Pradaxa...The Truth is Out There but Still Hidden.....

Anticoagulant Dabigatran Bleeding Deaths Raise Safety Concern.


MedPage Today (11/3, Kaiser) reports that according to an article in the German publication Die Zeit, "the anticoagulant dabigatran [Pradaxa] has been linked to about 50 deaths from bleeding in atrial fibrillation patients," which is raising concern "but the drug's manufacturer said the safety profile is where it should be." Boehringer Ingelheim said, "The clinical effectiveness and favorable safety profile of Pradaxa is positive and remains unchanged in light of recent reports about fatal cases of bleeding in the media." The company said "the bleeding events and fatal bleedings reported to date are considerably fewer than expected based on the trial data that support the use of Pradaxa in clinical practice," citing two studies (N Engl J Med 2009; 361: 1139-1151 and N Engl J Med 2010; 363(19): 1875-1876).

Well, it seems that what I said six months ago is coming to life....Pradaxa may indeed have more bleeding complications then seen during the original drug trials.  That's the problem with post marketing problems.  You don't know about it until problems arise.  Still nothing you can do if the patient comes in and has a brain bleed or GI  (internal bleeding) to reverse the effects like Coumadin.  So, you really need to weigh the risks and benefits...

Pradaxa...A Dangerous Drug?

Lately, I have made reference to a recent new drug that was approved by the FDA called Pradaxa (trade name).  This drug is licensed as a blood thinner to be used specifically in patients who may develop blood clots as a result of an abnormal and irregular heart rhythm known as atrial fibrillation.  The more commonly used drug is Coumadin or warfarin.  The problems with using the latter is that frequent blood tests need to be conducted to monitor the level of "blood thinning" and many patients need frequent adjustments in their dosing.  A common problem is that people forget to have the blood test performed or inappropriately take the wrong doses because many adjustments need to be made.  If patients' levels are too high, it increases their bleeding problems if they were to develop a bloody nose, GI bleed, or head injury as the result of a fall.

When people are taking Coumadin and their levels are too high and they suffer an injury or complication, the level of "blood thinning" can be reduced if they are actively bleeding by administering Vitamin K and blood product, the most common known as fresh frozen plasma.  These will "reverse" the level of blood thinning and return levels back to normal depending on how much "antidote" is given.  This is especially important if one falls and hits his or her head and develops bleeding ot hemorrhaging in their brain which often is fatal.  Of course if the effects are reversed, the patient is then put at risk for developing clots from the atrial fibrillation which can cause a stroke.  Obviously, the benefits outweigh the risks if someone is actively bleeding.  This is especially true with life threatening bleeding from accidents, nose bleeds, or GI bleeding (ulcer or rectal which tend to increase as one gets older).  Blood tests can also be performed to ascertain the level of "blood thinning."

With the use of Pradaxa, the level of "blood thinning" cannot be accurately determined with a blood test.  Likewise, there is no immediate antidote.  So if a patient is taking the oral medication and develops an injury or bleeding problem, there is little that can be done other than replacing the blood with additional blood transfusions.  Most people who are taking Pradaxa are older and have co-morbid underling medical conditions which inherently place them at higher risks for bleeding complications.

Physicians in Emergency Departments are often the first ones to encounter such complications. I have personally cared for patients who have become hypotensive (low blood  pressure) secondary to hemorrhage from nose bleeds and GI bleeds (rectally) that have nearly exsanguinated (bleed to death) because I could not give them blood fast enough.  If these patents were on Coumadin, I would have at least been able to try to successfully counteract the effects with antidotes.  With Pradaxa, you have to basically wait for the drug to be excreted out of the body.  There have been very limited studies to suggest that renal dialysis may help.

I suspect that as more patients are placed on Pradaxa, we will eventually see more serous side effects of the drug...time will tell, but I suspect at the cost of additional lives.

Where Have I Been....

Well I admit, after many many months, I have returned to write some more. I guess the frustrating part about writing blogs is that I haven't figured out how to get people to read my blog! And, of course, hence the circular reasoning...no one reads what you post so why bother posting!



Sooo where should I begin...Obama care has done nothing for my patients or my practice...people still come to the ED with and without insurance whether they need to be here or not...but time will tell...



Perhaps the most frustrating part of the health care reform act is the placement of patients into Medicaid-like plans...Yes, people will be insured...but insurance does not equal access. Take for example the current standing for Medicaid...in my state physicians are paid almost the lowest in the country to the tune of approximately $27 per patient for an ED visit...but when you factor in operating expenses, malpractice, benefits for physicians, billing costs, etc. the $27 does not even cover the overhead. Sooo...how can you expect ED physicians to cover their expenses? Some will argue that $27 is better han nothing (and I agree that is true) but if the volume of patients visiting ED's increases and these patients would never have been in the ED because they did not have insurance, then the loss experienced by physicians will even be greater. This does not take into account the fact that the physician needs to cover his malpractice premiums to have the privilege of caring for patients covered by Medicaid...and they have the right to malpractice claims if the patient suffers a bad outcome (regardless of who is to blame)....

More to come on Medicaid and access issues...dealing with reality...

Bleeding Penis...Where Do I Go...Am I Going to Die?

Well, this was a good one...Working the night shift, picked up a chart with a chief complaint of "I"m bleeding from my penis." The patient was a 24-year-old male. I walked into the room and he was with a young woman approximately his age at the bedside. He was lying on the stretcher wearing sweat pants and had his hand in his pants holding his crotch. You can't make this shit up!

I said, "I understand that you have some bleeding from your penis."

His reply, "Yeah and it hurts," with some anxiety.

"OK, does it hurt when you try to urinate?" I asked inquisitively.

"Well, no, I'm afraid to try," he replied with more anxiety. "Do you think I will be able to have children?"

I replied with some reassurance, "Well, I think so, but let me take a look. Where you doing anything when this happened?"

Timidly he responded, "Well, ahhh, no not really." His fiancee, replied, "You have to tell him, it's OK." So I'm thinking...this is going to be a good one...

"Well its kind of embarrassing (with a blush). I was having sexual intercourse and I felt pain and when I took out my penis there was blood all over the place, I lost a lot of blood and it hurts, I want to have kids, were engaged," rather embarrassingly.

So...to make a long story short...I checked his equipment out and he had a small laceration of his foreskin which needed a few stitches. Hey, anything is possible. I actually see more vaginal trauma following sex then penile, but all bets are off. Guys are always freaked out about their apparatus working properly! This guy was going to be fine and he survived the stitches, not that bad with local anesthesia since I'm really not that heavily handed with any potentially painful procedures. I think he was happy that he was going to live. I actually never saw anyone die of penile hemorrhage but anything is possible. This guy was in no danger, but I had a chuckle for the rest of the shift. Sometimes I tell people, "I decided to be an emergency medicine physician since I find humor in the misfortune of others." Something I call "black humor." But seriously, I do smile...there is so much other misfortune in this field...

That said...why am I commenting on this patient? Well, first, it's funny, not for the patient, but certainly funny from my perspective. Guy has sex...hurts penis...gets freaked out that he will never have an erection...thinks he's bleeding to death...etc. But all joking aside, that's why I'm here to help people like this.

What bothers me is all the politicians and policy makers who think that visits to the ED like this are unnecessary. Hmmm maybe not if it was their penis or vagina....There was a recent study published concerning the health care in Massachusetts which cited that many ED visits were unnecessary. The researchers took the discharge diagnosis for patients and retrospectively judged whether or not the patient could be treated by a primary care physician. Honestly, if you have a good primary care physician, this problem could be taken care of by that person. Most primary care physicians - internal medicine physicians don't do stitching in my area...What is a person suppose to do at 1:00 a.m. I know if they called their physician they would be instructed to go to the ED. Sooooo, despite what politicians think, there aren't as many unnecessary ED visits...certainly this patient perceived an ED visit!

The Internet and Emergency Care...

I suspect that the use of the Internet has saved many lives. With extensive search engines like Google and Wikipedia, people have easy access to information (not necessarily accurate information). There is a tremendous amount of medical information sites, some with great information and others with not so great info. Nevertheless, people use the Internet every minute of the day.

It is not uncommon for me to see a patient in the ED who comes in and says, "You know, I just didn't feel right, I developed some chest discomfort or indigestion, and I went on the Internet and the site suggested that I seek out medical attention." Well in general, that's a good thing since, for example, many woman do not have typical symptoms of a heart attack such as "crushing chest pain" but rather fatigue which they downplay and do not often seek timely medical attention. Clearly, when someone is having a heart attack or MI (myocardial infarction), "time is tissue" meaning the shorter the duration of seeking medical care the better chance of saving heart muscle. And, that is no different for strokes or "small" strokes (TIA's). With strokes, many people are not educated on the symptoms and often neglect them until it's too late.

On the other hand, the Internet has also driven up the cost of health care for ED visits. Frequently, I'm scratching my head at 4 a.m. when a patient presents with a variety of symptoms, and I'm trying to figure out exactly what is going on. Why did the person decide to come to the emergency department at 4:00 a.m. with a constellation of symptoms that don't make sense other than generalized anxiety. I often ask the question, "I'm curious, the way you're feeling started at 10 p.m. last night, what changed for you to come in at 4:00 in the morning?"

Often I hear, "I couldn't sleep, so I went on line and plugged my symptoms in and I thought I had cancer!" Something that wouldn't change at 4:00 a.m. but adds to the patient's anxiety.

Where in the world could you get a reasonable answer to your medical concerns 24/7. Try calling your physician at 4:00 a.m. to tell him or her of your symptoms and let them know you think you have cancer...see what the response is...sometimes it's "go to the ED" (so they could go back to bed)!

More Expensive Medical Care & Duplication of Testing...

So I spoke about the poor integration of information systems in medicine...and here's even more. The technology is out there to convert radiology imaging and other ultrasound imaging into an electronic format. Some hospitals have that capability. You no longer have to get a copy of an x-ray and stick it on a view box, rather it's transmitted to a computer terminal and you view it on a screen. Systems can be very sophisticated where you can essentially connect via secured Internet sites with encrypted information) to view these studies in your office or even in your home called teleradiography.

The biggest issue however, is if you are not a part of a hospital (meaning you don't have privileges as a physicians) you do not have access to the information. There is a total lack of integration. There is also a concern that somehow, people will get sensitive health care related information, and inappropriately disseminate it. Where this is true with any electronic data, there are enough mechanisms in place to assure security.

Let me give you an example of how ridiculous this is for the EM physician. Mr. A presents to the ED at Hospital B with a chief complaint of chronic headaches for the last few months on a Friday at 6 p.m. He states he was called by his doctor, physician C, who had ordered an MRI of his head and was told that he has an abnormality and needs to go to the hospital - perhaps a brain tumor and he has had the MRI at hospital D's outpatient department. You call physician C, but physician E, a covering doctor, does not know anything about the patient or the results and cannot get in touch with physician C. You call hospital B, only to find that they cannot give you the information because the MRI department is closed. It closed at 5 pm. So, what are stuck doing - you can either repeat the MRI, which is an extremely expensive test and not easy to get even in your hospital at 6 p.m. or you perform a CT scan of the head (less expensive but still expensive and has a small risk for radiation exposure). Hours later you get the results of the CT scan - a brain tumor, you still need the results of the MRI but that can wait tonight since you have a diagnosis and the patient needs to be admitted to the hospital for a biopsy and treatment.

And you ask, why did the patient not go to hospital D's ED after the call...the answer, "because your hospital has a better reputation" but I lived closure to hospital D to get the MRI and it was easier....Of my God, not easier for the poor physician working in Hospital B's ED trying to care for the poor patient (who by the way, will ultimately probably die within a year despite chemotherapy, radiation, and surgery) all further expensive care with a low yield for survival.

Again, do you really think that physicians enjoy working this way?

Robust Medical Information Systems...an Oxymoron!

Sometimes policy makers and elected officials are right on...and one of the truths to medicine is "there is too much diagnostic testing performed." There are many reason for this...medical liability...lack of research to guide physicians into best practices, comfort level of the physician, pressure from patients, the lack of an integrated records system, etc.

Today, I want to focus on the latter - the lack of integration of medical records. It amazes me that there is some "computer in the sky" or "big brother" who has all my financial information...credit reports, balances, the ability to go to a bank on the east coast and withdraw money from the west coast bank, etc. What we are lacking in health care is that same ability (at least as a nation) for health records. Most physicians are in private practices and these practices may be a solo practitioner or small groups (at least in the majority of the country). Most hospitals are nonprofit entities with small systems, again the majority in this country. Despite what you may think, the profit margin (as a provider) is not much and therefore people have limited funds to integrate an electronic record.

What this means, is that there is limited financial resources (and lack of motivation) to have a well organized record keeping system that is in an electronic format. The financial industry can transmit much information electronically and the systems have a unified way in which a combination of systems can operate (thus, the above bank analogy). But many hospitals and the majority of physicians do NOT have electronic records. In fact, it was only in the last few years that my hospital incorporated a partial electronic record. Not only is there a lack of systems, but many of the systems (within a hospital) don't have the capability to speak with one another. I know for those involved in business, it is hard to believe, but when a hospitals profit margin is only 1-2% per year, you can see there is little revenue or incentive to modernize!

Add to this the ablity to integrate with independent practitioners' records in the community is a disaster. Again, it wasn't until a few years ago could physicians in my area get outpatient lab results that were performed at the hospital.

Think about it, Mrs. A cannot have labs done at lab B because her insurance company doesn't participate so she has to go to lab C but lab C sends the results by mail and there is no lab interface directly with Doctor D, so he not only can't get the results (unless he calls - an added step) but no one else caring for Mrs. A has access to the records (especially when Doctor C's office is closed) and Mrs. A does to the ED at Hospital D...get the big picture! And do you think that most emergency medicine physicians like to practice this way...more to follow tomorrow...

Is the ED Cost Efficient?

Emergency medicine is a 24/7/365 day of the year service. The visits are not scheduled and ED's cannot hang up a sign on Friday afternoon that says, "Closed at 5 p.m. will open on Monday at 9:00 a.m." Our society has grown to understand that it is the only place in the nation where they can get around the clock assistance for "unscheduled and emergency care." And, other physicians, (both primary care and specialists) have found that out too. They also send their patients to the ED when they cannot provide for their patients' care during office hours or after office hours when the office is closed.

That said, ED's have been accused of not being "cost efficient" and "expensive." By the nature of the business, there is a basic operating cost to staff and operate an ED - equipment, personnel, etc. Barring volume, there is a certain amount of fixed costs regardless of whether there are 10 patients seen in a day or 20. Obviously, as volume increases, costs increase for personnel and equipment. So is it fair to say, that it is inefficient? I don't think so, since the ED is now the FRONT door to the hospital. Most hospitals have over 50% of the admission enter through the ED.

In fact, no longer do many hospitals have direct admissions, where patients come sick directly from home or a nursing home. Rather they come to the ED first to have further diagnostics testing and initiation of their treatment prior to being admitted to an inpatient bed. Years ago someone presented to the ED with abdominal pain, they may have had lab studies, x-rays and maybe admitted for observation or consultations and over the course of 2-3 days have a CT scan, further consultations, and other testing. But now, the same patient comes in and can spend 6-8 hours in an ED but the work-up is streamlined and a decision made to either safely send the patient home, send them home for further outpatient management and testing, or admit them to the hospital for further care that they cannot receive as an outpatient. A far cry from what happened years ago. Actually most of us would consider that MORE efficient and cost effective avoiding an even more expensive hospitalization.

Optimizing Visits to Blogs

Still trying to figure out how to optimize exposure for blogs, if anyone has any suggestions I would like to hear from you (as long as you are not some sales person selling software or a spammer). I thought perhaps people would want to know what really goes on in ED's but maybe that's just not the case.

People assume that when they need emergency care, ED's will be there for them. Unfortunately, not all ED's are alike. Although many physicians who work in ED's are board certified in the speciality, many are not.

Recent staffing studies suggest that there will be a continued shortage of emergency medicine physicians. Emergency medicine is a relatively new specialty (only 40 years old). The "baby boomers" who started emergency medicine are moving on to other things or are retiring.

Interestingly, the majority of patients go to smaller and midsized ED's that may not be staffed with board certified emergency medicine physicians. That means the physician may still be trained in some other field - surgery, internal medicine, family practice, etc. Where I don't mean to degrade the capabilities of those who have practiced emergency medicine for a far longer time than I, I think the public needs to know this. That said, I have seen less than optimal care provided by physicians who are board certified in many specialities so board certification does not guarantee excellent care but it does imply specialized training in the field.

Many hospitals require physicians to be "board certified" but that does not mean that the person working in the ED be certified in emergency medicine. For the educated consumer, you need to find out what percentage of those physicians in the ED are "board certified or residency trained in emergency medicine." Where you don't have this luxury to shop around when you have an emergency, it helps to know what hospitals near home fall into this category. You may be surprised. And the size of the hospital may not determine the percentage of EM trained physicians!

Undocumented Immigrants & Health Care...

As I spoke of in the past, EMTALA federal legislation applies to all patients presenting to the ED. This includes the care for the estimated 11 million undocumented immigrants who are a part of our population and add to the burden of the uninsured. What is interesting is that no national Health Care Reform plan takes on this issue to date (or maybe it does because of the purposeful exclusion of these patients).

Where I don't want to get into a philosophical diatribe about whether to insure undocumented immigrants, what does the public expect ED's to do when these patients arrive? Probably the same we do now....treat them and expect no payment for services. At least (for the most part) one does not have to worry about malpractice since most attorneys will not touch these cases since there is very little room for economic damages - the guy planting your shrubs or mowing your lawn or the woman cleaning your house or the person behind the counter at McDonald's can't claim millions of dollars in damages if he or she is disabled. Our society really is twisted!

Our elected officials in state and federal government are smart. They can avoid this issue (so they can't be labeled as bigots and worry about loosing votes if they refuse to insure undocumented immigrants). Congress and policy writers know that these people can at least get "free care" in any Emergency Department in the nation off the backs of physicians, hospitals, and other providers, including insurance companies and other patients secondary to cost shifting! Who said Congress was stupid?

Bad Things Happen...

I saw a 50 yo Hispanic gentleman who came into the ED because his blood sugars were running high. He was recently treated for a "bronchitis" and placed on an antibiotic...at that time his sugars were high and he had not been compliant with his diabetes medication. He had no insurance and paid for his medications himself. He started back on the medication but his sugars were still high and wondered what was going on.

He also was complaining of continued shortness of breath with some wheezing. I repeated his chest x-ray which showed a large mass (probably cancer) and a new pneumonia secondary to the tumor. I then performed a CT scan of his chest which confirmed my suspicion. The man had a tumor that had also spread to his lymph nodes in his chest. I was shocked since he was relatively young, a nonsmoker, and no history of any occupational exposure to explain why he had the tumor.

He was subsequently admitted for further treatment. He, of course, has no insurance so I will not be paid and the hospital will receive some money from the state to cover some expenses. All the other physicians who care for him will not receive any payment either. I'm not complaining about the money, I at least made the unfortunate diagnosis and was able to get him help. Perhaps he has a lymphoma that may respond to treatment. My point is...did his lack of insurance lead to a delay in diagnosis and if he had better care would the diagnosis have been made earlier? Who knows...

Too Long for Silence

OK, I admit, that it has been well over 6 months since writing anything here...I suspect not because I am not motivated to find anything to write about. On the contrary, I can go on for years about my experience. Rather, the issue is the time. After working in the ED, one is totally exhausted. Often times, you get the feeling that everyone is sucking every vital juice from your body...the staff, the patients, the family members, EMS, your colleagues, everyone...you get sucked dry.

And, despite this, you still need to perform at your best with every patient encounter, never leaving your guard down to make the wrong diagnosis, or somehow not being able to filter through what a patient is telling you...Mrs. Smith complains of a headache, chest pain, insomnia, depression, menopause, diarrhea, weight gain, abdominal pain, tingling....is it all real, or is there one or two things here related to her medical condition. Is she just anxious, or is there really something wrong with her that may kill her if I send her home...that's the way most EM physicians think, because the number one reason for EM malpractice cases is "failure to diagnosis" and even crazy or anxious people get sick and die...

It's almost like Chicken Little, and the "Sky's falling..." except Chicken Little doesn't have a family who can find a personal injury attorney to build a case against your decision making ability when the sky actually does fall down and kill, or worse yet, maim Chicken Little! Somehow, I don't believe that leaders in Washington (the majority who are supported by trial attorneys) will ever come to terms with any meaningful tort reform in this country.

Why Emergency Medicine Can Add to Health Care Costs....

In America, everyone expects perfection...people want to live forever (or as long as they possibly can). Hence my candid feelings about prolonging the inevitable. Frequently, patients are transferred from Nursing Homes sick...very sick. They arrive with limited information (hopefully a copy of the medical list and a short one page synopsis of their medical history). Unfortunately, many cannot speak secondary to their condition.

Many times treatment decision need to be made rather swiftly, sometimes in seconds, sometimes in minutes and more frequently in an hour or two. The decisions will ultimately add to the costs of medical care and perhaps to their suffering or perceived discomfort. What is frustrating to providers in the ED, is the lack of communication for advanced directives, documents that would help health care professionals determine "how far, and at what costs" patients and next of kin want for care.

All too often in these extreme cases, the patient is too sick or comatose to make such a decision and family members are guilt ridden with making a decision that may ultimately lead to a loved one's death. Unfortunately, families do not always make decisions in the best interest of the patient but rather for the best interest of the psychiatric care of the family - like placing octogenarians on ventilators when there is absolutely no hope of recovery let alone a decent quality of life.

In America, we spend a considerable amount of money near the end of people's life's but, even with health care reform, I can't see the government changing this. Do you really expect Presdient Obama and the rest of Congress to say, "Grandma's lived long enough, time to pull the plug?..." NOT!

The Economy's Impact on ED Visits...

As the year's end approaches, I wonder what the ED will be like. During a recession, people loose jobs and for the most part, their health insurance, which is tied to their employment. Very seldom will people still have the ability to pay their health insurance premiums without employment.

That said, it is a vicious cycle. People loose their jobs, they loose their health insurance and still need health care. But most often, without insurance they do not get routine health care, (except perhaps for their children). Parents tend not to be selfish, and will still provide for their kids at the expense of their own health and needs. People are less likely to take care of themselves and end up looking for episodic care - care when they need it. They forgo elective hernia repairs or perhaps put off having their gallbladder removed because of the loss of insurance.

People also tend to suffer not only financial but also emotional distress. Depression, drug and alcohol dependence, anxiety, etc. increases. The bottom line, society suffers in more than one way. And the impact on the ED - perhaps more visits for sicker and more desperate people who can't afford to pay their bills. They come to an even more expensive health care environment (the ED) to have their needs met.

Whether this will ultimate happen, is yet to be seen. But if the economy continues in a downward spiral with more people loosing their health insurance along with their jobs, the results are inevitable. With the new Obama administration, perhaps more will be insured, but the jury is still out. Financing for health insurance has to come from somewhere, and if that means from public funds either additional taxes, or cuts in other programs will have to pay for a hefty and expensive plan regardless of what the final product looks like...

It's Not Always the Obvious...

We clearly see different injuries and illnesses in the ED based on the time of the year. Frequently, during the winter months, we see many viruses that are responsible for gastroenteritis (nausea, vomiting, diarrhea, abdominal cramping and often times fever). Well, it's that time of year and out of 25 patients per shift ,we are seeing at least 5 patients with acute viral gastroenteritis.

Most of these patients need a few hours of intravenous (IV) fluids and some medication given in the IV for nausea. Infrequently, I will give some IV narcotics to help with the pain as long as I am convinced that I am right about the diagnosis with ample warning given to the patient in case symptoms do not improve or worsen. The last thing I want is to think the patient has gastroenteritis and is sent home with appendicitis (it does occasionally happen but you can't CT scan everyone who has vomiting and diarrhea).

Anyway, on my last shift I picked up a chart that read, "Nausea, vomiting, diarrhea for two days." The patient was in her early seventies and allegedly had no medical issues. She fit the picture of every other patient I had seen with similar symptoms that week - low grade fever, blood pressure (BP) was normal and her heart rate was slightly increased which could be a reflection of her temperature. Her examination was benign, she had no tenderness on examination of her abdomen. She appeared slightly pale (but frequently I have seen older patients look pale and yet the have no signs of anemia on blood testing).

I did the usual - IV hydration, and IV medication for nausea, no pain medication (as she had no pain) and re-assessed her. She felt better, had no temperature, her BP was fine and the faster heart rate had improved. I could see many physicians sending her home without performing labs. But I learned a long time ago to at least check people's electrolytes and kidney function with a simple blood test under these circumstances especially with patients in the upper or lower age limits. Her kidney's were not working as well (although that could be normal as people get older) and I had performed a cell count (CBC) to check her white cells (to check for infection), her hemoglobin (a sign of anemia) and her platelet count (needed for clotting). I had noticed a bruise on her thumb and she told be she had been lightheaded and fell a few days ago.

To my surprise her CBC revealed her to have a low white count, dangerous low hemoglobin and dangerously low platelets count. It all made sense retrospectively, but I was surprised at the findings. She subsequently received IV antibiotics, along with blood products and more IV fluids and was admitted to the Intensive Care Unit. I updated her son, who felt uncomfortable with hospitals.

I wasn't certain which came first - her blood work, which suggested bone marrow suppression perhaps form a viral or bacterial infection, or perhaps even early leukemia (her mother had died of leukemia). I thought three days before Christmas...was she going to die, did she have leukemia? I told him, "Your mom is very sick and needs to be cared for in the ICU. I have contacted her doctor and she will also be seen by an infectious disease doctor and a hematologist and will require further treatment and testing." He had no further questions but I wondered if he really understood the potential of her dying in the next few days. If this was leukemia, she would live for a while even without chemo but if it was an overwhelming bacterial infection, she had a high likelihood of dying in the next 2-3 days...and Christmas was in three days. Life is so cruel, but perhaps she only had MDS (myelodysplastic syndrome - a chronic disease that affects most often elderly patients with bone marrow suppression)...time would tell. I'll follow-up to see what happens to her and pray that her family gets through the holiday season.

By the way, this is where mediocrity begins in medicine, especially emergency medicine. For physicians who don't have any interest in follow-up, business ends that day with this patient. You can choose never to do follow-up either in the form of speaking with her doctor to see what happens or checking her medical record to see how she does while in the hospital. I guess for many, you just forget it and go on with your own life, it's easier that way. Go home, enjoy the time with your family and forget about her.


I could never bring myself to practicing this way, but many would disagree. I'll keep her name on a list with others to follow-up and see how she does. Without following up patients after you admit them or discharge them you can never be certain as to whether or not you made the correct diagnosis, and if you were wrong (even though a consultant finds the right answer and the patient does OK), you have not learned from the patient and will continue to make the same wrong decisions...something that happens more often then physicians will admit or will even recognize...there is no room for mediocrity!

The Woes of Emergency Medicine...

First, I find it a huge challenge to write weekly, let alone daily and I apologize - not that anyone has read anything on here. I give people credit who can find the time to write a daily blog. I guess that's why I never could keep a daily diary when I was a kid. The demands of work are great, and when I'm done with a shift, the last thing I desire is to re-hash the last 12 hours.

Years ago, people went into the field of emergency medicine because of a great lifestyle. No call, days off when you wanted them, no pager, you left work and had no other responsibilities. I suspect that for some places, this may still be the case but for me, my work doesn't end at the end of the shift. At the end of my shift, I am still stuck trying to get dispositions on the patients I have seen. The work-up is not complete, consultants have not called me back, I'm waiting for the radiologist to read a CT scan on a patient with belly pain, etc.

Once I stop seeing patients I still need to figure out what to do with the ones I've seen. And even if I know what I'm going to do with them - admit them to the hospital or discharge them home, I still have to complete the paperwork. Since I mainly work in the area of the ED that sees most of the acute injuries and medical complaints, most of these patients are complicated. I'm not talking about a kid with a sore throat, an infant with a fever (although that can be very complicated), or a twisted ankle, I'm talking about patients with headaches, dizziness, shortness of breath (SOB), chest pain, falls, motor vehicle collisions, strokes, loss of consciousness, etc.

In the end, the headache may be nothing but a tension headache or related to stress or anxiety or it may be a brain tumor, a ruptured blood vessel in the brain, or meningitis (infection of the outer lining of the brain). And, the emergency medicine physician's job is to figure that out. Unfortunately, if you are wrong and you send the patient home and the patient dies or suffers ill consequences you more than likely will be faced with a major law suit and end up in court settling a case for a few million dollars (that is of course if your malpractice insurance has greater than one million dollars as it limits). You see, physicians are right if the patient suffers no harm, but once a patient suffers harm, everyone (especially lawyers) puts on the "retro scope" and looks for something that could have been done differently.

Recently, someone asked me what the "standard of care" was in a certain situation. My reply was there may not be a standard of care with every issue since many patients present in so many different ways. There is generally an accepted way to treat patients. You only potentially breech the standard of care if something goes wrong. "Standard of care" is a legal term and can differ in different parts of the country based on resources, hospitals, specialties, etc.

Clearly from time to time I will speak about law suits and other legal issues because in medicine, especially emergency medicine the stakes are high and I practice a high risk speciality. Society expects me to be right 100% of the time and there is no margin of error. That's no different that an airline. The plane has to take off and land safely 100% of the time but in health care, hospitals do not have the same resources and financial incentives as airlines. This is a concept that the public, elected officials, and policy makers don't recognize, or refuse to recognize!

We Don't Live in a Perfect World...

When I decided to go into the field of medicine, I was a young naive high school student who was idealistic. Some of my idealistic traits still persist (perhaps one of the reasons why I choose emergency medicine - so that I could treat all who come to the ED). But part of being realistic is accepting the fact that not all health care providers are idealists.

As an example is the heart attack patient I cared for on my last shift. Physicians (and patients) not only rely on the physician in the ED to care for them but also the nursing, ancillary, and secretarial staff. Unfortunately, the staff may have other agendas. Where we all would like to believe that when you arrive in the ED with a chief complaint of, "I have chest pain and the last time I had pain like this was when I had my heart attack in 1980!" patients do not always receive prompt care. Indeed, this patient presented at the triage desk saying just that and was brought back to a ready bed. We really were not busy and yet for some unknown reason it took the staff over 20 minutes to perform an EKG. Excuses like, "The ED tech is not available, there is only one tech or we can't find the tech," somehow just doesn't cut it in my book when I really need an EKG to diagnose a heart attack. Time is muscle (heart muscle) and if indeed a patient is having a heart attack that can be recognized on an EKG, I need to know as soon as possible to optimize the patient's management. One of the physicians actually said, "Give me the EKG machine," out of his frustration, "I'll do it myself" (knowing full well that he had not performed an EKG since he was a student.

The patient finally had an EKG performed and to no surprise, it revealed he was having a heart attack. The federal government, by way of the Center for Medicare and Medicaid (CMS) tracks outcomes and treatments for certain disease including heart attack for the hospitals nation wide. In this particular case, the evidence is very clear...the earlier someone who is having an a cute heart attack and receives either a medication known as a "clot buster" or is immediately taken to a cardiac cath lab for emergency angioplasty (using a balloon to open up the clogged artery) the better the outcome. In this case, the patient went directly to a cath lab after notifying the cardiologist.

It ceases to amaze me why other people just don't do their jobs. I suspect some of what I see is related to a lack of motivation (an individual issue), perhaps burn out, or a need to feel empowered over others. Regardless, when it comes to taking care of sick patients, I have zero tolerance for such behavior. I might add, I'm embarrassed when I'm faced with such a situation, but sometimes feel helpless.

Fortunately, the patient did well...despite the staffs efforts to be obtrusive!

Alcohol....The Good & the Bad....

Well, just finished up a string of night shifts and things just don't get better. It amazes me how many ED visits are linked to alcohol. One night shift (a Saturday), alcohol contributed to 25% of the visits. Take for example the 30-some-year-old who fell outside of his new house after loosing his footing. He didn't have any serious (as defined by life-threatening) injuries but required a plastic surgeon to repair the multiple complex and complicated lacerations to his face and ear (and that cost him a lot, especially if his insurance didn't cover some of the expenses).

Or how about the other 20-some-year-old who was at a party at a friend's house (and I suspected "mouthed off to someone else") and ended up getting punched in the head. He fell and suffered a brief period of unconsciousness. Fortunately, both patients were awake and pleasantly drunk as opposed to the many nasty drunks who present with possible injuries and needed to be sedated for their safety, the safety of the staff and my safety. The last thing I want is getting into a nasty altercation with a nasty drunk in the ED.

Alcohol obviously is not limited to older folks. The same evening I had two separate teenagers come in by way of ambulance. One 16 and the other 19 (both under the legal age of drinking). Both were drunk as hell, one vomiting. When the parents arrived, they were mortified. If you have any children, you can understand getting a call from the ED saying that your child was here and not knowing what to think.

The 16 year old female had a blood alcohol of around 350. To give you some perspective the legal driving limit in most states is 0.08 or 80%, and she was over 4 times the legal limit. Fortunately, she was not driving! As a parent, I pray that I never have to deal with a call from the ED, let alone for a drunk kid. Fortunately, both kids left after giving them some IV fluids, IV medication to avoid them from vomiting again, and a period of observation.

I've had staff members and parents say, "Let them suffer, why make them feel better, teach them a lesson!" That's part of emergency medicine, treating everyone the same, and maintaining an unbiased approach to all patients. Unfortunately many physicians in the field suffer from burnout and end up becoming very jaded in their approach and treatment of patients. The day I become jaded will be the day I leave emergency medicine.

I have been a physician for approximately 20 years and despite much frustration for caring for patients in the ED, I have no intention of leaving quite yet...although the night shifts do take their toll and you often feel sorry for yourself and your life style since many in America have "9-5" jobs, weekends, and holidays off...

Why Do I Make a Big Deal about "EMTALA?"

OK so why make a big thing out of this EMTALA stuff? Well, what EMTALA means is that all comers to the ED must have a medical screening examination to assess the "stability" of the patient.

The "examination" consists of eliciting a history for the patient and an examination. The examination may be directed to an injured area (i.e. the patient's ankle if complaining of a sprain, or a comprehensive examination, in the case of a serious motor vehicle collision). What also is included in the evaluation is any diagnostic tests performed, blood tests, urine tests, throat cultures, x-rays, CT scans, ultrasounds, etc.

If someone presents complaining of "twisting' their ankle, further testing may not be needed or the patient may have an x-ray. However, if the patient is involved in a motor vehicle, he or she may have blood and urine tests, multiple x-rays, a bedside ultrasound, and multiple CT scans; and, all of these tests and the physician's time and services can be billed to the patient, but if the patient does not have any insurance or cannot afford the services, care for the patient (including the evaluation) cannot be denied. And, neither the physician nor the hospital may be paid! Oh did I forget the part about not getting paid but still have the threat of a law suit if I make a mistake...more of that much, much later...

The cost of EMTALA mandated care is substantial for the emergency physician. According to a May 2003 American Medical Association (AMA) study, emergency physicians annually incur, on average, $138,300 of EMTALA-related bad debt. Approximately 95.2% of emergency physicians provide some EMTALA mandated care in a typical week and more than one-third of emergency physicians provide more than 30 hours of EMTALA-related care each week. Physicians in other specialties provide, on average, less than six hours per week of care mandated by EMTALA, and each incurred, on average, more than $25,000 of EMTALA-related bad debt in 2001. Information taken from the American College of Emergency Medicine (ACEP).

What's the big deal? Try going to McDonald's to buy a hamburger and see what happens when you don't have any money to pay...do you get a free one, or does McDonald's give out a free hamburger for every hamburger it gets paid for? Now I realize that this may be overly simplistic, but is an economic fact of emergency medicine and health care delivered in the US.

Of course, liberals will scream, how can you deny people emergency health care, it is a right! After all, it's not a right to eat at McDonald's. But I would counter argue that, it is a right for people to eat (perhaps not at McDonald's since the last time I checked most of what's served there has a high fat content) - that could be good for the emergency medicine business (heart attacks, strokes, gallbladder disease, obesity, diabetes, etc.) but only if those individuals can afford health care or are insured with decent coverage. Well, enough for now, as I have to get ready to rest up for an upcoming night shift...

EMTALA - An Unfunded Federal Mandate...

Since I don't work everyday in the ED, I have decided that on my days off that I discuss some of the many issues in the practice of emergency medicine (EM). Perhaps one of the biggest challenges faced in this field, is a law known as EMTALA. EMTALA is a Federal statutory-regulatory complex, consisting of statutes (laws passed by Congress) and regulations (rules adopted by the Centers for Medicare and Medicaid Services (CMS), a division of the Department of Health and Human Services, to enforce and further define the EMTALA statute).

EMTALA stands for the Emergency Medical Treatment and Active Labor Act (EMTALA) which was passed by the U.S. Congress in 1986.

In the case of a hospital that has a hospital ED, if any individual comes to the ED and a request is made on the individual’s behalf for examination or treatment for a medical condition, the hospital must provide for an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. Not written into the law is who will pay for the services. In essence, all ED's and physicians must provide the services regardless of costs!