American ER Doc Gone Walkabout Episode 019a
Dispatches from ACEP/fake news from North America:
Newsflash from ACEP: For the first time at ACEP Scientific Assembly, the number Ultrasound courses on offer exceeds the total number of registrants. ACEP notes that each registrant should be able to have truly personalized attention.
On a related note: EMF has a announced a grant for researchers interested in trying to show unequivocally that there is some bodily part that remains resistant to bedside ultrasound imaging.
(In another related note, an EM physician has reported a new technique for ultrasonographic relationship imaging that will allow rapid bedside assessment of adequacy of interpersonal relationships. Ancillary applications for single EP’s to assess availability of other staff for romantic approaches seem likely. An editorialist cautions married EP’s to be really circumspect in their use of the relationship probe.)
Change in policy for Scientific Meetings: all meeting have had their maximum permissible attendance cut in half: the American obesity epidemic has reached Emergency Medicine and a substantial proportion of our attendees require two chairs thus necessitating the cut in allowable attendance. Attendees “bumped” from meeting attendance will be offered a free voucher for a Big Mac with Large Fries to enjoy while awaiting another education session that might have two chairs available per person.
In a remarkable development, Greg Henry gave a talk on the neurologic exam that not once recommended a test or imaging procedure! In a tour-de-force of last century diagnostics, he explained that there were in fact diagnoses that could be made by the history and physical/neurologic examination. Unfortunately, he included the ophthalmoscopic examination (including evaluation of retinal venous pulsations) – a lost art last noted in ancient Mayan text. A search of the literature found allusions to Dr Henry’s talk in a Babylonian papyrus dated 1190 BC. (Seriously, the talk was great!!! And a reminder of the importance in neurologic evaluation of the history and exam.)
On a related note: I taught a course on the eye exam to medical students this week. I am currently hearing impaired, though recovering, having been deafened by the squeals of delight as students (and many of the residents helping to teach the course) for the first time actually visualized the retinal vessels and optic disk. Shrieks of: “OMG, there it is – that is so cool!” still reverberate through my brain.
The opening session – a mix of medical policy, politics, and economics – included an interesting conclusion by a policy and management guy: Obamacare, no matter the outcome of the national political theater of the next month, is likely to continue on. The insurance companies and the states have tread so far down the process of adapting to the new realities of improved insurance coverage in the US, that even a political reversal is unlikely to reverse the development that has already taken place to have in place the system to insure about 30 million more Americans by the beginning of 2014 – about 10% of the population. We can only hope.
In a related national news item: Mitt Romney, candidate for president, has announced a finding that may come as a surprise to many American EP’s: Medical care for all Americans is readily available, merely go to the Emergency Room! In this announcement, he echoes an identical statement by the last great American example of truthiness, George Dubya Bush – best known for his other dramatic finding, that Iraq possessed weapons of mass destruction that could be used to destroy America’s Emergency Departments, thus limiting the access to chronic care that those ED’s provided.
More seriously, a quick scan through the courses demonstrated:
As expected, large numbers of ultrasound sessions. Refreshingly, a number of sessions dedicated to an attempt to decrease the amount of radiation administered – often to little effect. The usual selection of session providing refreshers of the various subspecialties that we face (although, I couldn’t bring myself to look in on the session covering visual diagnosis of urogenital injuries.) Some of us would be disappointed at the number of sessions addressing the provision of primary care in the ER – I understand that the Mittster would send everyone poor to the ER for their primary care, but I fear that treating hypertension and such just might dilute out my time and my skill set for doing what rumor has suggested that we do: treat emergencies. Just Sayin’.
A number of sessions addressed the use of specific nerve blocks. An interesting issue: I’ve learned, used, and discarded quite a few of these from my armamentarium of the years. Many are technically challenging enough that the skill set extinguishes among those of us who use the conduction blocks relatively rarely. I suspect that for many (most) EP’s, getting really good at procedural sedation that can be used for a wide variety of circumstances, thus maintaining skills without having to learn a lot specific techniques for different illnesses and injuries, might be a more practical approach.
A panel discussion and case review on Critical Care in the ED: not much new: antibiotics are good, fluids are good, lactate clearance is good though should not give a false sense of security if the vital signs remain abnormal, norepinephrine is better than dopamine, and CVP seems less important than we thought a few years ago. And femoral lines really are OK – just wash the area real good first. Next topic—–
Prominent sessions on improving revenue streams and how to deal with the legal nightmares within American medicine might be somewhat foreign in the Australian (and UK) setting – though my French friend and colleague, Nicholas Peschanski tells me that such issues are infiltrating into French Emergency Medicine – along with McDonald’s big Macs. My most profound apologies to the French.
Speaking of French Emergency Medicine:
Nico showed me some video. He spends a week each year at a Search and Rescue site in the Alps, where he averages about 5 rescues per day – almost all done by helicopter. The video shows two guides and rangers, followed by Nico and a liter, being lowered 80 meters on a cable to the victim who had fallen into a canyon. The victim is winched back up in the litter, followed by the rescuers who are still dangling on the “wire” as the helicopter flies of to the hospital, finally arriving back in the mother ship only as they are well on their way. I concluded from watching this video that the French EP’s are truly nuts.
On the other hand, spending a few days with Nico, comparing the differences of our experience in the different settings is truly exhilarating. 24 hour shifts in a 107,000 per year ED? Ok, French EP’s are nuts, you betcha!
And then there’s the exhibits:
A walk through the exhibits showed, as expected that new companies continue to produce and market new ultrasound and video airway technology in expanding variety. Some of it is pretty cool, some is clunky, and some is just more of the same. The land of Oz would recognize the profusion of locum tenens agencies, and the scheduling software, but might be truly perplexed by the EMR software and its profusion of billing support, and the profusion of billing agencies, coding companies, and management consultants. Ozians might also be surprised at the rapid increase in the number of companies providing “scribes” – Emergency Medicine appears to have recognized two things: Doctors can’t write legibly, and EMR’s detract vast chunks of time from our interactions with the patient. I’ll have to drop Dr Henry a note explaining that my EMR takes so long that I only have time to document the neurologic exam, not actually perform a neurologic exam or talk to the patient.
Not surprisingly, although there were exhibits for a variety of medications that were relatively new and very expensive, there was not a single exhibit of any cheap drug. Fail.
CDC (the US government’s Center for Disease Control) had a small exhibit about tick-borne diseases. The woman manning the desk was giving folks advice about tucking pant legs into sox, and using DEET, etc. But, she turned out to be an epidemiologist with a remarkable grasp of the field of tick borne diseases, and taught me a bunch: A developing nest of Rocky Mountain Spotted Fever on the Indian Reservations of Arizona seems to be related to the uncontrolled dog populations of the Rez, abetted by the large number of abandoned mattresses that provide nesting for both dog and tick. And, remember doxycycline really is relatively OK for kids, and a little graying of teeth generally beats dying of rickettsial disease. And, I was surprised that relapsing fever (Borrelia species) which I had only diagnosed as imports in returnees from California, actually has had a number of local cases in Colorado – but since it is not a reportable disease, there is no educational program out there – you learn about it by sheer dumb luck.
Finally, Colorado has some larger animals than Oz does – although our bears appear to not be coordinated enough to put a stethoscope in their ears (it’s that lack of thumbs thing):
Next time: The News from #ACEP12 Days 2 and 3
American ER doc