How to use your Emergency Room

The more I work in the Emergency Department, the more I grow tired of the misuse of the facility. Just last night I had to evaluate someone with 1 year of groin pain and another patient with 10 years of back pain. Another patient who was not mine has been seen 3 times this month (16 days, not 30). One woman with "multiple complaints" brought her daughter in with her because of bad headaches and severe stomach pain.

The Mother-daughter "Two-for" started out well. I took a thorough history of the 9-year-old daughter which came up with only some non-specific symptoms like subjective fever, congestion, cramping pain, etc. After the physical which was essentially normal, I began evaluating Mom. Little girl interrupted the exam with more information for me at which the mom gets annoyed and says that it is her turn. She then partially covers view of her mouth and whispers to me that there is nothing actually wrong with her daughter she just likes to be seen when she(mom) brings her in. All of this would normally not phase me, but I chose this "Two-for" to be more efficient since there were 4 patients waiting to be evaluated. Mom actually had the nurses triage the girl, make up a chart and put both of them in the computer. With the chart made up, I have to do a full evaluation for fear of the hospital being sued, and document the encounter. The staff physician then has to see the patient also and do more documentation. The chart then goes to the nurses for discharge, then to billing to be put into the computer and sent to insurance companies if the patient has insurance. If she does, the paperwork gets sent to the insurance company who has someone look at the encounter and inevitably decide that this wasn't an emergency and then sends notice back to the hospital that they will not be reimbursed. The hospital then gets to decide whether it is worth while to attempt to collect from the patient. It will almost certainly not be beneficial and the hospital eats the cost of the encounter.

As for the pain patients, there are very few scenarios where 10 years of back pain culminates into an emergency. This particular man came in because his pain was affecting his sleep and he was getting short with his wife. This will be his 3rd ER visit this year. An ER visit costs between 7 and 30 times more than an office visit or urgent care visit.

Groin pain guy came in because it had finally become too much. There had been no change in symptoms and he had already been seen by 3 different specialists. I did not ask what help he was expecting from physicians trained for emergencies when he had already seen 3 specialists.

In summary:
Inability to sleep is never an emergency. See your Primary doctor or psychiatrist
Chronic pain without new symptoms is never an emergency. See your primary or psychiatrist
Medication refills are never an emergency. (symptoms due to not having medication can be an emergency). See your primary.
Very, very rarely are you justified in having a family visit to the ER. Some good times to have a family visit are after a car accident, if two kids were to smash their heads together, if siblings are all acutely ill with identical symptoms that are suggestive of emergency.

If you are a health care provider doing time in the Emergency Department, your obligation for patient education still applies. Talk about the misuse of medical resources and the increased cost of getting care through the ER.

Flu Shots Have Been Associated with More Time Spent in the Hospital

It has come to my attention that there is a huge movement against flu shots. I'm sure you've seen people posting articles in the most obnoxious places about "the jab". There are websites such as theflucase.com that post articles with titles such as "Top insurer warns 1,000 GPs to not give the flu vaccine".
It is a nice title, but if you read the article, you'll see it has nothing to do with the safety of the vaccine, but instead the legal issues involved in endorsing a treatment for special populations.

The idea is that "They" are trying to get you to inject "who knows what" into your body. "They" of course are the government, and they want you to inject "who knows what" so that they can do "who knows what" to you. This of course is the same government that the anti-flu population complains can't deliver mail reliably.

My recommendation is to read the articles people post and not just the titles. One article I read from another misleading site www.mercola.com reads, "People Who Get a Seasonal Flu Shot Are Twice as Likely to Catch Swine Flu". It uses "Suggestions" from an "As-yet-unpublished" Canadian study, but the title is as sure as the evening news.

I've gotten my seasonal flu shot and I'm going to be getting my H1N1 as soon as it is available to me. I'm doing it for my baby son who can't get vaccinated, and for my patients who don't need swine flu on top of their other issues. I'm doing it for me, because a sore arm and a day or two of cold symptoms is far better than feeling like i'm going to die and missing enough work to require a repeat of an entire month of hospital training.

In Summary:
1. When you see an article that sounds ridiculous, read the entire thing and look at sources.
2. Get your flu shots, seasonal and H1N1.
3. Post your comments. If you have suggestions, comments, or rants, I will read them and likely ignore them.
4. The title of this post is an example I made up to show how ridiculous information can be when completely misinterpreted. A higher number of health care workers get the flu shot than the general population, especially health-care workers in a hospital situation, so people who get the flu shot report spending more time in the hospital than than the average person.

Quick! Hit the Treat button

So i just got the opportunity to observe some ECT (Electro-Convulsion-Therapy) and it was pretty uneventful.
For those who don't know, ECT is a completely safe treatment mostly for Depression, but also for some acute psychotic episodes as well as mania and is used in a few other scenarios. ECT is the safest treatment for depression in pregnant women and is a better alternative in geriatric populations than pharmacotherapy which may have adverse effects that are amplified in the older population. There is a chance of mild memory loss that usually resolves fully within 6 months. There can be some permanent memory loss in the hours just prior and following the treatment.

So the process is this: First the patient comes in a lays on the stretcher or bed. An anestesiologist then administers some drugs that put the person to sleep and temporarily paralyzes the muscles. Electrodes are place on the temples and the chest, and then the doctor walks over to the machine and presses the yellow "treat" button. About a minute later, the seizure (which is localized to the brain thanks to the muscle relaxant) ends and the anesthesiologist wakes the patient up. The patient is groggy and is taken to recover. A normal treatment consists of between 6 and 16 sessions and dramatic results can be seen.

This is one of the only places in medicine where you get an "Easy button". ECT is AWESOME!

A Simple Sample of Series

I knew that the sum of the sequence of reciprocals of integers (1 + 1/2 + 1/3 + 1/4 +... + 1/n) diverges to infinity.

Today on www.xkcd.com it was shown that the series of the reciprocals of prime numbers (1/2 + 1/3 + 1/5 + 1/7 + 1/11 + 1/13 + ... + 1/P_i) also diverges to infinity.

I got to wondering which subsets of integers and subsequent reciprocals would diverge to infinity. For example, reciprocals of n^2 (1, 4, 9, 16, 25, ... , n^2) is a series that converges, not diverges.

So how about the fibonacci sequence? Twin Primes? All integers with exactly 3 prime factors?

If you know the answer to any of these or have interesting subsets of integers whose series of reciprocals diverge, let me know. 20 cool points may hang in the balance.

Whose Idea was it to start Psychiatry with "P" ?

So i've successfuly completed an entire week of psychiatry. My team is great and we've had some good moments. I will highlight a few below, of course protecting the identity of all involved. If I can remember, I will make all patient stories about males, unless it requires opposite sexes to make sense. I'm sure many of these will have required you be there, but this is going to be a reminder for me later in the dead of winter when I have forgotten how much fun medicine can be.

One of my favorites was on a Monday morning, when I got to hear a colleague ask her patient (Who has spent the entire weekend on the Psych ward) "So, Did you have an exciting weekend?!". For the first time, the patient smiles and says "Yeah...Real Exciting"

A patient dealing with mania pulls me aside and informs me that someone across the hall has sleep apnea and that I needed to know. "You know he is suicidal, I thought you needed to know because they could go anytime they want in their sleep." For thoroughness's sake, I did some literature research and couldn't find a single case of suicide by sleep apnea. I told the patient I would let the nurses know just in case.

One patient was asked about his marriage. "I've been married for going on 11 years now. Our 10th anniversary is this September.

Interviewer: "Do you have any weapons in your home?"
Patient: "Weapons?"
Interviewer: "You know, like guns?"
Patient: "No guns, I have some kitchen utensils though. And Nunchucks. And there are some pretty big rocks outside."
Interviewer: "I think those are okay"