Emergency Medicine

Emergency physicians, nurses, and residents writing on KevinMD from the emergency department: acute care, the realities of the ER, boarding and overcrowding, violence against staff, and medicine practiced under pressure. Most contributors work in emergency departments. For what emergency physicians and nurses have said about being assaulted at work and told it was part of the job, see Violence against health care workers: what physicians and nurses say, in their own words. For what emergency physicians wrote in the first weeks and months of the pandemic, see COVID-19: what physicians wrote as it happened. For what emergency physicians and pain patients have said about opioid prescribing, see Opioids: what physicians and pain patients say, in their own words. For what physicians in the highest-burnout specialty have said about burnout since 2009, see Physician burnout: what physicians say, in their own words.

Are emergency department pediatric transfers always necessary?

Christopher Johnson, MD

Physician

August 24, 2012

There are about 27 million visits by children to America’s emergency departments each year. About a quarter of those are to rural EDs or ones at some distance from a dedicated children’s facility, such as a children’s hospital. Over the last decade or so it’s become clear that, for critically ill children, early transfer to an advanced pediatric facility improves outcomes. The children do better if they can be transferred …

Mandating care in the ER but not payment: Why that’s a problem

Thomas Pane, MD, MBA

Physician

August 16, 2012

A recent case from Dayton, OH highlights the tangled mess of emergency department specialty coverage, federal law, and out-of-network insurance benefits. When these interact, patients, doctors, insurers and hospitals can be left frustrated and perplexed.

Here’s a brief summary.

A 6-year old boy suffered a fingertip injury and the emergency staff called the covering plastic surgeon, who repaired the injury. The surgeon, who does not participate with insurance, submitted a bill for …

Why must medical care be provided for free?

Edwin Leap, MD

Health Policy

August 16, 2012

Our septic tank backed up recently. When I say backed up, I mean, into the basement. And when I say into the basement, I mean, out of the bathroom and onto the carpet. And under the walls. The stars were aligned, and I had to go to work. My wife borrowed a Shop-Vac and rented a steam cleaner. I was assigned to call the septic-tank guy. The kids helped clean …

Is the death of Rory Staunton really the result of a simple mistake?

Skeptical Scalpel, MD

Physician

August 8, 2012

If you pay attention at all to news about medicine, you must have heard about the tragic death of a 12-year old boy who was seen and discharged from the emergency department of the prestigious New York University Medical Center. He had developed sepsis from what appears to have been a small cut and the diagnosis was missed. When he eventually returned to the ED and was admitted, it …

Improving medical care needs to involve the doctor

Leana Wen, MD

Physician

August 2, 2012

A few days ago, I received a question that stopped me in my tracks. I was giving a talk to a local church group on the importance of patient advocacy, and most everyone was nodding. Yes, doctors don’t always listen — let’s do something about it! Yes, we need to control of our health.

Then someone raised her name. Her name is Susan, and she is the owner of a mom-and-pop grocery in …

Doctors experience trauma to their hearts and stress to their souls

Edwin Leap, MD

Physician

July 23, 2012

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I was talking to some new friends over lunch recently, at the nationally renowned Hominy Cafe, in Charleston, SC. Any place with a fried green tomato BLT, and shrimp and grits for breakfast, has my vote!

To the point: my question to these esteemed emergency medicine educators was this: “Do you ever have irrational fears about the people you love, because of …

MKSAP: 79-year-old man with vertigo

mksap

Conditions and Diseases

July 21, 2012

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 79-year-old man is evaluated in the emergency department for vertigo that began suddenly about 1 hour ago, associated with severe nausea and vomiting. He noticed that he could not seem to sit up straight and could not walk without assistance. The patient denies confusion, motor weakness, hearing loss, dysarthria, diplopia, fever, or paresthesias. …

Read more…

MKSAP: 79-year-old man with vertigo

5 questions to change your end-of-life path

Monica Williams-Murphy, MD

Physician

July 1, 2012

I had just put him on a ventilator. Mr. Barnes (not his real name) had come in by ambulance sweating, barely responsive, gasping for air. The paramedics said he was from the local rehabilitation hospital and had just been sent there 2 weeks ago after a protracted hospitalization for a stroke which had left him partially paralyzed. Then they showed me medical orders indicating that he was “full code,” medical …

Burdening families with CPR decisions in the face of futility is cruel

Monica Williams-Murphy, MD

Physician

June 13, 2012

Those who know and work with me have heard me state without hesitation that it’s morally wrong to do CPR on 90-year old great grandmas. So, it was with great relief that I read the “Do Not Offer CPR” option in a recent JAMA article urging a revision of our present approach to the use of CPR for those who are unarguably at the end of life.

This is a change …

The influence of fatigue on claim quality

Adam C. Powell, PhD

Health Policy

June 6, 2012

While there is an extensive literature on how tired, overworked physicians provide lower quality medical care, one thing that has been ignored by advocates of quality improvement is that overwork financially harms hospitals as well. Just as tired physicians sometimes fail to attend to certain clinical details, they are also more likely to commit errors when writing the notes which ultimately are used during the coding process. If hospitals consider …

When self-evident truth in medicine is systematically ignored

Edwin Leap, MD

Physician

June 3, 2012

Some things in medicine are obvious. Despite the endless worship of ‘evidence-based’ medicine, and the constant barrage of studies on every conceivable topic, we do certain things because we know they just seem right. I take as evidence the fact that we daily try to save lives, devoting research time, untold gazillions of dollars and heroic clinical effort to our continued goal of staving off death. Why is this? Do …

Protecting patients by solving the problem of defensive medicine

Ellis Weeker, MD

Physician

June 2, 2012

In the United States many people feel it is their God given right to sue anyone, anytime for anything. Whether you are successful or not may be another story. So what are the cost implications for healthcare in the United States? Few other developed countries rely upon this method for resolving malpractice issues. What is the cost-benefit equation? To protect themselves, American physicians practice what is called defensive medicine designed …

Patients are more than multiple choice questions

Rick Pescatore, DO

Medical Education

May 27, 2012

It felt good to stuff the stethoscope back into my pocket and slip into the emergency department last night. The constant ringing of phones, beeping of cardiac monitors, and distant wail of inbound EMS units was a welcome cacophony compared to the isolated silence of the library study rooms. Sweeping the curtain back as we stepped into the first patient room, the hours of frustration with biochemical pathways and embryological derivatives …

What medicine can learn from the Titanic

Rushil Patel

Physician

May 26, 2012

April 15th marked the 100th anniversary of the sinking of the Titanic, yet the mystique surrounding its demise has not faded. When the colossal vessel first collided with the iceberg, eyewitness accounts described an eerie sense of serenity that pervaded the ship. Passenger J.J. Astor even remarked, “We are safer here than in that little boat,” before later drowning.

To prefer drowning over safety strike us as irrational, but this behavior …

Medicine involves a tension between isolation and connection

Reflex Hammer

Medical Education

May 19, 2012

I was skeptical when a doctor casually mentioned that 2% of all pregnancies are ectopic pregnancies (in which the fertilized egg is implanted somewhere other than the uterus, usually the fallopian tube). Without treatment, a common outcome is fallopian tube rupture, which jeopardizes the life of the mother. It is a serious medical concern. I shot a confused look at a fellow first-year medical student. Two percent? It seemed way …

Keep the care in the health care

Myles Riner, MD

Physician

May 18, 2012

I believe the greatest challenge in medicine today is keeping the “care” in healthcare. One of the most frustrating aspects of practicing medicine for me had to do with how difficult it had become to incorporate caring into my practice. I am not necessarily talking about the kind of caring associated with having a long-term, close and mutually appreciated association with my patients: if that had motivated me, I would …

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Keep the care in the health care

The malpractice risk of volunteer medical coverage at sporting events

Shadowfax, MD

Physician

May 16, 2012

From Outside Online, an article about how physicians are increasingly hesitant to provide volunteer medical coverage at athletic events:

“Last year, 13 Americans died during running races, and another eight while competing in triathlons. While those numbers might seem troubling, the deaths are attributable mostly to the booming popularity of endurance sports—13 million Americans enter running races each year, and 2.3 million compete in triathlons. But the rising participation and the …

Repairing the tear in health care’s safety net with social media

Mark Britton

Health Policy

May 8, 2012

The nation’s “safety net” hospitals are designed to ensure that uninsured, lower income and indigent populations receive adequate medical care – a noble and necessary function within the U.S. healthcare system. No one dedicated to the field of care giving can deny the importance of providing appropriate medical care for this population. The safety net is literally a lifeline for many in need.

But for all of the vital and positive …

Death with dignity in the emergency department

Dike Drummond, MD

Physician

May 8, 2012

The ambulance crew rolled him into my ER breathless in his pajamas, O2 mask on his face, gasping for air, his short cropped hair a mess, standing straight up. Eugene was what the staff called a “frequent flyer.” As the nurse injected some IV Lasix I reviewed his chart to find a classic downward spiral.

It was a busy evening. The bays were full of the usual cuts, broken bones and …

Injectable epinephrine often isn’t used quickly enough

Paul M. Ehrlich, MD

Conditions and Diseases

May 5, 2012

Mark Twain once said, “The difference between the right word and the wrong word is the difference between lightning and lightning bug.” He was referring to the power of language. With an allergist, the consequences of the right and wrong words have measurable consequences, ranging from comfort to chronic misery, to medical payments spent wisely or wasted, and sometimes life or death.

For example, people with lactose intolerance will mistakenly believe …