to compliantly bill at the level the MDM deserves.

And this is where the bureaucratic hassle now becomes a catch-22. "Medical Necessity." Medicare considers it fraud to bill for things which are medically unnecessary. If I see an ankle sprain and order blood tests and a CT scan to try and get the bill up to a high level, that legitimately is fraud because the tests ordered are not medically necessary. But what is happening now is that Medicare (in the form of the private contractors who administer it regionally, along with some private payers) are reviewing charts and claiming that the physicians are fraudulently upcoding because we are documenting complete Reviews of Systems when they were not ... wait for it ... medically necessary.

To be clear: Medicare set the rules, and made them arbitrary and disconnected from reality, and now is coming back and punishing physicians for attempting to follow the rules to the letter of the law.

And the format this takes is scary. You get a letter from the Medicare carrier (or a RAC or a Medicare Advantage administrator) telling you that you've been reviewed, found guilty of upcoding, and this finding, based on a handful of charts, is extrapolated back several years. The result is a large demand for reparations, usually in the mid-to-high six figures. The physician group can either write a check or lawyer up and argue it chart by chart in front of an administrative law judge.

What I hate about this is the underlying dishonesty. This is about saving money. I get that, and that is in fact a reasonable goal. Healthcare is astoundingly expensive, and as a society we need to ratchet back the expense. If there's an argument to be made that physicians are paid too much, then let's have that debate on its merits. But the attempt to save money by harassing physicians and exploiting the contradictions within the rules that the government itself wrote is beyond maddening.

Write this down for me

2012-11-14T05:00:00.000-08:00

I have a lovely pen. It's a Mont Blanc Meisterstück fountain pen. My group bought it for me on my tenth anniversary as a partner in our Emergency Medicine practice.

It's a luxury I would never have paid for myself, though I have loved and used fountain pens since I was in college. Ironically, about the time I got it, the window of opportunity to use it in my professional life closed. For a decade, we had a hybrid paper-and-dictation documentation system, but around the time I hit my milestone, we went to an Electronic Medical Record (EMR). And with that, I never again had to touch pen to paper, except to sign the odd prescription. Such is life.

I am a computer guy, tech-savvy and fearless, and I was one of the few docs who saw the move to an EMR as a good thing. My documentation improved, and now that we are with Epic I would say it's even better. As I am a quick typist, the workload of documentation was only modestly increased by the transition to full physician documentation in the EMR. The other docs in my group varied in how well they adapted, from a few whose productivity improved, to the mass who accepted it with grumbles and minor complaints, to a few outliers who simply refused to use it at all.

Recently, though, we started a pilot program using medical scribes.

Honestly, I resisted the scribe initiative for years, though there were a few docs who really wanted them. I wasn't opposed, but I was too busy to do it, and it wasn't high enough on my priority list to make it happen. It finally happened when I challenged one of our younger, energetic docs to "make it happen," and she went out and did just that. Very impressive initiative. She formed a committee, put together a business plan, had presentations from scribe vendors, took competitive bids, and soon enough there were young enthusiastic faces greeting us in the ER. I watched, bemused, from the sidelines for a couple of months and finally took the plunge and signed up for a scribe myself for a few shifts.

These are my thoughts and observations so far, after about a dozen shifts with my own personal scribe.

First, the general structure of the program, for our group. We pay a flat hourly rate to a scribe vendor. The vendor recruits the scribes from a local university, mostly pre-med students, and manages all the HR functions associated with such a program. Docs who are interested in having scribes sign up and choose which shifts they want a scribe for. The cost of the scribe is deducted (pretax) from the doc's individual paycheck. The program is entirely voluntary and about a third of our docs have signed up so far, usually just for the busier shifts.

The social aspect of having a scribe is more than a little weird, though I got used to it quick enough. I added another line to my standard introduction: "I'm Dr Shadowfax, and this is Jenny, who is working with me today." Almost never has the presence of the scribe occasioned any further comment or discussion. The scribes step out of the room for pelvics or other uncomfortably intimate exams and are generally invisible during the H&P (hidden by the large monitor of the computer on wheels they bring with them). During the physical exam, I verbalize what I'm seeing/doing, as if I am talking to the patient. "Your lungs are clear and your heart is regular without murmurs." This allows the scribe to document my exam in real time, and, from what I can tell, patients seem to like it, since they are getting a sense of what I am looking for and seeing. If there are "issues" such as psych, substance abuse or simply an unpleasant patient, I'll wait till we're out of the room to tell the scribe what I want documented.

I've never had a secretary or personal assistant before and have always prided myself on self-sufficiency, so it feels odd to have someone whose whole job is to do the little scut work (like putting a chart in the rack or pulling reports off the fax machine) for me. I can do that perfectly well myself. I can also document perfectly well myself. Better, in fact, than most. Getting over the idea of someone else doing "my" work for me has been and remains probably the biggest barrier for me in fully accepting the scribe. But these small efficiencies are of course the whole purpose of having a scribe in the first place, so I am getting over that.

The workflow is quite different now. It's actually very pleasant. I have the freedom to simply sit down and talk to the patient. I can take a bit longer and have more of a free-flowing conversation. I'm facing the patient, not facing a computer screen, I'm not making notes on a clipboard, and I'm not frantically trying to remember the necessary data points for the chart. I just chat. I feel like I have more mental energy to spend on the patient and I can simply forget about the chart, confident that the scribe is capturing the important data points. Simply put, I can focus on the patient, and I feel like that allows me to be a better doctor. I suspect, though I have no proof, that it also helps with patient satisfaction, which matters a lot these days.

The quality of the documentation is a little more variable. It's hard to let go of control of the chart. There are some odd little verbal tics some of the scribes have that I would never use. To me, reading these charts are like fingernails on a chalkboard, though they're perfectly accurate and acceptable. Sometimes a really important historical point gets left out of the chart because the scribe didn't realize its significance. It is very important to proofread the charts and make sure they say what you need them to say. I'm learning to "let go" and not spend so much time editing each chart that it negates the point of having a scribe in the first place. And I think the scribes, as they learn, are getting better and better at picking out the important bits of the conversations they are documenting. When there is an important point I want emphasized I can simply repeat it back to the patient as a cue that I want this verbatim in the chart, and if I note an omission I review that afterwards with the scribe as a "teaching point" for them, as I would with a med student. Since they are all pre-med, they really seem to appreciate it. One of the best points (and a pleasant surprise) was when I reviewed my charts and found entries like:

1645 - patient re-evaluated. Abdomen still nontender. Taking po well.
or, 1015 - neurosurgery paged. 1025 - Dr Shadowfax speaking with Dr Jones, who requests MRI

Stuff that I had never before had the discipline to document and time, now 100% of the time in the chart. This is a huge benefit, especially when it comes to med mal defense.

Another thing that this has forced me to do is be more rigorous with my H&P. Once you have been working in an ER for a while, there are quite a few diagnoses you can literally make from the doorway. Say, a kidney stone. I don't need to do a Review of Systems or even a physical exam for a kidney stone patient, and over the years I may have become a little lax on this point from time to time. But we have trained the scribes that "if it didn't happen, you cannot document it." So now, knowing that the scribe cannot document a complete ROS unless I actually did that ROS, I am more compulsive about making sure I hit all ten systems. (Even when it's not clinically relevant. Such is the Kafkaesque world we live in.) And I make sure to do a full exam where before I may have elided over a few systems. This is, of course, only for cases where the complexity of the case will justify a service level requiring the complete H&P. So the scribe effectively helps keep me honest and improves my compliance.

The productivity side is also a net positive. Once I learned to let go and trust the scribe to get all the charting with minimal oversight, this freed up my time enormously. I can go from room to room to room seeing new patients, with only a brief interlude to enter orders (which the scribes are not allowed to do in our hospital). I've always been able to see 2+ patients per hour with no problem, and with the scribes 3+ has been easy, when volumes permit. I think I could go even higher but I haven't had a really busy shift since the program began.

At this point I am, I think, not making money on the scribes. I think, in fact, that I am losing money. I have been told by experts that in the startup phase of a scribe program you should expect to lose money for the first year. This seems reasonable with our experience. We have 8 docs on duty in our ER at peak times, and only a fixed number of patients. To the degree that I can see more patients, that's taking money from my partners' wallets, which puts an upper bound on my appetite, out of courtesy. Worse, if I have a scribe on a slow shift, it grates on me that I am paying for them do essentially do nothing. If I have a scribe, I feel pressure to be more productive than I otherwise would. Over time, I hope, we can contract physician staffing to the point that we will all realize increased productivity and revenue. This requires more than a 1/3 physician buy-in, which we have yet to achieve. We will see. For the moment, I can at least hope to break even on the program, though some of it may come at my partners' expense. Maybe that will induce them to get their own scribes as a defensive measure.

The final, and perhaps most important, point for me is this: quality of life. If I have a scribe shift, it's a good shift. I save so much mental energy not having to chart. When I have a five-minute conversation with a patient, ordinarily, I am carefully committing about 30 key points to my short-term memory. I then have to dash out of the room, while it's still fresh in my mind, and enter that into the computer. I never realized how much that was wearing me down till I didn't have to do that any more. My "external memory" is passively (from my point of view) capturing all these data points and I can focus on my clinical impression from the get-go. I can forget the details and focus on the big picture. The saved "brain strain" takes a busy shift and makes it seem nearly effortless. When I have five free minutes, which is rare enough, I can check twitter or my email or text my wife rather than frantically trying to catch up on my charting. And when my shift is over, I am generally done with my charts and can walk out the door as soon as the last patient is dispo'd. Granted, I was generally one to leave at the end of my shift even without a scribe, but that took work. Now it's easy. I like my job better. I've never felt like I was one of those docs susceptible to burnout, but it is endemic within emergency medicine, but for someone who is riding that razor's edge, a scribe could be the difference in job satisfaction between having to leave the field and keeping their career going another decade.

I'll update this when I've more experience, but so far I am continuing my scribe utilization and would describe myself as very happy with the experiment. Now I just need to figure out how to get them to blog for me.

Are low acuity patients congesting the ER?

2012-10-01T05:30:00.000-07:00

I had an interesting twitter chat the other day with one of my colleagues, a young ER grad studying healthcare policy by the name of Seth Trueger. You should check out his blog over at MDaware.org. The twitter conversation wound up involving about a dozen ER docs and nurses. You can review an edited summary over at storify. Yes, of course Gruntdoc was involved. That guy never shuts up.

The point in contention is an interesting one: we know the nation's ERs are overwhelmed and overcrowded. That's old news. We also know a big driver of this is boarding of admitted patients in the ER due to limited inpatient beds. If you're a 20-bed ER and you're boarding 5 patients, you've lost 25% of your throughput capacity. Common sense that this is a big issue. But, the argument hinged on, what is the contribution of the proportion of ER patients who "don't need to be there," the patients whose care could have better been delivered elsewhere?

There was, I hasten to add, no disagreement as to why the "worried well" and the "walking wounded" come to the ER. PCPs are too busy to see them, both because their clinics are booked up and also because they often don't have the resources to provide much in the way of acute care services — IVs, nursing staff, etc. In part this is because it may not be economical to provide this care in the office. Furthermore, most medical offices are only open during working hours and acute care centers are only slightly more accessible. There are also many patient-side barriers, including the hassle involved in making an appointment, the need for co-pays and insurance status. So, given the many obstacles involved in getting care in the more appropriate, most cost-effective settings, the ER becomes the default for many of these patients.

Now Seth argued at some length, that these low-acuity, ambulatory care patients were "a drop in the bucket" of ER overcrowding and cited the example of the ubiquitous URI patient who can be seen and streeted in less than 20 minutes. These folks, he and others argued, are not the problem that our nation's ERs struggle with. This is, I might add, in line with ACEP's argument that only 7% of ER patients are non-emergent.

I have pointed out in the past that my BS-meter starts pinging when people start claiming that the ER is only caring for emergent patients and that non-emergency cases are rare. So this set me off, of course. My perception — and that of many of us in the trenches — is that we are absolutely beset by non-emergencies and that the ER is viewed by many as the "convenience clinic," if not the "vicodin clinic." But is this true? How can we quantify this?

ACEP has, for their PR campaign, relied on the National Health Statistics Report to establish whether a patient in the ER was actually an "emergency." The problem with that method is that it takes the 5-point triage scale perhaps a bit more literally than the typical triage nurse does. To the point, it considers a level 4 "green" patient to still be an emergency since the definition of that level is that a patient needs to be seen in 1-2 hours. Which is not at all the way it is applied in the real world.

In this case, I would advocate using the coded level of service by the ER physician to stratify patients. Low acuity probably correlates nicely with the E/M code applied. The lower-level ER codes, level 1, 2 and 3 tend to be associated with not being admitted to the hospital, with not receiving advanced imaging studies like CT scans and with not receiving complex work-ups with blood tests, CT scans and X-rays. Put simply, an ER patient level 3 or lower may receive one or two ancillary tests (like a simple x-ray or a single lab test) but not much else before they get bumped into the level 4 range. So a level 3 patient is one that generally is simple and hopefully quick and one who, in theory, could have been cared for elsewhere were an appropriate care environment available.

So I pulled our numbers. Our ER is a pretty typical, moderately high-acuity community ER. We seen nearly 300 patients every day, and of those about 20% get admitted to the hospital. Our numbers indicate that we see about 100 patients every day who fit this definition, about 1/3 of the total volume and about 45% of the non-admitted volume.

Is this "a drop in the bucket"? Are these patients who we should be seeing and streeting in 20 minutes? Put simply, the answer is no.

When I look at the time stamps on the charts of these patients, it's clear that they are not in and out of the ER all that fast. It's all relative, of course, and your mileage may vary. We have a very efficient ER. We don't board patients and our average door-to-bed time is about 15 minutes. Pretty good. But for the majority of patients who are not admitted, the typical time in the ER is still in the 1-3 hour range:

The lower-acuity patients are there less time, it is true. About 1-2 hours on average. Why so long?

There are two factors at play here. First of all is the fallacy that just because a patient is easy and quick from the physician's point of view, they are also quick and easy for the facility. But unfortunately, the many steps which a patient must go through in the ER are fixed and take about the same amount of time for each and every patient. Let's use our shop's numbers for perspective. The patient must present at the greet desk and be entered into the system, must be placed in a bed, must be triaged, must be registered, and there are often obligate waiting periods between each step. In a highly efficient ER, where patients are bedded rapidly, much of this takes place in the treatment area. Then the doctor swoops in, does his or her black magic and is gone. If there are orders or treatments to be applied, that takes time from when the orders are entered to when they are executed. Eventually, the physician enters a discharge order, and after some time, the patient is actually discharged. Each step in this process takes time. So from door to bed: 15 minutes. The triage process itself takes a good ten minutes (bear in mind all the irrelevant data points ERs are required to capture, like domestic abuse screening, etc). The patient must be registered, which takes another 5-10 minutes. Then there is a waiting period until the doctor gets in to see the patient. That's another 5-10 minutes. So we are talking 30-45 minutes even before the doctor assesses the patient, on average. Assuming the doctor has no orders, the time from the decision to discharge to the actual discharge may be another 15 minutes, depending on nursing workload. So in a typical case where the doctor's face time is very minimal and there are zero orders entered, the process phase of the ER visit takes an entire hour! This is, I might add, a "best case" for an ER visit. (Bear in mind that we are talking average times here. So for each person who comes in at 5AM and is seen immediately there's one who comes in at 7PM and has to wait twice as long.)

The second fallacy at play is the idea that a low-acuity patient is in fact a low workload patient. Seth cited the URI patient. Nothing faster from the MD's point of view. In our department, that represents about 4% of patients. That's maybe 15% of the total low acuity patient load. What are the other typical level 1-3 patients here for? Well, based on our ICD-9 coding, in rough order of frequency, things like:

Back pain
Headache
UTI
Neck Strain
Minor head injury
URI/Bronchitis/Pharyngitis/Sinusitis
Extremity Cellulitis
Laceration
Dental pain
Extremity sprains/strains/contusions
Pediatric fever (non-infant)
Abscesses
Corneal Abrasions
Rashes
Allergic reactions

A lot of these are, in fact, not at all easy from a time point of view. Abscesses/Lacerations/Corneal abrasions all take physician time doing procedures (and associated set-up time, etc). The musculoskeletal injuries often require imaging and splinting. The back pain/headache/cellulitis often require medication administration. Concussions and toddlers with fevers may not require tests but do consume a lot of physician time face-to-face. Some of these cases require multiple physician assessments. Some require labs. Each additional step adds time, sometimes quite a lot of time, to that one-hour best case baseline I described.

So what's the total time burden?

Our experience is that for the ambulatory population, i.e. excluding admitted patients, we have about 510 patient-hours per day in our ER. Of this, almost exactly a third, 160 patient-hours is attributable to the lowest-acuity patients, the E/M level 1-3s. That correlates also to nearly a third of physician staffing and RN staffing. Bear in mind that our institution just built a whole new hospital at a cost of $500 million, in part because the ER needed a much larger physical plant. The costs involved in this care are not insignificant, and the burden placed on the nation's ERs from these less acute cases is major, not at all a drop in the bucket.

I want to take a moment here that I am not commenting on whether these patients should be in the ER. In the current healthcare environment, they have to be here because there is nowhere else to go as often as not. And many of these cases will always be with us: if you have neck pain after a car accident at 2AM, the ER is the right place to be treated, even if it winds up being just a sprain. We embrace our role as the care provider of last resort, the ones who are always open and always available, no matter what. It is also true, however, that we are an expensive place to receive care. The fixed costs of operating an ER are horrendous, compared to a clinic. Our health care system would be far better served if there were accessible sites of care that could care for these less intense patients in a more cost effective manner.

Upcoding is in the eye of the beholder

2012-09-24T12:57:00.000-07:00

There was an interesting and important article in the NY Times the other day about the gradual increase in the average E/M coding levels used by doctors over the last few years. For the non-docs, med students and ER trainees out there, here is a brief summary of the way physician billing works in the ER:

During and after the patient encounter, the physician creates a medical record. This is a pretty standardized document including the history the doctor got from the patient, the exam, any tests and the medical decision-making. And, of course, the diagnosis. This gets reviewed, typically, by a professional coder who then applies Medicare's rules to determine what level of complexity the service was, and the associated cost of that service. (In some cases, the doctors code their own charts, and some are automatically coded by a computer, but both of these are exceptions to the rule.) ER visits are coded on a 5-level scale, with a Level 1 (99281) being the simplest and a Level 5 being the most intense. These are called E/M codes because they refer to the "Evaluation and Management" of the case, as opposed to, say, a surgical procedure.

The amount Medicare pays the doctor for an E/M code in the ER ranges from about $20 to $175. (If you've ever received a multi-thousand-dollar ER bill, chances are good that was the hospital bill. The physician's fees are much more modest in most cases.

Medicare, of course, tracks utilization and recently published a report (PDF Link) about the recent trends in the doctors' use of the codes. What they found is that over the last decade, we have shifted from using the lower codes and towards the higher ones:

This is where it gets interesting. The feds and some consumer watchdogs view this trend as clear evidence of fraud and abuse, that the physicians are "upcoding" the visit levels to increase their income. On the other hand, I've spent the last decade trying to educate physicians on how to document the patient encounter so that you can accurately capture the legitimate value of the service provided. So I look at that trend and think to myself "Job well done."

From the perspective of a practicing physician, the rules that govern the documentation required to capture a service level are deliberately onerous and designed to produce downcodes. They require the doc to collect far more data than is actually necessary based on the actual condition of the patient. You forget to check one box, you leave out one required element, and despite the complexity, gravity and risk of a patient's condition, you will not be paid for the service. For years, we have been losing money to these archaic rules (they date from 1995), and we have been struggling to stem the leakage of revenue from our practices.

The industry responded to these rules by developing tools to comply with them. The first thing was to have professional coders. Prior to 2000, a substantial majority of ER charts were hand-coded by the physician; now that is quite rare. Then we got templated paper records which prompted the docs to get all the required data points. Now we have EMRs which do the same thing more efficiently. It's no surprise that as an industry we have gotten better at meeting the guidelines.

And then there is the fact that the ER is a different place than it was in 2000. Our patients are older and sicker. We do more in the ER than was true in the past. Patients are rarely directly admitted any more, but rather get the majority of their admitting workup done in the ER. I don't know how much of the skew in the above graph is due to these factors, but they shouldn't be disregarded.

But I don't like where this is going. The government is desperate, understandably, to save money on healthcare expenditures. They seem to have assumed their conclusion that the increased coding levels is fraudulent and unjustified, and there seem to be few voices disagreeing with them. Furthermore, there is some inappropriate upcoding, and it's very easy for a patient with an egregious bill or a certain physician (or group) who pushed the envelope too far to be held up as anecdotal proof that doctors are all a bunch of thieves.

The article quotes some insurers as saying that nearly half of the charges being submitted are "upcodes," without noting that the insurers have a vested interest in not paying and may not be presenting an honest picture of the claims. We had a run-in with a certain national insurer who analyzed a few hundred claims, found that 80% of them were upcoded and demanded a couple of million dollars in restitution. We fought back, of course, defended each chart on the merits of the care, and established that in fact 97% of the time the correct, higher, code was appropriately used. That the insurers are not necessarily honest players here passes unremarked.

I think changes are coming, and it worries me. We already have one insurer saying that they simply won't pay for cloned records — but how will they tell if a chart has been cloned? Do charts have DNA? I think what we are going to see is the carriers becoming very aggressive in arbitrarily denying payment or demanding restitution. I would love to see revised and streamlined coding rules to replace the old ones, but I suspect that if that were to happen, the new rules will be designed to be more restrictive and more burdensome.

Just go to the ER, redux

2012-09-24T00:17:00.001-07:00

Sweet Breakdancing Jeebus, we are back to this:

Downplaying the need for the government to ensure that every person has health insurance, Mitt Romney on Sunday suggested that emergency room care suffices as a substitute for the uninsured.

"Well, we do provide care for people who don't have insurance," he said in an interview with Scott Pelley of CBS's "60 Minutes" that aired Sunday night. "If someone has a heart attack, they don't sit in their apartment and die. We pick them up in an ambulance, and take them to the hospital, and give them care."

If this quote sounds familiar, it was previously uttered, near word for word, by the intellectual giant who was the standard bearer of the Republican party for most of the last decade, George W Bush (remember him?). He said, in 2007:

"The immediate goal is to make sure there are more people on private insurance plans. I mean, people have access to health care in America," he said. "After all, you just go to an emergency room."

I was going to expound on my long-held point that "Just go to the ER" is not a substitute for national health policy, and that the ER is unable to provide comprehensive and preventative care yadda yadda yadda but fuck it. You all know that already. I can't stand it. I'm gonna go have a drink instead.