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Share your views on what it takes to survive and thrive as an Emergency Physician.

 

Monday
Jun222015

IEC MONGOLIA 2015

Last week Dr Robert Melvin and I visited Mongolia as part of a contingent of 8 Emergency Physicians and a sonographer to participate in the Initial Emergency Care (IEC) course.

The visit was part of an annual cooperative project founded by Northern Health Anaesthetist David Pescod over ten years ago. Emergency Medicine has been a part of the program since 2011 when Dr Helen Stergiou joined the anaesthetic team and added topics such as Trauma Management and ECG interpretation to the topic list.

The Mongolian interest has been so strong that the Emergency Training is run seperately and has led to the establishment of an Emergency Medicine Residency Program there.

This year’s program included delivery of workshops covering BLS, ALS, PLS, ECG interpretation, Radiology, Trauma skills, Wound management and the ISBAR communication tool.

Bedside ultrasound was included for the first time as, whilst there are no CTs outside the capital Ulan Batar, many remote doctors have access to a portable ultrasound.

In Mongolia the team split into two to cover two remote provinces with the eventual aim to deliver IEC to all twenty regions.

It was a truly spectacular and enjoyable experience with the local team demonstrating how to be amazing hosts. Other members of the team came from Bendigo, Western/ Sunshine and Maroondah hospitals and could only be described as a great bunch of people to be around.

For more information on this ongoing project contact Dr Loren Sher or Dr Rob Melvin.

 

 

 

 

 

Sunday
May032015

Focus on Nepal

 This week, we have seen devastating scenes of destruction caused by a massive earthquake which has struck one of the poorest countries of the world.  With thousands dead and multitudes injured, the worst is yet to come.  Nepal has always been reliant on foreign aid but will now need it more than ever.  There are many ways to contribute.  Dr Yash Ayuja will be departing today for a 2 week missions with TrekMedic to provide emergency aid.  The Northern ED staff wishes him well and a safe journey.

For those interested in donating towards Trekmedic, visit their Facebook page for more information, email trekmedic@hotmail.com or contact Peter Jordan or Phyllis Fu for more ways to contribute.

 

Wednesday
Apr292015

EM MINDSET: REUBEN STRAYER – 8 RESPONSIBILITIES OF THE EM DOC

From EMDOCS.net

Author: Reuben Strayer, MD (@EMUpdates)

 

Dr Ruben Strayer (responsible for the FOAM blog EMUpdates) believes every emergency doctor has eight discrete responsibilities.

Whilst the context is obviously North American his discussion of each of these (in ascending importance) rings true.

  1. Public Health

At least in the US, primary care is mostly available only to a privileged minority, leaving many folks to use the ED for all of their medical concerns. This has led to an expansion of the clinical purview of emergency medicine to include a variety of primary care responsibilities. Depending on where you work, such efforts could include screening for HIV, hypertension or domestic violence, offering harm reduction programs related to alcohol or drug abuse, or interventions that feel like acute care but are really public health measures like providing tetanus vaccine. Many EPs were not taught to think about public health initiatives as part of their job; it feels too many of us like a task that takes away from the acute care we’re more interested in, a task someone else should be doing. Indeed, the most successful ED-based public health programs use non-EP clinicians to carry them out. At the same time, you make a much bigger difference when you convince your patient to stop smoking or lose weight, enhance their diabetes or asthma management, or pick up an occult case of HIV, then you do resuscitating stroke or sepsis or whatever your favourite dangerous condition that mostly affects older, sicker patients. So, especially when you’re not getting creamed by the board, you will do well to do a little public health.

  1.  Resource stewardship

Acting as a gatekeeper for tests, therapies, and consultants is usually not explicitly recognized as a responsibility of the EP but we are often the crossroads of care between the outpatient and inpatient realms and determine which patients require the assessment of a specialist, which most of the time will entail a battery of tests and therapies, not that we don’t ourselves over-test and over-treat. As everyone grapples with the complex consequences of over-doctoring, we are all increasingly held accountable for the tests and therapies we order. The best way to overcome the barriers to reducing resource use, which are also complex but centre around fear of missing a dangerous condition, is to develop departmental and institutional care pathways that are designed to optimize the balance between patient safety and resource expenditure. Otherwise, try to practice with the recognition that there is a chance of harm with every test and every therapy ordered, and that this chance of harm should always be weighed against chance of benefit. Avoid routine tests, be especially mindful of the effect of CT radiation on young people, and when you can’t decide whether or not to consult, don’t. ACEP has joined the Choosing Wisely campaign, know what our College has to say about the practices it considers wasteful. http://www.choosingwisely.org/doctor-patient-lists/american-college-of-emergency-physicians/

  1. Customer service

Many EPs would say that customer service is actually our most important responsibility that we are in fact in the customer service business. Even if you’re not willing to go that far (I’m not), you can greatly improve your customer service – which has perhaps the biggest return on investment of any professional skill you can augment – by firstly recognizing that customer service and best medical practice are not related. That means that you can provide optimal medical care and your patient can still leave the department cursing your name and threatening with lawyers, or you can commit malpractice, try to kill your patient, and if you fail, that patient can leave singing your praises and writing letters of commendation. The point is that medical best practice and customer service are separate skills, and you have to be good at both of them.

There are a few things you can do that will have a huge impact on customer satisfaction. The first is to set expectations low: under-promise and over-deliver. Most patient disappointments centre on delays in care – waits to be seen, waits for tests, for consultants, for a bed upstairs. If you routinely and proactively counsel patients with time estimates that are double how long you think these things will actually take, you might get some surprise and frustration up front, but you have set yourself and your patient and your patients’ relations up for satisfaction.

Figure out what the patient wants. Some patients want to feel better, some patients want to know what’s causing their symptoms, and some patients want a Percocet prescription. If you know that a patient is here for a Percocet prescription but you focus on what’s causing their symptoms, or if you know the patient is here because they can’t handle taking care of their elderly mom at home but you focus on symptom control in the ED, you are going to have dissatisfied customers. Commonly, patients want things that you cannot or will not provide (e.g. a Percocet prescription), and making those customers happy is very difficult, but you are more likely to do so (or at least manage them more effectively) if you focus on why they came.

The most common patient desire that we cannot fulfil is to know what is causing their symptoms. In most cases of abdominal pain and chest pain, for example, what we do is make sure it’s not dangerous, we don’t determine a specific diagnosis (though many EPs assign a benign specific condition – what I call as BS condition – without conclusive evidence of such, I don’t recommend this). If you specifically acknowledge your patient’s desire to know what is causing their symptoms, acknowledge that you didn’t give that to them while emphasizing what you did give them (reassurance that it looks like the symptoms are not caused by something dangerous), your patients will leave happier, which will make your life a lot easier. 

  1. Managing ED flow

Emergency Medicine is unlike all other specialties in many ways, one way is that we are entirely reactive; an EP has no idea what they will encounter when they shows up to work. Although other specialties joke at how focused we are on disposition, when you don’t control the entrance, you have to be constantly thinking about the exit. Learning how to move through patients efficiently is a core EM skill. An easy way to improve your efficiency is, after every patient you see, to run your list asking one question: what is this patient waiting on? Unless an unstable patient requires care, always take care of tasks that move existing patients forward prior to picking up a new patient, as tempting as it is to just see another one. Another lesson hard learned is that multitasking is a myth: you cannot simultaneously do two things at once that require a high level of attention, and most of what you do as an emergency physician requires a high level of attention. “Multitasking” is actually ordering and taking care of a group of tasks in series. When you are interrupted with a task that needs to get done, either stop what you’re doing and do the new task, immediately delegate that task, or write it down. The demand for your cognitive resources exceeds supply, so rely on your memory as little as possible.

  1. Determination of disposition and level of care

 The essential question with regard to disposition is how likely is this patient to get sicker?  While determining how sick this patient is is a cornerstone of emergency medicine, determining how likely a currently well or mildly ill person is to become more ill is much harder and more important. Although we want to make dispositions as soon as possible, some patients require a period of observations to declare their clinical trajectory; if a patient you just admitted to an unmonitored bed decompensates shortly after arrival to the ward, you may have made a consequential error. Most of the time it’s clear what level of care an inpatient requires, but when it isn’t, don’t be afraid to watch the patient for 2, 4, 6 hours to see which way they go.

Discharging patients is of course a sharper edge. Not all discharges are the same. Sometimes you know there’s nothing going on with this patient, in which case there’s a sense in which it makes no difference what you do, send them out into the cold, godless world with a pat on the back and some shitty pre-printed discharge instructions. Many patients that you discharge, however, you’re not as confident that there is no occult dangerous condition. In these cases, make it clear to them that although you don’t see any evidence of a dangerous condition right now, sometimes there are dangerous conditions that can be hidden, so, Ms. Jones, if you develop new symptoms that concern you, or you get worse, come back to the ER immediately, we’re here 24 hours a day, 7 days a week.

There are some patients that you are really nervous about discharging. You’re discharging them, but reluctantly. For those patients, bring them back. In 24 hours. In 12 hours. If they’re feeling a lot better, don’t worry, they won’t come back, and if they’ve gotten worse, you want them seen again. Bring them back.

And I give a lot of patients my phone number, with the instruction here is my phone number – if you have any concerns about today’s visit, or you feel like you’re getting worse, call me. The phone number I give them is a Google voice number, which is free, and I’ve configured it to just be a voicemail; when someone leaves a message, I get an email and can listen to the message. I give out this number routinely and only get a couple calls a month. Am always glad they called. Almost always.

  1. Symptom relief

Symptom relief is a core responsibility of emergency physicians. And it’s usually pretty easy, once you remember to do it. The key is to remember to do it. All non-malingering patients who have a symptom amenable to treatment (pain, nausea, vertigo, whatever) deserve to have that symptom treated, and it’s so easy to know whether to write for another dose of morphine – you just ask the patient. Do you want more medication for pain? If you get into the habit of asking, is there anything I can do to make you more comfortable you will make your patients so happy, which will make you happy, in addition to making you a better doctor.

  1. Identification of dangerous conditions

Identification of dangerous conditions is probably the toughest part of what we do, truly the hard science and art of emergency medicine. The best way to do this is to become intimately familiar with the roughly 150 immediately dangerous conditions in medicine, and, when you approach the patient, do your history and physical not in a template, med student like way, but in a way that is specifically designed to rule out (or rule in) these dangerous conditions. When you identify the complaint as headache, you call to the forefront of your mind a list of dangerous causes of headache (there are 13 –http://emupdates.com/2015/01/15/headache-in-the-emergency-department-13-dangerous-causes) and then ask questions and perform exam manoeuvres specifically to cross elements off that list. Although 150 conditions seem like a lot, and it is, those 150 conditions are the house of emergency medicine; emergency physicians live in a house made up of those 150 conditions. Welcome home.

  1. Resuscitation

Resuscitation and identification of dangerous conditions are tied for the most important responsibilities of the emergency physician, but resuscitation is a lot sexier. It’s also a lot easier. Here is a particularly well-done video that gives you a framework on how to approach the first five minutes of resuscitation to give you a leg up.http://emupdates.com/2014/07/03/the-first-five-minutes-of-resuscitation/

There is a lot more to the EM mindset than the eight responsibilities. Like being comfortable making very consequential decisions with incomplete information, being comfortable being interrupted every 30 seconds, being comfortable being screamed at (and vomited on) by strangers, being comfortable giving strangers the worst news they’ve ever had. And being comfortable reducing fractures, and defibrillating people in cardiac arrest, and delivering babies, and sewing up the laceration on the billionaire everyone’s heard of who’s lying one gurney over from the undocumented immigrant who also has a laceration and speaks a language no one’s heard of, and providing comfort care to the 96 year-old taking her last few breaths, and intubating the nearly dead 10 day-old with undiagnosed congenital heart disease.

But tackling these eight responsibilities is a good start.

Another excellent take on this topic (its a series really ) by Rob Orman can be found here:

http://www.emdocs.net/em-mindset-rob-orman-the-successful-ed-mindset/


Thursday
Mar122015

Teaching doctors how to engage more and lecture less

Clinical empathy was once dismissively known as “good bedside manner” and traditionally regarded as far less important than technical acumen. But a spate of studies in the past decade has found that empathy is essential to provision of high quality care:

 

  • Empathy is essential to establishing trust, the foundation of a good clinician-patient relationship
  • Empathy is now recognised as a cognitive attribute, not a personality trait, and the validated Jefferson Scale of Empathy
  • Today’s  patients have higher expectations and are less willing to tolerateclinicians they consider arrogant or unapproachable.

Rather than being a product of a fixed personality trait it is increasingly recognised that empathy can be taught. Empathy training focuses on self-monitoring to reduce defensiveness, improve listening skills and decode facial expressions and body language. It also teaches clinicians take stock of one’s own emotional responses to patients or situations.

Many clinicians believe they don’t have the time to be empathic but the skill has proved to be a timesaver rather than a time sink. It can help doctors zero in on the real source of a patient’s concern, short-circuiting repeated visits or those “doorknob moments” doctors dread, when the patient says “Oh, by the way . . . ” and raises the primary concern as the clinician is headed out of the room.

Doctors are explainaholics. Their answer to distress is more information. In reality, bombarding a patient with information does little to alleviate the underlying worry.

Here are some simple rules to consider when getting things started:

Make eye contact

Introduce yourself by name

Don't stand over the patient

Pay attention to facial expression body language and tone of voice

Never answer an emotion with a fact

 

Extracted from: Teaching doctors how to engage more and lecture less - The Washington Post

 

Friday
Jan302015

Australian of the Year 2015

     

Rosie Batty has risen above the loss of her 11 year old son, Luke, who was the victim of domestic violence at the hands of his father and jolted Australia into recognising that family violence can happen to anyone.             

 Domestic Violence or family violence refers to a complex range of situations including abuse of the elderly, sibling abuse, violence between same-sex couples, adolescent children being violent towards parents, carers being violent towards people with a disability, or female to male partner abuse however the majority of family violence is perpetrated by males against their female partners. It is now the the highest cause of mortality in women <45 years of age in Australia.

Intimate Partner Abuse often results in presentations to Emergency Departments where we are in a unique position to activate support services that may help break the destructive cycle of abuse and reduce the significant risk of injury and death associated with this all too prevalent phenomenon.

In all cases of suspected or disclosed Family Violence a referral to the ED social worker should be made. In many cases where inpatient admission is not required an admission to SSU is appropriate to allow time for the necessary psychosocial  assessment and  risk management planning to occur.

The Northern Health Social Work Clinical Practice Guidelines are available on Prompt and include a clear outline of the relevant issues and processes: http://nhprompt/prompt/Search/download.aspx?filename=1266990\1276674\14816568.pdf

 

The current issue of Annals of Emergency Medicine also includes a clinical management guide to intimate partner abuse which provides further considered and insightful guidance which can be accessed here.