C-SPAN & C-SPAN2

The Alliance for Health Reform has done a number of Congressional briefings recently with some very good panelists. For those of you who missed them on C-SPAN & C-SPAN2 and forgot to set up their DVR, links below.

Perhaps most importantly, these mark my debuts on C-SPAN & C-SPAN2 as an audience question-asker/commenter.

1) Am I in the Hospital or Not? Why Hospitals are 'Observing'--Not Admitting--Patients

C-SPAN2 video

My appearances @

1:19:35 -- post-hoc decision by hospitals re: fear RAC audit/Part A denial

1:41:00 -- fixing operative vs medical equilibrium

(my overview of obs vs admission)


2) Tackling Health Care Costs: Finding Common Ground

C-SPAN video
My appearances @ 1:01:00

SGR Bill Comparison

Congress is working on some bills to eliminate Medicar's SGR (i.e. a permanent "doc-fix"). There's some optimism to get it done now, as opposed to the usual annual (or shorter) temporary patches, because the CBO's cost projections for Medicare are lower than they've ever been, so there's a nice little window to get rid of the SGR at a bargain price.

There are two bills gaining traction now; the first was passed unanimously out of the House Energy & Commerce Committee this summer. A few days ago, the House Ways & Means and the Senate Finance Committee announced their version. Both seem to have strong support, at least in principle, and both basically keep the payment rate flat, and tie traditional fee for service Medicare providers to some quality-based bonuses. Providers who are paid with alternative payment models (e.g. ACOs or bundled payments) get exempted from the P4P measures (i.e. paid more) and the Ways & Means bill gives them a frank pay increase as well. Details in the side-by-side comparison below.

Available as a Google doc here.

Sources:

Energy & Commerce

Ways & Means

ACA Primer

UPDATE: Be sure to check out the ACA 2014 Update

Matt Pirotte came up with a great idea: a primer on the Affordable Care Act, focusing on the basic tenets and issues, aimed primarily at medical students who are about to start residency interviews.

This is also now available from the AAMC's MedEdPortal iCollaborative.

Here's the audio:



Some resources I mentioned:

• Washington Post's WONKBLOG: Ezra Klein & Sarah Kliff et al cover some great issues
• Kaiser Family Foundation on Health Reform

More questions? Feel free to contact me directly either through the comments below or @MDaware

Massachusetts Health Reform & ED Volume

This post also appears on Policy Prescriptions

Open enrollment for the ACA exchanges starts on October 1. As more Americans get health insurance, what will happen to ED visits? What happened when Massachusetts enacted similar reform?

Like many Republicans in Congress, orthopedic surgeon and Wyoming Senator John Barrasso is an outspoken critic of the Affordable Care Act. I’ve seen him speak twice – first when he was an invited speaker at the 2012 ACEP Leadership and Advocacy Conference, and again this winter when we brought our residents to Congress on our annual Capitol Hill Day. Both times, he predicted that ObamaCare would increase ED visits; after all, ED visits increased in Massachusetts after the state enacted health reform in 2006

Senator Barrasso is not the only one who makes this connection. It’s a claim repeated by Avik Roy, one of Mitt Romney’s key health care advisors,¹ as well as John Goodman, who the Wall Street Journal calls “the father of HSAs”² (not the actor). Journalists repeat the same argument: “In the wake of the Bay State’s 2006 health care overhaul, which provided the model for ObamaCare, emergency room visits soared”³ and “emergency department visits will rise with health reform, just as they did in Massachusetts after the state enacted a health reform law in 2006.”⁴

Prominent emergency physicians have recognized the trend as well. Referring to a 2011 poll of emergency physicians, then-ACEP president Sandra Schneider, stated: “This poll confirms what we are witnessing in Massachusetts — that visits to emergency rooms are going to increase across the country, despite health care reform, and that health insurance coverage does not guarantee access to medical care.”⁵

The argument makes some intuitive sense. As some people gain health insurance coverage, they will have one less barrier to going to the ED, driving up visits. And similar to the Affordable Care Act, Massachusetts' reform focused on covering the uninsured but did little to increase primary care, so of course they will come to us.

It's true. After implementing health reform from 2006-2007, ED visits in Massachusetts increased, rising between 6.7% from 2006-2009.^6,7

Many attribute this increase to health reform. But ED visits have been increasing everywhere. According to numbers from the CDC's National Center for Health Statistics, there were 119 million ED visits in 2006⁸ and 136 million in 2009,⁹ an increase of 14% nationwide. While total ED visits went up in Massachusetts, they increased less than they did across the country. In fact, when looking not at total ED volume but the per capita ED visit rate, after holding steady for a few years, by 2010 individuals in Massachusetts were actually less likely to go to an ED.¹⁰

A New England Journal of Medicine study compared ED visit rates across the same time period between Massachusetts and two neighboring states, neither of which implemented any state-level health reform.⁶ New Hampshire and Vermont saw nearly identical increases in ED visits over the same time period, too. Looking just at ED visits that led to admissions, the numbers look the same, implying the acuity levels were comparable in Massachusetts and its non-reform neighbors. Other studies have found that the “increase” in Massachusetts ED volumes after reform was not from low acuity or non-emergency visits.^11,12

Of course there are differences between Massachusetts and the country as a whole. The health care environment in Massachusetts is different than in the US, both before and after reform. For starters, state health reform decreased Massachusetts’s uninsured rate from only 10.9% in 2006 to 6.3% by 2009, compared to the >17% national uninsurance.¹³ And the ACA is not identical to Massachusetts’ reform.

The ACA is by no means perfect. Neither was health reform in Massachusetts. But despite the pessimistic views of some, health reform in Massachusetts did not flood EDs with patients. It’s no secret that EDs across the country are busy. But the increase in ED visits in Massachusetts doesn’t mean that ObamaCare will flood our EDs.

1.         Roy A. Emergency Room Visits Increase in Massachusetts. Critical Condition, National Review Online, and The Apothecary. July 7, 2010. http://www.avikroy.org/2010/07/emergency-room-visits-increase-in.html

2.         Goodman J. What Will Happen To Emergency Room Traffic? Health Affairs Blog. July 12th, 2010.

http://healthaffairs.org/blog/2010/07/12/what-will-happen-to-emergency-room-traffic/

3.         Suderman P. Like Long Medical Wait Times, Crowded Emergency Rooms? You’ll Love ObamaCare. Reason Hit & Run Blog. May. 4, 2011.

http://reason.com/blog/2011/05/04/like-long-medical-wait-times-c

4.         Becker AL. Health care reform likely to increase pressure on emergency rooms. The CT Mirror. August 18, 2010. http://www.ctmirror.org/story/health-care-reform-likely-increase-pressure-emergency-rooms

5.         Emergency Visits Are Increasing, New Poll Finds; Many Patients Referred by Primary Care Doctors. April 28, 2011. http://www.acep.org/Content.aspx?id=78646

6.         Chen C, Scheffler G, Chandra A. Massachusetts' health care reform and emergency department utilization. The New England Journal of Medicine. Sep 22 2011;365(12):e25.

7.         Massachusetts Emergency Department Visit Volume, FY2005-FY2009. Massachusetts Division of Health Care Finance and Policy.

            http://www.mass.gov/chia/docs/r/ed/ed-volume-fy05.pdf

            http://www.mass.gov/chia/docs/r/ed/ed-volume-fy06.pdf

            http://www.mass.gov/chia/docs/r/ed/ed-volume-2008.pdf

            http://www.mass.gov/chia/docs/r/ed/ed-volume-2009.pdf

8.         Pitts SR, Niska RW, Xu J, Burt CW. National Hospital Ambulatory Medical Care Survey: 2006 emergency department summary. National Health Statistics Reports. Aug 6 2008(7):1-38.

9.         National Hospital Ambulatory Medical Care Survey: 2009 Emergency Department Summary Tables. National Center for Health Statistics.  http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2009_ed_web_tables.pdf

10.       Long SK, Stockley K, Dahlen H. Massachusetts health reforms: uninsurance    remains low, self-reported health status improves as state prepares to tackle      costs. Health Affairs. Feb 2012;31(2):444-451.

11.       Miller S. The Effect of Insurance on Emergency Room Visits: An Analysis of    the 2006 Massachusetts Health Reform. 2012;           http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1711502.

12.       Smulowitz PB, Lipton R, Wharam JF, et al. Emergency department utilization after the implementation of Massachusetts health reform. Annals of Emergency Medicine. Sep 2011;58(3):225-234 e221.

13.       Massachusetts Health Care Reform: Six Years Later. Kaiser Family Foundation. May 2012.  http://www.kff.org/healthreform/upload/8311.pdf

How to PE

Surprisingly, there was a twitter conversation about PE workup. Here is my PE algorithm. Most of you will recognize most of it.

Additionally, an incredibly similar path was articulated very well by Jeff Tabas on the June 2013 EM:RAP.

If you do it right, you should never be angry at a positve d-dimer.

The Secret Life & Hidden Costs of Inpatient Obs Status

You think they're just like [admissions].
You're wrong. Dead wrong.

Observation status has been making news lately. Office of the Inspector General of the Department of Health & Human Services released a memo re: Obs in Medicare, and Jay Schuur and others have been sharing some great links on the issues of inpatient observation status.

While a fairly dry topic, what might seem like some simple behind-the-scenes administrative/paperwork issue has a very real impact on our patients. Here are many of the key issues:

• Many patients who are seemingly admitted to a hospital are billed as an Obs, not a traditional admission
• Generally, the difference happens behind the curtain, and the patient has no way of knowing that they are Obs and not admitted
• Even the ED docs are usually unaware of status change, partially because:
• The switch is often made well after the decision to admit, usually by non-emergency staff (often non-clinical staff)
• Part of the reasoning for the switch is that billing people fear that a "short" inpatient admission may be challenged, whereas the Obs bill will just be paid
• However, patients can be on the hook for a much larger share of the bill for Obs vs. admission (Obs is counted as outpatient and covered by Medicare Part B, vs inpatient admissions covered under Part A)
• This can mean the patients receive charges as high as tens of thousands of dollars!
• Notably, the OIG report below notes that the overwhelming majority of Medicare patients pay less out of pocket for the Obs for the same conditions, but a small fraction pay much, much more (mostly those who need post-acute SNF care)
• The big problem is that Medicare only covers post-acute SNF stays if a patient is actually admitted for 3 days, which Obs doesn't count toward, and around 40% of Obs stays are 3 days or more!

HHS Inspector General's memo

Great summary via Kaiser Health News

Another nice overview in NEJM

Recent Boston Globe article

The last bullet above re: SNF coverage was a key issue that ACEP pushed in Congressional lobby visits during the 2013 Leadership & Advocacy Conference. The 3-day rule for SNF coverage makes the issue particularly tough because Medicare is essentially speaking out of both sides of its mouth, as Medicare is also sadly encouraging some of the shift from inpatient admissions to Obs:

Boston Globe article:

"[Private recovery audit contractors] are paid based on how much they save Medicare. They achieve savings by punishing hospitals after the fact if a patient who might have been booked as an outpatient is classified by the admitting doctor as an inpatient."

Boston.com article:

Beth Israel Deaconess Medical Center paid $5.3 million on Monday to settle allegations by the federal government that it overcharged Medicare by admitting patients to the hospital who should have been treated less expensively as outpatients.

While outpatient Obs status is cheaper for Medicare, it can shift costs to the patients. But Medicare seems to be trying to fix the situation.

Medicare has proposed a regulation that would add clarity: inpatient hospital stays of 2 nights or longer would generally presume to qualify for inpatient payment ("defined by encounters crossing 2 'midnights.'") and shorter stays would not. This rule aims to reduce the number of long Obs stays and short inpatient admissions, and it's expected to result in a net result of more inpatient admissions. Of concern is the exception that time spent in any outpatient area of the hospital (i.e. the ED) would NOT count toward the 2 nights -- meaning time spent boarding doesn't count toward the 2 midnights.

What happens if the patient doesn't actually need 2 midnights to get better? the proposed rule seems fairly appropriate:

It is the documentation [at the time of admission] of the reasonable basis for the expectation of a stay crossing 2 midnights that would justify the medical necessity of the inpatient admission, regardless of the actual duration of the hospital stay and whether it ultimately crosses 2 midnights.*

On the other hand, Obs statistics might be used in the future as clinical quality measures (of course, potentially tied to payments). That is, the patient might be billed a lot more for the visit and the ED might be paid differently based on decisions made days later by non-ED administrators, that neither the patient nor the ED docs have any control over or even knowledge about.


*see 78 Fed. Reg. at 27644-27650 (dense regulatory document; lots of good stuff at page 27648)

Fun Medicare Obs Facts!

• 1.5 million Obs stays in 2012
• Another 600k patients started off as Obs, then were admitted
• Obs: 26% stayed 2 nights, 11% stayed 3+

• Most common reasons for Obs:
• #1 Surprise! chest pain, 340k visits (22.5%)
• #2: digestive disorders, 93k visits
• #3: syncope, 81k visits
• #9: respiratory symptoms

• 78% of Obs started in the ED
• 9% came from an "OR procedure"
• Most common "OR procedure"? 
• Suprise! coronary stents (hence the "airquotes")

• Most common reason for 2+ nights? back pain
• Least common reason for 2+ nights? chest pain

• Another 1.4 million "long outpatient stays" 
• (1+ night in hospital, coded as outpatient, but not Obs)
• Also most commonly chest pain & digestive disorders
• 63% of "long outpatient stays" started in the ED

• 1.1 million "short inpatient stays" (<2 nights)
• Similar reasons to Obs
• #1: chest pain
• #2: stent

• Average costs:
• Obs: $1,741
• Short inpatient stay: $5,142

• Average patient payment:
• Obs: $401
• Short inpatient stay: $725
• Patients paid more for stents when they were Obs stays
• 6% of Obs patients paid more than what their inpatient deductible would have been

QOTD: What Works

"Most interventions are bad unless someone is acutely dying." 
-Doctor Gus

Tweet-in-brief: Horse>>Unicorn

@AllergyKidsDoc An uncommon presentation of a common disease is still more common than a made up disease. #asthmonia

— Chris Carroll MD MS (@ChrisCarrollMD) July 30, 2013

Regulatory Capture

Came across this fascinating & comprehensive overview of the RUC in Washington Monthly. It's on the longish side but well worth the read.

Some other great recent articles on the RUC:
Washington Post (covers most of the same issues)
KevinMD (insider view mostly defending the RUC)


Briefly, the RUC sets RVUs (relative value units) for Medicare, essentially determining how much physicians get paid for each thing that they do. The RUC is run by the AMA, and representation by each specialty is nearly equal. So like the US Senate, each specialty gets one vote. 8k urologists, 30k EM docs, and 200k IM docs = 1 vote each.

Many attribute this absurd degree that we "overvalue" (read: overpay for) procedures is due to their gross overrepresentation on the RUC. And of course, this comes at the expense of paying for other things, such as primary care.

One fundamental issue with the way the system works is that it's the Resource-Based Relative Value Scale -- RVUs (aka price) is determined by inputs. The technical details are summarized well in Wikipedia:

For each service, a payment formula contains three RVUs, one for physician work, one for practice expense, and one for malpractice expense. On average, the proportion of costs for Medicare are 52%, 44% and 4%, respectively. The three RVUs for a given service are each multiplied by a unique geographic practice cost index. The sum of the three geographically weighted RVU values is then multiplied by the Medicare conversion factor to obtain a final price.

Note again that what Medicare pays is determined by inputs only -- hence the "Resource-Based" part of RBRVS. Nothing about outputs, or what non-economists would call "outcomes" or "does this help the patient?"

And we wonder why so many patients get procedures that we know don't help them.

Acknowledgments:

Thanks to Ashish Jha, Austin Frakt & Jeffrey Flier for tweeting links to the article.

And of course Haley Sweetland Edwards for writing the article.

Quick glossary:

RBRVS: Resource-Based Relative Value Scale = Medicare's payment system that pays physicians based on RVUs

RVU: relative value unit = "a measure of value used in the United States Medicare reimbursement formula for physician services" (thanks Wikipedia!)

RUC: AMA/Specialty Society Relative Value Scale Update Committee = the committee that determines RVUs

CPT: Current Procedural Terminology = "a medical code set maintained by the American Medical Association... [which] describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes." (also from Wikipedia)

Glossary Entry: Even Ste7en

synemia; also, septecemia (noun)

A patient with multiple blood tests showing the same value,
e.g. pH = creatinine = potassium = hemoglobin= lactate = bicarbonate = GFR (7@7)



Don't forget to check out the other glossary entries!

Glossary Entry: Just a Drop

drop (verb) [drōp, rhymes with "rope"]

To sedate an agitated or dangerous patient, such is with IM droperidol.


Don't forget to check out the other glossary entries!

A Graphic Reanalysis of the Leukocyte Count in Acute Appendicitis

The leukocyte count (aka white blood cell count; WBC in North America; WCC in Oz) has fallen out of favor with many, particularly in the diagnosis of acute appendicitis. Most EM docs I know love regaling each other with stories of the CT showing acute appy and the surgeon asking "what's the white count?" Always struck me like standing in the rain asking about the weather report.

(In all seriousness, I have a lot of respect for surgeons -- most that I know are very smart and incredibly hard-working; please don't cut me with your surgery knifey-thing).

A fun little paper that Scott Weingart has posted on his webtext shows likelihood ratios* (LR+) for appendicitis for different WBC levels.* Their sample is not huge but it's still nice.

The main conclusion is that WBC is only really useful in diagnosing appendicitis if it's below 7 or greater than 17, which is pretty much nobody.

Here is a graphic representation I put together of their results:

And here is their table with all the actual values:

This isn't to say that every patient with a possible appy should forego a CBC or that they all need CTs. See, for example, Choosing Wisely.

The lesson is that we should know the value -- or lack thereof -- of the tests that we do.

What's the deal with the title?

*Explanation of LRs that I wrote for The NNT a while back:

LR, pretest probability and posttest (or posterior) probability are daunting terms that describe simple concepts that we all intuitively understand.

Let's start with pretest probability: that's just a fancy term for my initial impression, before we perform whatever test it is that we're going to use.

For example, a patient with prior stents comes in sweating and clutching his chest in agony, I have a pretty high suspicion that he's having an MI – let's say, 60%. That is my pretest probability.

He immediately gets an ECG (known here as the "test") showing an obvious STEMI.

Now, I know there are some STEMI mimics, so I'm not quite 100%, but based on my experience I'm 99.5% sure that he's having an MI right now. This is my posttest probability - the new impression I have that the patient has the disease after we did our test.

And likelihood ration? That's just the name for the statistical tool that converted the pretest probability to the posttest probability - it's just a mathematical description of the strength of that test.

Using an online calculator, that means the LR+ that got me from 60% to 99.5% is 145, which is about as high an LR you can get (and the actual LR for an emergency physician who thinks an ECG shows an obvious STEMI).

Glossary Entry: Too Much Ultrasound

procrUStination (noun):

when residents spend too much time ultrasounding their patients, at the expense of other clinical duties.

The intern's been in with that patient for over an hour...

Don't forget to check out the other glossary entries!

Lactate Debate at BroomeDocs

Following the publication of this editorial by Marik & Bellomo, Casey Parker & I discuss the utility of lactate and/or physiology in the severely septic patient.

Broome Docs: The Lactate “Debate” with Dr Seth Trueger

EMCrit's response to Marik & Bellomo

Here's a little bit on the sepsis bundle as a pay-for-performance quality measure from Surviving Sepsis (overview)

This is NOT Gambling Advice

An adapted version of this post appears in print & online here in the August 2013 issue of EP Monthly

Subtitle: "Why You Can Stop a Trial Early for Harm but not Benefit"

This builds on a recent Twitter discussion with Jeremy Faust, David Marcus, Minh Le Cong, Pik Mukherji and CKB (and everyone else linked below).

It sounds odd when you first hear about it, but EBM experts say that you should stop a study if it shows sufficient harm early on, but stopping a study early because it showed great results is shady.

Why? Well, it's tough to explain, so here's an analogy I came up with*:

Stopping a trial early for benefit is like winning money gambling at a casino. If you've ever won money, why aren't you there right now, winning more?

Take any of the big games where you play against the House: slot machines, blackjack, or craps. I like craps -- it's fun, when you win everybody wins (except the one guy sitting next to the dealer betting wrong), and I hear that it's the best odds in a casino, other than counting cards at blackjack or cheating.

Now I know that the odds are stacked against me. The House has an edge, something like 51%. As the cliche goes, casinos are not built for me to make money.

But I know that the 51% House advantage is an average over time -- there are fluctuations around it. I saw a great video comparing it to walking a dog on a leash: the person walks in a straight line (overall trend) but the dog walks a little this way and a little that way (variation) but overall still follows the same path.** I'm hoping to catch a little variation in my favor, and quit playing before the game regresses back to the mean. And so is the drug company.

I know that overall, I am more likely to lose than win (the drug doesn't work). Now if I win some money in the first hour or two (early benefit) I know it's probably a fluke and not loaded dice (drug that works). I can take my money and walk away (stop trial) or I can keep playing. If I stopped with a few extra dollars in my pocket, would I conclude that I can win at craps (blockbuster drug!)? No -- I know that I just caught a little variation in the overall pattern, but in the long run, craps will cost me money.

What about if I lose money (harm)? Maybe I can win it back, should I keep playing? The problem is that eventually, if I keep losing money (drug doesn't work), large men will come after my family (drug is really harmful), and I don't want that.

Do not want.

Of course, in a clinical trial, we don't actually know whether or not the therapy works. Clinical trials start from a position of equipoise: we don't think the drug is harmful, but it might benefit patients, and the risk of harm vs risk of benefit is balanced. But if we show harm early, we lose that equipoise, and we have stop the trial before we harm the study subjects too much (before burly men show up at my house), knowing that we may have given up on a worthwhile drug but that it was just too risky. While it seems that the two are symmetric, beneficence vs maleficence is not a symmetric equation.

Are there times when we should stop a trial early for a huge, obvious benefit? I think so, but only if the study is adequately powered at that point, which it's very unlikely to be, because studies are designed to be powered at the end of the study, not midway through.

Back to the casino: if I walk into a casino, drop a quarter into a slot machine, and on my first try win $1 million, would I conclude that the machine is a winner? What if I win $10,000 on 3 of my first 5? It would take a combination of a big enough benefit over a big enough sample to demonstrate the power needed to end the study early, and that is rare.

At what point do I decide that the machine might be mis-calibrated (the drug works), and I should tell my parents to cash out their 401k and spend it all playing on this machine before the casino catches on (FDA approval)?

In summary: you have to stop early for harm because the study is hurting too many people, but stopping early for benefit isn't allowed, because that shows benefits that don't really exist.

UPDATE June 13, 2013:

Minh Le Cong brought up some good points regarding the ethics of stopping a trial early for benefit, i.e. if your trial is showing good results, is it ethical to withhold treatment from the control group (or others who may benefit)? (Snippets of this conversation.)

My main response is that until the study has acquired adequate power, the trial isn't showing good results. This is the essential question in statistics: do the differences that the study shows represent a true difference between the groups, or is it just a normal fluctuation in the data?

This is the point I was trying to make in the last few paragraphs above about the slot machine paying off early. Just because you win on the first few pulls (early benefit) does not mean the machine is a winner (true benefit). To quote myself: apparent benefit before adequate power is an illusion confusing our primitive brains.

Some others chimed in with some great points as well:

@rfdsdoc @mdaware No. If we KNEW the Rx was saving folks, the trial itself would be unethical. IRB approves trial due to uncertainty.
— Pik Mukherji (@ercowboy) June 13, 2013

@mdaware @ercowboy @rfdsdoc Yep. Until definite adequately powered result, randomisation is ethical. Stopping early renders trial worthless.
— Chris Cole (@DocOnSkis) June 13, 2013

Tessa Davis brings up another great point:

@mdaware @bengoldacre drug companies should be forced to publish the trial if had to be stopped early for harm
— Tessa Davis (@TessaRDavis) June 13, 2013

I apologize for being unclear. ALL of these results should be published, whether the trial was stopped early for harm or if the study is completed, with positive, neutral or negative results. Otherwise we end up with "publication bias" or the "file drawer problem." My discussion above is simply about when to end a trial early, not whether or not to publish the results.


*I would guess that others have had the same idea before, like Newton & Leibniz simultaneously discovering the calculus, and a whole bunch of people simultaneously coming up with the term "FOAMites"

**I tried and failed to find the video. Sorry. 

Sharpie?

Scott Weingart got me hooked on carrying a Sharpie on shift (nb it should be industrial strength), primarily for marking neck landmarks on people whose airway may deteriorate. He also advocates using it for marking external landmarks for LPs, before they get distorted by local anesthetic and hidden behind a fenestrated drape.

I've since found a few mostly obvious uses:

1) Cric landmarks

2) LP landmarks

3) Paracentesis: find a pocket of fluid with ultrasound, mark with Sharpie. Then sterilize and tap; no need to fumble with sterile US probe.

4) Outlining cellulitis

Some others:

5) Serial or alternate site ECGs:

6) Quick labeling of syringes (pretty much any sticker will work)

7) Alexander Sammel shared this one: marking added meds

8) Chris Edwards adds: signing kids' casts

Any other ideas?

Updates: 

Per Bryan Kitch's suggestion (and kicking myself for not thinking of it):

Also, I got tired of counting out 20 floor tiles every time I used the Snellen chart on the wall:

Glossary Term: Zebras

Zebra reverse-availability bias (noun):

The observation that reading about a rare condition is quickly followed by a patient encounter with the same condition.

If you read about it, they will come...

Don't forget to check out the other glossary entries!

ASX HTN

"My BP went from 160 to 170. Should I take an extra dose of my clonidine? or my metoprolol? or my enalapril?"

"No. You should stop checking your BP unless you have symptoms."

"Which should I take then?"

"911."

Tweet of the Day: Now What?

@justanerdoc airway mgt or trauma resus, you pick.

— Klint W. Kloepping (@KlintWKloepping) April 20, 2013

White Whale

There he is.

I've been trying to find this paper for a while, finally was able to. I saw Judd Hollander quote it in a grand rounds as PGY2:

Costochondritis. A prospective analysis in an emergency department setting.

This might be the coolest chest pain study ever done.

Rheumatologists evaluated 122 consecutive ED patients with chest pain at the Cabrini ED in 1991-2, and used the American College of Rheumatology criteria for diagnosing costochondritis.

Costochondritis was identified by digital palpation, applying enough pressure to induce partial blanching of the examining finger (=4 kg/cm2), over the costochondral and costosternaljoints (CCSJ), as previously reported. Patients were asked if such a maneuver: (1) caused no pain, (2) caused a pain different from original chest pain, or (3) caused a pain similar to the original one. Patients were considered to have CC if the answer was (2) or (3). The rest was used as a control group. Not included in this study were patients whose chest pain was associated with recent trauma, surgery, infection, fever, or malignancy.

Punchline:
6% of patients with costochondritis diagnosed by Rheumatologists in the ED = acute MI.

That's right. One out of every 17 patients who was diagnosed by a Rheumatologist, using the ACR costochondritis diagnostic criteria were having a heart attack.

Not ACS. Not positive stress. Biomarker-positive my-o-cardial in-farct.*

Judd Hollander's conclusion was: don't ever use the word costochondritis. If a resident uses it, send them home for the day because they did a bad job.

One big question remains:

How hard were these Rheumatologists pushing?**

For features from the HPI that make ACS more likely, see Salim Rezaie's great summary in Academic Life in EM.

A great question came up:

@mdaware @mgkatz036 Who has ever seen a Rheum in an ED, and why were they seeing CP pts?
— Cynic (@Apathetic_Cynic) March 29, 2013

(Perhaps that's why Cabrini closed? Also, I recently called a Rheum fellow for what I thought was a clear "can I send this patient to you on Monday?" and shortly thereafter, fellow + attending were in the ED injecting patient's ankle, at 9pm on a Saturday!)

On a historical note, I find it interesting that the authors included this line in their discussion:

One of the most interesting observations in  this study was the low frequency of AMI in the CC group,  which was four times lower than in the control group, in spite of having similar risk factors for CAD,  based on age, history of smoking, and hypertension.

That thinking on working up chest pain is (in hindsight) now outdated. See this great discussion on ERCAST.

Basically, the "risk factors for CAD" are just that: risk factors for developing CAD, which is a very different question than: does this patient with chest pain have ACS?

The way I think about it: traditional risk factors don't differentiate between which patients in the ED with chest pain have ACS; rather, the Framingham risks tell us which patients will end up in the ED with ACS at some point in the future. 

*plasma CK-MB. It was the early 1990s, after all.

**Actually we know: about 4 kg/cm2, "enough pressure to induce partial blanching of the examining finger"

Tools of the Trade

"What do you carry with you on shift?" 

This question has come up a few times, so I figured I'd put it down in one place:

Breast pocket:
3 pens
Sharpie (industrial) for marking landmarks (#13; eg cric, LP, and paracentesis)
scalpel

Rear pocket:
2 sheets of paper, folded in quarters for signout, notes, etc. I print out the track board intermittently and put some brief notations
iPhone (not pictured, because it's taking the picture; usually in breast pocket these days)

Waistband:
Trauma shears: most useful ED tool

ID:
mini-LED (like these) so I always have a light without ever needing to think about it
retractable reel clip

Desk:
stethoscope; still useful in a handful of situations, mostly wheezing, reiki, and leading into questions about smoking

Shift bag:
head lamp (AA battery powered) for things like finger & scalp lacs
paper prescription pad
[UPDATE 8/7/2018: I don't carry these anymore because we stock them]
big clamp
meconium aspirator & swivel adaptor for messy airways
extra guaiac cards & developer
3-way stop cocks -- poorly stocked in my ED, can come in handy (here, here, here, here, here, here)

Glossary Term: Not Looking So Hot...

crackophrenia (noun):

(1) the state or condition of being crazy from smoking crack cocaine

(2) the morphotype of the same

The patient has crackophrenia hair.

Credit to: David Lehrfeld

Special thanks to Scott Goldberg

Don't forget to check out the other glossary entries!

RSA A-OK

The patient has neck & face tattoos

With all due respect to Darren Braude (who is both smarter and significantly more qualified than me!) I'm admittedly not a huge fan of RSA -- rapid sequence airway. The concept is simple: give RSI meds (sedative + paralytic), place EGA* to preoxygenate, then intubate. The main concern I have is that you are taking patients who already think there might be an issue in oxygenating, and paralyzing them. Not much of a safety net.

However, the main reason I don't like RSA isn't because RSA is terrible or wrong but because the patients who need RSA are sick, tricky patients and all paths are fraught with danger.

There's been an twitter discussion over the past day or so between Nicholas Chrimes, Minh Le Cong, myself, and few others (Pik Mukherji, Alexander Sammel, Taylor, Brent May, Alan Grayson, Crystal Upshaw, Chris Edwards, Valerio Pisano, Kath Woolfield... sorry if I missed anyone!). And sometimes 140 characters (plus all the @tags taking up space) just isn't enough.

The main discussion skeptic of RSA here is Nicholas Chrimes, who asks:

Why not just try to intubate these patients? If they desat or the airway is unexpectedly difficult, then place an EGA and reoxygenate.

To me, the patient who needs RSA is the patient who you need to intubate now (no time for awake or AFOI or OR), and while you can preoxygenate, that preoxygenation is tenuous. This is admittedly a very, very small group of patients (smaller than the small group of patients who require DSI).

And I want to be very specific: I mean the patient who is preoxygenated to 100% on NIV for 3 minutes with 10 of PEEP and by the time the spatula hits the glossus, the sat is 85%. Doesn't happen much but when it does, no one is happy.

I think that the best thing you can do with this patient is slip in an LMA, reoxygenate, then intubate via the LMA. Dr. Chrimes disagrees, for a few reasons.

First, he contends that an attempt at ETI is just as fast as LMA placement. I disagree. I think that in the time it takes me to get the blade in the mouth, I could already have the LMA in place and start reoxygenating. I haven't done a formal lit search on this but in addition to my experience, there is at least one paper that at least suggests it (PMID 22796543**).

Next, Dr. Chrimes suggests that the goal is airway protection from aspiration, not oxygenation. Aspiration is very bad, but I think one of the lessons from NAP4 is that desaturation kills in the ED, aspiration kills in the OR.

As Minh suggests, in these patients the risk of aspiration is low but the risk of critical desaturation is very real and the consequences are dire. The goal here isn't to leave an LMA in place. It's to bridge the patient to a protected airway without critically desaturating. The patient who critically desaturates injures their brain and/or arrests. Which is bad.

“It's not about plastic in the trachea, it's about oxygen in the lungs." (Rich Levitan)

Sure, there is a risk for aspiration. But if the patient is desaturating precipitously, then the risk for hypoxia is much higher than it usually is. Here RSA is used to avoid hypoxia -- which you know will be a problem, while aspiration only might be a problem.

I don't think the answer is necessarily clear. But to me, this seems like the least dangerous path in a very dangerous patient.

UPDATE March 8, 2013:

As the twitter argument conversation continues, something I realized I forgot to include:

Part of Nic's contention is that ETI is just as fast as LMA placement. Again, I disagree. In fact, to me, part of the reason RSA makes so much sense here is that while you may not have enough time to intubate the patient before a critical desaturation, you very well might have time to slip in an LMA. After rexoygenating, you can then intubate through the LMA, which should also take less time than a laryngoscopy & tube placement attempt.

Basically, you're breaking up your intubation attempt with the LMA, and adding a chance for the patient to catch their breath.

Plus, attempting to intubate via an LMA has an added benefit: if you need to bag the patient back up, the time it takes to abandon your attempt and start ventilating is very short -- certainly shorter than backing out from an attempt at ETI and going back to bagging. And, now you're LM bagging, which is often better than FM bagging.

Lastly, Scott Weingart chimed in:

@nicholaschrimes @mdaware @rfdsdoc @socalexmd @ercowboy best place for rsa imho is solely met acidosis pt you want to bag thru ap period

— Scott Weingart (@emcrit) March 8, 2013

*Extra glottic airway, such as a laryngeal mask or King-LT. I happen to prefer LMAs -- and I know that technically LMA is a brand name but I don't want to keep typing "laryngeal mask"

**I happen to have been a subject in this study

ACEP Chooses Wisely

Kudos to ACEP for joining the Choosing Wisely campaign! I think this is a big step forward in helping reign in unnecessary care, which not only will help our patients but also happens to save money. Note that helping patients is the priority here; saving money is nice added benefit (and will help keep other people's noses out of our professional business).

As explained briefly on The Central Line:

“Choosing Wisely” is part of a multi-year effort of the American Board of Internal Medicine (ABIM) Foundation to help physicians be better stewards of finite health care resources. The campaign encourages medical specialty organizations to identify five tests or procedures commonly used in their field, the necessity of which should be questioned and discussed by patients and physicians.

ACEP had considered joining 3 times before, but was concerned that and most recently had declined to join in the summer of 2012. Some concerns expressed by then-ACEP president David Seaberg include:

Many of these patients have been sent in with expressed instructions from the family physician to have this or that test ordered 

It is simply not possible for emergency physicians to talk about reducing ‘unnecessary’ testing without including messages about the need for medical liability reform.

it very well may assure that emergency physicians will not receive reimbursement for the five identified procedures or tests.

Although those concerns are not unwarranted (mostly the latter 2), I think they are generally outweighed by the benefits. As I explained in a reply on the EP Monthly re-post of the same essay by Dr. Seaberg:

Choosing Wisely is gaining national recognition for its patient-centered approach to decreasing unnecessary care. This is one major way we -- as professionals -- can decide what is appropriate for our patients. Parsimony is coming. If we don't take the lead then others will decide how we should care for our patients. As a specialty, we can define our standard of care so groups like CMS don't have to.

Tweet-in-brief: Prescient Synchronicity

Patient says he is short of breath, I asked when it started and I'm told "any minute now." Me: so you are not short of breath now? Pt: "no"
— HopHeadMD (@HopHeadMD) February 18, 2013

Colleague has a pt w CC: chest pain that started while driving to the ED. Prescient, that patient.
— GruntDoc (@gruntdoc) February 18, 2013

note that:
a) these were 2 minutes apart
&
b) these guys do not work together

Glossary Term: Seldinger's Cat or Schrodinger's Wire

Seldinger's Cat or Schrodinger's Wire (noun):
when you just don't know which vessel the wire is in...

Don't forget to check out the other glossary entries!

Empty the Dishwasher

True story: a few months ago, I walked into my apartment, and noticed the sink was overflowing with dishes. My first reaction: The dishwasher must be full.

I had been taught a few years ago that the main cause of crowding in the ED is boarding of admitted patients: patients who came to the ED, got admitted, and are waiting for beds upstairs. It seemed a bit odd at first, but the explanation makes sense. There are 3 possible causes: input, throughput, and output. Either there are too many patients coming to the ED; patient time in the ED is too long; or, we can't get patients out of the ED.

While the mainstream media and many policy people who aren't fluent with the topic are quick to attribute crowding to armies of low-acuity patients clogging up EDs with sore throats and ankle sprains, empirical evidence shows that's just not the case.

And it makes sense. If an admitted patient sits in the ED for an extra 6 hours, that's the equivalent load as 6 low-acuity patients who each take an hour. They may not take up a lot of physician time (although they do use some) they require a nurse, and a space in a room (or hallway).

Same idea with throughput. Although some emerging evidence suggests that throughput is a bigger factor than we thought. But much of this is probably due to EDs doing more comprehensive workups in order to avoid admitting patients.

So why is boarding such a pervasive problem? The reasoning is that hospital administrators think that hospitals generate more revenue from elective, procedural admissions than from ED admits. Therefore, elective surgical schedules are kept full in order to bring as as much revenue as possible, and the ED patients will still get admitted (after waiting for a while). If hospitals cancelled elective admissions because the hospital was full, they would forgo that revenue.

However, there is some evidence that this calculation is mistaken, and hospitals actually lose revenue by filling up the hospital, forcing the ED to go on diversion, so that critically ill patients are lost (and they pay pretty well).

Oh, and keeping the ED crowded leads to all sorts of badness for the patients, not just longer wait times but worse care.

Further, lack of space in rehab and nursing facilities (and lack of payment by insurers) is another hospital-output problem, particularly for public hospitals.

In addition to dialing down elective procedures, hospitals can help with crowding in a number of ways. Overall, a lot of it is a matter of hospital operations (the business/admin stuff, not the surgical stuff. coincidence?) Simple things like automatically calling housekeeping to clean a room when an inpatient is discharged.

Perhaps the best plan, concocted by Peter Viccellio, is brilliantly simple. If all the admitted patients can wait in the ED hallways, why can't we spread them throughout the inpatient hallways? There are certainly a lot of hallways and nurses upstairs, too. It's been shown to be safe, preferred by patients, and, not surprisingly, places that institute inpatient hallway boarding "magically" find beds for half of the hallway boarders fairly quickly.

Yet EDs across the nation are still crowded, most of the time, pretty much everywhere. Perhaps if hospitals made better decisions, things would be better -- for revenue, for healthcare workers, and for patients.

Tweet-in-Brief & Glossary: Arresting Developments

@mdaware if there wasn’t ROSC, it’d be a preflordial crump.

— Michael Katz (@MGKatz036) January 16, 2013

Don't forget to check out the other glossary entries!

Tweet-in-Brief: Beginnings

Ditto MT @precordialthump: @mdaware If u think s'thing is crap, leave a comment, tweet it, or write yr own blog... Ditto if its good #FOAMed

— Javier Benítez (@jvrbntz) January 18, 2013

@mdaware @jvrbntz @precordialthump It was actually your second post.Glad that I could stimulate you to blog and tweet!

— Robert Centor (@medrants) January 18, 2013

Capnography PK SMACC Talk

Here's my SMACC PK on Capnography (LITFL page)



plus check out the great PK on ETCO2 in Cardiac Arrest by Jon Schonert

QOTD: Minh Likes the Airway

“Airway day? Every day is airway day!”

- Minh Le Cong