got public health?

Feb-stache-uary

Folks….it’s February. For some, it signifies the recognition of historical figures in Black History. For others, it is counting down to Feb 15th when Valentine’s Day will be officially done for the year. For us, it marks the beginning of Feb-stache-uary.624x600eatftmustacheIn its second year in existence, our fellow male residents band together for one month to grow facial hair like it’s going out of style. The cause: to show support in preparation for the Emergency Medicine Inservice Exam. Last year, the females joined in on the cause by wearing fake moustaches. Overall, comraderie was in the air…and if anything, some great photos were taken which will definitely be a part of the graduation roast.

Historically, moustaches were worn by men in the military…the higher in rank, the more prominent the moustache. In some cultures, the moustache is a sign of virility. Villanous characters are often portrayed with a moustache. Some notable moustache types include Dali, Fu Manchu, Handlebar, and the Walrus.

For a complete listing as well as monthly mustache interviews, please visit the American Mustache Institute

The moustache holds its own place in the public health spotlight. Since 1993, the “Got milk?” campaign has recruited famous political and social figures to wear milk moustaches to promote the benefits of milk consumption (osteoporosis, sleep, cavities, muscle rebuilding, strong hair, skin and nails).

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Movember is a charity event in November to raise funds and awareness for issues in men’s health, specifically prostate cancer. Originating in Australia, men worldwide can register online as “Mo Bros” with a clean shaven face and work on growing their “Mo” all month while raising money in support for the cause. The Gala Partes festivities take place at the end of the month, wear Borat and Hulk Hogan look-alikes come out and celebrate. Check it out!

Last but not least, reflect on some of these famous moustaches (we need to get Dr. Tabbey on this list):

Groucho Marx, Charlie Chaplin, Adolf Hiler, Friedrich Nietzsche, Josef, Stalin, Albert Einstein, Mahatma Ghandi, Frank Zappa, George Harrison, Dennis DeYoung, Steve Perry, Freddie Mercury, John Oates, Otis Redding, Jim Croce, Howard Hughes, Tom Selleck, Mark Spitz, Hulk Hogan, Salvador Dali, Pat Morita, Mike Ditka.

Happy Feb-stache-uary!  Here is a little treat…can you identify the face behind each stache

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Thanks for reading.

Your comments and thoughts are much appreciated!

Dr. Marjan Siadat is a second-year Emergency Medicine resident at Detroit Receiving Hospital, Wayne State University. She is the editor of the public health section for Receiving.

Answer quizzER Vol 2.1

quizzER Winners:

David Mishkin           Marjan Siadat           Ryan Phillips             Allison Loynd

Julie Nguyen              Maria Pak                  HVSH CRNAs           Devon Moore

Maria Pak                   Brian Kern                 Richard Gordon        Rob Klever

Last Week’s Question

The answer is c.

Spinal abscesses are most commonly found in immunocompromised patients, IV drug users, and the elderly.Signs and symptoms of epidural abscess usually develop over a week or two and include fever, localized pain, and progressive weakness. An elevated WBC count is also commonly seen. MRI is the most useful diagnostic test. S. aureus is the most common causative organism, followed by gram-negative bacilli and tuberculosis bacillus.

___________________________________________________________
(a) A lung abscess is a cavitation of lung parenchyma resulting from local suppuration and central necrosis. It is often precipitated by aspiration of oropharyngeal secretions. (b) Inflammatory conditions, including ankylosing spondylitis, may cause back pain. The key findings in this disease include gradual onset of morning stiffness improved with exercise in a patient less than age 40 years. On physical examination, these patients may have limited back flexion, reduced chest expansion, and sacroiliac joint tenderness, all of which are nonspecific. Fever and weakness would not be expected. (d) Back pain may result from vertebral compression fractures. These may be secondary to trauma or may be atraumatic in a patient with osteoporosis. Osteoporotic compression fractures usually involve patients over 70 years or patients with acquired bone weakness (e.g., prolonged steroid use). (e) Metastatic lesions invade the spinal bone marrow, leading to compression of the spinal cord. Most common primary tumors include breast, lung, thyroid, kidney, prostate (BLT with Kosher Pickles), as well as lymphoma and multiple myeloma. Maintain a high level of suspicion for any cancer patient who develops back pain; these patients must be investigated for spinal metastases.

Thank you for everyone who submitted an answer.  Please stay tuned for next week’s quizzER.

quizzER is a weekly contest consisting of a question selected from various areas of emergency medicine that are central to the education of medical students and residents in training.

#1: Customers, Patients, Ostriches and Turbulence

sully-with-blood-drops2

Welcome to Incision and Drainage. On this blog, we’re going to drain some pus.

Of course, we’ll talk about a lot of things, but if I do my job right, most of the topics will be provocative. I like controversies in medicine and health care. I like the fuzzy gray areas, where the laminar flow of clear-cut clinical decisions degenerates into turbulence, where the evidence (or lack thereof) supports more than one point of view.

So I should have plenty of stuff to bloviate about, as is my wont. Why the hell would we give vitamin K to any human patient? Do we really believe ECASS 3 and push t-PA at 4.5 hours? After more than a quarter century, why do we still wring our hands over who should get a head CT?  Why does Lewalski wear red shoes? What’s he trying to say? More or less fluids for hemorrhagic shock? Do we really need more EM subspecialties? Hell—do we need the ones we’ve got? Why is it, exactly, that a patient in the ED “belongs” to a particular doctor, but not to a particular nurse? Is it rational, or even ethical, to board patients in our ED when a growing body of literature says we shouldn’t?

Oh, yes, there’s plenty to talk about. Plenty to argue about. Plenty to get hot about. And I’m the kind of guy who believes that a really successful journal club is the one that ends with a fist fight. Laminar flow is boring. Turbulence is mysterious, maddening,  and beautiful.

So that’s what I hope to do with this column. Create turbulence.

Patient as Customer

I’m going to kick this off with a concept that has wormed its way into health care over the last couple of decades: the patient-as-customer. This is an idea that appeared at about the time that the era of the Medicare orgy was stumbling to a close. It was clear that the health care pie was going to get smaller, that hospitals and physicians would have to practice in a more explicit and scrutinized fashion, that expenditures would have to be justified, and that American medicine would generally have to become leaner and more competitive.

In other words, health care was a “business,” an “industry.” True, of course, but that’s a bit like saying that an ostrich is a bird, and then expecting it to behave like any other bird. And so, for the last 25-30 years, our approach in the US has been to treat healthcare more and more as if it were any other industry, and then wonder why it continues to get more and more FUBAR with each passing year. Naturally, treating health care as a business means that you have to shoehorn its institutions and values into configurations that make businessmen and administrators feel more at-home and comfy. And from there it’s easy to see how we get to the idea of the patient-as-customer.

Of course, an ostrich isn’t just any bird, health care is not just any industry, and—let me just say it as bluntly as as I can—patients are not customers.

Now, before any of my colleagues holds up an objecting finger, let me just say that I’m pleased to report that I have yet to hear any of you—not a single physician, ever—refer to one of his or her patients as “my customer.” So the good news is that, even though the administrator class within healtcustomersh care continues to push this concept, physicians don’t seem to be swallowing. Maybe that’s because, at some innate level, physicians know the difference. They know what a customer is, and they know what a patient is, and they made a decision to devote their lives to serving the latter, not the former. And despite all the PC propaganda, all the attempts at indoctrinating us with this particularly insidious and subversive example of Newspeak, physicians haven’t bought in. Yet.

That’s because we know, or should know, that patients are not customers. Here, for your consideration, and to celebrate the maiden voyage of this blog, are just ten reasons why not.

1. The relationship is fundamentally different.
A customer enters into a commercial relationship with a merchant. A patient enters into a healing partnership with a physician. Everything else flows from this critical distinction.

2. Customers are “always right,” or at least they may reasonably expect to be treated as such. But ask yourself: when the patient swears to you that he’s “just got the stomach flu,” do you shrug, accept his diagnosis, and sell him a bottle of Pepto? You better not. No, our patients are most certainly not always right. In fact, sometimes they need to be told that their behavior is irresponsible, idiotic, or self-destructive.

3. Customers are legally entitled to a product only if they can pay for it. Right now, in this country, the debate over health care entitlement is about to boil over. But it has already been established—morally and legally—that patients are entitled to emergency care whether they can pay or not. This puts our patients squarely outside any classical understanding of  what a “customer” is.

4. Merchants may refuse service to any customer. You might think this is a restatement of #3 above, but look more closely. This goes beyond the ability to pay. A paying customer can buy only if a merchant will sell. An emergency department cannot and must not refuse to treat any patient, paying or otherwise.

5. The doctor-patient relationship enjoys legal privilege. The customer-merchant relationship does not.

6. Termination of service. When a customer enters a commercial relationship, either party may terminate that relationship as long as the contract so permits. Once a patient enters the emergency department, the physician has a duty to treat, and as long as treatment is indicated only the patient or his legal surrogate may terminate the relationship.

7. Purpose. The primary goals of the commercial relationship are, well, commercial. They are also asymmetrical: the customer seeks to acquire a product or service, preferably at a bargain price, and the merchant seeks to turn a profit. The primary goals of the doctor-patient relationship are completely non-commercial, and they are symmetrical. Both parties seek to relieve suffering, maintain function, and preserve life.

8. Suitability of product or service. A merchant seeks to sell as much product or service to the customer as possible, and customers are at liberty to purchase any legal product or service, whether or not it is unneeded or even harmful. A physician seeks to provide the patient only with what he or she needs, and may not lawfully or morally provide services the physician knows to be unneeded or harmful.

9. Socioeconomic biomarkers. When a lot of customers patronize a lot of businesses, the indications for the economy and society at large are generally positive. When a lot of emergency departments are jammed with sick, nonpaying patients, there’s a good chance that both society and the economy are seriously awry. Health care isn’t just any bird.

10. Sacred vs. Profane. The relationship of the customer to the merchant is temporal and ultimately prosaic. The relationship of the patient to the physician is far more transcendant and, for lack of a better word, special.

Actually, I do have a better word: sacred. The robust analogy to the doctor-patient relationship is not to be found at the mall, but in the church, the temple, the schoolroom, the family gathering. It is not the visit of a patron to a vendor; it is the reaching out of a parishioner to a priest, a firefighter to a victim, a distraught medical_symbolbrother to a caring sister. The patient comes to the emergency physician not with a desired transaction, but with pain, fear, sorrow, hope and vulnerability. The patient comes at the moment of birth, at the nadir of loss, at the precipice of death. The patient comes with his or her aspirations, pride, dignity and very life in the balance. Moreover, a good emergency physician adds some of his or her own emotional stakes to the ante. The patient needs and deserves compassion, unconditional positive regard, deep concern guided by informed intelligence, and the physician’s personal commitment to technical excellence. Both patient and physician have more than currency or commerce at stake in this encounter, which has an importance and a meaning and a humanity far beyond the two-dimensional workings of the marketplace.

Perhaps some can see in our work a similarity to selling hamburgers, giving haircuts, or fixing cars. I do not, and I find the comparison degrading and offensive to my patients and to my profession.

Patients are not customers. They are two different things. That’s why we have two different words for them.

Some things don’t have a price. Some things aren’t for sale.

quizzER Vol 2.1

A 43-year-old man, who currently uses drugs intravenously, presents to the emergency department (ED) with 2 weeks of fever, back pain, and progressive weakness in his arms bilaterally. He reports having a cough with whitish sputum.  He denies any history of recent trauma. His blood pressure (BP) is 130/75 mm Hg, heart rate (HR) is 106 beats per minute, temperature is 103°F, and respiratory rate (RR) is 16 breaths per minute. On physical exam, he has tenderness to palpation in the midthoracic spine, and decreased strength in the upper extremities bilaterally, with normal range of motion. Laboratory results reveal a white blood cell (WBC) count of 15,500/μL, hematocrit 40%, and platelets 225/μL. Which of the following is the most likely diagnosis?
a. Lung Abscess
b. Ankylosing spondylitis
c. Spinal epidural abscess
d. Vertebral compression fracture
e. Spinal metastatic lesion

Please post your answer in the “reply box” or click on the “comments” link  You will not see your answer post until next week when all of the submitted answers will be posted.  Good luck!

quizzER is a weekly contest consisting of a question selected from various areas of emergency medicine that are central to the education of medical students and residents in training.

Morrison’s Pouch: Answer 1.1

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Although we had many submissions – there were NO WINNERS this week

A 75-year-old woman presents with left lower extremity swelling and pain behind the knee for the past few days.  She has been taking ibuprofen and was referred from her PMD, who was concerned that she may have a DVT.  The patient has a history of hypertension and diabetes.  She smokes cigarettes daily.   Her vital signs are within normal limits.  On physical exam, her legs are symmetric in size, her dorsalis pedis pulses are 2+ and symmetric, there is no erythema, but she is tender to palpation in the popliteal fossa.

Questions:

1.  What is the diagnosis?
2. Which veins of the lower extremity are visualized in the DVT examination?
3. Name a finding seen on ultrasound exam that is consistent with the diagnosis of DVT?

Answers:
1.  Baker’s cyst
2. from the exam includes the veins from the iliofemoral junction to the popliteal fossa.
3. Veins that are not completely compressable are indicative for a DVT.

This patient’s leg veins were fully compressible, so a DVT was ruled out.  The ultrasound exam demonstrated a Baker’s cyst, which explains the pain she is having behing her knee.  The patient was discharged with pain medications and instructions to follow-up with her PMD for a repeat ultrasound in 1-week.

baker2-labelled

pop2-labelled4 saph2-labeled4 split2-labeled3

Discussion:
As ED physicians, we are using ultrasound with increasing frequency to evaluate the lower extremity for DVT, Baker’s cyst, and abscesses.  A Baker cyst is a synovial cyst that is located posterior to the medial femoral condyle, between the tendons of the medial head of the gastrocnemius and semimembranous muscles. It usually communicates with the joint by way of a slitlike opening at the posteromedial aspect of the knee capsule just superior to the joint line. An extension of the knee joint, a Baker cyst is lined with a true synovium.  The common symptoms of baker cysts include localized swelling and pain, and decreased range of motion of the extremity. Baker cysts commonly resolve following rest; analgesics and extremity elevation help to reduce swelling and pain. If symptoms persist, an orthopedic surgeon can excise the cyst.

Over the past decade, emergency ultrasound is well established in its use to detect lower extremity DVT.  The exam is traditionally performed by ultrasounding from the iliofemoral vein junction to the popliteal vein. After identifying these vessels, the vein is followed and compressed at 1-centimeter intervals. Full collapse indicates that no DVT is present, while partial or incomplete collapse is diagnostic of DVT.
Several studies have shown that ED ultrasound interpertation is equivalent to formal ultrasound studies. A 2000 study showed ED ultrasound exams and formal ultrasound studies agreeing in 110 of 112 cases of possible DVT. Of the two discrepancies, one was a false positive ED reading. The other was an ED-positive exam that was initially read as negative by formal ultrasound but later shown to be DVT-positive by venography. Another study done in 2004 showed that 154 of 156 DVTs were diagnosed by ED ultrasound, the remaining two being false positive results.

In addition, the ED evaluation of DVT saves time in correctly diagnosing the presence or absence of DVT, prevents a potentially unstable patient from having to leave the ED department for a study, and ensures the timely diagnosis even when an ultrasound technician is unavailable.

This case prepared by Dr Sam Lee, PGY-1 Emergency Medicine Resident, Detroit Receiving Hospital

Bibliography

  1. Blaivas, Lambert, Harwood, Wod, Konicki. Lower-extremity Doppler for Deep Vein Thrombosis – can emergency physicians be accurate and fast? Academic Emergency Medicine. Feb 2000. Vol. 7, number2. pgs. 120-1262.
  2. Stephen A. Shiver MD and Michael Blaivas. Acute Lower extremity pain in an adult patient secondary to bilateral popliteal cysts. Journal of EM: Volume 34, issue 3, April 2008. pgs 315-3183.
  3. Theodoro, Blaivas, Duggal, Snyder, Lucas. Real-time B-mode Ultrasound in the emergency department saves time in the diagnosis of Deep Vein Thrombosis American Journal of EM Vol 22, no. 3, may 2004. pgs. 197-200

“Morrison’s Pouch” is an educational module that utilizes ultrasound video clips from case presentations in the Emergency Department.  The section is hosted by Dr. Daniel Morrison, Director of Emergency Medicine Ultrasound for Detroit Medical Center, and case presentations are submitted by the EM residents of Detroit Receving Hospital.

Morrison’s Pouch: case 1.1

morrisons-pouch-redo2A 75-year-old woman presents with left lower extremity swelling and pain behind the knee for the past few days.  She has been taking ibuprofen and was referred from her PMD, who was concerned that she may have a DVT.  The patient has a history of hypertension and diabetes.  She smokes cigarettes daily.   Her vital signs are within normal limits.  On physical exam, her legs are symmetric in size, her dorsalis pedis pulses are 2+ and symmetric, there is no erythema, but she is tender to palpation in the popliteal fossa.

You decide to ultrasound her lower extremity and obtain the following images.

Ultrasound 1

Ultrasound 2

Questions:

1.  What is the diagnosis?

2. Which veins of the lower extremity are visualized in the DVT examination?

3. Name a fiding seen on ultrasound exam that is consistent with the diagnosis of DVT?

Please post your answer in the “reply box” or click on the “comments” link  You will not see your answer post until next week when all of the submitted answers will be posted.  Good luck!

This case prepared by Dr Sam Lee, PGY-1 Emergency Medicine Resident, Detroit Receiving Hospital

“Morrison’s Pouch” is an educational module that utilizes ultrasound video clips from case presentations in the Emergency Department.  The section is hosted by Dr. Daniel Morrison, Director of Emergency Medicine Ultrasound for Detroit Medical Center, and case presentations are submitted by the EM residents of Detroit Receving Hospital.

Interview: Dr. Mark Reiter

mreiterportrait

Dr. Mark Reiter has held multiple leadership positions in Emergency Medicine, including the Board of Directors for AAEM, AMA Council of Legislative Affairs, and President of AAEM Resident and Student Association to name just a few. Dr. Reiter is CEO of Emergency Excellence, LLC, a company whose aim is to improve emergency department processes through data analysis, benchmarking, surveying stakeholders, and the application of lean principles to optimize quality, efficiency, and satisfaction.  Dr. Reiter is a rising star in the field of emergency medicine and is sure to be a leader for this generation of emergency physicians.  Dr. Reiter currently practices emergency medicine at St. Luke’s Hospital in Bethlehem, Pennsylvania.

Receiving: You were involved in many leadership roles very early in your EM career, including serving on the Board of Directors of the American Academy of Emergency Medicine, the Board of Trustees of the Medical Society of New Jersey, and on the American Medical Association Council on Legislation.  How has your experience in these roles influenced you?

Dr. Reiter: I’d encourage all physicians, no matter what stage of training, to get involved with medical professional organizations or other organizations.  Active participation helps you to see the big picture, which allows you to advocate more effectively for your patients and for your colleagues.

Receiving: You strongly support AAEM, what is the big difference between AAEM and the other national EM organizations?

Dr. Reiter: AAEM takes a very active role in advocating for the individual emergency physician.  In particular, AAEM takes strong positions for workplace fairness (and combating workplace abuses) and protecting the value of board certification and residency education in emergency medicine.

Receiving: How has your MBA degree impacted your life as an emergency physician?

Dr. Reiter: My MBA has made me a more effective leader, both within professional organizations, or working within my ED to improve care.  In addition, my MBA has been invaluable in preparing me for the recent launch of Emergency Excellence, the emergency medicine benchmarking and consulting company I recently co-founded with Dr. Tom Scaletta.

Receiving: What are some of the toughest issues facing the specialty of emergency medicine?

Dr. Reiter: Unfortunately, there are many tough issues facing emergency medicine, and most we cannot solve on our own without help from outside of EM.  Overcrowding will continue to be a massive problem, as we have no national plan to deal with an aging, progressively sicker population, in the face of the fraying of our primary care system and a decline in staffed hospital beds.  The lack of action on tort reform or fixing our broken reimbursement system will continue to compromise our patients’ access to on-call sub-specialists, especially to our most vulnerable patient populations.  Physician autonomy is threatened by the continued consolidation of health insurers and the increasing corporate practice of medicine by for-profit non-democratic groups.

Receiving: How will emergency physician compensation be affected if this country adopts universal health coverage?

Dr. Reiter: No one knows.  Emergency physicians see more uninsured patients than any other specialty, so many expect to see an improvement.  However, in many areas, reimbursement from uninsured patients is on par with Medicaid or often better.  If uninsured patients were enrolled in a Medicaid-like plan, there would be little effect.  On the other hand, the federal government may decide to decrease reimbursement across the board to pay for the increase in the insured population, essentially putting the costs of insuring millions on the backs of the nation’s physicians, rather than the taxpayers.

Receiving: If you can change one thing today about emergency medicine, what would it be?

Dr. Reiter: Place a qualified practicing emergency physician in a position of power within the upper levels of leadership of every hospital, physician group, and relevant government agency.  Watch how quickly things could get done – does anyone make more important decisions a day than an emergency physician?

Receiving: When will you be President of AAEM?

Dr. Reiter: We’ll see….

Receiving: What are the biggest challenges of having two young kids and being a young emergency physician?

Dr. Reiter: Keeping my wife happy – she works harder than I do.

Receiving: Any relation to Dr. Reiter of “Reiter’s Syndrome”?

Dr. Reiter: Nope – some other guy.

“The Meeting Room” is devoted to interviewing leaders in Emergency Medicine.  Please email me with suggestions on people you would like to see interviewed or if you would like to conduct an interview.