The Joys of Rural Practice by Dr. Edwin Leap – EdwinLeap.com

I practice in the rural, northwest corner of South Carolina, also known as “The Upstate.”  It is a place of expansive lakes, white-water rivers and the mist covered foothills of the Blue Ridge Mountains. The area includes thousands of acres of Sumter National Forest.  The natural beauty is breathtaking.  Sumter National Forest and our various parks are laced with hiking trails, which are lined with unique plants and trees, some found nowhere else.   Fish and game abound.  In fact, our wooded hospital grounds support a flock of at least 30 wild turkey.  And last deer season, the only deer I saw were the three does grazing at the end of the ED driveway one night, spotlighted by two of our paramedics.

We have a lot of wonderful things here, things that are gifts of the rural life.  We have good people, the salt of the earth types who care about personal morality and Southern courtesy.  People who bring you a glass of sweet tea when your car breaks down.  We live with a low crime rate, and minimal illicit drug use compared with more populated areas.  It is a good place to raise children.  It’s also a cool place to practice, where a busy summer shift can bring an acute MI, a near drowning (from inner-tubing on Class IV white water while drunk), a pit viper bite, a bull goring and many other pathologies, more or less interesting.

But, as physicians in a rural area, we pay a price.  Because we have to endure a certain stigma.  The stigma is this:  if you practice in a small, rural hospital, you must be less than competent.  Because if you were competent, you’d practice in a large, urban teaching/trauma center.  I frequently face this when I speak to the out of state parents of  local university students.  You can tell that they are hesitant.  Many are from the urban northeast, and they exude a discomfort with any physician willing to put out a shingle in a place so far off the beaten path.  They want to know about the hospital, the consultants, my training, etc., And of course, this is fine.  I understand that anyone might want to know the credentials of the person caring for their sick or injured child.  But, as emergency physicians, I think we should try to dispel this unfortunate stereotype among patients.  And the best place to start is to dispel it among our colleagues.

I read some time ago of the difficulty rural areas have in recruiting residency trained emergency physicians.  I’m not surprised.  Our training, mostly in large urban centers, tends to focus us on that type of medicine.  We see trauma care as effective only when provided by trauma teams.  We feel that cardiac care must be supported by immediate angioplasty and, if needed, cardiac surgery capabilities.  We love to hear the thump-thump of those helicopter blades.  Our hearts thrill at the thought of thoracotomies for  penetrating trauma.  We sometimes even buy the line that children have to be cared for in children’s hospitals.  We like to see herds of residents and students descend to the department to evaluate admissions in the early morning hours.  It’s shiny and exciting, and it’s very hard to resist.

I must admit, I was a victim of the myth myself at first.  When I first came to Oconee Memorial Hospital seven years ago, I was happy about the job. But somewhere deep inside I felt that I had taken the low road.  I felt that, if I were “a real doctor”, I’d have gone to a trauma center, in a large city.  And no wonder.  I moved to a town of 5000 persons.   I became the fifth doctor in our group, seeing some 27,000 patients per year in a 10 bed ED, in a 120 bed hospital.  We had one cardiologist, but no cath lab.  We had no neurologist, pulmonologist, neurosurgeon, toxicologist, trauma team or pediatric subspecialties.  We had nine ICU and four telemetry beds. Although our group, our department and our hospital staff have grown dramatically since the time I arrived, it was and still is a far cry from Methodist Hospital of Indiana where I trained.  Thankfully, the staff at Methodist prepared me well for the adventure of rural emergency medicine.

Here’s why. In my rural department, in this relatively isolated area, my partners and I have to practice a very autonomous form of emergency medicine.  We don’t have residents to help with the volume and we don’t have a trauma team.  There is no helicopter service taking our patients to the regional trauma referral center;  it’s at least 40 minutes away by ground.  We still lack many of the support specialties I listed above.  Most nights we are the only physicians in the hospital at all.  We have to manage the difficult airway, obtain the emergent vascular access,  make the transfer arrangements and all the rest.  Like physicians at many rural centers, we sort of do it all.  Of course, this is not really different from many emergency physicians in urban areas, but the difference is, we don’t have options.  We are relatively alone.

But my point is not self adulation.  My point is that, all across the country, emergency physicians at small hospitals provide excellent, state of the art care for patients that are just as sick as the ones in large centers. But they do so with less help, less resources, and in many ways more pressure than their friends and classmates in teaching centers.  The view from the large centers sometimes gets skewed because only the sickest patients are transferred to them.  So it sometimes looks like the smaller facilities do a bad job.  Actually, most of them give excellent care.  But patients deteriorate and patients die in hospitals of every size.  It happens at Oconee Memorial and it happens at Methodist.

I believe that our specialty should encourage graduating residents to go to rural areas.  I’d like to see residents taught that they can contribute to the specialty as certainly in a remote area as they would in any large city in America. There is enormous need, and there are great rewards in making a rural area safer and healthier.  There is tremendous satisfaction in being appreciated by patients who might have done poorly if not for modern emergency care.   When my family and I drive home to West Virginia, through rural Appalachia, I often wonder who is staffing the departments nearby, should we become intimate with a coal truck.  I always hope it is someone well trained for the job.

Rural areas require that physicians sacrifice certain big city amenities, both professionally and socially.  But the payoff is worth it. And if anyone reading this is considering rural emergency medicine, I encourage them to make a difference and go to the country.  They won’t regret it; I certainly don’t.

Source: The Joys of Rural Practice | EdwinLeap.com

Rural doctors, you may be the last, best hope for someone. by Dr. Edwin Leap – EdwinLeap.com

Recently, while on a locums assignment in a very small, rural hospital, I cared for a gentleman with chest pain.  His discomfort seemed classic for an MI, but his EKG did not. So I treated him as normal with aspirin and nitrates, and waited for his cardiac markers to come back from the lab.  In the interim, his chest pain worsened.  Sure enough, he developed an anterior MI.  The tombstones of tombstones, you might say!

Well, this wonderful facility did not have a cardiologist on staff, much less a cardiac cath lab.  So, I went ‘old-school.’  I gave him a thrombolytic.  I know, seems pretty Stone Age, doesn’t it? But it was the right thing to do.  There was no interventional cardiologist in the area; in fact, the patient would ultimately be transferred by fixed-wing aircraft to the nearest cardiac care center.

While he had one brief episode of ventricular fibrillation (responsive to one shock), his event was otherwise unremarkable and his EKG normalized before the flight crew ever arrived.  He was pain free and grateful as he was loaded for his trip to the referral center.

Afterward, two things became evident. First of all, the charge nurse thanked me for making a decision quickly. Apparently, she had experienced some locums physicians who were uncomfortable simply making the call on their own. They inevitably wanted to show their patient’s EKG’s to cardiologists and have discussions.  I looked and acted.  Second of all, I realized yet again how much fun it is to be…important!

We live in an era of specialists and subspecialists and sub-sub specialists.  In large cities, the job of the emergency physician is to order the EKG as quickly as possible (hopefully before the patient arrives it seems), and call the right interventional specialist in something like a nano-second.  In some places, we serve as facilitators, almost brokers.  But in the small centers of America, where the advanced technology of medicine isn’t always immediately available, our job becomes absolutely critical.

I find that refreshing. And exhilarating!  Too many young emergency physicians have grown up in the long shadows of never-ending back-up. But a few short miles out of the city, an airplane flight over a mountain, a drive along a jagged coast and one may discover that he or she, as an emergency physician, is the truly the last, best hope for patients who populate the remote parts of America, doing hard work in hard industries.  We are needed by farmers and timber-workers, miners and fisherman, hunting guides and raft guides, truck drivers and oil-well workers and all their precious loved ones.

I encourage physicians to reach out and work in the remote places.  Take the chance and take your skills out to the places where they are truly precious!  If you are older, your experience will be priceless.  And if you are younger, well be bold and do your best.  And learn to make decisions ‘all by your lonesome.’

You may find that working in those out of the way places is just the thing you need to remember how very special, and very valuable, your skills and experience really are. And why worry?  Help is only a fixed-wing flight away!

Source: Rural doctors, you may be the last, best hope for someone. | EdwinLeap.com

Life & Limb: In Rural E.R. by Dr. Edwin Leap – EdwinLeap.com

Today we welcome a new columnist, Edwin Leap, M.D. His column, “Life & Limb,” will show rural America from the perspective of an emergency-room physician. Dr. Leap is medical director of the emergency department in a rural hospital in North Georgia. He’s worked in emergency medicine throughout his career, most recently as a traveling physician in critical access hospitals in several states. “I came to love those very small facilities with very big missions,” Dr. Leap says. Look for the doctor to share his perspectives on multiple topics – sometimes funny, sometimes serious, but always rural.

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“So tell me why you think you you’re having a stroke?”

The nice lady, mid 40’s, sat on the ER exam table in work-clothes, an anxious look on her face. “Well, I was working the cattle up in the timber and when I got back to my 4-wheeler my heart was racing and I was short of breath. My arms were tingling and so was my face. I’m concerned it might have been the start of a stroke.” Before I could go much further, her sister chimed in: “tell the doctor what else happened, go ahead!”

My eyes went from sister back to patient as I waited for the tale to unfold. “The thing is, a black bear sow chased me when I got between her and her cub. Do you think that could have made me feel badly?”

“Yes ma’am! Maybe you were just hyperventilating.” (I certainly would have.)

It was the sort of situation that isn’t really surprising in rural emergency departments across America. Although I saw my “bear-chasing” victim in Colorado, most of my practice has been in South Appalachia. Rural Southerners have the same standard health issues as all Americans. However, while their assorted afflictions are often the same as those suffered by urban or suburban dwellers, there are unique problems, often involving nature, that bring patients to the rural ER. Hardly a summer goes by that I’m not giving someone anti-venin for a snake-bite from a copperhead. The last person I gave it to was a seven-year-old boy who was bit walking along a river with his family.

Dr. Edwin Leap
Dr. Edwin Leap

I have spent a lot of time suturing lacerations from chain-saws, machetes and pocket knives. I have treated patients whose hands were crushed in log-splitters. I have removed fish-hooks from assorted body-parts (including the eyelid of a two-year-old) and seen innumerable bites from insects and other creatures. I have also had to reassure frantic, visiting urbanites that all those red marks probably don’t reflect Lyme’s Disease but more likely come from mosquitos. I have cared for more than my share of hypothermia, hyperthermia and no small number of drownings and near-drownings.

When physicians work in rural areas, we become comfortable with certain behaviors and patterns of injury. When a man walks in with dozens of tiny holes in his back, in April, the standard question is, “Did you get a Turkey?” Falls from tree-stands elicit appropriate queries like, “Were you knocked out, does your neck or back hurt?” and the slightly accusing, “Were you wearing a safety harness?”

Thanks to rural life and work, I know what a log-skidder is, and what it means to hear that a tree or saw “kicked back.” I know to be very worried when I hear that the local rodeo is sending someone kicked in the face by a horse, and I was not surprised to see a man who shot himself in the leg while re-holstering his .44 Magnum after killing a wild hog.

The challenges of the rural ER, however, extend beyond pathology and into problems with resources. We have few specialists. A rural hospital with a decent ER, some family physicians, an obstetrician and a general surgeon is rich indeed. Typically there is no cardiologist, no neurologist, no pediatrician, no trauma team; no heart center, no stroke center.

But it gets more challenging. To many Americans, the answer would simply be, “Well, if they’re very sick, just call the helicopter!” But rain, wind, fog, snow, ice and smoke from wildfires often keep us helicopter free. Even ambulance transfers are challenging, as most counties have only two ambulances and only one can be away at any time.

In addition, transfers to big centers can be confusing when physicians on the other end, in the big hospital, simply can’t fathom the fact that the small town doesn’t have things they take for granted, like an intensive care unit, a neurosurgeon or even an MRI.

The reality of medicine in rural America is often very different from the way the profession looks on medical dramas, which are usually set in well-stocked, well-staffed urban centers. Rural hospitals have plenty of struggles, and those troubles are growing. But what we lack in money, equipment and personnel we more than make up for in rewarding work, challenging situations, grateful patients and awesome stories.

City or country, a doctor can’t ask for much more than that.

Source: Life & Limb: In Rural E.R., Exams Include the Obvious Questions, Like ‘Did You Get a Turkey?’ – Daily Yonder

Creative Solutions to the Rural Doctor Shortage

I was recently at a meeting where some very influential physicians were discussing a question that I’ve been thinking about for a while: how do we find medical staff for rural emergency rooms and hospitals? It’s a tough question, because, increasingly, it seems that young physicians are trained to work in urban hospitals. Those are also the places these young doctors prefer to practice. Big hospitals and teaching centers in the city. Modern medicine is highly technical and remarkable specialized, so many young docs are very uncomfortable when they have to practice far from ‘the mother ship’ (the term we use to jokingly refer to large referral centers with every specialty under the sun).

This discussion of the medical work force is complicated, but it’s clear that for the foreseeable future, rural hospitals will struggle to get physicians. It’s bad enough that we frequently lack the specialty back up of larger urban centers (just try to find a neurologist or cardiologist outside a large urban area), but we don’t even have all of the advanced technologies that are common elsewhere. You won’t get a coronary stent placed in a small county hospital, for example. Getting highly specialized, cutting-edge care often requires patients be transferred over long distances to larger facilities.

It’s an interesting phenomenon; people in urban areas would be shocked and outraged if their hospitals suddenly had to transfer all of their complicated patients to another location. And yet, Americans accept this as axiomatic in rural areas.

So let me suggest that rural America lead the way in creative alternatives to care, and in the process offer our young people some fantastic new career options.

One thing that’s being employed in some areas today is the ‘community paramedic.’ More than a provider of emergency care, the community paramedic is a professional with extra training who goes to patients’ homes. The community paramedic manages other routine medical issues as well. They can provide some basic primary care and health education and help sicker patients stay out of the hospital by engaging in good health behaviors and by following their hospital discharge instructions if they were recently inpatients.

As hospitals struggle with patients coming back over and over to be admitted for preventable problems (something for which Medicare punishes hospitals), the community paramedic can be a valuable member of the care team. Becoming a community paramedic would require that one undergo training as an EMT, then as a paramedic (which now requires a two year associates degree). Then there will be some additional training. It appears that the extra training would involve a little over 300 hours of classroom and clinical exposure for one to qualify as a community paramedic.

Next there are what we in medicine call ‘mid-level providers.’ These come generally in two varieties: the nurse practitioner (NP) and the physician’s assistant (PA).

A nurse practitioner has a four-year nursing degree, followed by a masters (and increasingly doctoral) degree as a nurse practitioner.

A physician assistant gets a four-year degree, takes specific prerequisites, then goes to PA school for two years, culminating in a master’s degree.

Members of both groups do many of the same things as physicians, particularly in primary care fields. Some work alongside specialist physicians as well. Many a night I have tried to reach on on-call cardiologist or surgeon, only to speak to their personal NP or PA (who often has a more pleasant personality in the wee hours of the night).

In many rural areas, the NP or PA may be the only available care provider. Some models suggest that this would work well if supplemented by telemedicine supervision; the doctor on the other end, who could be hundreds of miles away, connects via video-conferencing technology to offer insight and guidance on the complex, difficult situation.

I’m a huge advocate for physicians going to rural areas to practice. But current trends suggest this is happening less. So in order to get the best care, we need to be flexible and creative.

Many young men and women in rural areas are deeply connected to their homes and regions, and want to go back after school and make life better for their families and neighbors. They also know that medical school is long and costly and that they want to get on with life and have families instead of continuing training for over a decade.

So tell the kids (and the adults contemplating a new career) to consider the fields I’ve listed above. People in rural America are just as sick (and sometimes sicker) than those in urban locales. They deserve good care. And they’ll get it from well-trained community paramedics, nurse practitioners and physician assistants.

And phooey on the doctors who won’t work there! They don’t know what they’re missing.

Source: Creative Solutions to the Rural Doctor Shortage – Daily Yonder

Ten Tips for Airway Management that Absolutely Have to be Part of Your Practice

Airway management is one of the hallmark skills of an emergency physician, but to call it a single skill does not give enough credit to the complexity of the task. It is actually a long sequence of micro-skills and decisions. Fortunately, airway skills and equipment have improved, and it is relatively rare to face a true “can’t intubate, can’t ventilate” scenario. At every step along the airway algorithm, however, are small branch points that offer opportunities for incremental improvement and better patient outcomes.

Which steps can be taken before, during, and after intubation to elevate airway management from simply securing the airway to a well-choreographed routine that sidesteps potential complications? Here we discuss 10 airway techniques—before, during, and after intubation—that you can start using today. Some of these have robust evidence; others are based on physiology and expert opinion.

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Before: Optimize Conditions

1. The Checklist: It is the rare ED airway case that requires truly emergent intervention. All the rest give you at least a few minutes to plan ahead. Make the most of any planning time you have by employing a checklist and a verbal timeout. We get used to working with a rotating cast of nurses, respiratory therapists, technicians, and residents every shift. A checklist accompanied by a short verbalization of the plan cognitively unloads the to-do list, unifies everyone’s efforts, and provides a shared mental model. Airway checklist use in the ED has been found to improve adherence to recognized safety measures and to reduce complications. (Acad Emerg Med 2015;22[8]:989, http://bit.ly/2Kgjoso.) (See the checklist we use at the University of New Mexico.)

2. Resuscitation Before Intubation: Your airway checklist should also include reminders that will help steer you away from peri-intubation hypoxia or hypotension, which can contribute to secondary injury in fragile brain. More and more, FOAMed leaders have been reframing RSI as resuscitation (not rapid) sequence intubation. Our checklist has a single line—“Fluids? Blood? Pressors? CPAP?”—to remind us to resuscitate before we intubate.

It is worth delaying the intubation for a few minutes in many cases to optimize the patient’s physiology. This may be as simple as starting blood or hanging an infusion of norepinephrine. The intent is to mitigate the physiological changes associated with the reduced sympathetic tone from medications and paralysis as well as reduced venous return from positive pressure ventilation to decrease the chance of decompensation.

3. Preoxygenation: Make the Most of Position and Equipment: Lying flat promotes posterior atelectasis, and the pressure of the abdominal contents on the diaphragm reduces the functional residual capacity of the lungs, so keep patients as upright as possible until it is time to intubate. Sniffing or ramped positioning will facilitate preoxygenation and intubation.

Table

Table

Ideal preoxygenation takes at least three minutes of the highest flow possible delivered with the addition of PEEP to replace nitrogen with oxygen, effectively creating an oxygen reserve to extend the time before desaturation after paralysis. A standard partial nonrebreather will suffice in many cases, using what is now referred to as flush rate oxygen: Simply turn the wall oxygen up as high as it will go; this will typically give about 50 L/min. Multiple studies have shown that flush rate oxygen with a nonrebreather (NRB) mask is not inferior to bag-valve-mask (BVM) for spontaneously breathing patients. (Ann Emerg Med 2017;69[1]:1, http://bit.ly/2tJTodUAnn Emerg Med 2018;71[3]:381, http://bit.ly/2Kuchso.) NRB mask is technically much easier than BVM, and you don’t need to worry about mask leak.

Be wary if patients are still saturating ≤93% despite sitting up with a nonrebreather. They are teetering on the edge of the steep part of the oxygen desaturation curve. (Ann Emerg Med 2016;67[3]:389, http://bit.ly/2Kpd9yAPrehosp Emerg Care 2008;12[1]:46.) Time to desaturation will be measured in seconds, not minutes, at this point on the curve. It might be necessary to provide positive pressure with CPAP or BPAP for these patients. Do not forget to put the nasal cannula for apneic oxygenation on first.

We were all taught never to provide positive pressure during RSI to avoid the risk of insufflating air into the stomach, which can increase the risk for aspiration. We have found, however, that the risk of hypoxemia is often greater than the risk of aspiration, especially when hypoxemia leads to frantic bagging later in the procedure. It is better to provide gentle positive pressure up front than desperate bagging after hypoxemia ensues.

We also learned to avoid nasal intermittent positive pressure ventilation (NIPPV) in patients with altered mental status, but we use this liberally as long as the patient is attending one-to-one. Sedation may be required to facilitate NIPPV in some cases, though this can be fraught with danger in high-risk patients. Options are to titrate benzodiazepines carefully or use delayed sequence intubation (DSI) with ketamine. (Ann Emerg Med 2015;65[4]:349, http://bit.ly/2yNbNwt.)

Another nice trick is to apply the NIPPV using a ventilator with a back-up rate rather than a standalone CPAP/BPAP device. One can transition seamlessly from NIPPV to full-mask ventilation (with breaths delivered by the machine rather than a self-inflating bag in this case) without breaking the seal and losing the built-up PEEP. (See table for suggested vent settings.)

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During: Laryngoscope in Hand

4. Videoscope. Every Time: Multiple video laryngoscopes are currently on the market that utilize standard geometry (similar to a direct laryngoscope curved blade) and hyperangulated geometry blades to improve the glottic view. The video laryngoscopy technique with standard geometry blades is similar to direct laryngoscopy while the technique for hyperangulated blades is quite different.

Being able to see the cords does not guarantee that intubation will be successful, but why not practice with it every time if you have a tool that routinely provides a better view? Having unfamiliar equipment as a rescue device during difficult airways only invites fumbling and equipment problems at the time you can least afford it, so use it on all the easy cases too. This is especially critical for hyperangulated blades where the technique may not be intuitive initially. Anyone who has worked with residents or other learners in the ED setting will attest that a screen has the valuable second benefit of allowing you to see what the learner is seeing.

5. ELM, A Helping Hand: External manipulation of the larynx (ELM) may improve visualization and intubation success for some airway anatomy. This isn’t traditional cricoid pressure but rather a guided maneuver to actively bring the cords into view. This is most efficient with an assistant: Have him place his fingers directly on the thyroid cartilage and then place your hand over his, so you can let go once you have optimally aligned the airway while he maintains the view. (Photo.) This technique is simple and costs nothing, yet is still vastly underutilized. (Amer J Emerg Med 2013;31[1]:32, http://bit.ly/2IuC7Lp.)

6. Use the Bougie: The bougie is worth more than it costs—less than $10 each! It is an incredibly handy tool that many of us have available in case we run into difficulty with direct laryngoscopy, but does it have a role in video laryngoscopy and should it be used routinely? Our EM colleagues at Hennepin County Medical Center in Minneapolis compared using the bougie in place of stylet for every intubation in a recent randomized, controlled trial. They used it as a rescue device only in patients being intubated with a standard geometry video laryngoscope.

The first-attempt intubation success was significantly higher with bougie in patients with difficult airway characteristics (absolute between-group difference: 14%). The first-attempt success was also higher with bougie among all patients. (JAMA 2018;319[21]:2179.) As with video laryngoscopy, using this every time will also improve proficiency for the rare difficult case when you really need it.

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After: High Fives All Around

7. Skip Colormetric Confirmation: Qualitative detectors have become ubiquitous for ET tube confirmation, but we now skip this step and go directly to continuous waveform capnography, which we require for continuous monitoring of tube placement and to avoid hyperventilation, which has been shown to be devastating for our neuro patients. We were using the intermediate step of the color-based detectors, but it seemed to take forever to get the continuous monitors hooked up. Now everyone knows to have them ready before the intubation.

Table

Table

8. Turn Down That Oxygen: Leading up to sedation, preparation has been all about finding ways to provide moresupplemental oxygen and increase the patient’s oxygen reserves to give as much time as possible before desaturation. Now, however, get the patient settled on the ventilator, and flip your mindset to figuring out how little oxygen is actually necessary to maintain acceptable saturations. Hyperoxia has been linked with worsened outcomes in acute MI, stroke, and cardiac arrest in the ICU.

Even relatively brief hyperoxia in the ED has been associated with increased mortality. (Crit Care 2018;22[1]:9, http://bit.ly/2yP1aJf.) This is best done with a blood gas, but you can start by targeting a saturation less than 100%. We usually aim for 94-98%. Sometimes it is remarkable how far you can turn down the FiO2 before the saturation drops from 100% to 99%.

9. Avoid Benzodiazepines for Post-Intubation Sedation: The sedative and depth of sedation started in the ED may carry forward into the ICU, so consider both carefully. Benzodiazepine pushes can be helpful for managing acute anxiety, but long-term benzodiazepine infusions have been associated with prolonged intubation in the ICU. All benzodiazepines are also metabolized by the liver, and midazolam and lorazepam have renally-cleared active metabolites, so critically-ill patients with organ dysfunction may accumulate both.

Patients with seizures or alcohol withdrawal may benefit from benzodiazepines, but propofol offers better ability to titrate while giving the same benefits for the intubated patient. Sedatives like propofol won’t relieve pain, so target pain first with, for example, fentanyl. Then use a short-acting sedative like propofol to permit rapid titration to goal sedation if there is agitation unrelated to pain. (Crit Care Med 2013;41[1]:263, http://bit.ly/2N3fvVy.)

10. Elevate the Head of the Bed: Last but not least, elevating the head of the bed is an extremely easy and effective way to prevent ventilator-associated pneumonia. A recent review paper of 759 patients from eight randomized, controlled trials showed that you can decrease the risk of pneumonia more than 25 percent by just elevating the head of the bed to a semirecumbent position (30% to 60%) from the supine position. (Cochrane Database Syst Rev 2016:8;[1]:CD009946, http://bit.ly/2N5TEg7.) Elevating the head of the bed also lowers intracranial pressure in patients with TBI. Consider the reverse Trendelenburg position if elevating the head of the bed is contraindicated.

Reducing Risk: Confident management of the difficult and emergent airway is a daily part of work in the emergency department, but every case still carries risk. Incremental improvement at every stage of airway management can reduce the risk and immediate and long-term complications. Routinely using these tips will hopefully help you and your patients breathe easier whenever the next challenging intubation comes through the doors.

Special Report: Ten Tips for Airway Management that Absolute… : Emergency Medicine News

A day in the life of an emergency department doctor | TheUnion.com

Emergency Departments are known to be the most fast-paced and highly utilized areas of a hospital. According to the Centers for Disease Control and Prevention, more than 135 million people a year will visit their local ER – about 43 per 100 individuals. Emergency department staff works on what is considered their hospital’s frontlines, stabilizing patients before directing them to specialists who can take over their care.

At Dignity Health Sierra Nevada Memorial Hospital, the Emergency Department is open 24/7, 365 days a year to the approximately 75,000 residents that the hospital serves. The ED averages more than 100 patients a day, equating to more than 35,000 patients annually.

Popular TV shows often show individuals coming into emergency departments under life-or-death circumstances, however the majority of ED patients generally come in with problems ranging from cuts and broken bones to headaches and stomach pains. In addition to treating physical maladies, patients may also come to SNMH’s ED suffering from mental health or drug-related crises, or because they do not have a primary care doctor or cannot afford health insurance.

I had a chance to spend some time with Dr. Danner Hodgson, SNMH ED doctor, to better understand the complexity of what he deals with daily.

Upon meeting in the ED, he was quick to explain that his job is completely unpredictable, always exciting and incredibly rewarding.

Hodgson’s day starts off with a bike ride to SNMH. He rides his mountain bike to and from work as a form of exercise, which he says is important for his health since his line of work can be intense. After arriving for his shift – which can vary for all the ED doctors and for Hodgson can sometimes start as early as 4 a.m. – he prepares for what is usually a 10-hour shift by checking the roster of patients to see which are the most critical and need immediate attention.

On the day I met with Hodgson, he told me the patients he was seeing included: someone with chest pain, someone with belly pain, someone who fell, someone who got beat up, someone with knee pain, a cancer diagnosis, someone with smashed shins and a few patients in need of psychiatric assistance.

While visiting with patients Hodgson likes to sit down next to them to provide comfort, ask about their symptoms and review their medical history, surgeries, medical conditions, daily lifestyle and current medications. After assessing a patient with stomach pains, he tells them that there might be several reasons for the pain, but assures them that together they will figure it out. As Hodgson determines his next steps, he works with clinical staff to make sure the patient is made comfortable.

As he continues through his day, Hodgson comments that he enjoys his job a lot. He has been at the hospital for more than 10 years and his favorite part of his job is the hands-on caring of patients.

“The first two hours of care are crucial to patients that come in under traumatic or critical circumstances,” he said. “Making a diagnosis can be challenging when patients present with complex cases. We work very hard to get it right.”

SNMH ED and Ultrasound Director Dr. Carl Alsup agrees, adding, “We really are in the trenches in this department. They say emergency medicine is the most interesting 15 minutes of every other specialty.”

While SNMH ED staff and physicians like Hodgson and Alsup are able to consistently provide exceptional patient care, they work in a facility originally built to accommodate 15,000 patients annually but is now serving more than 35,000. In order to maintain quality health care at the local hospital, Sierra Nevada Memorial Hospital Foundation has launched a $2 million campaign toward SNMH’s overall project budget of $12 million to provide a crucial renovation to the ED.

This project will add two Rapid Treatment Units to provide an expedited pathway to less urgent medical needs, additional patient beds, a quiet and safe environment for patients in crisis, a family counseling room for difficult discussions, closer access for stroke care, and more.

In addition, an inpatient Diagnostic Imaging project is currently under construction, which will provide new equipment including an MRI, CT and Nuclear Medicine area that will ensure a greater capacity of care for patients needing diagnostic services. SNMHF previously raised more than $700,000 for this effort.

Source: A day in the life of an emergency department doctor | TheUnion.com

Southern States Identified as Opioid Hotspots 

If you suffer a sprained ankle, you’re 14 times more likely to get opioid pain medication at a hospital emergency room in Arkansas than one in North Dakota. That’s one of the unusual findings uncovered by researchers at Penn Medicine, who found a wide variability between states in opioid prescribing for a relatively minor injury.

Researchers analyzed private insurance claims for over 30,000 patients who visited hospital ERs in the U.S. for an ankle sprain from 2011-2015.

Nationwide, about 25% of the patients received an opioid prescription, with the chances of getting an opioid in Arkansas (40%) much better than in North Dakota (2.8%). The states with the highest prescribing rates were in the South and Southeast; while the lowest prescribing states were in the upper Midwest and Northeast.

 SOURCE: PENN MEDICINE SOURCE: PENN MEDICINE

“Although opioids are not – and should not – be the first-line treatment for an ankle sprain, our study shows that opioid prescribing for these minor injuries is still common and far too variable,” said M. Kit Delgado, MD, an assistant professor of Emergency Medicine and Epidemiology at Penn, who was lead author of the study published in the Annals of Emergency Medicine.

“Given that we cannot explain this variation after adjusting for differences in patient characteristics, this study highlights opportunities to reduce the number of people exposed to prescription opioids for the first time and also to reduce the exposure to riskier high-intensity prescriptions.”

Nearly two-thirds of the opioid prescriptions were for hydrocodone – a potent painkiller that was reclassified as a Schedule II controlled substance in 2014 to make it harder to obtain.

Most patients received only a 3-day supply of opioids for their ankle sprains, although 5% were given more than 30 tablets. Less than 1% of the patients were still getting opioid prescriptions 30 days after the initial one.

The study period preceded the release of the CDC’s opioid guidelines and came before many states enacted laws that limit the supply of opioids for acute pain. Some health experts are calling for more specific guidelines for ankle sprains and other health conditions.

“There is a clear need for further impactful guidelines similar to the CDC guidelines that outline more specific opioid and non-opioid prescribing by diagnosis,” said senior author Jeanmarie Perrone, MD, a professor of Emergency Medicine and director of Medical Toxicology at Penn Medicine.

“Medical, surgical, and subspecialty societies should convene to propose best practices similar to the popular ‘Choosing Wisely’ campaign, acknowledging that pain management for most diagnoses can be accomplished with non-opioids. And certainly, ankle sprains are a model example.”

Alabama District Leads Nation in Opioid Prescribing

A recent study published in the American Journal of Public Health also found high opioid prescribing rates in the South, Appalachia and rural West.  Researchers at the Harvard T.H. Chan School of Public Health focused on opioid prescribing in congressional districts, rather than the state or county level.

“It is important for public health research to focus on geographical units such as congressional districts as it allows for elected representatives to be more informed about important issues such as the opioid epidemic. Because a congressional district has a named elected representative, unlike say a county, it brings a certain degree of political accountability when it comes to discussing the opioid epidemic,” said S. V. Subramanian, professor of population health and geography.

The study found that Alabama’s Fourth Congressional District had 166 opioid prescriptions per 100 people, the highest rate of any district in the nation. Congressional districts in Kentucky, Tennessee, Mississippi, Arkansas, Virginia, and Oklahoma rounded out the top ten areas with the highest prescribing rates. Other high prescribing rates were found in districts in eastern Arizona, Nevada, northern California, rural Oregon, and rural Washington.

The Republican congressman who represents Alabama’s 4th District said the opioid crisis is worse in rural areas because there are fewer jobs and opportunities.

“I think this crisis, particularly in rural America, corresponds directly to President Trump’s popularity in my district,” Rep. Robert Aderholt said in a statement. “People here have felt left behind and have seen their jobs and opportunities disappear. Due to the epidemic of depression, some people have turned to prescription drugs to dull the pain.  However, I believe that President Trump’s renewed focus on these areas and increasing jobs has resonated here strongly.”

Harvard researchers say the lowest opioid prescribing rates were concentrated in congressional districts in urban areas, including Washington, DC, New York, Boston, Atlanta, Los Angeles, and San Francisco.

Source: Southern States Identified as Opioid Hotspots — Pain News Network

In Texas, health insurance industry puts profit over patients

In a matter of days — unless the Texas Department of Insurance intervenes — the largest health insurance company in the state, Blue Cross Blue Shield of Texas, will put into place a policy to retroactively decide if a patient’s emergency room visit is a legitimate ER claim worthy of reimbursement.

The health insurance industry will also decide retroactively whether to pay for your ER care based on final diagnosis codes and not the symptoms that a patient presented with— a clear violation of the Prudent Layperson Standard. Their “Monday Morning Quarterbacking” determination of whether your ER visit was justified sets a dangerous precedent, one that calls into question the future of emergency care as we know it.

This is a big deal because currently there are federal and state laws on the books that protect patients from predatory insurance companies. The Prudent Layperson Standard defines a covered “emergency medical condition” as “a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in—(i) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, (ii) serious impairment of bodily functions, or (iii) serious dysfunction of any bodily organ or part.”

What’s worth noting is that under the current model — which recognizes that the Prudent Layperson Standard is the law — if the average person with no medical training perceives that he or she is having a medical emergency, treatment is covered at the in-network rate. The key is symptoms dictate how the claim is treated, not the final diagnostic code (which is what BCBSTX is advocating for via its patient penalty policy set to go into effect on Aug. 6). Unfortunately, Anthem/BCBS has been able to push through similar anti-Prudent Layperson policies in other states.

For instance, take note of this well-publicized example in Kentucky (where an ER patient penalty policy is in effect); a young lady that rarely interacts with the healthcare system was seen for severe right lower quadrant pain after her mother, a nurse, recommended she go to ER to rule out appendicitis. The patient followed her mom’s recommendation. The emergency room did the normal work-up with labs, a CAT scan, then an ultrasound. They were able to determine it was ruptured ovarian cyst (a painful, though non-lethal condition) and she was medicated and sent home.

Later, Anthem refused payment based on the final diagnosis and the family had to appeal multiple times for that decision to be overturned. Finally, after the bad publicity from the scrutiny they were receiving, Anthem paid the claim. Even though it was eventually settled, remember that the ER had to float the amount of money owed, and the family was forced to deal with financial stress all so Anthem could maximize its profits.

I have been practicing Emergency and Family Medicine for 25 years. I have evaluated close to 200,000 patients. The presenting symptoms are hugely important and can sometimes be misleading to both doctors and patients alike. Chest pain that presents could be a heart attack, aortic aneurysm, a blood clot in the lungs, pneumothorax, pneumonia, heart valve issue, pleurisy, a strained muscle, or simply indigestion.

Abdominal pain could be the result of even more numerous diagnostic conditions, many of which are dangerous. Included in the murky waters are conditions that, while not life threatening, can be difficult for even doctors to determine — to say nothing of the average person who lacks medical training.

Health insurance companies like to hang their hats on the notion that diagnoses such as a sore throat, cough, fever, or ankle sprain are conditions they could deny service for as not being emergent. The problem is that a sore throat could actually be an indicator of a more serious condition — for instance, a peritonsillar abscess, epiglottitis, or ludwigs angina among other conditions.

A cough can easily be benign or the presenting symptom for pneumonia, asthma, or lung cancer. What seems like an ankle sprain—with the same initial mechanism and complaints — could actually indicate a fibula or metatarsal fracture. I could go on.

Insurance companies would have you believe that ERs are frequently abused by patients seeking convenience and treatment for seemingly minor medical issues. Yet, a recent CDC study found that only 4.3 percent of ER visits are later determined to be for non-urgent symptoms. Patients should not have to worry about what their bill might be in the middle of a healthcare crisis. They have enough to worry about already.

This is why the Prudent Layperson Standard exists. None of us should be discouraged from pursuing care because we fear our insurance company won’t cover the cost.

I urge you to take a few minutes to contact your elected representatives in Texas and the Texas congressional delegation, along with the Texas Department of Insurance so that the right people can hear firsthand from patients about their concerns with this proposed patient penalty policy.

By Dr. Tom Dorrell, Complete Care, Corpus Christi

Source: In Texas, health insurance industry puts profit over patients

State of emergency: An examination of freestanding ERs in Texas | Economic Snapshot | Dallas News

Since the Legislature passed a 2009 law allowing freestanding emergency rooms to operate in Texas, the industry has taken off statewide.

The facilities aim to add convenience by allowing patients to be seen faster than in full-service hospitals’ ERs — where overcrowding has been an issue — and by making emergency care more accessible in areas without a hospital nearby.

But health economists say the business model grew too fast, and questions have been raised about whether Texans were fully aware that the centers are not always a lower-cost option.

The big boom

Freestanding emergency rooms cropped up in Texas faster than weeds on a prairie.

The initial cost of a two-year license for a freestanding facility is $14,820, which means the state has generated at least $3.1 million in revenue from the openings since 2009.

But that number doesn’t include fees for facilities that have renewed their licenses, withdrawn applications or submitted paperwork to change ownership.

City slickers?

The facilities tended to multiply in more populated areas of the state, which critics argued did little for rural communities where care is sparse.

“Freestanding emergency departments can earn a steady stream of revenues in Texas if they can serve a well-insured patient population. But policymakers should consider options for encouraging their more efficient use and notify patients that the rates are comparable to hospital ERs.”

Vivian Ho, Baker Institute Chair in Health Economics at Rice University

Scaling back

The state began to issue licenses to freestanding ERs in 2010.

In 2016, the number that had let their licenses terminate spiked, and not just because facilities went out of business. Fifty-one of the 58 licenses that ended in 2016 were because the facilities became owned and operated by a hospital, and hospitals do not need a separate license.

“Since 2010, we’ve seen tremendous growth in the number of freestanding emergency medical care facilities in Texas. At HHSC, we work to protect patient safety by ensuring these facilities meet health and safety code standards. To assure greater consumer awareness, by law these facilities are required to post information about their fees at entrances, in patient rooms, at checkout stations and on their websites.” 
David Kostroun, Regulatory Services Division of Health and Human Services Commission

Claims check

As facilites proliferated, the number of Texans using them soared.

Insurance claims from freestanding ERs that were filed by policyholders of Blue Cross Blue Shield of Texas — the state’s largest health insurer — jumped 236 percent between 2012 and 2015. That outpaced the rate of claims the insurer received from both traditional hospital emergency departments and urgent care centers.

Hard bargain

Use of the facilities wasn’t the only thing to increase. The mean total price of visiting a free- standing facility, while still lower than the cost at a traditional hospital ER, is going up.

“Last year the Legislature added rules that require freestanding facilities to provide written confirmation to patients about a facility’s insurance network status. But the fact remains that stopping to ask doctors about insurance is not top of mind for patients seeking care in emergency situations, no matter which type of emergency department they rush into.” 

SOURCES: Texas Health and Human Services; Annals of Emergency Medicine

Source: State of emergency: An examination of freestanding ERs in Texas | Economic Snapshot | Dallas News

Texas must help consumers understand freestanding ERs  | Editorials | Dallas News

You probably drove by a freestanding emergency room today. Red crosses and vaguely optimistic names like “Excellence” and “Five Star” emblazon buildings all across North Texas, promising convenient emergency care with the ubiquity of a Starbucks.

But the names of these 24-hour facilities do little to clarify how they differ from the “urgent care” clinics that close early and treat only minor illnesses — or to make crystal clear that their prices still rival those of a hospital emergency room.

The state should bear more responsibility in monitoring these standalone centers and helping potential users understand them. In these instances of consumer protection, the consumers are patients and “harm” takes on a more consequential meaning.

Privately owned freestanding ERs offer little public data on their safety. Standalone clinics don’t have the multidisciplinary staff of an emergency room at a full-service hospital,  and they often call 911 for patients who need a higher level of care than they can offer on-site. Public records don’t reveal many details about those cases — just that they happen often.

No matter which type of emergency center you end up at, hospital-based or freestanding, you can bet you’ll pay.

Emergency rooms in general are overutilized, a problem that insurers are seeking ways to reduce. Earlier this year, Blue Cross Blue Shield announced a controversial move that might deny claims for ER visits later deemed as non-emergencies.  The policy’s implementation has been delayed, but it is still likely to go into effect.

Responding to concerns, Blue Cross officials specifically cited the proliferation of Texas’ freestanding emergency market as exacerbating the problem of ER overutilization. The insurer offered consumer education about what constitutes in-network vs. out-of-network care by issuing a sort of user’s guide for emergency care, called SmartER. This too was cited as a tool to help avoid the “unconscionable” prices of freestanding ERs.

The various ER options create a complicated system, and insurers can only do so much to inform consumers. A 2017 law requires freestanding ERs to post that they charge like traditional emergency rooms. That was a step in the right direction, but the terms don’t actually provide much information about the charges you’ll face — just know they will be big.

Additionally, the law didn’t receive much regulatory follow-up. A February report showed that more than six months after the bill became law, only 15 of 200 freestanding ERs had been inspected for compliance concerning their posted warnings.

Not that a posted notice will change much when you’re facing 2 a.m. chest pains.

State Rep. Tom Oliverson, R-Cypress, who introduced the 2017 bill, recently wrote to the Texas Health and Human Service Commission to urge better enforcement and more clarity. We hope he will expand his fight in the next legislative session.

There’s no denying that freestanding ERs save lives, and often do so more quickly than many hospital-based emergency rooms. But it’s precisely these lifesaving impacts that make transparency surrounding cost and safety even more important. There’s a lot at stake. The state shouldn’t look away.

Source: Texas must help consumers understand freestanding ERs  | Editorials | Dallas News

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