Adventures in Emergency Medicine

Ketamine instead of 5150?

2014-12-22T01:33:00.001-08:00

I frequently see patients who are depressed and suicidal. It's tough for our patients and I wonder what can be done for them.

My typical plan of action is to medically screen these patients, including: history, physical exam, labs, urine toxicology screen, and call for a psychiatry consult, if available.

Usually, these patients wait for a long time to be transferred to a psychiatric medical center where they can be evaluated by a psychiatrist.

Now, studies have shown that giving a low-dose ketamine (0.5mg/kg) intravenous push can rapidly alleviate these symptoms.

http://www.ncbi.nlm.nih.gov/m/pubmed/23982301/

http://mobile.nytimes.com/2014/12/10/business/special-k-a-hallucinogen-raises-hopes-and-concerns-as-a-treatment-for-depression.html?referrer=&_r=0

Would it be more beneficial for some patients to be treated with ketamine in the ED with outpatient psychiatry followup?

This would enhance medical care in several ways:

1. No waiting in ED for psych bed

2. Rapid alleviation of depression symptoms

3. Return to home sooner for patients

The next step is to do randomized controlled studies in ED patients who present with suicidal ideation and see if they benefit from a dose of ketamine.

Starting to Get it Right

2013-11-14T13:42:00.003-08:00

“The moment that you feel that, just possibly, you’re walking down the street naked, exposing too much of your heart and your mind and what exists on the inside, showing too much of yourself. That’s the moment you may be starting to get it right.”
- Neil Gaiman
“Neil Gaiman Addresses the University of the Arts Class of 2012” by The University of the Arts (Phl) on Vimeo. http://vimeo.com/42372767

3 Reasons To Change Medical School to 3 Years

2013-10-26T10:25:00.000-07:00

1. The majority of learning happens in the first 3 years. The fourth year of medical school is devoted for electives and interview season. Once interview season is completed, there's plenty of downtime. Accordingly, the fourth year should be eliminated completely. Or it can be offered as an option for those who don't know what specialty they have decided upon. Students don't need to be in school for interviews and could spend extra time recuperating for internship or working part-time to pay off loans.

2. There is a shortage of doctors. We can increase the number of graduating MDs each year and accordingly address the MD shortage that affects our society. "The Association of American Medical Colleges predicts bigger shortages in all types of physicians: 63,000 by 2015 and 130,600 by 2025." This means more doctors to help meet the needs of underserved areas, entering primary care, and more MDs doing research.

3. Doctors already have too much debt. In 2012, the average graduating MD starts out with $170,000 of student loans. If medical school were reduced by one year, it could reduce educational debt by up to $50K. Additionally, there is the opportunity cost to consider of this extra year.

So how can we make it three years? All schools should offer the option of an accelerated curriculum for interested students. Medical students will be graded upon clinical competency and test scores. If they are incompetent or failing, then they simply don't graduate.

Day-In, Day-out Practice of Medicine

2013-10-21T11:11:00.001-07:00

It’s the humdrum, day-in, day-out, everyday work that is the real satisfaction of medicine; the million and a half patients a man has seen on his daily visits over a forty-year period of weekdays and Sundays that make up his life. I have never had a money practice; it would be impossible for me. But the actual calling on people, at all times and under all conditions, the coming of grips with the intimate conditions of their lives, when they were being born, when they were dying, watching them die, watching them get well when they were ill, has always absorbed me. – William Carlos Williams

How to Quit Your Job Professionally

2013-08-01T08:36:00.001-07:00

1. Use simple, direct language

2. Realize this is not an exit interview.

3. Never burn a bridge.

4. Ask for a written letter of reference and commitment to give you a verbal referral on request.

5. Offer to submit, just for documentation purposes, a letter of resignation.

6. Never except a counter-offer

p.s. Have another job or business already lined up before quitting

Reference:
Harpers Rule's: A Recruiters Guide to Finding a Dream Job and the Right Relationship, by Danny Cahill

Brain Training to Be More Positive

2013-07-18T13:08:00.004-07:00

1. Write down 3 things you are grateful for each day for 21 days

2. Journal about one positive experience that happened in 24 hour period

3. Exercise

4. Meditate - Free yourself from our cultural ADHD

5. Perform random acts of kindness

The Happy Secret To Better Work, By Shawn Anchor

Residency Should Be Limited to 40 hours Per Week

2013-05-28T15:57:00.003-07:00

Residency should be set to a maximum of 40 hours per week. The idea that a person can be productive, efficient, and offer their "best" selves for 80-100 hours per week is false. By allowing a normal schedule for doctors in training, this will allow for balance in their lives and ultimately better care for patients.

Residents will be happier and nicer to patients. The majority of residents who are apathetic, short with staff and patients, and visibly burnt out are in specialities where they work more hours per week. One of the greatest gifts an MD can give to patients is truly listening and understanding their patients. When you've only slept for 3 hours last night, this is impossible.

"But we did it, so you have to do it too." I understand that before residency work hours were set to 80 per week, prior MDs' routinely worked 100-120 hours. But times have changed. We are busier than they were 20-30 years ago. Before they probably got more sleep and had less patients in the hospital. The number of patients seen in ED and hospitals has increased each year. More hospitals are shutting down and the hospitals that are open continue to see more patients.

"We won't get enough training." During residency, I noted there was a lot of downtime and a lot of "non-clinical" activity. For example, waiting for attendings in clinic to present, hunting down an old CT report that was done at an outside hospital, or faxing paperwork. Residents spend time doing miscellaneous activities, not relevant to their clinical skills. Residency should be like an espresso of information. The rest should be delegated or deleted.

Less depression, anxiety, and alcohol/drug abuse. Every year, 300-400 doctors commit suicide. That's almost an entire medical school. I believe that one of the contributors to this is being overworked and burnout. Since residency and medical school sets the foundation for our clinical careers, we need to get the right habits from the start.

Doctors are human and need balance. The way we treat and respect our residents will be the way they treat and respect their patients. And sooner or later, we will all be patients.

Living like a resident...Financially

2013-01-17T13:33:00.000-08:00

Living like a resident means working 80 hours per week, snagging free food, and driving an old beater car.

When doctors graduate and become attending level status, we want to spend our hard-earned money. For the most of us, this is a big mistake. Why?

First, we have an ocean of student loans to pay off.

Second, we have little to no savings during our time as students and residents.

Third, we will get used to a "rich" lifestyle and may get stuck on the never-ending treadmill of having more.

So, what's the solution? Continue to live like a resident until you have all loans payed off, maxed out on your savings, have a 6 month emergency cash reserve, and work as much as you can healthily handle.

This is SPARTA!

2013-01-10T10:40:00.001-08:00

"Medicine keeps getting harder. And fewer and fewer folks are doing it. America has no idea that the weight of it all is falling on the shoulders of the emergency physicians and hospitalists who lurk inside the trauma rooms and inpatient floors, the fast tracks and ICUs of their community and university hospitals. The pasty-pale, coffee-sucking, junk-food-eating Spartans of health care who will bear the full assault of health care reform when there aren't enough primary care doctors to manage an AARP convention, much less all of America."

Edwin Leap, Emergency Medicine News, January 2013

6 Tips to Get Inspired for Burnt Out MDs

2012-12-20T10:53:00.000-08:00

So, how can you get inspired if you're burnt and crispy?

1. Change your job. Go academic if you're a community doc or vice versa. Work locums tenens in Australia or New Zealand.

2. Take some time off to recharge. Relax in your favorite country. Maybe someplace where you're currency will stretch much further.

3. Add to your expertise. EMS, U/S, Critical care, or whatever niche you choose

4. Be the change at work. Try to associate with positive people and avoid negative people.

5. Remember your purpose in being a doctor. Dig out the files and re-read your medical school application essay, residency program essay, and even college essay.

6. Consider a life coach. Three MD life coaches to check out are: Dr. Heather Fork, Dr. Philippa Kennealy, and Dr. Michelle Mudge-Riley.

5 Stages of Physician Burnout

2012-12-18T18:56:00.001-08:00

I was reading Dr. Graham Walker's article, Operation Burnout. It made me ponder, why do nearly 70% of emergency physicians feel burnt out? Even more concerning, ER docs also have the highest burnout rate of ALL specialties.

Burnout is contagious. It's like MRSA and should be called a "staff infection" because it has a tendency to spread.

Ruptured MRSA abscess (via Wikimedia)

Haven't you noticed that when negative people are around you, it has a tendency to bring your energy down as well?

Jerry Edelwich, author of Burnout, writes that there are 5 stages of burnout:

1. Enthusiasm - When you first start the new position, you are super excited and everything is fresh.

2. Stagnation - Things become routine and everything becomes boring.

3. Frustration - By now, the new car smell has worn off and you see the imperfections. The frustration builds at work.

4. Apathy - It feels like you have no power to change anything, and you decide to go with the flow. The longer you stay in this stage, the harder it is to get out.

5. Inspiration - If you're able to get out of apathy, then you realize you can change or change your environment.

Have the courage to be happy and inspired.

20 Sacred Rules for Success

2012-12-12T10:44:00.000-08:00

Ask
Ask again
Ask again
Ask again
Ask again
Ask again
Ask again
Ask again
Ask again
Ask again
Ask again
Ask again
Ask again
Ask again
Ask again
Ask again
Ask again
Ask again
Ask again
Ask again

10 Tips For Med Students Going Into EM

2012-12-10T20:42:00.003-08:00

1. Join AAEM, EMRA, and ACEP. Free or very inexpensive for medical students.

2. Go to the annual meetings. AAEM is this Feb, 2013 and in Las Vegas. ACEP is this Oct. 2013 and in Seattle. Attend the medical student components of both conferences.

3. Get honors in your emergency medicine clerkship.

4. If you are committed to one program, do an away rotation there.

5. Check out www.freeemergencytalks.net and listen to these 3 lectures to start:

http://freeemergencytalks.net/2012/10/joe-lex-an-old-fogey-speaks-45-years-on-the-front-lines/

http://freeemergencytalks.net/2010/03/amal-mattu-finding-your-niche-in-em/

http://freeemergencytalks.net/2010/04/peter-rosen-beginnings-of-emergency-medicine/

6. Go to ACEP's leadership & advocacy conference in May 2013. http://www.acep.org/LACHome.aspx?MeetingId=LAC

7. Score well on Step 1.

8. Get a strong letter of reference from at least one emergency physician.

9. Identify a niche in EM (Ultrasound, EMS, Pediatrics, Hyperbaric, EKGs, Social Media)

10. Seek balance in career, life, health, family, and fun.

What tips do you have?

If I could live my life again...

2012-12-05T21:05:00.001-08:00

If I could live again my life,
In the next – I’ll try,
- to make more mistakes,
I won’t try to be so perfect,
I’ll be more relaxed,
I’ll be more full – than I am now,
In fact, I’ll take fewer things seriously,
I’ll be less hygienic,
I’ll take more risks,
I’ll take more trips,
I’ll watch more sunsets,
I’ll climb more mountains,
I’ll swim more rivers,
I’ll go to more places – I’ve never been,
I’ll eat more ice creams and less lima beans,
I’ll have more real problems – and less imaginary ones,
I was one of those people who live
prudent and prolific lives -
each minute of his life,
Of course that I had moments of joy – but,
if I could go back I’ll try to have only good moments,

If you don’t know – that’s what life is made of,
Don’t lose the now!

I was one of those who never goes anywhere
without a thermometer,
without a hot-water bottle,
and without an umbrella and without a parachute,

If I could live again – I will travel light,
If I could live again – I’ll try to work bare feet
at the beginning of spring till the end of autumn,
I’ll ride more carts,
I’ll watch more sunrises and play with more children,
If I have the life to live – but now I am 85,
- and I know that I am dying …

Attributed to Jorge Luis Borges

http://oceanflynn.wordpress.com/2007/06/13/if-i-could-live-again-my-life/

Phraseology for Crucial Communications

2012-11-30T15:43:00.000-08:00

It's nice to have a few scripts and templates when talking with others. Here are a few useful phrases for you to use:

“May I Speak Freely?”

“My purpose in talking with you is …” (a mutual goal)

“When you … I feel . . . ” (action you are giving feedback on – something they can change)

“I imagine that …” (positive intent/benefit of the doubt)

“And because we both want …” (common goal)

“I need …” (specific alternative behavior requested)

Most importantly, affirm him or her as a person

~Dr. Jay Kaplan's Lecture at ACEP Scientific Assembly, Boston 2009.

Take Action

2012-11-28T12:30:00.006-08:00

I came across this parable, while reading, "Action! Nothing Happens Until Something Moves," by Robert Ringer.

Every morning in Africa, a gazelle wakes up. It knows that it must run faster than the fastest lion or it will be killed.

Every morning in Africa, a lion wakes up. It knows that it must run faster than the slowest gazelle or it will starve.

It doesn't matter whether you're a lion or a gazelle; when the sun comes up, you'd better start running.

"Whatever you can do, or dream you can, begin it. Boldness has genius, power and magic in it." ~Goethe

Non-Medical Advice for Young Emergency Physicians

2012-11-26T08:29:00.002-08:00

I was browsing through AAEM's Commonsense Journal (Sept/Oct 2012 Issue PDF) last week and came across a brilliant article by Dr. Andy Walker. He is a mentor for young EM physicians and offers these points of advice:

Live beneath your means. Save 15-20% of income if you are employed. Save 25-30% if you are an independent contractor. Stay out of debt and pay off debt as quickly as possible. EPs should have at least 6 months of income saved, as ER jobs are inherently unstable. Money may not buy happiness, but it does buy freedom - and freedom is pretty damn good. Save your money.

Rent, don't own. There will be surprises and you will be in a stronger position if you can pick up and leave. Especially, rent for the first year.

Insure wisely. You absolutely need disability insurance, as you are far more likely to become disabled than to die early. Get "own occupation" disability insurance. If you do get life insurance, get term insurance.

Be a faithful and disciplined investor. Start investing early and time will be on your side. Diversify widely. Educate yourself. He recommends books by John Bogle, the founder of Vanguard.

Participate in organized medicine. The biggest enemy of physicians is their own sense of hopelessness. But a difficult fight is not an impossible fight. Join your state medical society. Join AAEM today.

I'd also like to add a couple of things:

Be happy now. You have arrived. Stop getting trapped in thinking, "I'll be happier, once I get the BMW, house, etc."

Seek balance. Residency can be extreme and now is the time to focus on your health, family, friends, fun, leisure.

Be Yourself

2012-11-25T02:14:00.001-08:00

"Be Yourself," is something frequently said and heard. But to be yourself, you have to know who you are. Take time to reflect on your life and how you came to be where you are right now.

What are your values? What do you want people to say at your funeral? What makes you different?

Emergency Haikus

2012-09-26T23:10:00.000-07:00

What's causing the pain?
Myocardial infarct.
Transfer to cath lab.

Trouble with sleeping?
Worries and anxiety.
ER is open.

Can't move your right side?
And your speech doesn't make sense?
Head CT and then....

The spider bit you
Redness, swelling, and fever.
Here's doxcycline.

Vaginal bleeding.
What is causing this problem?
Not your period.

Dr. Raul Ruiz for Congress in 2012

2012-07-14T19:20:00.000-07:00

During the CAL/ACEP Scientific Assembly in La Quinta, CA in 2009, Margaret Salmon MD, MPH (a close friend and co-intern) told me, "Sam, you have to meet my friend from Harvard." This was my first meeting with Raul Ruiz and would not be the last.

Sometimes, life surprises you with these incidental meetings that seeds the beginnings of life long friendships. Raul's story is awe-inspiring. He comes from a family of immigrant farm workers from the Coachella Valley desert. To get into college, he went to his neighbors' doors and made a promise, "Help me pay for college. I promise to come back here and make a difference."

Not only did he make it to college, but he went to Harvard and graduated with three degrees (MD, MPH, MPP). Afterwards, he went on to complete an emergency medicine residency and an international medicine fellowship.

Now, he is a community ER doctor back in the Coachella Valley desert and Associate Dean at the University of Riverside School of Medicine. He made a promise many years ago and kept it.

When Raul told me he was running for Congress, it just made sense to me. He is the kind of leader that I want to see helping create laws and addressing disparities. Raul is an emergency doctor who has the back ground in public health and public policy tools to make a positive impact.

Would you like to see someone who understands medicine, policy, and public health to help create legislation?

Do you want to have someone in Congress who keeps his promises?

Please make a donation to Dr. Raul Ruiz. Even $5 makes a difference in this grassroots campaign. Here's the link: www.drraulruiz.com

Raul Ruiz, MD, MPH, MPP

International Ultrasound Resources

2012-06-29T12:20:00.000-07:00

INTERNATIONAL ULTRASOUND RESOURCES
By Dr. Sachita Shah

BOOKS : Obviously there are many within our specialty, but these are
some ultrasound books outside of EM that have pertinent info for
practice in low resource settings and/or are written for generalist
health care providers

1) Cristoph Dietrich, MD, and colleagues have published a freely
downloadable, online full color textbook, including special chapters
on US in HIV and tropical diseases. It is an in depth resource that is
made more for experienced clinician-sonographers, and written in high
level /technical english. Great work and so inspiring that it is free!
Please check it out at this link: http://www.efsumb.org/ecb/ecb-01.asp

2) Ultrasound: A Practical Approach by William Marks. http://www.amazon.com/Ultrasound-Practical-Approach-William-Marks/d...

3) Training in Diagnostic Ultrasound Essentials, Principles and
Standards, WHO Study Group report. http://apps.who.int/bookorders/anglais/detart1.jsp?codlan=1&cod...

4) Manual of Diagnostic Ultrasound in Infectious Tropical Disease
(covers abdomen only, available by amazon too) http://www.wfumb.org/publications/books.aspx

5) Partners In Health Manual of Ultrasound for Resource Limited
Settings (free, electronic book in pdf, simple english, point-of-care
approach to abd/ob/dvt/skin/procedures etc) www.pih.org/publications/c/manual

COURSES:
1) Short Course on Abdominal Ultrasound in Tropical Disease
http://www.tropicalultrasound.org/
This course (YEARLY, April, Italy)is designed for clinicians who wish
to acquire basic skills in ultrasound of the abdomen and a general
overview of Ultrasound in Tropical Medicine. Imaging specialists who
want to acquire knowledge in the field of Infectious Diseases and
Tropical Medicine can benefit from this course as well. It is also
designed for MDs who plan to work in tropical/resource poor areas or
who are already experienced in field work but need to refine their
skills in this diagnostic tool.

2) Clinical Ultrasound in Tropical Infectious Diseases
http://www.georgiahealth.edu/ems/COM/InternationalMed/Peru.html
Join the faculty of the Instituto de Medicina Tropical, Alexander von
Humboldt, Cayetano Heredia, Lima, Peru; the Center of Operational
Medicine, Section of Clinical Ultrasound, Georgia Health Sciences
University; and the University of Pavia, Division of Infectious and
Tropical Diseases, IRCCS S. Matteo Hospital Foundation as they co-host
the first Clinical Ultrasound in Tropical Infectious Diseases course
in Lima, Peru, October 21-26, 2012. Providers with experience and/or a
special interest in clinical tropical medicine or infectious disease
with ultrasound experience are invited to attend. This unique course
consists of lectures, demonstrations, and small-group clinical rounds
for live ultrasound scanning.
------------------------------------------------------------------------------------------------
Dr. Sachita Shah is Assistant Professor at UW Division of Emergency Medicine in Seattle. She completed her US fellowship at Alameda County Medical Center-Highland Hospital. She is the first author of "The Partners in Health Manual of Ultrasound for Resources Limited Resources." (See the link in number 5 above)

Intro to Social Media for Newbie MDs

2012-06-28T01:03:00.003-07:00

Have you ever Googled your name to find vitals.com or healthgrades.com as the main link to your professional face online?

What hurts even more is when you have a one out of four star rating by an anonymous person.

Today, you will learn three places to get started in social media.

www.linkedin.com Go to LinkedIn and create a profile. This is free. Put up a professional picture online and parts of your CV. Remember, this is the internet and everything your put up in now public. So, no social security or DEA numbers.

www.twitter.com Create a twitter account with your real name and another professional picture. Do some searching on twitter. Find other MDs, RNs, Med students, PharmDs, etc to follow. Tweet useful links, thoughts, comments, & questions. Again, remember this is on the World Wide Web so imagine everything you put up will be published in the NYTimes Sunday Edition.

www.blogspot.com or www.wordpress.com Create a blog. A blog is shortened for weblog. It’s an online journal, but not everyone wants to hear about what you had for dinner or who you have a crush on. Write short articles on health related topics. Nothing that violates HIPPA or patient confidentiality. Use lots of pictures.

Be fairly diligent in the above activities, maybe 1-2 posts/tweets per week. Wait 6 months and do a google search with your name. You will see a difference!

Meditation for Physicians

2012-04-17T06:34:00.001-07:00

When stepping into a new patient's room, I must clear my mind completely. To make a diagnosis, it's crucial to listen with 100% attention. If I think about the patient I saw before, or what lab result I need to look up, my focus becomes divided. One way to be more aware of the present moment is through meditation practice.

During medical school, Jon Kabat-Zinn lectured at the U. of Rochester and led us through various awareness exercises. One exercise was to eat a raisin very s - l - o - w - l - y, savoring the taste and texture. I still remember how potent the single raisin tasted.

Now, I've re-discovered him on the EM Tutorials Podcast (By Drs Chris Cresswell, Qasim Alam and Andrew Dean-Ballarat, Australia and New Zealand)
http://itunes.apple.com/nz/podcast/emergency-medicine-tutorials/id441003312

I highly recommend you download # 7 Breath Meditation and give it a try for a week. It's also FREE.

Bottlenecks

2012-04-09T05:06:00.001-07:00

Once you've identified the time each patient spends at a certain step, you can identify which takes the longest.

NOW, you have identified the bottleneck.

Everything is dependent upon this bottleneck. Recall the rate limiting step (RLS) in chemistry. This step is typically a catalyst or rare substrate. It's the process that S - L - O - W - S everything else down. In the ED, this may be: time to get a lab report, a 5150 bed, or the the on-call dialysis nurse.

Use a multi-perspective approach by including RNs, Techs, ICU docs, etc. to reduce the time it takes in the slowest step. This can be challenging, but will reap huge rewards.

Lather, rinse, & repeat.

What are the important things to measure for ED flow improvement?

2012-04-02T20:03:00.001-07:00

There are many metrics in the ED, ranging from patient satisfaction to % of Medicaid patients. To improve patient flow and identify bottlenecks, there are 10 steps and times that should be measured:

1. Door to Triage

2. Triage to MD (assuming MD is in triage)

3. Bed to RN

4. Bed to MD

5. MD to Decision (DC vs. ADMIT)

6) Imaging order to read

7) Lab order to results

8) Recheck of patient

9) DC to actually being out of ED

10) ADMIT to floor

If you add the total time of each of these steps, this equals total Length of Stay in ED (LOS).

Based upon the review of the time needed for each of step, an ED director can determine which areas need more effort and time to reduce the time in ED. This is crucial because patient satisfaction is linked to the overall time in ED.