More JCAHO Nonsense

Dear Dr. Scalpel:

In accordance with Joint Commission regulations, we are required to request an evaluation of your clinical performance. The Credentialling Committee now requires the completion of an evaluation form by a peer in your specialty who is not a member of your group practice.

Attached, you will find a letter and accompanying evaluation form which you should forward to a peer of your choice for completion. In order to proceed with the processing of your reappointment application, it is necessary that you ensure that the required evaluation form is forwarded to a peer and returned to us in a timely manner. A return envelope is provided for this purpose. Please note that the evaluation form must be returned to us by the person completing the form. If we do not receive the evaluation form before ________, your clinical privileges may be interrupted.

Sincerely,

An Unnamed Bureaucrat


Now I've worked at the same hospital exclusively for almost 10 years, but that doesn't matter to the geniuses at JCAHO. They still insist that I track down some former colleague who I probably haven't even spoken with in several years so this old buddy of mine can vouch for my ability to perform a precipitous delivery of a newborn, a pericardiocentesis, or a bladder catheterization, among (many) others. Not that this "peer" would have likely ever seen me perform any of these procedures, of course, but his judgment of my abilities is presumedly as important (and necessary) to the bureaucrats as the opinions of my current colleagues.

Sometimes I wish stupidity were painful. How did we let this happen?

The Light of Day

Some of you have probably noticed that I haven't been posting as often as I used to. For that I apologize, because I hate it when bloggers slack off too. But a recent change in lifestyle has given me a new outlook, and I'm still adapting to it.

For the past several years I've been like a vampire, working exclusively the graveyard shift. Whenever I would see the sunlight, it would make me sleepy, and if I so much as walked past a bed I would be inescapably lured into a 2-3 hour nap. It was not uncommon for me to sleep 4 separate times in a 24 hour period. My days off were usually miserable battles against Hypnos, and my nights off were generally spent surfing the net and tiptoeing around the house, trying not to wake the family. There's just not much to do when you're wide awake at 3 am. Last year I created this blog, which gave me an escape from some of the late-night boredom. Most of my posts were written in the loneliest and darkest times of the night.

One day I decided that I didn't want to be a vampire anymore. Perhaps it was when my son asked me, "What do you want to do today, Dad?" and I finally realized that maybe "take a nap" wasn't the best answer. Or maybe I'm just getting older. Or wiser. Whatever the reason, I decided to put myself back in the normal ER rotation, and I love it.

The traffic sucks, the laboratory and X-rays are slower, the administrative busybodies are annoying, and the money isn't quite as good. But I have a life again, and I really don't know what I was thinking all those years.

I still haven't quite figured out how to make the most of my newfound life, but I doubt that I'll be posting quite as frequently as I have in the past. Or maybe I will, who knows? I still have a lot of things to say, I just might not be saying them as often. I've got a few bike rides to catch up on.

The Scalpel Cocktail

Everybody knows about the GI cocktail. The green dragon: a mixture of Maalox, Donnatal, and viscous lidocaine which has been soothing upset stomachs for generations of ER visitors. In my experience, it seems that most docs just use the dragon for GERD, gastritis, or ulcer-like symptoms. I've found that a simple modification makes this old standby useful for uncomplicated patients with gastroenteritis as well.

As I've mentioned before, I think we overtest and overtreat many cases of "stomach flu." An otherwise healthy low risk patient who maybe threw up once and is now having mostly cramps and diarrhea with a side of nausea doesn't necessarily need an IV and a thousand dollar workup, so sometimes I try this first:

Just substitute Zofran elixir for the viscous lidocaine.
If you don't stock the elixir form, you can squirt the IV form of Zofran right in the cup with the Maalox and Donnatal and mix well. Yes, the IV form can be taken orally, it is just as effective, and I find that 4 mg is sufficient most of the time. The Zofran stops the nausea, the Maalox soothes their stomach, and the Donnatal relieves the cramps. The lidocaine just tastes bad and numbs their throat, so I leave that part out.

In 10 minutes the majority of these carefully selected patients are going to be ready to go home, asymptomatically singing your praises as they leave. Some of them won't, and they will require the 2-4 hour workup and treatment plan you were going to do anyway.

Gig 'Em!

Texas A&M 38
tu 30

Happy Thanksgiving!

Here's to good friends, good health, a good meal, and a good nap.

I give thanks for the heroes who stand in harms way in the service of our country; I pray that you return home safely. I especially give thanks for those servicemen and women who have died for us, and I pray that their families know that their sacrifices are appreciated.

Thanks also for our policemen and firefighters who put their lives on the line to serve us, and especially for those who have given their all in the line of duty.

Thanks for the nurses, and the secretaries, and the paramedics, and the administrative staff, and the housekeepers, and the pharmacists, and the techs, and for all of those who are part of the healthcare team.

Thanks for all of you who have visited my blog, my family, and my friends for being a part of my life.

Thanks for my fellow bloggers who always keep things more interesting than television.

And of course a special thanks for the one who made it all possible.

Lightning Strikes Twice

Most healthcare workers will probably finish their careers without personally suffering a known exposure to HIV. Your humble narrator has scored a deuce.

It was less than a year after my first exposure, my residency training was almost complete, and I was about as comfortable as I could be.

Maybe I was too comfortable. Like my first accident, this one was easily preventable if I had taken proper precautions. But like my first accident, I didn't.

This gentleman had done some time in the pen, and he was older than most AIDS patients of his day, probably 50 or 60 if I recall correctly. He had CNS lymphoma (among his other problems) and that day he needed a spinal tap. I'm not one to wear eye protection routinely, and since a spinal tap is not the sort of procedure that typically is associated with airborne bodily fluids, I wore no mask or glasses.

Now for those of you who are familiar with the procedure, you are aware of the instruments in the LP tray, but for those who are not, I'll elaborate:

There is a long rigid plastic manometer (for measuring the pressure of the spinal fluid) which comes in two pieces that must be joined together before use, since the full-length apparatus is too long to fit in the tray. To this device, one connects a stopcock and a flexible short bit of tubing which is then connected to the spinal needle once it has been properly inserted. Many docs probably forgo this whole routine, simply obtaining the spinal fluid and getting the heck out of Dodge, but I always perform the procedure in its entirety. Click on the picture for a closer look at the instruments in the tray.

As before, the procedure itself went smoothly. Afterwards, as I was disconnecting the two pieces of the manometer before disposing of them, I used a twisting motion to separate them, which freakishly caused the flexible manometer tubing to catapult a droplet of HIV-infected cerebrospinal fluid directly into my right eye. Dagnabbit.

This time, I didn't even think about taking antiretrovirals; I just washed out my eye and went on to my next task. I've had a couple of careless needlesticks since then and I've been sprayed with blood and pus a few times, but after those first two experiences I just try to be cautious and I put my faith in a higher power these days. So far it's working out.

My First Needlestick - Part 2

There are several factors which determine the severity of a needlestick exposure.

The first factor is the infectivity of the source. If a patient doesn't have HIV, of course you can't get AIDS from exposure to his blood. If the patient is dying of AIDS, you would expect the infectivity of his blood to be somewhat higher. My patient, despite our best efforts, died of AIDS-related complications at age 19 the very next day after I injected his blood into my palm. His hepatitis tests were negative.

The next most important factor is the type of needle involved. Hollow bore needles are well known to be more infective than solid suture needles, presumedly because the hollow needle can hold (and transmit) more blood. Larger bore needles create bigger wounds too, so the thick pipe of a 14 gauge needle is a significantly more concerning vector than a flimsy 27 gauge.

Other factors are the location and depth of the injury. A deep needlestick into a vascular area is thought to be more infective than a superficial prick into the pad of a fingertip or the sole of a foot.

Considering all of those factors, I assessed my risk to be not much better than if I had been sharing a heroin syringe while mainlining in a back alley with this guy. Of course I scrubbed and irrigated the wound like crazy, and my palm finally stopped bleeding after I held pressure for a bit. So I went ahead and made rounds with my team for the next couple of hours, thinking about my fate instead of my patients.

After rounds, I hurried down to the ER where I was fortunate to find one of the Infectious Disease fellows moonlighting as faculty. He tried his best to reassure me that the odds were in my favor, but freaking hell, I had just been badly stuck with a dirty needle carrying the blood of a critically ill AIDS patient. Of course I was going to take the PEP (post-exposure prophylaxis).

The research at that time was inconclusive; there just weren't enough cases of HIV conversion after needlesticks to know if PEP really helped, and there weren't any blinded placebo-controlled studies either. For all I know, there still aren't any.

The only preventive option at that time was AZT, so I eagerly filled the prescription and started taking the medication five times per day, as directed. The GI side effects were so intolerable that I only lasted one week of the recommended six, deciding to take my chances instead. Blessedly, my wife and I had already conceived our first child less than a month before my needlestick (which was also the very first month we had stopped using contraception). Otherwise, we would have had to wait another year.

Still, it was a pretty stressful year wondering if I was going to convert, and it was probably harder for my wife than it was for me. Every kiss was subtly tainted by the spectre of AIDS hovering overhead, transforming an expression of love into a grim reminder of the dangers of this job and the fragility of our false sense of invulnerability. As I mentioned, we sort of take AIDS for granted now, but back then it was a certain death sentence.

Fortunately, my tests came back negative, my wife delivered a healthy son, and all was well in my world....until my next HIV exposure, which was potentially even worse than this one.

My First Needlestick - Part 1

It's really amazing how much progress has been made in the treatment of AIDS. It seems like the only really sick AIDS patients I see now are street people who don't take their medications. But only 15 years ago, our ICUs were full of dying young men with ravaged immune systems; skeletal petri dishes clinging to life with glazed eyes and cottony mouths. Unfortunately, it was just such a patient whose blood touched mine early one morning.

He was 19 years old and probably weighed 100 pounds. His CD4 count was hovering around zero, and while we didn't test for viral load in those days, I'm sure his was maxed out.

I was the senior Medicine resident in the ICU, it was 0530, and I'd been awake for more than 24 hours. Most of that time was spent on high alert, putting out fires, juggling life and death.

But there was to be no rest for the weary that morning. Rounds were coming up, and this patient needed a central venous catheter pronto. His blood pressure was 60 systolic, and he was losing his battle with entropy. His femoral pulse was barely palpable, and his slight agitation made finding the vein difficult. After several attempts, finally I got it. I probably breathed a sigh of relief as I threaded a long wire through the 4 inch long 14 gauge needle, withdrew the needle over the wire and placed it down on the sterile drape where it disappeared, rolling unnoticed under a crease in the paper.

The rest of the procedure seemed like smooth sailing as I tried to make up some time. A third year resident is the master of central lines, and at that time I considered myself the best (I wish I was as good at them now as I was then). The lines were flushed, the pressors were started, the catheter was sutured quickly in place and adeptly dressed. I might just get to rounds on time after all, I thought.

After removing the fenestrated drape from the patient's groin, I wadded it up to throw it away.

OUCH!

That humongous bloody hollow bore needle had stuck me right in the palm. Sonofabitch.

Part 2.

Weekend in the ER

Dr. Shroom describes it hauntingly well.

From part 2:

"The next few hours were very ER.

The details blur around me, faster and faster as the days go by. I remember his colour, a pale, waxy yellow. It's never good, but you don't need me to tell you that. His chest laid bare, the wounds on his chest so small, so innocuous looking. So little blood.

That didn't last."

Perfect Timing

An awesome collection of dramatic moments frozen in time through the use of high speed photography.

h/t Conservative Grapevine

Heresy

Sometimes, an answer is so simple that nobody thinks of it. It takes a really simple-minded person like me to come up with the solution.

It is obvious that our ERs are overcrowded. Patients wait too long to be evaluated and even longer to finally get admitted to a room upstairs. A few have even died in our waiting rooms. Some people suggest that the biggest contributor to this problem is the lack of available inpatient/ICU beds upstairs which causes admitted patients to tie up our ER rooms and our nurses. I'm going to suggest another important cause.

Often when I start my shift, 9 of my 12 rooms are filled with patients who are waiting for admission. Sure, I can try to fast track a few patients in triage, but many patients are not good candidates for the "fast track" approach, and without a dedicated nurse to do all the stuff that I order, even simple patients are not easily managed in this fashion. And often when I need something done for one of my three patients, their nurse is busy managing an "admitted" patient.

So what can we ER docs do about it? Complain to management? Write a letter to our congressman? Wait for ACEP to fix everything?

How about not admitting so many patients (gasp!):

• Chest pain with normal ECG and negative enzymes and maybe a CT angio? Follow up with your Cardiologist, or I'll find one for you.

• End stage renal disease and short of breath early on a Monday morning? We'll knock your blood pressure down a bit and you can keep your regularly scheduled dialysis appointment. Usually you'll get dialyzed sooner there anyway. Potassium a little high too? We'll work on that for a bit then give you a swig of Kayexalate for the road.

• Pyelonephritis with vomiting? Have a shot of Rocephin and a Zofran. If you are still vomiting tomorrow, come back and see us. Otherwise oral meds will probably work just fine.
  

• Gastroenteritis? We probably admit more gastroenteritis patients than any other country in the world. There is an old-timey treatment known as "oral rehydration solution." Use it.
  

• Diverticulitis? No abscess = no admission.


• Cellulitis? Have a dose of IV antibiotics in the ER and complete the course with oral meds. See your doctor in the next day or two to be re-evaluated.
  

• Weak and dizzy? If your tests are negative, you can see your doctor tomorrow. Besides, you really aren't that weak anyway. Or that dizzy. Loneliness isn't a reason to admit a patient.

• Diabetes out of control? We'll aggressively manage it in the ER, and you can see your doctor in the morning. By the time a bed becomes available, I've probably already fixed you anyway.
  

• Suicidal? Really, or do you just want a comfy place to stay for a while?

You get the point, and I hope you recognize that exceptions will be necessary. Certainly not all of these patients can (or should) be sent home, but many of them could be. Sure, we'll miss some things, and a few "this should never happen!" cases will be paraded about by the media. But the clogged-up ERs are already causing some of those situations. I think we admit too many people as it is, and our overcautious approach seems to be contributing to at least some of our own problems.

We want to see acute patients in the ER, not manage already admitted patients who are waiting for a bed upstairs or twiddle our thumbs while patients wait in triage. If we stop admitting so many soft cases, the ones who REALLY need to be admitted won't have to wait so long to get a room and maybe the patients in the waiting room won't have to wait so long to be evaluated.

The success of this plan will depend on several factors:

1. Patients and their families will need to be willing to provide some of their own care at home.


2. Reimbursement for outpatient medicine will need to be increased, so PCPs will be willing and able to share some of the load.
   


3. The provision of adequate home health services will probably need to be improved in some areas.


4. Of course appropriate tort reform legislation is a must.


5. But the most important factor is that some of us ER docs will have to start growing some balls.

The default approach of many ER docs is to just order some tests and get the patient admitted, whether they really need admission or not. I'm suggesting that those of us who take the easy way out are part of the problem. Maybe raising our thresholds for admission would help our own cause, although currently we don't really seem to have much incentive to do so. We only get blamed for bad outcomes when patients are sent home, but we don't get any props for preventing unnecessary admissions.

Maybe if we were able to crank through a few more patients per shift, the extra income would be incentive enough. You try it first, and let me know how it works; my balls are a little gun shy right now.

ER Waiting Room Drama

From the incredibly prolific Girlvet, an overview of the different roles played by some patients while waiting to be seen. Too funny (and absolutely true).

The Martyr
The Enforcer
Nervous Nelly/Ned
The Instigator
Disappearing Dan/Diane
Mom of the Year
The Unknown Patient
The Skipping Record
The Drama King/Queen
Emotional Exiter

The Quicker Picker-Upper

An asthmatic man in his 20s presented to the ER in acute respiratory distress. He was immediately brought back to one of the critical care rooms, IV access was obtained, and inhaled bronchodilators were initiated while I performed a quick history and physical examination. I ordered a dose of IV steroids, and because his air movement was so restricted I also ordered 0.5 mg of epinephrine to be given subcutaneously.

There are two concentrations of epinephrine that we use in the ER. The first is 1 mg/mL (1:1,000) which is administered subcutaneously and used in cases of anaphylaxis or asthma. The second is 1 mg/10 mL (1:10,000) which is administered intravenously (IV) and used in cases of cardiac arrest. The first concentration is therefore 10 times stronger, so that it can be administered in a smaller quantity underneath the skin, typically with a tiny insulin syringe. IV epinephrine, particularly in bolus form, is rarely given to an awake patient with a heartbeat.

On that particular day, however, an ICU nurse was working an extra shift in the ER, and she happened to be caring for our patient. I was writing my note in the room when suddenly the patient exclaimed "OH MY GOD, WHAT IS HAPPENING TO ME??!!"

I looked up at the monitor and his heart rate had jumped up to 180, and he appeared frantic and wide-eyed. I immediately knew what had happened.

"Where did you give that epi shot?" I asked the nurse.

"Right there, doctor," she pointed at the IV catheter.

Oh. My. God. Apparently she had never given epinephrine subcutaneously before.

Despite the unfortunate epinephrine infusion, the patient still required intubation but made an uneventful recovery. Since then, I always overemphasize SUBCUTANEOUS when I give a similar order.

Once again, thanks to KevinMD for the link!

The Ultimate Sacrifice

A picture that will move you to tears.