A 67-year-old man is evaluated in the emergency department for confusion and agitation secondary to malignant hypertension. Initial blood pressure is 230/130 mm Hg, and funduscopic examination reveals papilledema.
He is admitted to the intensive care unit, and therapy with nitroprusside by continuous infusion is begun; the …
In the era of accountable care, you’ll notice that many hospitals and health systems are already driving towards more collaborative workflow. The integrated delivery network (IDN) is changing significantly, and for the better. But in high-acuity care areas, like the emergency department (ED), the challenge of treating patients more holistically in what is already a fast-paced environment is concerning for physicians evaluating the pay-for-performance model.
Almost four years ago now, I left my practice as an emergency medicine physician to enter the business world. However, the medical world isn’t easy to escape. I just couldn’t seem to forget some of the problems I used to face in the emergency department. So, when I had the chance to fix one of them, I took it.
The most intractable problem for me was fraud, especially as it related …
Historically, American physicians and surgeons were fiercely independent practitioners, who owned their own practices, worked long days and maybe longer nights, made a good income, but saw little of their families. They trained in a male-dominated world in “residency,” so named originally because their extended 120 hour/week work schedule demanded them living in dormitory type residence adjacent to the hospital.
They developed long-standing professional commitment to their patients that superseded time …
I recently sat by a man whose young wife was dying. Her cancer was taking her away from her husband and toddler. She was sleeping intermittently as the pain medication we administered did its work. Her husband’s eyes were red from crying and he could barely suppress a sob. He touched her and looked at me. I barely kept my own composure.
The recent budget crisis in many state Medicaid programs has led the directors of these health care programs for the poor to cast about for ways to cut their costs, and many have landed on a ‘solution’ that puts lives at risk and undermine the financial viability of an emergency care safety net that is already severely underfunded and overwhelmed. Some 21 states use a variation of the old definition …
It’s a sad commentary when human beings have to be reminded how to act like human beings, especially when they’re in the helping profession.
Loni Hildebrandt was a 29-year old certified nursing assistant who was pregnant with her first baby. Make that two babies because she was pregnant with twins. Hildebrandt considered her pregnancy miraculous because she had infertility and was a diabetic since the age of one. Together, she and …
The recent New England Journal of Medicine article, highlighting burdensome healthcare transitions in a subset of nursing home patients, is certainly of documentary value. However, for many of us with real-world experience in the nursing home medical care venue, the article certainly falls short of newsworthy. Not even mildly surprising really.
Too many of our nation’s nursing home staffs suffer from a lack of onsite MDs for evaluating acute …
Under current guidelines from the American Stroke Association, tissue plasminogen activator (tPA, commonly known as a “clot buster” drug) should be administered within 3-4.5 hours of “last seen normal” – and 1 hour of patient arrival – to potentially ameliorate a new onset stroke. (“Last seen normal” means exactly what it says. A patient who went to bet at 10 PM and awoke with slurred speech at 6 AM was …
On the theme of knowing when and when not to follow the diktats of emergency medicine, one of the greatest challenges for a practicing ER doc is chest pain. Missed MI is still the biggest driver of malpractice costs, and last I hear, ER docs still send home something like 2% of patients who are having MI or unstable angina. Not good. So over the last decade we’ve gotten all …
Of all possible times, it happened during Ramadan. The test of faith would be extreme.
Azka was the first of four children born to Persian parents in a small town thirty miles outside of Tehran, Iran. Being devout Muslims, her father chose the name Azka in part because it meant “pious”. His wife later revealed to Azka that he also liked how the name rolled off the tongue when spoken in …
Ask most patients, and they say their doctor has a good reason for ordering tests and prescribing treatments. Turns out their doctor may secretly disagree. That’s the conclusion of a new study. The implications are more than a bit disturbing.
Researchers from the Dartmouth Institute for Health Policy conducted a survey of more than six hundred physicians. Forty-two percent of family doctors admitted that patients in their own practice receive too much care – meaning …
A couple of years ago, a frail 88 year old Filipino woman came into the emergency department of my hospital complaining of confusion and weakness of her left arm. Her blood sugar level was extraordinarily low, so low that she would have died had she not received immediate treatment.
The emergency room doctors treated her by injecting her with sugar, and then called the team of internists on call to admit …
I gather my belongings: stained white coat, stethoscope, pen light, black ballpoint. I stuff the last two granola bars into my canvas bag. I glance at the clock on the microwave, which is three minutes fast.
Twenty-two minutes until my shift begins. One minute before I will lock the door to my apartment.
Precision is critical: ER shifts change fast and blend together, from late nights to early mornings to mid-afternoons. Suns …
On a recent international flight to London, a passenger required medical assistance. I don’t know if it is the karma of London but this is the second medical emergency on a plane headed to London that I have encountered.
I was only a couple rows behind the passenger and could see even before the crew announced the need for a doctor that he needed assistance. I jumped over the woman …
At a recent committee meeting, my hospital’s administration announced new quality measures and targets. Striving for top performance, the board of the hospital system set the bar extraordinarily high. The bonuses of senior management are tied to achieving the targets, so the announcement had everyone’s attention.
One target that caught my interest was for achieving a door-to-balloon time of less than 90 minutes in STEMI patients. As an interventional cardiologist who …
I walked up to the closed door and paused, exhaling a deep breath weighted with disappointment, trying to clear my thoughts for the conversation about to come. My clenched fist was briefly suspended, mid-air, ready to knock. Beyond the door, I could hear muffled conversation and movement.
A calm, pretty woman stood beside me. An emergency department case manager. She held a notebook and pen, ready to jot down any useful …
One of my patients thanked me for saving his life. Apparently, many years ago I had told him that most men’s first complete physical is in the emergency room in the midst of their heart attack or stroke. I have been in practice long enough to have forgotten many of the things I have told patients. I try to capture the pearls I have learned over the last 30 …
So you’re not having a heart attack like your wife thought. That’s the good news. But what is wrong, what did cause that pain, and what should you do from here on out?
That’s the purpose of discharge instructions, and it’s not enough for the ED staff to just print out some forms, say “sign here,” and send you on your way.
What constitutes good discharge instructions, and why are they critical …
Seniors spend a lot of time at hospital ER’s. Now, a small but growing number of hospitals in the US have built ER’s especially for the aging patient – with wider hallways, motion detectors, hearing and visual aids. To me, this is long overdue.
Older patients are avid consumers of emergency medical services. Older people make up a significant percentage of the total population of ER patients. A 2008 Read more…
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