Diagnostic tests: Asking the right questions

You have picked up the next chart and have drawn your differential diagnosis based on the patient's demographic, chief complaint, and vital signs.

Pattern Recognition vs Probabilistic Diagnostic Reasoning2:

Pattern Recognition See it and recognize disorder ⇓ Compare post-test probability with threshold (usually pattern recognition implies near 100% and so above threshold)

Probabilistic Diagnostic Reasoning Clinical assessment generates pretest probability ⇓ New information generates post-test probability (may be iterative) ⇓ Compare post-test probability with threshold

You can approach diagnosing diseases by using either of these two patterns or a combination of both. Keep in mind these two methods can also complement each other. Pattern recognition is more of an intuitive approach, often referred to as System 1 thinking. It is much faster, heuristic. Probabilistic diagnostic reasoning may be referred as System 2 thinking, meaning it’s slower, but more analytical and systematic.

After you draw your differential diagnosis and before seeing the patient, you have a pretest probability of the diagnosis that ails the patient. After you obtain a focused history and physical exam, you have gathered information that will help you draw a more accurate post-test probability and narrow your differential diagnosis. The essence of being a doctor does not lie on the tests, therapies, signs, or symptoms, but on how you use them. Every sign and every symptom represents a diagnostic test.

Understanding statistical terms helps us interpret diagnostic test results.

Sensitivity:

• SnOUT: If a test has a high sensitivity and the elicited test is negative, you have essentially ruled OUT the disease.  
• How accurately the test picks up patients WITH disease

Specificity:

• SpIN: If a test has a high specificity and the test is positive, you have essentially ruled IN the disease. 
• How accurately the test picks up patients WITHOUT disease 

As you can see there are limitations when applying sensitivity and specificity on patients since we don't know if the have the disease or not. Predictive values have their limitations as well, these change with prevalence. Therefore, a test used to detect disease in a population with high prevalence would not be adequate in a population with low prevalence. Keep in mind that tests should not be used to replace your clinical judgement.

Prevalence:

• This is your pretest probability, used before you go into the room to see the patient. 

Likelihood Ratio (LR):

• Compares results of patients with disease vs patients without disease
• More accurate than sensitivity and specificity
• Helps you derive the post-test probability
• Takes sensitivity and specificity into account simultaneously 
• When LR >1 it means the probability of disease increases 
• When LR <1 it means the probability of disease decreases 
• When LR = 1, the probability of disease is unchanged 
• Before ordering a test, eliciting a symptom, or finding a sign, ask yourself: How will the absence or presence of this factor change my post-test probability? 
• Use the Fagan Nomogram to determine post-test probability.

Does the post-test probability drawn after your assessment change your threshold?
When the post-test probability falls between test threshold and treatment threshold, further investigation needs to be done. If it lies above the testing threshold it is encouraged to treat, but if it falls below the testing threshold, it is encouraged to pursue a different diagnosis.

Diagnostic and Test Threshold 7

There are three aspects that determine test and treatment thresholds:2

1. Properties of the test
2. The disease prognosis
3. The nature of the treatment

Changing testing thresholds

If	Then
Test: safe and less expensive Disease: worse prognosis Treatment: safe and effective	The LOWER the test threshold
Test: not as safe, more expensive Disease: benign Treatment: not safe or effective	The HIGHER the test threshold

Changing treatment thresholds 

If	Then
Test: safe and less expensive Disease: benign prognosis Treatment: expensive and major adverse effects	The HIGHER the treatment threshold The characteristics require a higher diagnostic certainty so that we cause less harm from this treatment.
Test: less safe, more invasive than the treatment Disease: worse prognosis Treatment: safer than the test	The LOWER the treatment threshold The treatment may be more preferable than the test.

Four Lessons of Diagnostic Testing as per David Newman 4

1. All tests are imperfect 
2. Context trumps results 
3. All tests have a threshold 
4. Likelihood ratios have it all

These four axioms are important to keep in mind when navigating the diagnostic and therapeutic process in medicine. If used appropriately, these four axioms can help us avoid harming patients.



References:
1. The Rational Physical Examination: Systematic reviews of the diagnostic properties of the history and the physical examination.

2. Users' Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice, 2nd Edition

3. NNT Website by David Newman that looks into the number-needed-to-treat of different therapies and also the website contains a scale where likelihood ratios can be manipulated to calculate post-test probabilities.

4. SMART EM: by David Newman podcast on diagnostic tests

5. A universal model of diagnostic reasoning. Croskerry, P; Academic Medicine; 2009 Aug;84(8):1022-8.

6. A life at risk: a website with lots of LR on signs, symptoms, tests

7. Hayden SR, Brown MD. Likelihood ratio: A powerful tool for incorporating the results of a diagnostic test into clinical decisionmaking. Ann Emerg Med. 1999. May;33(5):575-80.

8. Anthony K. Akobeng. Understanding diagnostic tests 2: likelihood ratios, pre- and post-test probabilities and their use in clinical practice. Acta Paediatrica; 2007 Apr;96(4):487-91. Epub 2007 Feb 14.

9. Paucis Verbis from Academic Life in Emergency Medicine: multiple cards with likelihood ratios, pre- and post-test probabilities

10. mdcalc: Bayesian, sensitivities, specificities, probabilities: if you know the prevalence, sensitivity, and specificity of a disease mdcalc has a calculator to obtain the likelihood ratios, and the predictive values.

11. Center for Evidence Based Medicine. Interactive Nomogram January 2009

Do you know your resuscitation room?

When I was in medical school doing my critical care elective in EM, I remember seeing the interns preparing tubes and IVs before their shifts started. Since then it was instilled in me that coming early to the shift was essential to make sure that at least your resuscitation room was adequately set up for any major emergency coming through. With the help of a few friends, I made up a list of the equipment that should be present and working appropriately in your resuscitation room.

Not only should you have to have the appropriate equipment, but you should also make sure they are working appropriately. You may be surprised at what is missing or non-functional. The most important part of our job is to be prepared: 

“Hope for the best, anticipate the worst.”

I tried looking for a proper definition and a list out there in the “interweb” that I could modify, but didn’t find one. I would recommend you get to know all of your nurses by name (especially the charge nurses) and have a good working relationship with them. It is essential, they are an integral part of the team.

1. Oxygen

• There should be two outlets: make sure there are two and they work appropriately with appropriate tubing. Have the bag valve mask ready 

2. Pulse ox detector

3. The CO2 detector should be ready and functional (contributed by @AndyNeill)

4. Suction with canister, yankauers, and tubing 

5. Intubation kit and airway cart: lots of stuff in this cart

• Endotracheal tube introducer (Bougie)
• Working laryngoscope (make sure light bulb is working, straight and curve blades) 
• Tube sizes 
• BVM, OPA, NPA (contributed by @jcillo)

6. Video laryngoscope with appropriate stylet, working light, plugged, and tongue blade

7. Cardiac monitor

• Blood pressure cuff: make sure you have different sizes 
• Pulse oximetry: know the different kinds 
• ECG leads: cables and stickers

8. Gurney

• You want a working gurney where you can lift the head of the bed at least 45 degrees 

9. Central line kit: different sizes, triple lumens, trauma infusers

10. Code Cart with their appropriate drugs

• This is usually checked by the charge nurse, just make sure it’s in every resus room

11. Blood products (in the oven)

• What’s the blood bank’s extension number? 

12. Chest tubes

• Chest drainage systems

13. Ultrasound

• Plugged, clean machine and probes, probe covers.

14. Ventilator Machine

• What’s the respiratory therapist’s extension number? 
• Know your ventilator machine.

15. Intravenous pumps

• Nurses are usually in charge of these, but make sure they are in the room.

16. Blood draw equipment

• Tubes, tourniquets,  syringes, butterflies, intravenous catheters.

17. Foley catheters

18. Naso/Orogastric tubes

19. Childbirth equipment

20. Naso/Orogastric tubes

21. Childbirth equipment and warmer

22. Ophthalmoscope

23. Broselow tape

24. Telephone and phone/pager contact list (contributed by Matthew Mac Partlin)

25. Routes and distance/time to key locations (Radiology, OT, ICU, Blood bank)  (contributed by Matthew Mac Partlin) 

I hope this serves as a guide to make sure your resuscitation room is working appropriately.

The essay of all essays: "The biology of emergency medicine" (2 of 2)

Dr. Peter Rosen

This is part 2 of my review of Dr. Rosen's 1979 article on "The Biology of Emergency Medicine" (see part 1).

According to Dr. Rosen, there are 3 broad categories of ED patients:

• The emergent
• The urgent
• The non-urgent 

We must know how to identify and prioritize these. Medical students and residents are poorly taught the differences. “There are two shocks to residents: not every patient is sick, and many patients are sicker than they first appear”, he writes.

There are 3 critical ingredients which define a valid residency experience, according to Dr. Rosen who trained in surgery:

• Pathology
• Adequate faculty
• Adequate number of residents

Uniquely, the specialty of EM is not defined by diseases, but rather by the level of acuity. Per Dr. Rosen our most important responsibility in the ED is proper assessment and stabilization. As emergency physicians (EP), the proof of the diagnosis is not as important as the assessment and stabilization. He states, “The quality, appropriateness and timeliness of the initial care is the biology and responsibility of our specialty.” Thus, EM training cannot be learned under someone else’s service.

The article has many other important points that every EP should keep in mind. This article is at the top of my list of reading whenever I encounter a medical student interested in EM. Even though it was written many years ago, many elements still hold true in our profession.

Dr. Rosen ends the essay by quoting Oliver Wendell Holmes:

“I find the great thing in this world is not so much where we stand, as in what direction we are moving: to reach the port of heaven, we must sail sometimes with the wind and sometimes against it - but we must sail, and not drift, or lie at anchor.”

Javier Benitez, M.D.

References:

1. Rosen P. The biology of emergency medicine. JACEP. 1979 Jul;8(7):280-3. Pubmed.
2. Peter Rosen’s lecture at UCLA. All L.A. Conference May 5, 2011: Reflections on 40 Years of Emergency Medicine. (Need to download actual video)
3. Zink BJ. The Biology of Emergency Medicine: what have 30 years meant for Rosen's original concepts? Acad Emerg Med. 2011 Mar;18(3):301-4.  Pubmed . 

The essay of all essays: "The biology of emergency medicine" (1 of 2)

Dr. Peter Rosen

This post is based on one of the most interesting articles I have ever read in EM. The article written by Dr. Peter Rosen in 1979 and published in The Journal of the American College of Emergency Physicians (later become Annals of Emergency Medicine) is a landmark piece. It defines the specialty with so much precision that even contemporary authors find very little discrepancy of what Dr. Rosen wrote and the state of EM in present time.

There is a very clear opinion of what Dr. Rosen believed the unique biology of EM should be. He explains the birth of EM, which was not validated by other specialties in the house of medicine. It was more a reaction from multiple factors, which included financial incentives, growth of urban centers, need of a doctor in a geographic region, and the decreased numbers of physicians house calls.

One of my favorite sections in the article is when he writes “Defining The Specialty.” He states that the responsibilities of the emergency physician (EP) entails differentiating the sick from the non-sick patient, handling multiple patients at the same time, and instituting life/limb saving interventions. He uses the analogy of a climber who for whatever reason has fallen from a precipice and the job of the EP is to get the climber to a much safer place as possible, assuming 100% safety is not attainable.

Interesting enough, he also states that prehospital care should also be managed by the EP. This is an aspect of EM in which EPs are more directly involved. In Dr. Rosen’s opinion, the hardest task of an EP is sending home a patient with a potentially life-threatening diagnosis when the patient presents with nonspecific signs or symptoms.

• I have worked with some amazing clinicians, and their diagnostic skills are impressively accurate. They arrive at the correct diagnosis with very little information due to the patient's altered mental status, his/her being a poor historian, or even how atypical the disease is presenting.

In the essay, he states that stabilization takes priority over diagnosis. This contrasts medical school teachings where the emphasis of education is on primary care. Consequently, the priority is to take a history, do a physical exam, and then treat the patient-- in that order.

• This statement reminds me of a web search that I did last year on how to think like an EP. I came across Dr. Reuben Strayer's (@emupdates) 30-minute video "How to Think Like an Emergency Physician" delineating how an EP should go about seeing patients in the ED. I think this is what Dr. Rosen envisioned the specialty should focus on. Treat the patient first when indicated, and then do a history and physical.

The hardest thing to teach residents, according to Dr. Rosen, is to “assume the worst even if statistically improbable”. I believe that Dr. Amal Mattu (@amalmattu) refers to this as a “healthy paranoia”. This means that we still need to rule out life threatening diagnoses for seemingly non-emergent patients. We must also have enough knowledge of NON-life threatening diagnoses in order to address these in the ED, if possible. If we feel confident that the patient has no life threatening diagnoses and can be discharged the patient home, then we should ensure appropriate follow up.

In tomorrow's post (part 2), we will look at how Dr. Rosen categorized ED patient visits and his views on EM administration and research.

References

1. Rosen P. The biology of emergency medicine. JACEP. 1979 Jul;8(7):280-3. Pubmed.
2. Peter Rosen’s lecture at UCLA. All L.A. Conference May 5, 2011: Reflections on 40 Years of Emergency Medicine. (Need to download actual video)
3. Zink BJ. The Biology of Emergency Medicine: what have 30 years meant for Rosen's original concepts? Acad Emerg Med. 2011 Mar;18(3): 301-4.  Pubmed . 

Trick of the Trade: Needlestick hotline 888-448-4911

You are a fourth-year medical student and super-excited to be doing your first supervised central line procedure on an actual patient. You have done so many central lines on mannequins and simulations. You feel ready. In your excitement, however, you stick yourself with the 22 gauge finder needle after you successfully get a flash-back of the patient's venous blood.

After handing off the procedure to your senior resident, you go into a mild panic. Your patient is a known HIV patient with an unknown CD4 count and viral load. After taking off your gloves and washing your hands, you report this to the attending.

Should you start post-exposure prophylaxis medications for HIV? You remember that if post-exposure HIV medications are recommended, you should start it immediately and definitely within 2 hours of exposure.

It's difficult to concentrate when faced with so many questions whirling in your mind.

Trick of the Trade:
Use the National Clinicians' Post Exposure Prophylaxis (PEP) Hotline - 1-888-448-4911

"The PEPline provides around-the-clock expert guidance in managing healthcare worker exposures to HIV and hepatitis B and C. Callers receive immediate post-exposure prophylaxis recommendations.  Available 24/7."

Remember this is for providers who are exposed and not the lay public.

I was not only surprised to find that this national hotline is hosted by UCSF/SFGH (my home institution!) but also helmed by my friend Dr. Goldschmidt (Professor and Vice Chair, Department of Family and Community Medicine).

For more information about the National HIV/AIDS Clinicians' Consultation Corner, which staffs the PEPline, view their website at: http://www.nccc.ucsf.edu/about_nccc/pepline/

On the website, they also feature a "Warmline" at 800-933-3413, which is staffed by physicians, clinical pharmacists and nurse practitioners Mondays through Fridays, from 5 am to 5 pm (Pacific Time). They provide up-to-date information for the care of your HIV-positive patient.

Beware the night shifts!

Night shifts in the Emergency Department are not just shifts when it's dark outside. They are wrought with risk. Thanks to the folks over at RN Central for this eye-opening infographic.







Research and design by Nursing Schools Site

Advice for the new EM interns

One of my favorite blogs, Better in Emergency Medicine, by Dr. Rob Cooney reviewed the 1991 article entitled "The Ten Commandments in Emergency Medicine". These commandments are timeless and still hold true today. Rob gives a helpful review of each commandment's relevance in today's ED.

1. Secure the ABC's
2. Consider or give naloxone, glucose, and thiamine
3. Get a pregnancy test
4. Assume the worst
5. Do not send unstable patients to radiology
6. Look for common red flags
7. Trust no one, believe nothing (not even yourself)
8. Learn from your mistakes
9. Do unto others as you would do to your family (and that includes coworkers)
10. When in doubt, always err on the side of the patient

Video: On being wrong

Always question whether you are wrong. Step back and rediscover the possibilities. Don't be afraid to admit that you are wrong.

This is great philosophy to live by in both your personal and work life.

This is a fascinating 18-minute TED video by Kathryn Schulz, a "wrongologist" and author of "Being Wrong: Adventures in the Margin of Error.

Specifically in Medicine, many instances of medical error occur when physicians just can't admit to themselves that they may be wrong in their assumptions. So in the Emergency Department, when I encounter a challenging or perplexing case, I step back and challenge what I assume is true. Maybe my assumptions that the patient is clinically intoxicated or malingering are wrong. Maybe my bedside ultrasound of the gallbladder was falsely normal.

Step back.
Reassess.
Repeat the exam or test, if necessary.

Such questioning has often saved me from going down a completely wrong path.

An especially funny anecdote was the speaker's insight about how one psychologically processes the fact that someone else thinks you are wrong:

• The ignorance assumption
• The idiocy assumption
• The evil assumption

Do any particular consultants come to mind?

Article Review: Emergency physicians interruptions

What exactly do ED attendings do on shift? 

This novel prospective, time-motion study tracks the activities of ED attendings at 2 academic and 2 community sites. All sites used paper charting in the ED and computerized medical records for labs and radiology results.

METHODS
Trained observers recorded tasks in 1-minute increments over a 2-hour period. Three general categories were defined as:

• Direct patient care (lifting patients, bedside history/physical exam, direct interaction with patient, ordering tests or medications, interpreting ECG, performing procedures)
• Indirect patient care (charting, reviewing records, teaching learners, interpretation of diagnostic tests, talking with patient's friends/family; interacting with nurses, paramedics, consultants, ancillary staff)
• Personal activity (waiting, eating, social conversation with colleague, surfing the internet)

Specifically, the observers tracked "interruptions", as defined as an event that briefly required the attention of the attending but did not result in switching to a new task. This included:

• Listening to an overhead announcement
• Nursing inquiry about another patient
• Quick update from a learner

Also "breaks in task" were also tracked, as defined as an interruption that resulted in changing tasks. Examples included answering incoming telephone call, stoping a procedure to care for a cardiac arrest patient.

Additional data points tracked included:

• Distance walked
• Patients touched
• Handwashing
• Time sitting
• Maximum # of patients under care

RESULTS
There were 203 two-hour observation periods (160 at academic sites, 43 at community sites). A total of 85 physicians were observed.

• The majority of time was spent performing indirect patient care. The median time was 61 minutes (academic) vs 55 minutes (community) over the 2-hour period.
• The median time for direct patient care was 36 minutes (academic) vs 41 minutes (community).
• The median number of different individuals interacted with was 35 (academic) vs 23 (community). Wow, we really do interact with a lot of people in a 2-hour period. I just never realized.
• Hand-washing occurred a median of 2 times at both the academic and community sites.
• Physicians walked a median of 0.3 miles (academic) vs 0.17 miles (community). I can definitely attest to all the walking, since I wore a pedometer several years ago. I used to walk over half a mile per 8-hour shift.

The most interesting finding is that interruptions occurred a median of 12 times (academic) vs 6 times (community). Furthermore, 5 of the 12 (academic) and 2 of the 6 (community) interruptions resulted in a "break in task".

BOTTOM LINE
The data from this study provide many interesting discussion points. For instance, emergency physicians need to have strong communication skills, since we interact with so many different individuals. Furthermore, it would be interesting to repeat this study with the implementation of an electronic medical record system in the ED. Would it decrease some of the inefficiencies?

Interruptions are definitely a part of our everyday lives when working the ED. It's more frequent in an academic institution, presumably because we work with medical students and residents who have questions and updates. Because interruptions are associated with a higher risk for medical errors, greater stress levels, and impaired task performance, we need to teach attendings (and EM residents) how to minimize and cope with interruptions.  It would be great if we could wear a "Do NOT Disturb" hat when we are already overwhelmed.

Kudos to the research team for coordinating and completing such a Herculean study. Can you imagine following attendings around for a total of 406 hours and tracking minute-to-minute activities?

Reference
Chisholm CD, Weaver CS, Whenmouth L, Giles B. A Task Analysis of Emergency Physician Activities in Academic and Community Settings. Annals of emergency medicine. 2011 - in press. PMID: 21276642
.

EM-RAP Educator's Edition: Patient Handover

The latest podcast on EM-RAP Educator's Edition features our very own Dr. Stella Yiu (who is part of our blogging team!) and Dr. David Carr. The topic is on Patient Handover -- the transition of one physician to the next.

Take a listen to the 36-minute podcast. Some tips:

• Patient handover is a critical part of EM resident training. It takes practice. Signout rounds is a known high-risk time for errors.
• Be aware of the sign-out statement "... and there's nothing for you to do." You should still go check out the patient to corroborate.
• Consider calling a consultant before leaving your shift, if you would have called them regardless of the result of a pending study (eg. CT head, D-dimer). You know the patient much better than the oncoming new provider.
• Create a clear decision tree.
• Don't be afraid to restart your history and physical when something doesn't make sense or the clinical course changes. Don't rely solely on the previous provider's story.
• When signing out, try to anticipate "forks in the road" and highlight the high-risk patients.

Trick of the Trade: Website resource on HIV medications

At our department's first annual UCSF High Risk Hawaii Conference 2 weeks ago, Dr. Rachel Chin taught about complications from all of the HIV drugs on the market now. It's a virtual alphabet soup: EFV, TDF, FTC, oh my. How do you keep track of them all?

Trick of the Trade:
HIV InSite website

The website is actually hosted and constantly updated by the Center for HIV Information at UCSF. Take a few minutes to browse through the extensive website: http://hivinsite.ucsf.edu/InSite

Specifically, I find the following sub-links most useful in the Emergency Department:

• Side effect profile of antiretroviral (ARV) drugs: http://hivinsite.ucsf.edu/InSite?page=ar-05-01#S2X. For instance, this is the side-effect profile for Indinavir:

• ARV drug profiles: http://hivinsite.ucsf.edu/InSite?page=ar-drugs
• Interactions with other ARV and non-ARV medications: http://hivinsite.ucsf.edu/InSite?page=ar-00-02

Trick of the Trade: Conveying risk for postexposure prophylaxis

A health care worker hurried in to the ED after being poked with a needle.

'It was an old 18G needle with dried blood', she said. Her puncture had drawn blood. You discussed the very low risk of contacting HIV and the side effects of postexposure prophylaxis (PEP). She asked, 'What does very low risk mean?'

Is there another way to covery risk for patients?

Trick of the Trade:
Convey probabilities with everyday risks.

This article uses a risk stratifying tool to convey probabilities that compare to everyday risks such as flying, cancer diagnosis, having an MI, etc. Below is the calculation tool from the paper.

Using this tool, the risk of contacting HIV for this patient would be:

5/ (1000 x 100 x 100) = 1/ 2,000,000

According to the everyday risk table in the article, this is similar to the risk of dying in the next 12 months from lightning. You left her to decide on PEP.

My take:

As the author pointed out, the risks cited are probabilities instead of exact measurements. This is an important caveat.

I find this helpful to provide context, especially for those who have difficulty deciding on PEP.

Reference
Vertesi L. Risk Assessment Stratification Protocol (RASP) to help patients decide on the use of postexposure prophylaxis for HIV exposure. CJEM : Canadian journal of emergency medical care. 2003, 5(1), 46-8. PMID: 17659153

Read the free article from CJEM. 

New ACLS guidelines from the AHA, ERC, and ILCOR

Last month the AHA, ERC, and ILCOR released the 2010 Resuscitation Guidelines. They build on the 2005 and previous guidelines and continue the trend towards more, higher quality, uninterrupted CPR. The complete summary and recommendations are published in Circulation and are available for free.

Here is my summary for you!

CHANGE

• Trained rescuers should change BLS sequence from A-B-C to C-A-B
• Chest compression rate should be GREATER than 100 beats per minute
• Chest compression depth should be GREATER than 2 in./5cm.
• Untrained rescuers should perform Hands-Only CPR

DELETE

• "Look, listen, and feel" for breathing is no longer recommended
• Atropine is not routinely recommended for all PEA or Asystole cases
• Central venous catheters (deleted 2005, replaced by IV or IO)

ADD

• If available, continuous quantitative capnography is recommended throughout the peri-arrest period to assess physiologic change
• Adenosine is recommended for stable, regular, monomorphic wide complex tachycardia
• Post-cardiac arrest care including PCI and Therapeutic Hypothermia when indicated

Keep/Reinforce

Our colleagues from the blogosphere have published their audio and written summaries and opinions too:

EMCRIT.org summary and podcast: http://blog.emcrit.org/podcasts/acls-guidelines-2010/

Life in the Fast Lane: http://lifeinthefastlane.com/2010/10/resuscitation-guidelines-2010/

From my point of view, these guidelines include most of what we've been teaching students, residents, medics, nurses, and others in our simulation center with the addition of a few new pearls. It'll be helpful to show our colleagues these guidelines as we advocate for more CPR and less of other things in the prehospital setting and for more critical care, PCI and therapeutic hypothermia on the in-patient side. In the ED we will need to continue to improve our team work skills, communication with colleagues and families, and our ability to provide effective, efficient, and affordable care for all.

Demian Szyld, MD

Boston, MA

Practicing Judo in the ED: Secret to success

OK, you don't actually practice Judo in the Emergency Department, but the principles in Judo are interestingly relevant in approaching our work in the ED.

Thanks to Garr Reynolds of Presentation Zen fame for introducing me to the 7 rules of judo practice by the great Judo master Kyuzo Mifune. In his blog post, Garr specifically talks about how these rules are relevant in the realms of leadership and public speaking.

These rules in fact are extremely relevant when you are a senior EM resident or an EM attending. These 7 simple rules really are the heart of maintaining respect, calm, and efficiency in the ED.

1. Do not make light of an opponent.
Although it is easy to do, try to avoid speaking negatively about any consultants or ancillary services. It only breeds negatively and draws focus away from patient care. Give others the benefit of the doubt. Just because people may speak ill of the ED doesn't mean that you should reciprocate. I consider the ED team as having a higher set of professional standards.

2. Do not lose self-confidence.
You have been trained well in EM. This doesn't mean to be over-confident but rather just deliberate. Second-guessing yourself makes you inefficient. If you don't know an answer, just look it up, get help, or consult someone.

3. Maintain a good posture.
To me, this means positioning a patient appropriately so that you aren't straining to do a procedure. Is the bed too high or too low? Adjust accordingly.

4. Develop speed.
Practice not only your clinical skills but also your efficiency skills. Focus on developing your multitasking abilities and speed. Recently, I've been pre-writing a few Vicodin and Percocet prescriptions just before I start a shift. I then just write-in the patient's name and off they go with the prescription. A few minutes saved per patient adds up to significant time savings over the course of the shift.

5. Project power in all directions.
I interpret this as being professional at all times. As the senior EM resident or EM attending, you are the leader of the ED team. Whether you realize it or not, the tone of the shift is set by how you treat others. No interaction is unnoticed. Imagine that an invisible yet impressionable 1st year medical student is shadowing you at all times. Don't say or do anything you'd feel bad about in his/her presence.

6. Develop self-control.
Inevitably, sometimes patients or other providers can make you angry. They just are able to push your buttons. Be cognizant of when this happens and try your best not to reciprocate. This is harder said than done, but you lose serious credibility points all-around if you lose your temper. When I get flustered, I often have my default responses:

• "I'm just trying to do what I think is best for the patient."
• "I totally understand your perspective, but we are going to have to agree to disagree."
• "Could I talk to your attending?" (Usually ends heated discussions quickly when asked of a resident. I hate to pull the Attending Trump Card, but sometimes it's just necessary.)

7. Never stop training.

You will never learn everything there is to know in Emergency Medicine. That's the blessing and curse of the specialty. Keep reading. Keep learning. My goal is to always surprise a consultant with information that they don't think a typical emergency physician would know about their specialty.

Any other good rules for success in the ED?

Trick of the trade: Discounted medications at pharmacies

Many times, patients who we deem as "noncompliant" with medications may actually be financially unable to afford medications that we prescribe them. Thanks to Amy Kinard, I just learned about this great new website where you can find pharmacies with amazing discounts for common medications.

http://www.genericmedlist.com

I went to Walmart and Target myself to see if this was indeed true, because frankly I couldn't believe the amazing deals. For example, you can get 20 tablets of ciprofloxacin (500 mg tabs) for only $4.

Download the list of eligible medications and the price list from:

• Target pharmacy 
• Walmart pharmacy

Even more cool is that fact that this same information can be found in a free iPhone app called Generics. Now you can refer patients to the most affordable pharmacy (see below).

Getting a subpoena: What is an expert witness?

Well, it's an inevitable part of working in an Emergency Department. I got a subpoena recently and now have to go in to testify on a trauma patient. I've gotten a few subpoenas before on trauma patients, but fortunately most cases were settled out of court.

First of all, I think it's an ethical responsibility of emergency physicians to describe what we saw and did in the care of the injured patient in the legal system. However, I have found that the few lawyers I have interacted with slowly expand their scope of questions to cover things NOT in the medical chart. Has this happened to anyone else? They essentially start to ask me things which an "expert witness" should answer. Expert witnesses receive expert witness fees.

• "What is a typical expected course for..."
• "Do patients with this type of injury usually have pain for so long?"
• "What do you think about..."
• "Can you describe the nature/ cause/ definition of..."
• "What's the prognosis for..."

Actually ACEP has created Expert Witness Guidelines.

So I read more about our rights as emergency physicians when we get subpoenaed to testify for a patient. We are supposed to just testify about the facts on the medical chart. No opinions. If we start giving opinions, we are essentially giving expert witness testimony.

Interestingly, the California Medical Association has a recommendation on this: If asked to give expert opinion, the physician should ask if s/he is being asked for their expert opinion. If so, that they would like to receive expert witness fees. In 1995, the California legislature passed bill AB1204 that ensures a treating physician expert fee payment if asked for a medical opinion. Read more here in EP Monthly. This is becoming increasingly true in many other states.

Even better, there is a great template letter (thanks to Dr. Clement Yeh for telling me about it) that you can preemptively mail the lawyers who sent you a subpoena. It basically says that you would be happy to testify what's on the medical chart and ONLY on the chart. If they want expert opinion, you should be treated as an expert witness with "x" number of dollars/hour recompensation. It's pretty hard-core, but I think it averts many misunderstandings and potentially can you save a lot of time. All the time in court and preparing for the case takes you away from work.

Wish I had this earlier. Here is the template (download here):

Dear {name},

I was recently subpoenaed by your office. In the past, there have been several incidences where there has been a misunderstanding whether attorneys are requesting factual or expert witness testimony. In the event, you ask me to provide any response or responses that calls for an opinion or medical conclusion, that will be considered to be expert witness testimony. Receipt of this letter will confer your acknowledgement that in the event you request expert witness testimony, you and/or your agency will be responsible for bills for my time. As a courtesy, I am sending my fee schedule for your review.

My fee is $___ an hour for consultation and/or expert testimony. Expert services include review of records, telephone and or office conferences with attorney(s) or other relevant individuals, and preparation for deposition and trial if indicated. The minimum fee bill will be $____.

As is standard, all reasonable expenses incurred will be billed to your agency or firm. If travel is necessary, travel time will be billed at $___ per hour. If testimony is required the following charges apply. If I am called to testify in the morning, I assume that testimony will involve a minimum of eight hours, and you will be billed for eight hours at $___ per hour. If I am called in the afternoon, I assume that testimony will involve a minimum of four hours and you will be billed for four hours at $___ per hour. If meetings or trials are subsequently canceled on short notice your agency or firm may be billed for the time scheduled.

Video: Caution about patient hand-offs in the ED

Kudos to Dr. Vineet Arora (Univ of Chicago) on creating a great video on the importance of clear, concise, and updated hand-off information on patients. This is especially important in the Emergency Department where patients are constantly being "signed out" to other residents for continued acute care. Whatever hand-off process you are using now, we can always do better.

I thought this video was especially timely given that today is the first day of the new (academic) year for residents! Let's be extra careful out there.

Hospital Handoffs for Intern Orientation

View more videos from Vineet Arora.

Article Review: Impact of family presence in a code

Family presence in the ED resuscitation of a dying patient is a controversial topic. Some surveys suggest that families favor this practice and would repeat it again in a similar situation.

An article in Critical Care Medicine examines the impact of family presence on the ED personnel's actions, rather than the impact on the families themselves. Second and third-year EM residents were randomized into paired teams in simulation exercises. All resuscitations involved a cardiac arrest patient. Each team was exposed to one of three types of resuscitation groups:

1. No family witness
2. Non-obstructive family witness (quiet person) - quiet crying and conversation with social worker
3. Overtly grieving family witness - loud crying, attempts to hug patient during resuscitation

Outcome measures:

1. Length of resuscitation attempt
2. Time to critical events (eg. intubation)
3. Recognition of potential drug administration error

Results

• n = 60 residents
• The timed outcomes were compared across the 3 groups using a one-way analysis of variance.
• There was no difference across the 3 groups when comparing # of minutes to CPR, to intubate the patient, and to making a death pronouncement.
• "Overt reaction witness" group: Residents took longer to deliver the first defibrillation shock than the other 2 groups. Also residents delivered fewer shocks overall than other 2 groups.

Bottom line

Mortality improves with PROMPT defibrillation for ventricular fibrillation patients. Delays contribute to worse outcome. This study suggests that overtly-grieving family witnesses during the resuscitation may negatively impact process outcomes of the actual resuscitation.

Of course because this study was conducted on residents (not attendings) and on a human simulation (not on actual patients), more studies need to confirm these preliminary findings.

Reference

Fernandez R, Compton S, Jones KA, & Velilla MA (2009). The presence of a family witness impacts physician performance during simulated medical codes. Critical care medicine, 37 (6), 1956-60 PMID: 19384215

Paucis Verbis card: Appendicitis - ACEP Clinical Policy

Appendicitis is a common presentation in the Emergency Department. Dilemmas arise when deciding whether to image patients with equivocal symptoms and WBC lab results. Given the risk of ionizing radiation with CT scans, we should ideally minimize the number of CT scans ordered in these patients without mistakenly sending patients home with an early appendicitis. A perforated appendix places the patient at risk for bowel obstruction, infertility (in women), and sepsis.

Where does the American College of Emergency Physicians (ACEP) stand on the critical issues surrounding the evaluation of appendicitis?

This installment of the Paucis Verbis (In a Few Words) e-card series reviews the ACEP Clinical Policy on Appendicitis. In the end, the policy conjures up more questions than answers, but a comprehensive presentation of the literature to date and helpful risk-stratification data are provided.

I'm curious, what protocol do you use for your CT scans for ruling out appendicitis? What combinations of PO, IV, and PR contrast do you use, if any? At our site, we use PO and IV contrast.

Feel free to download this card and print on a 4'' x 6'' index card.

[MS Word] [PDF]

See other Paucis Verbis cards.

Poll: How do you recover from a night shift?

There are so many amazing things that we get to see and do as emergency physicians.

• We see sick, undifferentiated patients who need our help acutely.
• We have cool toys, such as ultrasounds.
• We get to do great procedures.
• We work on a shift-based schedule.
• We work in team-based fashion with fun nurses, technicians, and staff.
  

However, one major down side is that almost all of us work some night shifts.

Question for the readers:
Let's say you just finished your shift at 6 am. Your next shift is at 6 am the next day. How do you recover from your night shift?

For me, I try to work 3-4 night shifts in a row and then try to stay up as late as possible after the last shift. Usually, I pass out at 7 pm and wake up at 5 am the next day. I'm good to go.

Other options I've heard of include:

• use of medications such as ambien
• short nap mid-day after a night shift and then getting 6 hours of sleep at night
• incorporation of rigorous exercise after your night shift

I'm curious. What do you do?