The “EM Paradox”

From the Student Doctor Network:

I’ve been posting some recently about a paradox that exists in EMS which is basically a need vs. resources problem and it got me thinking about a similar paradox in EM. I currently see 2.5 to 3 patients per hour. That’s just the volume/staffing of the places I work. I would really be happier seeing ~1.5 patients per hour. That’s just me. I know this because when I have a slower shift I’m much happier.

Here’s the paradox:
When you work at a slower ED your resources a fewer and you have to work harder. I could go work in a nearby rural ED and see my 1.5 per hour BUT that place has no ICU and few consultants so many patients must be transferred. The nurses are less comfortable with the critical stuff. Because the inpatient census is low and there are few consultants the IM and FM docs are reluctant to admit anything. The transfers require a lot of extra work, phone calling and so on.

You are on your own for a lot of things in a small ED/Hospital. There’s no L&D so a precipitous 28 weeker rolls in you’re on your own. Bad multi-casualty trauma, all you. If you’ve never been the only doc in a rural ED with several critical patients and you have to start choosing who gets the helicopter versus the ground ambulance it sucks.

So, even though EM provides more flexibility than any other specialty we will always be trapped at the intersection of a few factors; volume, consultants/resources and what ever rolls in the doors. You can change jobs all you want to find the best fit for you but you’ll always be at the mercy of those three elements.

Happy Thanksgiving


Country (ER) Doc

From the WSJ Health Blog:

If you get sick in Murfreesboro, Arkansas, there’s a good chance you’ll meet Hiram Ward, age 81. He’s been practicing medicine in Murfreesboro (pop: 1,678) since 1953, and lately he’s been spending his nights and weekends taking calls at the emergency room there.

Ward went back to work in the ER at the start of this year because the town’s 32-bed hospital couldn’t find anybody else to take the job, and couldn’t afford to pay them.

For the first few months of the year, Ward was the only doctor covering the ER, which he says sees about 20 patients a day. Now he splits the job with one other doctor, and also works a few days a week (unpaid) at a local clinic.

First Person Account of HIV Needlestick

From the outstanding Scalpel or Sword, in two parts (thus far):

Part One (excerpt):

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.

Part Two (excerpt):

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.

“Stroke Code” Success

From Healthline

Last night, John was enjoying dinner with his wife. Suddenly he dropped his fork, a pain seared through his head. His right arm went limp, he tried to talk, but only incomprehensible slurs emerged. John at just 55 years old had suffered a massive, debilitating stroke. When he arrived at the Emergency Room a team of doctors and nurses had to quickly calculate if John was a candidate for a specialized drug therapy which could reverse his symptoms. Saving a life is a team effort. Not only must Paramedics, Nurses, and Physicians work together in perfect harmony, in a race against time, to make the correct medical decisions, but families must place their trust in those caring for their loved ones as well. John and his family had to hold out hope that all was not lost.

Illinois Med Mal Caps Unconstituitional?

An Illinois circuit court judge yesterday ruled unconstitutional a 2005 state law that caps non-economic damages in medical liability cases at $500,000 for physicians and $1 million for hospitals. Cook County Circuit Court Judge Diane Joan Larsen ruled that the law violates the state constitution’s separation of powers clause. Illinois Hospital Association President Ken Robbins commented, “We are confident that the Supreme Court will uphold the medical liability reform law as enacted by the General Assembly and signed by the Governor and determine that they acted legitimately in the best interests of the public health and the citizens of Illinois. This law is critically needed to preserve and enhance access to health care for Illinoisans and remains the most appropriate, meaningful and comprehensive solution to address the medical liability crisis.”

Meth Lab Menace


So here you are, with three victims with undetermined injuries and a situation that is one of the most hazardous EMS personnel will ever face. What do you do? Slow down, fully assess the situation, and then back off. This is not a normal scene. You are not equipped to enter this scene.1 Wait till police and firefighters arrive and apprise them of the situation. If fire and hazmat have not been notified, contact them. Your charge is to save lives, and in this case that means your own. The meth lab is more dangerous than any legal laboratory or chemical manufacturing plant. A legitimate production operation will have safety equipment and procedures, fire-suppression measures, appropriate ventilation and chemical-handling equipment in place. In contrast, an illegal lab will have no safety procedures or equipment, nor likely much concern for safety. Ventilation will be minimal, and chemical handling will be haphazard. Open fires, exposed electrical wires, broken glass and other hazards may be present.

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Quality Indicators: CMS Reporting

From the Iowa Hospital Association Friday mailing:

PPS hospitals must begin submitting data on seven indicators (reduced from 10) to an as yet undisclosed contractor beginning with outpatient services provided on or after April 1, 2008 in order to receive the full payment update for 2009. Like the inpatient PPS quality reporting program, non-compliant hospitals will receive an update factor reduced by 2 percentage points for the duration of 2009.

The seven measures CMS is requiring for the initial implementation of the the Hospital Outpatient Quality Data Reporting Program have been endorsed by the National Quality Forum and include (emphasis added):

• Emergency department (ED) transfer acute myocardial infarction (AMI) 1: Aspirin at
• ED-AMI-2: Median time to fibrinolysis
• ED-AMI-3: Fibrinolytic therapy received within 30 minutes of arrival
• ED-AMI-4: Median time to electrocardiogram
• ED-AMI-5: Median time to transfer for primary PCI

• Physician Quality Reporting Initiative (PQRI) #20 (Perioperative Care): Timing of antibiotic prophylaxis
• PQRI #21 Perioperative Care: Selection of prophylactic antibiotic

No liability for doctor who revived newborn

From the Seattle Times

A doctor can’t be held liable for resuscitating a baby who was born without a heartbeat and survived with severe disabilities, the state Supreme Court says.

The baby’s parents filed a malpractice lawsuit after the baby’s 2004 birth. They claimed doctors in Vancouver, Wash., were negligent when they continued to resuscitate the baby for almost half an hour, after he was born without a heartbeat.

The parents also said the medical team should have gotten their consent before continuing to revive the baby.

But the Supreme Court justices say the doctor can’t be held liable for failing to stop resuscitation efforts on a baby.