If you are a serious about pursuing a career in emergency medicine, I highly recommend taking a quality course in emergency ultrasound techniques. The potential for ultrasound in the ED is vast. All EM residency programs must now provide ultrasound training for their graduates to be board-eligible.
This year, I attended both the Introductory and Advanced emergency ultrasound courses by 3rd Rock Ultrasound. The experience was excellent and by far one of the best emergency medicine CME experiences I have attended to date. My next working day, I was able to put these new skills to work as an extension of my physical examination.
The view available courses, visit: http://www.emergencyultrasound.com/
Friday, May 20, 2011
Thursday, May 19, 2011
Gastritis gone sideways.
A woman in her early 60's came to the ER with complaints of "stomach pain" for the last six months. She localizes her discomfort to the epigastric and left upper abdomen, and a very discreet association with food. "It hurts mainly when I eat greasy foods." She reports some relief in the early weeks with Tums antacid and occasional use of OTC Omeprazole, but admits that she has taken these only sporadically. "I have a lot of burping," she tells me, "and when I do burp a lot, the pain gets a lot better." She also told me that her symptoms were worse when she was lying down at night. Though the patient had her symptoms for six month, she did not have health insurance and did not report them to her doctor "because I can't afford to have any tests done."
She denies and complaints of chest pain, weakness, diaphoresis, shortness of breath or other symptoms of concern. She also has noted no association of this illness with any physical exertion. "It's just really when I eat."
Her medical history is remarkable only for hypertension and high cholesterol. She takes medication for both, but tells me she can't take statins because they cause a lot of muscle weakness. Unfortunately, she does smoke cigarettes. She has had no surgery in the past.
On exam she is an alert, refreshingly non-obese and generally healthy-appearing lady. She is in no acute distress, but does have some complaint of her upper abdominal discomfort on exam. Her area of focal pain is mildly tender, but without peritoneal findings. Bowel sounds are normal and the aorta is not appreciated on exam. Her vitals signs are within normal limits.
I performed a bedside abdominal ultrasound and noted a normal aorta and IVC. Her liver was unremarkable, but she did have gallbladder wall thickening (5mm) with no stones, sludge, or significant edema. The common bile duct was 3-4mm. There was no sonographic Murphy's sign. I felt it likely that she had some chronic cholecystitis.
I ordered IV Zantac and Protonix and during treatment her pain subsided and she tolerated clear fluids well. Laboratory analysis showed a normal CBC and differential, essentially normal Chem 7 except for a mildly elevated glucose of 121. Liver functions showed normal bilirubin, but the AST, ALT, and Alkaline Phos. where modestly elevated. UA was normal. A cardiac profile and EKG were also ordered, the CK was normal, with a pending Troponin. I reviewed the EKG and noted inferior and lateral ST/T-wave abnormalities, Unfortunately, this was the patient's first visit to the ER, and no old EKG was available for review. Eventually, the Troponin resulted at 0.893 (MI threshold is 0.125). Chest Xray was normal.
I consulted with the hospitalist service and arranged to admit the patient for further workup. The first repeat Troponin was 0.769. I suspect that since the patient had a normal CK, this had peaked and return to normal before that patient came to the ED, and her MI was subacute. Still the extent of her coronary disease needed to be investigated and managed before a more serious event occurred.
We are taught that many MI patients will present with atypical symptoms. The higher risk groups are women and diabetics. The biggest point of liability in emergency medicine remains the missed MI. Even in a patient with clear-cut signs, symptoms, laboratory, and ultrasound findings of a compelling GI condition, you have to consider coronary disease in those with risk factors (age, HTN, hyperlipidemia, smoking). This case cannot punctuate that lesson enough.
Always consider and investigate the potential of a cardiac origin in any patient with upper abdominal complaints with coronary risk factors.
She denies and complaints of chest pain, weakness, diaphoresis, shortness of breath or other symptoms of concern. She also has noted no association of this illness with any physical exertion. "It's just really when I eat."
Her medical history is remarkable only for hypertension and high cholesterol. She takes medication for both, but tells me she can't take statins because they cause a lot of muscle weakness. Unfortunately, she does smoke cigarettes. She has had no surgery in the past.
On exam she is an alert, refreshingly non-obese and generally healthy-appearing lady. She is in no acute distress, but does have some complaint of her upper abdominal discomfort on exam. Her area of focal pain is mildly tender, but without peritoneal findings. Bowel sounds are normal and the aorta is not appreciated on exam. Her vitals signs are within normal limits.
I performed a bedside abdominal ultrasound and noted a normal aorta and IVC. Her liver was unremarkable, but she did have gallbladder wall thickening (5mm) with no stones, sludge, or significant edema. The common bile duct was 3-4mm. There was no sonographic Murphy's sign. I felt it likely that she had some chronic cholecystitis.
I ordered IV Zantac and Protonix and during treatment her pain subsided and she tolerated clear fluids well. Laboratory analysis showed a normal CBC and differential, essentially normal Chem 7 except for a mildly elevated glucose of 121. Liver functions showed normal bilirubin, but the AST, ALT, and Alkaline Phos. where modestly elevated. UA was normal. A cardiac profile and EKG were also ordered, the CK was normal, with a pending Troponin. I reviewed the EKG and noted inferior and lateral ST/T-wave abnormalities, Unfortunately, this was the patient's first visit to the ER, and no old EKG was available for review. Eventually, the Troponin resulted at 0.893 (MI threshold is 0.125). Chest Xray was normal.
I consulted with the hospitalist service and arranged to admit the patient for further workup. The first repeat Troponin was 0.769. I suspect that since the patient had a normal CK, this had peaked and return to normal before that patient came to the ED, and her MI was subacute. Still the extent of her coronary disease needed to be investigated and managed before a more serious event occurred.
We are taught that many MI patients will present with atypical symptoms. The higher risk groups are women and diabetics. The biggest point of liability in emergency medicine remains the missed MI. Even in a patient with clear-cut signs, symptoms, laboratory, and ultrasound findings of a compelling GI condition, you have to consider coronary disease in those with risk factors (age, HTN, hyperlipidemia, smoking). This case cannot punctuate that lesson enough.
Always consider and investigate the potential of a cardiac origin in any patient with upper abdominal complaints with coronary risk factors.
Saturday, April 2, 2011
Never trust a normal EKG
It's said that up to 20% of patients experiencing an acute MI will have a normal EKG. With over 25 years of emergency medical experience under my belt, I would dispute this statistic. I think it would be more accurate to say that a high percentage of these patients will have a "non-diagnostic" EKG. However, the totally normal EKG does occasionally happen, as in the case I am about to relate.
I recently treated a very pleasant and healthy older lady. I would say...a young eightly-year old. She came into the ER with complaints of chest pain that had been bothering her for the past 3 days. The pain was a mid-sternal pressure than radiated to her back and both axilla. She said it "cut off her wind," but didn't notice any specific provacative factors. It had been intermittant, but on the day she decided to come visit with me in the ER, she had been experiencing pain for a little over 6 hours. EMS placed her on a cardiac minitor and had started an IV.
There were no interventions because the patient had a normal EKG and told the paramedics that she had a normal stress test only 3 months ago.
When I saw this nice lady, she was still having pain and still had a normal EKG. Not a "non-disgnostic" EKG, but normal like it had been copied out of a textbook of normal EKGs. Despite this, her description of symptoms was pretty alarming, and her blood pressure was significantly elevated, she was started on typical cardiac chest pain treatment. She had already taken an aspirin at home and remained on oxygen. She was started on SL nitroglycerin and IV lopressor, which resulted in a modest reduction of her pain. Subsequently, she was started on IV nitroglycerin and titrated doses of morphine with more improvement. The EKG remained "normal," but the lab returned CK-MB and Troponin-I values well into the positive for MI ranges. Her BP and pain continued to improve with the nitrates, now in concert with Lovenox and Integrilin. Finally, now on maximal therapy, her pain was reduced to zero.
I consulted with her primary physician and cardiology and wrote orders to admit her to the ICU. The expectation was that she would undergo cardiac catheterization within 12 hours if she remained pain-free.
A few take-to-work messages:
1) The history is the most important diagnostic tool in your box
2) AMI can certainly happen, even with a stone-normal EKG
3) A negative stress test (treadmill, nuclear, or stress-echo) means nothing. These studies are only significant if they are abnormal (positive).
4) Don't delay treatment waiting on enzymatic testing
One more thing regarding cardiac catheterization reports. A normal cath may rule out CAD, but I have still seen patients die from arrhythmias and suffer MI caused by coronary vasospasm (printzmetals). In younger patients (<40) especially, screen for cocaine abuse. A cath with small (20-40%) lesions without critical stenosis does NOT reduce the risk of AMI. It is these younger and less stable lesions that will often rupture and cause an acute thrombus. Larger lesions (>50%) tend to be more stable (less likely to rupture), but may cause anginal pain and occlude with smaller thrombi.
I recently treated a very pleasant and healthy older lady. I would say...a young eightly-year old. She came into the ER with complaints of chest pain that had been bothering her for the past 3 days. The pain was a mid-sternal pressure than radiated to her back and both axilla. She said it "cut off her wind," but didn't notice any specific provacative factors. It had been intermittant, but on the day she decided to come visit with me in the ER, she had been experiencing pain for a little over 6 hours. EMS placed her on a cardiac minitor and had started an IV.
There were no interventions because the patient had a normal EKG and told the paramedics that she had a normal stress test only 3 months ago.
When I saw this nice lady, she was still having pain and still had a normal EKG. Not a "non-disgnostic" EKG, but normal like it had been copied out of a textbook of normal EKGs. Despite this, her description of symptoms was pretty alarming, and her blood pressure was significantly elevated, she was started on typical cardiac chest pain treatment. She had already taken an aspirin at home and remained on oxygen. She was started on SL nitroglycerin and IV lopressor, which resulted in a modest reduction of her pain. Subsequently, she was started on IV nitroglycerin and titrated doses of morphine with more improvement. The EKG remained "normal," but the lab returned CK-MB and Troponin-I values well into the positive for MI ranges. Her BP and pain continued to improve with the nitrates, now in concert with Lovenox and Integrilin. Finally, now on maximal therapy, her pain was reduced to zero.
I consulted with her primary physician and cardiology and wrote orders to admit her to the ICU. The expectation was that she would undergo cardiac catheterization within 12 hours if she remained pain-free.
A few take-to-work messages:
1) The history is the most important diagnostic tool in your box
2) AMI can certainly happen, even with a stone-normal EKG
3) A negative stress test (treadmill, nuclear, or stress-echo) means nothing. These studies are only significant if they are abnormal (positive).
4) Don't delay treatment waiting on enzymatic testing
One more thing regarding cardiac catheterization reports. A normal cath may rule out CAD, but I have still seen patients die from arrhythmias and suffer MI caused by coronary vasospasm (printzmetals). In younger patients (<40) especially, screen for cocaine abuse. A cath with small (20-40%) lesions without critical stenosis does NOT reduce the risk of AMI. It is these younger and less stable lesions that will often rupture and cause an acute thrombus. Larger lesions (>50%) tend to be more stable (less likely to rupture), but may cause anginal pain and occlude with smaller thrombi.
Thursday, February 10, 2011
Sexual Harassment: Not just for women anymore
In the ED, as in most health care fields, men and women work closely together. The work-friendship bond in this environment, sometimes develops into a very casual familiarity between the sexes. In this setting, the line between good-natured banter and out-right harassment can be a narrow one. Most reported cases of sexual harassment involve women being harassed by males. As I recently found out myself, this is always not necessarily the case.
One day a few months ago, I was working a shift in the ED minor care area. The ED was uncharacteristically slow, and the nurses and secretary were working with an off-duty nurse on a special project. I was sitting at my desk a few feet away doing something on the computer. The visiting nurse, with who I have had a couple of friendly conversations with previously, came over to my desk and starting looking at the computer too. She asked me what I was doing and slowly sidled up very close to me. Leaning in, she very explicitly propositioned me in a sexual way.
I was more than a little caught off-guard, but managed a nervous laugh and told her that I was in a relationship. I thought that would be it, but her reply was, "So am I, but I'm not interested in a relationship...I just want a little fun." I avoided eye contact, and just said something to the effect of "thanks, but like I said I am in a relationship." She then told me to think about it, but before she left the ER a little bit later, walked by and planted a surprise kiss on my cheek.
A day or two later, we were in the main ED together, and she suggested that we have coffee after work. She was getting off at 7pm and myself at 9pm. I politely declined and told her that I wasn't interested. I actually wound up working until 10:30pm, but when I walked out to the medical staff parking lot, this nurse had pulled her car up next to mine. I stopped to talk to her for awhile and repeatedly told her that I was not interested, and declined multiple invitations to join her in her vehicle. I told her that I was only interested in maintaining a friendly, professional work relationship with her. Eventually, I got into my car and drove away.
Several days later, I received a letter from this nurse at my home. I was actually at work at the time, and since it was addressed to Roger Scott Best PA, I asked my girlfriend to open it up and see what it said. The letter was full of personal information from this nurse...about her life, her marriage issues, sexual preferences and the like. The letter was "signed" with lipstick mouth-print.
A couple of days after that, this nurses approached me with questions about PA programs. She suggested we get together outside of work. I was busy and in a very public area of the ED, so I asked for her email and told her I would get back in touch with her soon. When I got home, I composed an email about her behavior, advances, and most particularly the matter of her letter. I made it very clear that I was not interested in anything other than a professional relationship at work, and that I expected no further inappropriate offers in the future. I eventually received an email in reply, which was unapologetic, but did say that I would receive no further inappropriate advances. I left it at that.
A week later, we worked together again with a critical patient. After work, I went home, had some coffee and talked with my girlfriend on the telephone. Almost 11:30 pm and as soon as I hung up the phone, my doorbell rang. I answered the door and it was this nurse at my home. She was dressed in some type of "costume" under a jacket, and was very persistently attempting to persuade me to allow her into my house. Despite the night being very windy and near freezing outside, I refused to let her into my house. Despite this, it still took me almost 45 minutes of telling her to "get in your car and go home," for her actually to do so. I told this story to a physician colleague of mine the following day, and he said she had mentioned to him the prior evening that she might do that (go to my house). He made comments to her in an attempt to dissuade this idea, but it apparently fell on deaf ears.
Finally, I had a sit-down with the ED director and went over the entire ordeal. I told her my opinion regarding this nurse as a valuable member of the team, and my desire for her not to lose her job, but that if this continued I would be forced to make a formal complaint. She later spoke with this nurse and made clear to her that she expected to observe nothing other than a completely professional relationship between she and I in the future and reiterated this again a couple of weeks later in a follow-up conversation. Fortunately, she did not have to lose her job...the certain outcome of a formal complaint. The directer, in our conversation, alluded to the fact that this was not an unheard of situation.
I have dwelt on that for some time. In work environments where a male presence predominates, you often hear of male on female sexual harassment. However, when the female-to-male ratio is reversed, my experience and the director's comment suggests that the reverse may be true. In addition, being a man, I was somewhat embarrassed by all this and didn't want be the "guy" that whines about sexual harassment from a woman. In retrospect, I should have done that after the parking lot incident, and certainly after the letter incident. After all, does "no" not mean no when a man says it to a woman? Apparently not to everyone. In my reality, it seems that both sexes have the equal propensity to inappropriately harass the other. Only in my case, and likely that of many other men, I was less likely to report it until the situation became intolerable. I hope the outcome will cause this nurse to re-evaluate her behavior, but I suspect that with the lack of definite consequences, she will eventually redirect this behavior towards someone else.
One day a few months ago, I was working a shift in the ED minor care area. The ED was uncharacteristically slow, and the nurses and secretary were working with an off-duty nurse on a special project. I was sitting at my desk a few feet away doing something on the computer. The visiting nurse, with who I have had a couple of friendly conversations with previously, came over to my desk and starting looking at the computer too. She asked me what I was doing and slowly sidled up very close to me. Leaning in, she very explicitly propositioned me in a sexual way.
I was more than a little caught off-guard, but managed a nervous laugh and told her that I was in a relationship. I thought that would be it, but her reply was, "So am I, but I'm not interested in a relationship...I just want a little fun." I avoided eye contact, and just said something to the effect of "thanks, but like I said I am in a relationship." She then told me to think about it, but before she left the ER a little bit later, walked by and planted a surprise kiss on my cheek.
A day or two later, we were in the main ED together, and she suggested that we have coffee after work. She was getting off at 7pm and myself at 9pm. I politely declined and told her that I wasn't interested. I actually wound up working until 10:30pm, but when I walked out to the medical staff parking lot, this nurse had pulled her car up next to mine. I stopped to talk to her for awhile and repeatedly told her that I was not interested, and declined multiple invitations to join her in her vehicle. I told her that I was only interested in maintaining a friendly, professional work relationship with her. Eventually, I got into my car and drove away.
Several days later, I received a letter from this nurse at my home. I was actually at work at the time, and since it was addressed to Roger Scott Best PA, I asked my girlfriend to open it up and see what it said. The letter was full of personal information from this nurse...about her life, her marriage issues, sexual preferences and the like. The letter was "signed" with lipstick mouth-print.
A couple of days after that, this nurses approached me with questions about PA programs. She suggested we get together outside of work. I was busy and in a very public area of the ED, so I asked for her email and told her I would get back in touch with her soon. When I got home, I composed an email about her behavior, advances, and most particularly the matter of her letter. I made it very clear that I was not interested in anything other than a professional relationship at work, and that I expected no further inappropriate offers in the future. I eventually received an email in reply, which was unapologetic, but did say that I would receive no further inappropriate advances. I left it at that.
A week later, we worked together again with a critical patient. After work, I went home, had some coffee and talked with my girlfriend on the telephone. Almost 11:30 pm and as soon as I hung up the phone, my doorbell rang. I answered the door and it was this nurse at my home. She was dressed in some type of "costume" under a jacket, and was very persistently attempting to persuade me to allow her into my house. Despite the night being very windy and near freezing outside, I refused to let her into my house. Despite this, it still took me almost 45 minutes of telling her to "get in your car and go home," for her actually to do so. I told this story to a physician colleague of mine the following day, and he said she had mentioned to him the prior evening that she might do that (go to my house). He made comments to her in an attempt to dissuade this idea, but it apparently fell on deaf ears.
Finally, I had a sit-down with the ED director and went over the entire ordeal. I told her my opinion regarding this nurse as a valuable member of the team, and my desire for her not to lose her job, but that if this continued I would be forced to make a formal complaint. She later spoke with this nurse and made clear to her that she expected to observe nothing other than a completely professional relationship between she and I in the future and reiterated this again a couple of weeks later in a follow-up conversation. Fortunately, she did not have to lose her job...the certain outcome of a formal complaint. The directer, in our conversation, alluded to the fact that this was not an unheard of situation.
I have dwelt on that for some time. In work environments where a male presence predominates, you often hear of male on female sexual harassment. However, when the female-to-male ratio is reversed, my experience and the director's comment suggests that the reverse may be true. In addition, being a man, I was somewhat embarrassed by all this and didn't want be the "guy" that whines about sexual harassment from a woman. In retrospect, I should have done that after the parking lot incident, and certainly after the letter incident. After all, does "no" not mean no when a man says it to a woman? Apparently not to everyone. In my reality, it seems that both sexes have the equal propensity to inappropriately harass the other. Only in my case, and likely that of many other men, I was less likely to report it until the situation became intolerable. I hope the outcome will cause this nurse to re-evaluate her behavior, but I suspect that with the lack of definite consequences, she will eventually redirect this behavior towards someone else.
Monday, October 4, 2010
On the doctoral degree for entry into either PA or NP practice.
A doctorate as an entry-level clinical degree is a bit much for either group. I'll admit that my knowledge of DNP programs is limited, but unless there is additional advanced training in clinical medicine...then it wouldn't enhance the care given and makes the degree pointless from a clinical standpoint. If the degree hinges on some type of research project, then it is essentially the same thing as a PhD degree in nursing and again, becomes pointless from a clinical standpoint. If the goal is simply to get the title of "Doctor," and makes you feel better about all the extra money you spent...great.
I've been acquainted with PA's and NP's for over 30 years. I've been a PA myself going on 15 years. The first NP I ever met was a diploma RN, who completed a certificate NP program. I dare say all the master's (and now doctorate) prepared NP's have nothing to offer above and beyond what she had. I believe the same is true for the varied degrees offered by PA program. In the end, we all take the same standardized national examination for licensing. "Degree creep," "credentialism," of whatever you want to call it for attaining an entry-level of practice only drives the cost without offering any tangible benefits to patients.
I do think an advanced clinical degree is appropriate if in imparts advanced clinical knowledge and skills. The Baylor EMPA program for example. But a doctorate for entry-level PA or NP isn't really reasonable or necessary.
Everyone wants to be a doctor today. Medical doctors, pharmacists, physicial and occupational therapists, audiologists, now nurses. In essence, like like the comedic "hello doctor, doctor, doctor" skit...the title actually become meaningless. Many licensed physicians I have worked with actually hold a bachelor of medicine and surgery from UK medical school. We call them "doctor" when they don't actually hold a doctoral degree. Should I be called "master" by the "doctor?" That would be a hoot. Regardless of degree... you are licensed as a 1) physician, 2) pharmacist, 3) physicial or occupational therapist, 4) audiologist, 5) registered nurse. I am licensed as a PA. That should be the focus...not getting caught up in a title.
I've been acquainted with PA's and NP's for over 30 years. I've been a PA myself going on 15 years. The first NP I ever met was a diploma RN, who completed a certificate NP program. I dare say all the master's (and now doctorate) prepared NP's have nothing to offer above and beyond what she had. I believe the same is true for the varied degrees offered by PA program. In the end, we all take the same standardized national examination for licensing. "Degree creep," "credentialism," of whatever you want to call it for attaining an entry-level of practice only drives the cost without offering any tangible benefits to patients.
I do think an advanced clinical degree is appropriate if in imparts advanced clinical knowledge and skills. The Baylor EMPA program for example. But a doctorate for entry-level PA or NP isn't really reasonable or necessary.
Everyone wants to be a doctor today. Medical doctors, pharmacists, physicial and occupational therapists, audiologists, now nurses. In essence, like like the comedic "hello doctor, doctor, doctor" skit...the title actually become meaningless. Many licensed physicians I have worked with actually hold a bachelor of medicine and surgery from UK medical school. We call them "doctor" when they don't actually hold a doctoral degree. Should I be called "master" by the "doctor?" That would be a hoot. Regardless of degree... you are licensed as a 1) physician, 2) pharmacist, 3) physicial or occupational therapist, 4) audiologist, 5) registered nurse. I am licensed as a PA. That should be the focus...not getting caught up in a title.
Tuesday, April 27, 2010
Nomenclature
Once again, Physician Assistants are raising the issue of changing the name of the profession. I suppose it's appropriate to consider adopting a professional title that accurately reflects the job that we do. As the PA concept is being eagerly adopted internationally, more appropriate titles for the PA role (Medical Care Practitioner, Assistant Physician, etc.) are being utilized. In the US, the term Physician Associate seems the preferred title amongst our profession. The title accomplishes two important goals; it more accurately reflects the role that PAs provide as part of the health care team and preserves the "PA" acronym.
A professional name change does present challenges, namely the revision of the practice codes in every state and the federal government that makes reference to Physician Assistants. Despite the advances and inroads the profession has made in it's 43 year history, every revision attempt opens the opportunity to lose something in return. A name change would likely raise the ire of some of the more insecure physicians organizations, who would undoubtedly take the opportunity to try and curtail PA practice in some way. Take for example the idiots in NJ right now up in arms to keep PAs from performing EMG studies. Perhaps the way to go is simply to alter state and federal licensing codes to recognize the two titles as interchangeable. Thus you might be licensed as a "physician assistant/associate." This would allow you legally to use the title "associate," without affecting insurance and other regulatory codes that recognize the "assistant."
I like the term Physician Associate. I am an associate of the physician, a colleague. In no way do I "assist" physicians, other that to assist them in increasing their revenue and occasionally provide input on patient care questions. In professional school, I studied the theory and application of clinical medicine, not how to assist physicians. In practice, I evaluate patients with acute and potentially life-threatening complaints, order diagnostics, interpret tests, order treatments, perform invasive procedures, evaluate the effectiveness of said treatments, consult specialists, and make diagnoses and patient dispositions. Somewhere at the end, somebody signs off on the chart. Nope...not alot of assisting going on here, but rather a lot of practicing medicine. Been doing it for 14 years. Yes, personally I would like the title change, since it more accurately reflects the work I am doing.
So the change would be appropriate, but is it worth the risks? What are the negative consequences? How will the change benefit the profession down the road? These are all questions that need to be addressed before moving forward on the issue.
A professional name change does present challenges, namely the revision of the practice codes in every state and the federal government that makes reference to Physician Assistants. Despite the advances and inroads the profession has made in it's 43 year history, every revision attempt opens the opportunity to lose something in return. A name change would likely raise the ire of some of the more insecure physicians organizations, who would undoubtedly take the opportunity to try and curtail PA practice in some way. Take for example the idiots in NJ right now up in arms to keep PAs from performing EMG studies. Perhaps the way to go is simply to alter state and federal licensing codes to recognize the two titles as interchangeable. Thus you might be licensed as a "physician assistant/associate." This would allow you legally to use the title "associate," without affecting insurance and other regulatory codes that recognize the "assistant."
I like the term Physician Associate. I am an associate of the physician, a colleague. In no way do I "assist" physicians, other that to assist them in increasing their revenue and occasionally provide input on patient care questions. In professional school, I studied the theory and application of clinical medicine, not how to assist physicians. In practice, I evaluate patients with acute and potentially life-threatening complaints, order diagnostics, interpret tests, order treatments, perform invasive procedures, evaluate the effectiveness of said treatments, consult specialists, and make diagnoses and patient dispositions. Somewhere at the end, somebody signs off on the chart. Nope...not alot of assisting going on here, but rather a lot of practicing medicine. Been doing it for 14 years. Yes, personally I would like the title change, since it more accurately reflects the work I am doing.
So the change would be appropriate, but is it worth the risks? What are the negative consequences? How will the change benefit the profession down the road? These are all questions that need to be addressed before moving forward on the issue.
Tuesday, April 6, 2010
Just Say No: Drug-Seekers in the ED
One of the daily frustrations of working in the ED is dealing with drug-seeking patients. Presentations of these patients will vary, but with some time and experience most providers will generally be able to differentiate the "seekers" from patients presenting with legitimate pain. Regardless, it is important to always provide care appropriate to the patients immediate needs and to facilitate appropriate follow-up care. When these patients continue to repeatedly visit the ED for on-going chronic pain control, it is appropriate to just say "No."
The EMTALA definition of an "emergency" in the prudent layperson standard specifies "acute" complaints (which includes pain). When a complaint is not "acute," then the prudent layperson definition (and therefore EMTALA itself) does not apply to that patient encounter. However, it is still important to perform a history and examination sufficient to reasonably exclude any potentially serious problems.
In my experience, the "seekers" will generally present with a limited number of complaints. Most often, there and on-going complaints of back or other musculo-skeletal pain, toothaches, headaches, etc. A few may present with a myriad of minor complaints and then address their medication-seeking with an "oh-bye-the-way" type of request. Unlike most patients with actual acute pain, these patients tend to either be fairly nonchalant with their 10/10 pain, or overly dramatic. The vital sign abnormalities generally associated with acute pain (i.e. mild tachycardia, elevated BP, etc.) are often absent. Medication allergies are typically extensive and usually include all analgesics that the patient doesn't want. Toradol is almost always listed. Historical inaccuracies with these patients are common. Some may weave a story based on a thread of truth, while others will outright lie. Several could easily qualify for an Oscar-winning performance. One recent example that comes to mind was a patient that came to my ED for pain complaints stemming from being "injured by an IED in a Humvee in Iraq in July of 2002." Having been in Baghdad myself and knowing that the US didn't invade Iraq until March of 2003, I was able to get a handle on this one pretty quickly and had him bounced from the ED PDQ.
In less blatent cases, it is important to deal with the apparent acute need for pain management and reasonably attempt to facilitate appropriate follow-up care. Observing my own persoanl "three-strikes" rule, I will order appropriate analagesia for the complaint, and refer the patient back to the primary care provider (or refer to a primary care practice if the patient has no PCP) for continued outpatient management of the pain. I will give a short-term prescription for analgesics, generally a 4-5 days supply and tell the patient that the emergency department will not be able to provide ongoing care for his/her pain control needs. All of this is documented in the patient's record and spelled out in the discharge instructions that the patient signs.
On a second visit, I will do the same thing. Administer analgesia, refer again, but provide only a 2-day prescription for analgesics. Again, the encounter is documented and spelled out in the discharge instructions, with the statement that additional prescriptions for controlled medication will not be issued from the ED.
On a third visit, I will adminsiter only a single dose of oral analgesic medication and provide no prescription. I will tell the patient in no uncertain terms that there will be no prescriptions issued for his/her chronic pain on this or any subsequent visit to the ED and remind him/her of my prior referrals and instructions.
On subsequent visits for the same complaint, I will perform the H&P, document that the patient has no acute issues or emergency medical conditions, and will offer or provide only an oral dose or a non-controlled analgesic and discharge the patient without a prescription. If the "give them what they want" mentality hospital administrators disagree with my approach, I would invite them to head back to school to become qualified and licensed to do what I do. Otherwise, they can feel free to stay behind their desks.
With limited resources, the emergency department cannot be "all things to all people." EMPs cannot assume the role of both the acute and chronic care provider for the community, much less the prescription drug supplier. Trying to do so results in a disservice to all of our acute patients.
The EMTALA definition of an "emergency" in the prudent layperson standard specifies "acute" complaints (which includes pain). When a complaint is not "acute," then the prudent layperson definition (and therefore EMTALA itself) does not apply to that patient encounter. However, it is still important to perform a history and examination sufficient to reasonably exclude any potentially serious problems.
In my experience, the "seekers" will generally present with a limited number of complaints. Most often, there and on-going complaints of back or other musculo-skeletal pain, toothaches, headaches, etc. A few may present with a myriad of minor complaints and then address their medication-seeking with an "oh-bye-the-way" type of request. Unlike most patients with actual acute pain, these patients tend to either be fairly nonchalant with their 10/10 pain, or overly dramatic. The vital sign abnormalities generally associated with acute pain (i.e. mild tachycardia, elevated BP, etc.) are often absent. Medication allergies are typically extensive and usually include all analgesics that the patient doesn't want. Toradol is almost always listed. Historical inaccuracies with these patients are common. Some may weave a story based on a thread of truth, while others will outright lie. Several could easily qualify for an Oscar-winning performance. One recent example that comes to mind was a patient that came to my ED for pain complaints stemming from being "injured by an IED in a Humvee in Iraq in July of 2002." Having been in Baghdad myself and knowing that the US didn't invade Iraq until March of 2003, I was able to get a handle on this one pretty quickly and had him bounced from the ED PDQ.
In less blatent cases, it is important to deal with the apparent acute need for pain management and reasonably attempt to facilitate appropriate follow-up care. Observing my own persoanl "three-strikes" rule, I will order appropriate analagesia for the complaint, and refer the patient back to the primary care provider (or refer to a primary care practice if the patient has no PCP) for continued outpatient management of the pain. I will give a short-term prescription for analgesics, generally a 4-5 days supply and tell the patient that the emergency department will not be able to provide ongoing care for his/her pain control needs. All of this is documented in the patient's record and spelled out in the discharge instructions that the patient signs.
On a second visit, I will do the same thing. Administer analgesia, refer again, but provide only a 2-day prescription for analgesics. Again, the encounter is documented and spelled out in the discharge instructions, with the statement that additional prescriptions for controlled medication will not be issued from the ED.
On a third visit, I will adminsiter only a single dose of oral analgesic medication and provide no prescription. I will tell the patient in no uncertain terms that there will be no prescriptions issued for his/her chronic pain on this or any subsequent visit to the ED and remind him/her of my prior referrals and instructions.
On subsequent visits for the same complaint, I will perform the H&P, document that the patient has no acute issues or emergency medical conditions, and will offer or provide only an oral dose or a non-controlled analgesic and discharge the patient without a prescription. If the "give them what they want" mentality hospital administrators disagree with my approach, I would invite them to head back to school to become qualified and licensed to do what I do. Otherwise, they can feel free to stay behind their desks.
With limited resources, the emergency department cannot be "all things to all people." EMPs cannot assume the role of both the acute and chronic care provider for the community, much less the prescription drug supplier. Trying to do so results in a disservice to all of our acute patients.
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