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On "unnecessary" ED visits: background reading

Here are a bunch of very informative pieces on why trying to blame excessive costs or busy-ness on low acuity patients in the ED is, at be...

December 30, 2015

And I Didn't Know It

Inspired by Saurabh Jha:
Not exactly op notes, but some ED limericks I wrote:

Mr. Jones ate some bad guacamole
press on his belly, he shouts "holy moley!"
we did a CT
and what could it be?
then he went for a lap'r'scopic chole

Mrs. Smith was awoke from her nappy
her belly was feeling quite snappy
white count? twasn't high
a fever? tad shy…
but the CT, of course, showed an appy

there once was a man from Bologna
thought he had caught a touch of pneumonia
he seemed like whiner
and he got a d dimer
no PE; just some bad allodynia

Of course the cake goes to:

November 16, 2015

Roc vs Sux Revisited: Cochrane Update

I’m not going to reinvent the wheel, so a sweeping summary:
Traditionally, succinylcholine has been the paralytic of choice for RSI. However, succinylcholine can (rarely) lead to hyperkalemia, particularly in patients with chronic neurological problems.* Proponents of rocuronium for RSI suggest avoiding potentially fatal hyperkalemia by routinely using roc, summarized superbly by Reuben Strayer here. When dosed properly (1.2 mg/kg or higher), time of onset and intubating conditions are equivalent to between rocuronium and succinylcholine.

Defenders suggest that succinylcholine's shorter duration of paralysis is an advantage: if you can’t get the tube, the patient starts breathing. Unless the patient critically desaturates before return to an unparalyzed state:

Note the title of the source of this familiar graph: Critical Hemoglobin Desaturation Will Occur before Return to an Unparalyzed State following 1 mg/kg Intravenous Succinylcholine (Benumof, Dagg, Benumof. Anesthesiology. 1997 Oct;87(4):979-82.)

In the original 2008 Cochrane review, the authors (including Perry & Wells) find that time of onset and intubating conditions are inferior to succinylcholine… when dosed inadequately. Cochrane just released another update and reached the same conclusion with mostly same data, but again, note that when dosed appropriately, rocuronium is just as good as succinylcholine, with a p-value of 1.00.

Of course that’s only 86 patients dosed at 1.2 mg/kg, but the results were identical. The Cochrane authors further find that even some lower doses of rocuronium (down to 0.9 mg/kg) are just as good:

but then come to the same conclusion:

This is a bit odd. When I can’t intubate or ventilate a patient, they don’t nicely wake up in 9 minutes. In fact, more paralysis may even be preferred, particularly to optimize further attempts at mask ventilation, including EGD placement. And more importantly, to stop a panicking, suffocating patient from stopping me from stabbing them in the neck. But the bottom line is that if the succinylcholine has worn off, then they’ve probably already critically desaturated.

A number of Very Smart People (including Rob Huang, Minh Le Cong, Chris Nickson, and Reuben Strayer) have all pointed out that Cochrane is supposed to summarize the data, not editorialize:
There are some situations where I still reach for succinylcholine, primarly when I don’t want to lose my neuro exam for an extra half hour, mostly severe head trauma and status epilepticus. Also, if I can’t get a line or an IO and need to use IM drugs for RSI, rocuronium is probably too dilute.**

Ultimately, this isn't that big deal. Hyperkalemia is bad, but rare. But if we can avoid it without worsening time to onset or intubating conditions, why not?

My biggest problem with rocuronium? It comes in 50 mg vials. One*** great tip I learned from Reuben Strayer : when I ask a nurse for rocuronium, I always clearly specify that I need 2 (or 3) vials.

*Most of which are fairly rare and I (fortunately) don’t need to intubate very frequently. But when that relative zebra is really sick, I have enough on my mind and I don’t want to have to think to hard about which drugs may be dangerous. Note that in MG, you can use succinylcholine but have to use more; you can use a lower dose of rocuronium but a normal dose will just paralyze them longer, which is much safer than me having to remember this whole paragraph and do math when the chips are about to hit the fan.

**Bad day for everyone. Not ideal but I prefer to have my quiver more full than my diaper.

***One of too numerous to count. Read and watch everything at emupdates.com

Special thanks to Minh Le Cong & Reuben Strayer for their prepublication peer review.

Also from Twitter::

October 25, 2015

Tweet-in-Brief: Do the Right Thing

October 21, 2015

Get What You Pay For & Pay for What You Get

This post is co-authored by Seth Trueger & Cedric Dark and also appears on Policy PrescriptionsSee also the related post on Narrow Networks (PolicyRx).

Andrew Sprung and I had a great conversation about Republican presidential candidate Donald Trump's claim that premiums are rising (see the Storify below). Our view: premiums are generally flat. There is a lot of variation around this, mostly geographic, and also largely based on whose premiums you're talking about. Comparing premiums from before Obamacare to today’s is like comparing 1995 and 2015 cell phone plans. [caption id="attachment_5826" align="alignleft" width="300"]Source: Lauren (Flickr/CC) Source: Lauren (Flickr/CC)[/caption] Yes, some people who were insured on the non-group market prior to the ACA saw their premiums go up significantly. But this is a meaningless critique. First, the fraction of people who had non-group plans prior to the ACA is (and still is) pretty small - about 5% in 2011 [source: KFF]. Second, remember that most people who have individual plans only have them for a fairly short period of time; most only enroll in a plan for 6-18 months, such as for a few months while searching for a job and until their next employer-sponsored plan kicks in (see this post for example). And while some were happy with their coverage, remember the two most important caveats to pre-ACA nongroup premiums:
  1. What did these plans cover?
  2. Who didn't these plans cover?
The first of these big problems: people who ostensibly had insurance would find that it didn't help them when they needed it, because they hit annual or lifetime benefits limits; certain medical problems or services weren't covered; or, the insurer cancelled their plan when they made a claim. Even in the best-case situation, remember how frustrating it is to deal with actually getting an insurance claim paid.
"If you think government healthcare is bad, wait until Comcast runs it." - Seth
Personal example #1: I (Seth) had cheap private insurance for a few years in med school after getting kicked off my parents plan well before age 26 (Thanks, Obama) and I paid $60+ a month for essentially useless coverage that didn't really cover anything. Fortunately, I never got sick and I only really needed my insurance to satisfy my school’s requirement (and, maybe, piece of mind. But not really). While we don't know how many people were "happy" with their pre-ACA plan, we can estimate. Per Andrew Sprung, about half of the 16% of people in the non-group market now have grandfathered plans... which is roughly 1/2 of 1/6 of 1/20 of the insurance market, so 1 in 240 insurance plans. The second of these major issues that arises when comparing premiums before and after the ACA: preexisting conditions. How many people were completely blocked from getting insurance because of a preexisting medical problem? And relatedly, how many people were either charged higher premiums because of a preexisting condition? Or, were only given a plan that didn’t cover anything remotely related to their preexisting condition? ("You can buy insurance from us but we won't cover surveillance or treatment for a relapse of your Hodgkin's Lymphoma.") Personal example #2: My (Seth’s) wife was previously charged more (plus had to do a ton of frustrating paperwork) for the preexisting condition of "having a pre-cancerous benign mole removed." Remember: private insurance companies aren’t incentivized to keep us healthy; they are incentivized to keep us healthy until we turn 65. While a small fraction of individuals now pay a little more for their premiums, their insurance actually now has to cover stuff; and, they aren't getting a discount by excluding all the people who have serious health problems (or benign moles). Given all these caveats, it's really remarkable that premiums are pretty much flat at all. Let’s consider one last thing. “Premium price" can mean a lot of things. Is it subsidized or unsubsidized? Subsidized premiums are most likely pretty flat, and are what individuals actually pay. Unsubsidized premiums have gone up, but not by as much as people like Trump claim. I'm the first to admit that probably the biggest question the ACA poses is: will premium subsidies simply cost too much? And so far, it doesn't seem like it.
We have a great review forthcoming from Laura Medford-Davis on this issue. Stay tuned! - Cedric
Premium subsidies are simply the price we pay for insuring millions and millions of Americans in a functioning market for non-group insurance. And let’s not forget the quasi-secret but much, much, larger subsidies we already provide to people insured through their employers. We shouldn’t decry subsidies for insurance bought on the market while spending hundreds of billions of dollars subsidizing employer-sponsored insurance.

October 13, 2015

Narrow Networks: The Result of Competition, not the Barrier

Source: geralt (Pixabay/Public Domain)
Source: geralt (Pixabay/Public Domain)
This post is co-authored by Seth Trueger & Cedric Dark and also appears on Policy Prescriptions. See also the related post on premiums before & after ACA (PolicyRx).

This fantastic article by Dan Diamond in Forbes on Republican presidential candidate Donald Trump’s gibberish on health care during his 60 Minutes interview sparked some great discussion on Twitter – see the Storify below. Dan makes an amazing analogy:
Blaming Obamacare for insurance companies’ behavior is like saying Trump’s responsible for how America nominates its presidents.
Dan’s piece did, however, clumsily brush over one important issue, saying:
Trump has returned time and again to the idea that there’s not enough competition in the health insurance market. And you know what? He’s probably right. More than 40% of the doctor networks available through Obamacare exchanges are narrow network plans. Around half of all hospital networks on ACA plans are narrow networks, too.
This isn’t so much wrong as it is non sequitur. Narrow network plans aren’t evidence of insufficient competition in the health insurance market; narrow network plans are the result of competition and negotiation in the health insurance market.

Insurers try to find the best provider network (providers include both hospitals and doctors, which are negotiated separately) for their plan at the lowest cost, mostly using their enrollees as leverage. Insurers try to negotiate a discount by bringing volume. Plans basically say to providers, “Take this price and look how many patients we will bring you!”

Hospitals and doctors negotiate for the highest prices and the largest volume of patients they can get, leveraging their quality and brand name (i.e. desirability).

The main “market interaction” in the insurer-provider market is defining the network for the plan. This is primarily how premiums and other costs are determined (in addition to deciding which benefits are covered by the plan).

Incidentally, this is pretty much why selling plans across state lines doesn’t magically fix anything. Consider this example.

An insurer in Illinois still has to negotiate a completely separate provider network if it were to try to sell a plan in another state like Indiana or Georgia. That’s where all the work exists. It’s not the regulatory burden; it’s the provider network negotiation.

There is, in fact, a lot of competition in health markets, primarily in the negotiations between insurers and providers. All Obamacare did was make it so that for insurers to complete against each other they had to come up with new ways of making profits while keeping premiums and cost sharing competitive. Instead of the pre-ACA race to see which insurer could exclude the riskiest people, now insurers fight over patients by cutting costs while maintaining required coverage — and the primary way to do that is by narrowing networks and excluding providers that don’t (as Trump would say) “cut a deal.”

September 21, 2015

Bad Idea Jeans [UPDATED]

UPDATE 9/28/15:
This story NYTimes Well story that instructs laypeople how to perform table-side crics to choking restaurant visitors has, not surprisingly, gotten a bit of play, including a nice Letter to the Editor response from ACEP President Michael Gerardi.

One point that has been nagging me, however. I'm honestly not that concerned about an untrained layperson slicing the carotid of choking patient who failed Heimlich was going to die anyway in a last-ditch attempt to save them. They were going to die anyway, might help.

BUT my big concern is who the untrained layperson attempts to cric. I don't want a patient who just needed a good abdominal thump to instead gets a botched cric.

One of the big cliches in emergency airway teaching is "the most difficult part of performing a emergency cricothyroidotomy is the decision to proceed" -- the Times should not advocate untrained diners make that decision.


The Heimlich maneuver doesn't always work, maybe it's not such a a good idea for NYTimes Well to recommend this:
When all attempts to rescue a choking victim fail and emergency medical help is unavailable, there is a treatment of last resort: a cricothyrotomy, which is easier and quicker to perform than a tracheotomy. With the victim lying flat, tip the head back and locate the bulge of the Adam’s apple. Using a sharp knife, make a half-inch horizontal cut a half-inch deep between the Adam’s apple and the bulge an inch below it, the cricoid cartilage. Insert something like a straw or casing of a ballpoint pen (first remove the ink cartridge) and breathe into it. In case someone’s life depends on your ability to do this, review an illustrated description of the procedure at www.tracheostomy.com/resources/surgery/emergency.htm.
Upside: perhaps I will pay off my student loans selling my new poster to restaurants:

September 8, 2015

EM Mindset: emDocs

from Rich Winters
Special thanks to Alex Koyfman for inviting me to write an EM Mindset essay, Alex and Manpreet Singh for editing & posting it, and Reuben Strayer for the referral.

The post:

Some early Twitter chatter:

August 25, 2015

Streetlights & Counting Clicks

Someone recently sent me this 2014 Time Magazine article on metrics for web readership by Tony Haile, the CEO of Chartbeat, which does web metrics.

My first impression: this article seemed oddly familiar and I realized I read a similar article about Chartbeat by Farzad Manjoo in 2013 (with some of the exact same/similar graphs; note that this is not so much of a critique as just amusing to me):

Different articles, same graph. Bonus: see what's on Seth's bookmark bar

Technically different but essentially the same graphs. 

Go read either or both of these articles and come back here for my thoughts.

My key impressions:

-Of course neither clicks nor social media shares are a completely accurate proxy for what we really care about: engaged readers who understand, learn, and remember the content of an article

-but clicks and social media shares are (most likely) useful proxies.

Ultimately this is my more optimistic view of the "streetlight effect" -- sometimes it makes sense to look for your keys in the the light, where it's easy. See also: fruit, low-hanging.


Newspaper circulation: of course 1.4 million NY Times readers are not fully apprised of every topic discussed in each daily paper.

Symplur impressions: #ACEP14 had 33 million impressions; this does not mean that, on average, each emergency physician learned 1,000 things via Twitter during ACEP.

My take is that in all of these cases, of course there are limitations but these numbers are a "ceiling" -- an upper limit of theoretical impact, and they are still somewhat useful to compare numbers (e.g. one outlet's performance across time, or multiple outlets' performance against each other).

The rub is how accurate the surrogate marker is as a proxy. Compare impact factor, where it's probably useless to compare a clinical EM journal against an academic mathematics journal, where citations accrue at different rates and may signify more or less (for more on limitations of journal impact factor, see our piece on Altmetric).

Complete speculation: I suspect that clicks are a useful measure for Annals of EM, particularly as we have what seem to be fairly high visit durations (nearly 3 minutes) and 2.6 pageviews per visit (if I'm reading the data I have correctly).

I have not analyzed this formally in any way, but casually following Annals' top Altmetric score articles seems to give a handful of popular topics, in no particular order:

1) airway (always a popular topic, particularly on social media)

2) social media (tons of self promotion and mutual congratulations, as well as legitimate interest in social media)

3) public health (e.g. ACA, injury and violence, even Ebola)

I suspect the social-media-share-to-actual-reading ratio rises going down this list, particularly as there are a lot of overlapping online communities and general public interest in public health topics.

One last point about the Time article:

2/3 of reading is below the fold, which makes sense: the overwhelming majority of clicks result in 15 seconds or less of reading, but the small fraction who read below the fold spend much, much more time, just as half of Medicare spending is on 5% of beneficiaries.

June 8, 2015

Crowdsourcing: TVP

In an effort to demonstrate* the crowdsourcing potential of Twitter for EM medical education resources, I asked:

The crowd performed well and very quickly I got a number of useful responses:

Thanks everybody!

*to a skeptical resident

May 26, 2015

ACA Update: What do you want?

On June 13, I'm speaking at the Policy Prescriptions Health Policy Symposium at Baylor.

My talk is titled "The ACA: An Evidence-Based Update." To continue my new tradition of crowd-sourcing, what would you want included? What do you know that I should share? What don't you know that you want to?

April 12, 2015

Bow Transplant

Missing shoe bow

A generous donor was found

Suitable donor tissue identified

and harvested.

Donor tissue prepped

Transplant begun


The patient thanks the donor

Happy family reunited

See also Laryngectomy

April 9, 2015

Number Needed to Tweet

My recent lecture at Northwestern:

"Number Needed to Tweet:
How Social Media is Changing Medical Education"

Much thanks to Mike Gisondi & @NU_FAME for the invitation!

Want to: 

Watch the whole thing? Video

Read a summary & lots of tweets? Storify:

March 17, 2015

Keep your ProMISe

The ProMISe study was published in NEJM today -- I'm sure there will be great takes from all around. The first I saw was from Rick Body at St. Emlyn's, very nice summary indeed.

I'll leave the detailed analysis to others. My quick take, mostly based on comparing baseline characteristics of each group (Table 1), interventions in each group (Table 2), and outcomes (Table 3): ProMISe is a lot like ProCESS and ARISE.

The groups were similar, and the outcomes were similar, but most notably, the interventions were similar.

My bottom line interpretation remains the same; the keys in sepsis are:
  • early identification
  • early antibiotics
  • early aggressive resuscitation (particularly fluids)
We've gotten much better at all of those since 2001, which is (in my opinion) the main lesson from Rivers.

What ProCESS, ARISE, and ProMISe really tell us is that if you do all the things that are on a protocol, it doesn't matter whether or not you have a protocol.*

Like with ProCESS, it's a little tricky to decipher what fluids each subgroup actually got. I think Table S7 in the Supplemental Appendix is key:

*more on protocols from me, re: ProCESS

**Correction: just noticed the terminal "e" is not capitalized. Oh well.

February 10, 2015

Brussels Sprouts + Math = A Recipe for Confusion

My wife is a dietitian and a very good, healthy cook. Today she was cooking some Brussels sprouts (which I, evidently incorrectly, have been calling "brussel sprouts") and it brought up a great lesson in how hard it is to try to eat healthily in America. Rather, I just finished 26th grade and my wife went to school for this and has literally done this for a living for nearly a decade, and yet we can't figure out what we're eating.

We have a 1-pound bag of Brussels sprouts:
1 pound bag = 454 grams
According to the label, the serving size is 4 sprouts, or 84g, which contains 40 calories. There are 5 servings per container, which should be 20 sprouts in the bag for a total of 200 calories.


The label (photo) is identical to the official USDA label (image above).

My wife counted how many sprouts came in the bag, and we have 40, not the 20 the label says we should have (4 sprouts per serving x 5 servings). Which, on the one hand, is great, because, hey, who doesn't want free Brussels sprouts?

So does our bag just have really small sprouts? Or do we have a 400-calorie bag of Brussels sprouts?

4 of our sprouts in a 1-cup measuring cup
10 of our sprouts in a 1-cup measuring cup
This looks like <4 servings, probably closer to 3 with the (inedible) stems cut off

So how do we figure out the nutrition content? Do we have 10 servings of Brussels sprouts and there are 400 calories? Or, do use our measuring cup and we have 160 calories?

My point here isn't that I want bigger sprouts, or "hey look the Brussels sprouts people don't know how to do math!" But again, I just finished 26th grade and my wife went to school for this and has literally done this for a living for nearly a decade, and yet we can't figure out what we're eating.

February 6, 2015

Site Neutral Payments/Facility Fees: A Primer

Great article today on this topic by Margot Sanger-Katz in The New York Times's The UpShot. Go read that. I dug up a recentish email with my brief summary of SNP:

Traditionally outpatient care has been split between physician offices or hospital outpatient departments (OPD). Recent years have seen a number of incentives pushing hospitals to buy up physician practices (and physician practices to consolidate into hospital systems) and one of them is that as OPD, the hospital can charge more than the physician did. The physician share ends up being a bit smaller than before (see chart page 32 in this MedPAC summary) but now the hospital system can charge a facility fee in addition to the doc's professional fee (evaluation and management, or E/M) so the total payment is bigger. The doc gets less but gets all the benefits of being in the hospital system (brand, stability, infrastructure, etc) and the hospital gets money & a referral network, all for doing little less than flipping a sign on the front door (to steal directly from Atul Grover).

The rub here is that the higher payments to OPD basically used to be a hidden but legitimate subsidy to safety net hospitals (using the term loosely); broadly speaking, OPDs were part of bigger, underfunded hospitals serving poorer populations. Now, hospitals that operate on the different end of the nonprofit spectrum are cashing in a bit. There's definitely some abusive practices now, but how do we throw out the bathwater without the baby? I'd like to think that if we want to subsidize hospitals that serve poor patients we should just do that outright, but, well, Gruber got in trouble for explaining how that works.

There's a lot of parallel to the issues with the 340b system, except that is an explicit, not implicit subsidy.

February 4, 2015

Please Read-ux

One of my residents suggested: "I think it'd be super helpful for the residents if you sent out what websites/feeds/resources you use for finding all this [online] stuff"

Sadly there's no simple/easy answer to that -- but a bunch of us wrote a paper appropriately titled "Five Strategies to Effectively Use Online Resources in Emergency Medicine" (free full text).

By no means comprehensive, I think a great starting point:

1) check compilation sites, like LITFL Review and pretty much everything at aliem.com. LIFTL R&R and emlitofnote.com are great for actual studies.

2) use an RSS (instructions); or, I use Twitter as an informal/moderated RSS -- basically make all you online people filter stuff for me.

Probably the most important thing is to:

a) do something, but
b) don't do too much

It's very easy to sign up for a lot of stuff and then get overwhelmed and end up doing nothing, or to get too distracted and not do the most important things (i.e. read a text book).

January 1, 2015

Not Used to Being Naked Around Strangers

Chris Carroll recently shared this "Advice from a Patient," which seems to be from the PFCC Innovation Center 2013 Annual Report, and was not written by Gill Phillips:
This may be a normal day at work for you,
but it’s a big day in my life. 
The look on your face and the tone of your voice
can change my entire view of the world. 
Remember, I’m not usually this needy or scared. 
I am here because I trust you; help me stay confident. 
I may look like I’m out of it,
but I can hear your conversations. 
I’m not used to being naked around strangers.
Keep that in mind. 
I’m impatient because I want to get the heck
out of here. Nothing personal. 
I don’t speak your language well.
You’re going to do what to my what? 
I may only be here for four days,
but I’ll remember you the rest of my life. 
Your patients need your patience.
Some great thoughts to keep in mind for the upcoming year. Happy 2015!