Emergency Advocacy

In my first weekly conference as an emergency medicine intern at Yale, we had several lectures. Topics included D-dimer in pulmonary embolism, atrial fibrillation, chest x-ray reading and emergency medicine advocacy. What? Advocacy in the classroom? One of our EM professors is an expert in the subjects of accident prevention policy, so she gave us a primer on what we can do as new doctors to contribute to the current health care debate. Here's the letter I wrote this morning on my day off.

Dear (Insert CT lawmaker name here),

I am a resident physician in the Yale-New Haven Hospital emergency department. I'm writing to tell you a little bit about ER conditions so that you will have a sense of how emergency care is an important issue that should be included in the currently debated health plan. A health care plan in our country cannot be comprehensive if it does not address emergency care.

When I show up for my 12 hour shift at Yale's level one trauma center, I am immediately inundated with an atmosphere that to an outsider could be perceived as chaos. The scene is far from the clean depictions on your television set, and believe me, there is not time for the intrigue that home viewers expect from “Grey's Anatomy.” Every night at many of the top hospitals in this country, patients sit in emergency room hallways for lack of private rooms. It is not unusual for these folks to receive all of their care in the hallway. I will personally wheel patients in and out of rooms so that they may have the dignity of a private exam. It breaks my heart to tell these folks, “We'll only be in here for 10 minutes before I take you back out into the hallway.” Can you imagine your doctor saying, “You have appendicitis and will need surgery, but until then try to make yourself comfortable on this hallway stretcher,” like I have? When you are having the worst pain of your life, you can't understand there is someone sicker than you.

This brings me to the health plan. There are always really sick patients. President Obama has been championing primary care as the centerpiece of his plan; and rightly so: prevention and a steady relationship with one doctor will go far to reduce health care costs. But increasing resources to primary care will not alleviate the overcrowding problems we face in delivering emergency care. For example, with 97% of the population in nearby Massachusetts insured, ER use has increased by nearly 10%. A refrain we physicians wish to emphasize is: coverage does not equal access. Where do people go when they get sick after hours?

I am familiar with and applaud sections 214 and 215 of the current Senate bill (“Systems for Emergency Care...” and “Trauma Centers...” in “Quality, Affordable Health Care for all Americans” submitted by Sen. Reid), and hope you will support these provisions. The grants and mandates are based on recommendations a 2006 Institute of Medicine report and will go far to improve care through one of the most frequent access points for people in need. In the interim, I'll do my part to see as many patients as I can safely handle so that our ER's hallways are used for walking, not patient care.

Sincerely,

Thomas Robey, M.D., Ph.D.

If you are wondering why I don't post more here in the next year, it's because I'll be using my time to write other things. Such as letters like this...

Rotation Schedule

This week, I assumed my place in the national online call reqistry known as amion.com. (That's pronounced, "Am I on?") Like every other resident, my call schedule is available to anyone with the proper login. Since I'm not sure how protected said logins are, I'll relay for all those who are interested which rotations I've been assigned.

6/21 - 7/20 Yale ED & Orientation
7/21 - 8/17 Bridgeport Hospital ED
8/18 - 9/14 Bridgeport Hospital ED & EMS
9/15 - 10/12 Bridgeport Hospital ED
10/13 - 11/9 Pediatrics at Bridgeport Hospital
11/10 - 12/7 Medical ICU at Yale
12/8 - 1/4 Ultrasound & Anesthesia
1/5 - 2/1 Ob-Gyn at Bridgeport Hospital
2/2 - 3/1 Yale ED
3/2 - 3/29 Cardiac Care Unit at Yale
3/30 - 4/26 Orthopedics
4/27 - 5/24 Medicine at Yale
5/25 - 6/21 Yale ED

This is just one more step in my transition to residency!

Goodbyes

ED Shoes, click on the image for a Flickr interactive view.

There comes a time when all that's left to be said is, "Goodbye old friend." This week I used that phrase twice. Once to the Harborview emergency department and later in the same day to my clinic shoes. Over the past 2 years I've used a dedicated pair of shoes during ED shifts and overnight call. The day I stepped out of the Harborview ED was the same day I said goodbye to these old friends. The left toe bears the badge of ortho (plaster). The right foot has a spatter from irrigating my last wound in Seattle. Both bear marks from my away rotation at San Francisco General, as the heels and laces retained a tinge of the scrubs' cranberry pink dye. The real reason for discarding this pair was the torn apart left heel and loss of sole traction. Otherwise, with a splash of bleach they'd be ready for another shift!

An expanded version of this article was published at Medscape's student blog, The Differential.

911 Blogs

There's a blog published by the now online-only Seattle Post-Intelligencer called Seattle 911: A Police Blog. Many cities have similar sites that act as 21st century police scanner bulletins. While surfing for news this morning, I happened to find that the top three stories on the site involved patients I saw at Harborview Medical Center during my last shift. There are also pictures to help understand the injury mechanism. Here's one:

The entries each indicate transport to the hospital where I was on call. My willing compliance with HIPAA and patient confidentiality rules prevents me from saying any more about the specifics of the cases, but I will comment briefly on a facet of patient care that could use improvement. Information is often lost in the transition from witnesses to emergency response personel to emergency physicians to their hospital consultants. (I was a student on the orthopedics team at the time.) We hope that the important information is maintained, but invariably, there is something that we wish we had known at the time.

Even with excellent sign-offs between providers, patients come in to the hospital with limited histories. Patients could be 'out of it' due to shock, pain or pain medicine. There could be a language barrier. Patients are sometimes intubated. Important features may have been observed but not documented on the scene, in transit or during an initial physical exam.

One of the important questions in the patient's history for emergency docs are: How did this occur? Among providers, this question becomes: What was the mechanism? Discovering or confirming this info with the patient is one way emergency providers evaluate patient alertness and orientation while they do their injury surveys, so patients sometimes get annoyed at having to tell the same story over and over again. But that's if the patient can tell the story. Sometimes they cannot.

It turns out that the Seattle 911 blog had information that may have been helpful for providers to understand these patients' injuries. In two of the cases from Friday, the entry was made while (or soon after) the patient was in the emergency department, further underscoring the potential utility of electronic documentation of pictures. One of the patients described the accident in a way that when I saw the image, I thought, "I saw the person involved in that accident." The other image generated a, "So that's how that happened" response in me. The importance of pictures (yes, worth a thousand words) is well known in emergency care; the soon to be history Polaroids of automobile accidents are often taped to critically injured patients' charts. The photo below is more a reminder of how beautiful it was on Friday that how the accident occured.

It wouldn't have changed how we treated these patients to know the specifics documented in the blog entries; the primary determinants of treatment are derived from the physical exam and what the x-rays and CT scans reveal. But one wonders if speedy documentation of accidents and injuries in the field could ever be incorporated into the electronic medical record. iPhone medicine is already being practiced in many emergency departments. The fellow on our service used his Blackberry to photograph one of our patients' wounds. He only partially joked with the radiology tech that he needed it to plan for a surgery. The image was later used to communicate with the attending surgeon and was reshown the next morning during a sign-out conference.

Reforming and universalizing the electronic medical record is central to the Obama plan to reduce health care costs. I hope the software programmers include a mechanism for documenting accident photos. In the mean time, maybe I should keep the local injury blogs open on one of the ER's computers.

Photos are from the Seattle 911 blog and were taken by Ben Otteson and Dana Vander Houwen.

Emergency Policy

Now that I'll be moving to Connecticut to further my medical education, I've tried to start paying attention to health policy in that state. An article in the New York Times today sated my weekly appetite for such information. The punchline is that in this difficult budget cycle, the governor of CT (M. Jodi Rell) has proposed cutting state support to the state's only emergency flight system. LifeStar is headquartered in Hartford, but as this map shows, conducts about 250 flights a year to the Yale-New Haven Hospital.

If the cuts are approved, there will be financial capacity for only about half of the flights now made. The governor's office cites that this program is run from a private hospital as a reason to be included in the cuts. The problem with this reasoning is that there is no other service in the state making this kind of transport. According to the article, legislators on an appropriations subcommittee recently recommended restoring the entire $1.4 million that was cut. Even so, I think it's reasonable to engage in discussions about the cost of emergency transport. It seems to me the $9000 per flight cost is worth saving a life.

Thoughts and Prayers

There are some news stories that demand your attention. Those of us who gather information online are used to seeing the eye-catching news stories (like in the column of story links on CNN's webpage) that keep you from surfing to the next site. It says a lot about the media that headlines like Woman on horse shops at Target are adjacent to 3 Oakland police officers killed in shootings. I admit that I typically avoid the news stories about killings equally with the stupid sounding ones. So why did I read the articles about the tragedy in Oakland?

I think it was the personal connection.

1. In my career as an EM doc, I will see plenty of shootings.
   
2. I've already been a part of care for a man down.
   
3. I admire how firemen, police officers and medics put themselves at risk for a greater good.
4. In the recent match, I ranked the emergency medicine residency at Highland Hospital (in Oakland) very high on my list.

That I had already imagined myself living in Oakland, working at Highland and being a part of the trauma team that received victims like this struck a chord with me. Unfortunately this is not the last time I will face a situation such as this. Part of me believes that reading about this, reflecting on it and greiving in absentia will help me prepare for when I'm the one applying pressure, pushing fluids and wheeling the patient to the operating room as soon as possible. Would I also be among this group? Police officers, ministers, community organizers, political leaders and concerned citizens are gathered all around Oakland in groups shown in this photo. This scene just happens to be in an ER waiting room that I've walked through. A different kind of mourning was no doubt going on behind the waiting room walls.

Photo: Justin Sullivan/Getty Images

Is there is also a role for EM docs outside in the community talking about violence, safety and emergency response? I'm sure the answer is yes. I wonder what that would look like.

Match Day

We have 3 months to finish medical school and move to New Haven. Ready, get set, GO!!!

Hospital Diversion

Is it wrong for a university hospital to turn away a patient because he doesn't have insurance? What if it was a kid attacked by a pit bull? There's been a big splash in Chicago about a child with dog bites to the face being sent home to follow up at a different hospital. The situation has drawn criticism from the American College of Emergency Physicians, but the University of Chicago is defending its position to divert uninsured patients. This story's juiciness is enhanced by the direct connection between Michelle Obama and hospital’s Urban Health Initiative (UHI), which has as its goal to divert non-emergency patients away from EDs. It’s supposed to make the system more efficient by freeing up ED staff to treat the most urgent cases. But ACEP likens it to dumping unprofitable patients.

This creates a tough challenge for me. As the newspapers and ACEP present it, this policy clashes with my reasons for choosing a career in emergency medicine. But I've also held that innovative solutions for improving access to medical care should be able to be implemented from within the ED. I didn't hear much about the UHI when I interviewed at the University of Chicago. But in a recent email to applicants, the U of C emergency medicine residency program director did say that training will actually not be very much different because of the University's policy. This makes a lot of sense, given that training occurs at four hospitals around the city and there are always patients in urban ED waiting rooms. And as Ben points out below, it is important to see both sides of this story. But the impression of the program will suffer. Is that a risk I want to take in assembling my rank list?

If you're in my ethics class, we'll be focusing on this issue in two weeks.

Pet Therapy

A few months ago, we had a different sort of patient show up to the psychiatric emergency department. It had brown hair, floppy ears and four legs.

Read about it at my article on the Medscape blog. You'll need a free Medscape account if you don't already have one.

NTSB vs Flight Medicine

There are a few emergency medicine programs that require residents to fly on helicopters. I will not be ranking those programs at the top of my list. MedEvac is an important part about emergency response and I respect the folks who fly a great deal, but I'm not sure it is a necessary part of my hospital training. Especially when more that 35 people have died in the last year on medical helicopter flights. The National Transportation Safety Board is hearing testimony about this issue this week.

Ethics in the ER

This recent Wednesday was the first meeting of the Ethics in the ER course that I am co teaching with Harborview ER doc Stephanie Cooper. Our goals are to expose medical students to how the complex medical decisions made in the emergency department often demand a quick assessment and resolution of ethical dilemmas. The ER (especially in urban hospitals) is one place where physicians will rely on ethical principles every day.

So we've put together a course that features 20 minutes of lecture, 30 minutes of instuctor-led case reasoning, and an hour of student group reasoning. As the class moves forward, we will increasingly role play the fast pace neeed in the ER.

Since I'm a blogger, we're using a blog to enhance learning. If you want to follow along, feel free to stop by and read the students' posts. I'll be posting thinking exercises and links to relevant stories over there every week. There is also a course website, where you can peruse our reading list and syllabus. We're hoping to publish some of our motivations and experiences with this venture, as we are unaware of other efforts along these lines...

Interviews Continue

In the process of making some of my last reservations for airfare and hotel, I cannot help but think about how fortunate in these ever-worsening economic times we senior medical students are to have a say in where we will work next year. It seems more of a pain than a privilege to have to jet across the US in search of the best-fit residency. But as each interview unfolds and as I'm toured the guts of America's hospitals, and as I observe how emergency departments operate on this coast or that, I feel tinges of conflict. Here I am with great opportunities - only one of which I will pursue - while the patients I'm chomping at the bit to meet, treat and advocate for face the converse: evaporating opportunity, escalating suffering and vanishing resources.

When framed this way, I ponder canceling the rest of my interviews. My pro&con lists from each program pick out relatively small differences between places. In the end, I know I must continue on for another few weeks. While the next month may consist of greenhouse gas guilt, travel fatigue and missed loved ones, the four years of residency will consist of lost sleep, steep learning curves, stresses of responsibility and the anguish of bearing witness to great pain and suffering. It will be important to live in a context of a supportive environment. Academic, social and even political and geographic context will play a part in my decision to rank programs. After then, it is up to the big computer in the sky to decide where is best.

4th in 5 Days

I'm in NYC ready to interview at the NYU/Bellevue emergency medicine residency. It's my 3rd city in 4 days, and tomorrow will be my 4th interview in 5 days. On my day off, I observed for a few hours in the New Haven hospital before going by Amtrak to NYC. I'm not particularly tired, but I do miss being home. Some things that have made this trip easier include:

• Traveling by train in the northeast is easy: show up at the station, get on the train, work in peace and quiet for a few hours, get off the train & you're there.
• Staying with friends from med school is great. Since I took 4 years to do my PhD, my classmates are all 4th year residents and therefore very knowledgeable hosts. It saves lots of ca$h, too.
• Traveling light is a must. For me, that's a bike messenger bag and a shoulder garment bag.

Negatives include:

• Not seeing or talking to my wife much - The three hour time zone difference further complicates the fact that she is working a night shift and sleeping days, and "everything's in a fog" for her.
• Gum on transit seats. Bad form folks... If only we were in Singapore! My impromptu road extraction kit lacks a key solvent. Hopefully the friendly neighborhood dry cleaners will be able to help me next week. My evaluators will have to look REALLY CLOSE at my backside to notice the gum remnant!
• Answering the SAME QUESTION over and again. At least my response stays the same each time.

Well then! Enough from me...

EM Interview Questions

There are a number of standard residency interview questions that candidates are asked in the interview circuit. A Google search will provide you with some stock questions you should be prepared to answer. For various reasons, I tend to take advice from those sites with a grain of salt. So here are some actual questions I've been asked on my emergency medicine residency interviews.

• How did you decide to apply to our program?
• Where will you be in 10 years?
• You've a different background than many applicants. Describe your trajectory in deciding on emergency medicine.
• What have you been reading?
• What is Wunderkammern? (A hobby I listed on my application.)
• So! What do I need to know about you?
• Which of your letter writers do you admire the most?
• What questions about our program can I answer for you?
• How would you respond to (insert complicated ethical dilemma here)?
• What are you doing the rest of the year?
• What are your plans for the holidays?
• What courses are you enrolled in this year?
• Why emergency medicine?
  
• Where else are you interviewing?
• Why (insert city here)?
• What will your first book be about?
• How have you responded to a situation of personal conflict?
• What areas of emergency medicine need the most work?
• Do you want to go back to Seattle to practice EM?
• What do you do to relax?
  

I'll give periodic updates to this list. I've only interviewed in three places. Do any of you co-applicants have any additions?

Today is the Day

Today I interview at UC San Francisco for a spot in their emergency medicine residency. It is the first interview of many for me, but is one of my very top choices. I've spent the last month working in San Francisco General Hospital, and really like the place. Granted, it's the only academic ED I've worked in thus far...

Well then... Here goes!

Fog Horns

It's a reset weekend.

After doing mostly 6AM to 2PM or midday shifts, my schedule necessitates my transitioning to an inverse circadian rhythm. After two days off, I have one 2PM to 10PM shift, and then five 10PM to 6AMs. Just like flying across country there are a couple of tricks for adjusting that I'm trying to follow. Today, I:

• Slept until 9:00 AM
• Plan to have a late breakfast
• Am contemplating each toot of a distant foghorn
• Will take a midday bike trip (via BART) to my parents in the East Bay
• Plan to eat dinner as my second meal
  
• Anticipate catching up on my writing late into the night

Tomorrow, I plan to:

• Sleep in even later
• Wait for the (forecasted) morning rain to cease before returning to San Francisco
• Take an evening jog
  
• Eat lunch, dinner and a late night snack
• Study some topics in emergency medicine
  
• Sleep from 1AM to 9AM (Monday)
  

Then I'll have to figure out where is the best place to sleep during the day...

A similar plan worked for me when I flipped from 12 hour day shifts to the converse while working at Harborview. Stay tuned for the outcome.

Bummers

How would you feel if after being treated for a traumatic car accident, the ER doc comes back to tell you there's probably a tumor in your lung?

Medic Ride-Around

I just returned from 10 hours on a paramedic rig in San Francisco. This is part of the emergency medicine rotation at San Francisco General. It was a rather interesting day. Not very busy, but busy enough that I only napped for 10 minutes around 1:30 PM.

The cases included:

1. A morning commuter who fell in a crosswalk, skinned her knee and was bleeding from the head.
2. An older gentlemen one week out from a prostate surgery who had bloody urine and pelvic pain.
3. A kid who fell in gym class onto a tennis court and had midline neck and back pain.
4. An eleven year old who was post-ictal from his first seizure.
5. A different eleven year-old who konked heads with a classmate playing football.
6. An elderly diabetic woman who fell at the food pantry and incurred a non-bleeding scratch on her knee. She later offered to dance for us - for a fee.

Three of these went to a hospital. The medics apologized for not having any 'interesting' cases, but one pointed out that his favorite kind of day is one where no one gets hurt. It was interesting to me to see what people call 9-1-1 for, and the expense incurred for it. That's a difficult thing to get my mind around. And I'll have to think about that a little more.

2-10

Warning: humdrum domestic details ahead!

My first shift is today from 1400 to 2200. Last night I prepared by staying up until 11:00 PM. Today, I tried to sleep until 8 or 9:00. This morning, I'm reading emergency medicine stuff for a few hours, am soon going to track down some biking shorts (be very afraid) and a reflective vest, and will head over to the San Francisco General around 1:00 so I have time to shower and get my hair done. Then, since I have tomorrow off, I think I'll head over to the East Bay to get some computer work done. Now I just have to find a library where I can set up shop working on my various writing projects...

Take This Class

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