In 1920, professional ice hockey players began the universal use of the protective scrotal athletic cup. The use of protective head gear only became mandatory for National Hockey League players who signed their first contract after June 1, 1979. Basically it took these professionals 59 years longer to begin to recognize the need to protect their other head.
The cumulative and long-lasting effects of sports concussions have been the subject of recent heightened attention, including Congressional hearings in the United States. Since a head injury happens every 15 seconds and a patient dies of a traumatic brain injury every 12 minutes, a significant amount of research is being devoted to head trauma.
Recent research from the top Swedish professional ice hockey league on concussions offers us a potentially useful method that we, as Hospitalists and Emergency Medicine physicians, may soon be able to implement in our practice.
The calpain-derived alpha-spectrin N-terminal fragment (SNTF) is a serum protein that is present at undetectable levels in patients with healthy human brains. It is produced when neurons are traumatized and begin to die. Concussions that lead to lasting brain dysfunction cause SNTF to accumulate in long axon tracts of the brain. Its serum concentration elevation has been found to be a measure of diffuse axonal injury.
A study, published by investigators in the Journal of Neurotrauma, conducted an analysis of serum SNTF concentrations in 28 professional ice hockey players who had a concussion. Forty five other players were also evaluated during the preseason, 17 of whom were tested after a concussion-free training game.
The researchers found an increase in serum SNTF concentration in those players experiencing persisting post-concussion symptoms beginning one hour following closed head injury. This increased serum concentration of SNTF also remained significantly elevated up to 6 days post-concussion. Additionally, at 12 – 36 hours, these players’ SNTF levels differed significantly from the players with less severe concussions (p=.004).
In comparison, serum SNTF levels quickly returned to baseline in the players whose post-concussion symptoms resolved rapidly or within a few days. The players who were not concussed during training had serum SNTF levels that were found to be unchanged.
This study demonstrated that elevated blood levels of SNTF found in patients treated in the emergency room for mild traumatic brain injury (mTBI) on the day of injury predicted which subjects would go on to suffer diffuse axonal injury and long-term cognitive dysfunction. Serum SNTF concentrations exhibited diagnostic accuracy for concussion, especially so for those patients with delayed return to play decisions.
The plethora of head injuries plaguing the sports world and the community at large are of significant importance. This biomarker for axonal injury following mTBI may be a useful diagnostic tool to help guide our care, disposition and follow up recommendations for these common patient presentations. It may also be applicable in guiding neurobiologically-informed decisions related to clearance for “return to play”.
References: Siman R., et.al., Serum SNTF Increases in Concussed Professional Ice Hockey Players and Relates to the Severity of Post-Concussion Symptoms., J Neurotrauma. 2014 Nov 24. [Epub ahead of print]
The American Academy of Pediatrics (AAP) has taken a page out of the Rules of the House of God #13: THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE. New published guidelines from the AAP for the diagnosis and treatment of bronchiolitis were released in November of 2014. We should all become familiar with these as they have eliminated the majority of the armamentarium we have been using when caring for these patients.
There is a glaring omission of an important tool we have available to us that is useful for evaluating these patients. Capnography is not mentioned in the entire publication nor is it included in the Cochran reviews referenced in the guidelines. The more invasive testing of arterial PCO2 determination was also never included in the discussion.
Let’s consider how these guidelines fit into the Emergency physician’s and Hospitalist’s management of our bronchiolitis patients. These new guidelines infer that the prudent course is a simple one. However, these new guidelines lack a fundamental component in evaluating those borderline patients that require a better understanding of their pulmonary status for determining their best clinical management. Capnography is a noninvasive method of obtaining a more physiologic insight of bronchiolitis patients. It can provide details that may indicate a need for more aggressive, attentive, or individualized patient care, or simply provide reassurance for their safe discharge.
The take home message is one of the 10 commandments of emergency medicine: +(NOT EVEN YOURSELF). Use caution against blind trust in the expertise or opinions of others. Avoid inheriting someone else’s’ thinking whether it is related to diagnostic or personal bias. + These new guidelines lack a key tool for recognizing occasionally unheralded conditions that may be present in our bronchiolitis patients. This is an example of clinical guidelines that are not all encompassing and should be recognized as such.
Capnography makes sense for providing us information in these borderline cases. We should consider using this available physiologic data to augment these new guidelines of doing as much nothing as possible. It will be challenging enough to implement this new approach to our patients, and re-educate families regarding their preconceived expectations of care.
Reference: THE AMERICAN ACADEMY OF PEDIATRICS Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis, PEDIATRICS Volume 134, Number 5, November 2014 e1475
Previous studies have shown that emergency department (ED) intubation of the adult patient using GlideScope video laryngoscopy (GVL) is associated with a higher first-pass intubation success rate than direct laryngoscopy (DL). The efficacy of GVL for intubation of the pediatric patient in the ED setting is unknown.
A study abstract published in the Annals of Emergency Medicine reveals very useful considerations with the implementation to this technological marvel. The purpose of this investigation was to compare GVL to DL for emergency intubation of pediatric patients.
Of the 200 pediatric patients included in the study, 159 were intubated using DL and 41 were intubated using GVL as the initial device. The mean age of patients was 6.5 and 10.6 years in the DL and GVL groups, respectively. Unadjusted first-pass intubation success was 72% with DL and 68% with GVL. After adjusting for potential confounders such as age, sex, trauma status, reason for intubation, reason for device selection, operator experience and difficult airway characteristics, GVL was associated with decreased odds of first attempt intubation success compared to DL (p=0.035). The odds of first-pass intubation success also increased with patient age (p=0.001).
The authors concluded that in pediatric patients who undergo intubation in the ED, GVL is associated with decreased odds of first pass intubation success compared to DL. Intubation success also increases as the age of the patient increases.
What practical lessons can Emergency Medicine and Hospitalist specialists take away from this study? Don’t throw the baby out with the bathwater. Always maintain an element of skepticism
about old adages or new trends. Newer, more technologically advanced methods may not always be more efficacious. Furthermore, those of us directing our prehospital crew’s protocols should also consider this finding as a reason to encourage the field personnel to use their time-proven, trusted skills before implementing the GlideScope as a first line according to their protocols.
J.C. Sakles, J.C. et. al., Comparison of GlideScope Video Laryngoscopy to Direct Laryngoscopy for Intubation of Pediatric Patients in the Emergency Department. Annals of EM, October 2013 Volume 62, Issue 4, Supplement, Pages S75–S76
Emergency Medicine Physicians and Hospitalists have all heard the recent earth-shattering statistics about the modern world’s obesity rate. Only 36 % of Americans think they’re too heavy, even though data from the Centers for Disease Control and Prevention shows that 69 % of us are overweight or obese. Guidelines suggest that providers should intervene on patients’ weight abnormalities. To accomplish this, clinicians must first recognize that a patient may have a weight problem and weigh them.
A recently published study presented in the British Journal of General Practice examined whether general providers can identify overweight and obese body weights by sight, and if this influences whether they would discuss weight with a potential patient. Three-hundred and fifteen GPs participated by viewing 15 standardized photographs of healthy weight, overweight, and obese young males. They estimated the patients BMI, classified their weight status, and reported whether they would be likely to discuss with the patient interventions for weight loss. The study noted that GPs perceived overweight and obese weights as being of lower BMI and weight status than they actually were. This was associated with a lower intention of discussing weight management with a patient. They concluded that healthcare professionals should not rely on visual judgements when identifying patients who may benefit from weight interventions.
Interestingly, a study published in the Annals of Emergency Medicine in 2004 demonstrated that emergency medical personnel reliably estimate adult weights within 20% of actual weight; they are accurate within 10% only half the time. Patient estimates of their own weight are very accurate.
Furthermore, a study published in the Annals of Emergency Medicine in 2011 also noted that patients are much better at estimating self-weight than ED providers. ED providers are worse at estimating male patients and obese patients with BMI >30. They concluded that caution should be exercised when estimating patient weights for implementing critical weight-based medication therapies (i.e., thrombolytics). This is especially relevant when patients are unable to self-report weight due to an unstable clinical status.
The take home message is we cannot assume that the patient’s PMD has concluded that their patients are overweight or spoken to the patient about this potential health problem. We may be better suited to approach our patients about this subject. To accomplish this, clinicians must first recognize that a patient may have a weight problem and weigh them. Importantly, when faced with critical weight related decisions, physicians should consider adopting other accurate weight measures for such critically ill patients.
1. Robinson, E., et.al., Visual identification of obesity by healthcare professionals: an experimental study of trainee and qualified GPs, DOI: 10.3399/bjgp14X682285 Published 1 November 2014
2. J. Axelband et al., Can emergency personnel accurately estimate adult patient weights?, Annals of Emergency Medicine Volume 44, Issue 4, Supplement, Page S81, October 2004
3. T. Nguyen et.al., Accuracy of Patient Weight Estimations in the Emergency Department by Emergency Department Providers, Annals of Emergency Medicine Volume 58, Issue 4, Supplement, Pages S252–S253, October 2011
On October 22, 2014, the World Health Organization released its 2014 Global Tuberculosis Report, which showed that_ “9 million people developed tuberculosis (TB) in 2013 and 1.5 million died, making it one of the world’s deadliest communicable diseases.” _ To make matters worse, despite the high prevalence of this infectious disease, “companies and countries are actually cutting their investments in TB research and treatment.”
About 3.4 billion people, approximately half of the world’s population, are at risk of malaria._ In 2012, there were an estimated 207 million malaria infections, and an estimated 627,000 malaria deaths worldwide, making this one of the most serious, wide spread infectious diseases in the world._ Of note, 460,000 African children died from malaria before their fifth birthdays!
The much-publicized severe acute respiratory syndrome (SARS) is a viral respiratory disease of zoonotic origin caused by the SARS coronavirus (an RNA virus). Between November 2002 and July 2003, an outbreak of SARS in southern China caused an eventual 8,273 cases and 775 deaths reported in multiple countries.
Ebola hemorrhagic fever is a disease caused by one of five subspecies of the Ebola virus. Four of the strains can cause severe illness in humans and animals. The fifth (Reston virus) has caused illness in some animals, but not in humans. Ebola is an RNA virus that infects wild animals (fruit bats, monkeys, gorillas, chimpanzees, to name a few), as well as humans. Contact with an infected animal’s blood or body fluids is thought to be the original source of the disease. The first human outbreaks occurred in 1976 in northern Zaire (what is now the Democratic Republic of the Congo) and in southern Sudan (what is now South Sudan). The virus was named after the Ebola River in Zaire where it was presumably first discovered. According to the Centers for Disease Control and Prevention 2014 outbreak data, there have been 4555 deaths due to actual, probable or suspected cases of Ebola as of October 14, 2014
With this information in mind, what reassurances can we provide our patients when we are asked about the Ebola outbreak while performing our jobs as emergency medicine physicians and hospitalists? In short, we must put this outbreak into the proper perspective.
First, we may face questions regarding the fear that Ebola may mutate to airborne transmission as it did in the movie “Outbreak”. The virus, discovered as a human pathogen in 1976, must have been infecting humans long before that. It is likely to have been replicating for millions of years in animal reservoirs. With this in mind, Ebola has had ample opportunity to undergo mutation. Scientists have been studying viruses for over 100 years, and there is no known human virus that has ever mutated to change the mode of transmission. Examples include the RNA viruses HIV-1 Group M (the variant that infects humans) and Hepatitis C. There is no reason to believe that Ebola, also an RNA virus, is any different. Furthermore, a virus’s propensity to mutate is influenced by antiviral treatments. Ebola has not yet been confronted with any treatment that would induce it to mutate as an adaptation to said treatments.
The over publicized number of Ebola deaths can be placed in better perspective for our patients by reminding them of the infection and death rates of malaria, tuberculosis, HIV, and hepatitis C, which, when combined, number in the hundreds of millions annually. Malaria kills 138 times more people than Ebola, tuberculosis kills 329 times more. That is not to say that patients and caregivers should ignore the dangers of Ebola, and the current outbreak. One must maintain a healthy respect for this disease and manage it accordingly. Nonetheless, the facts must be placed into proper perspective and allowed to speak for themselves. We are in the right place to do just that.
Additional reference link:
A previous HPP blog brought to light the effect of malnutrition on the evaluation of an infant using the Broselow pediatric emergency tape. What about the effect of malnutrition in the elderly population? Malnutrition is not something we typically think about when our elderly patients present to our emergency departments or offices. In 2009–2010, 19.6 million emergency department (ED) visits in the United States were made by persons aged 65 and over.
A study recently published in the Annals of Emergency Medicine offers some surprising insight as to how often malnutrition should be considered as a comorbidity. Investigators sought to estimate the prevalence of malnutrition among older patients presenting to an emergency department (ED) in the southeastern United States.
The study sampled 138 patients aged 65 years and older. Among them, 16% were malnourished and 60% were either malnourished or at risk for malnutrition. The prevalence of malnutrition was higher among patients with depressive symptoms, those residing in assisted living, those with difficulty eating, and those who had difficulty buying groceries. The authors concluded that more than half of the patients studied were either malnourished or at risk for malnutrition.
The common presenting general signs and symptoms of malnutrition include cold intolerance, weakness, fatigue, lethargy, dizziness, syncope, hot flashes and sweating episodes. We all would have to concede that a significant number of our elderly patients present with these complaints as part of their chief complaint or review of systems. Additionally, it is not uncommon to encounter frequent or refractory hypoglycemia in this patient population. This condition may be exacerbated by diminished glycogen stores as a consequence of their malnutrition.
How does this finding impact our jobs as hospitalists and emergency medicine physicians? The take home message is the elderly population is at high risk for malnutrition. Its presence may contribute to their presenting complaints, and must be factored into our differential diagnoses and medical management.
1. Greg F. Pereira, G, et.al., Malnutrition Among Cognitively Intact, Noncritically Ill Older Adults in the Emergency Department .annemergmed.2014.07.018
2. Albert, M. et.al., Emergency Department Visits by Persons Aged 65 and Over: United States, 2009–2010: NCHS Data Brief, Number 130, October 2013 http://www.cdc.gov/nchs/data/databriefs/db130.htm
3. Eating Disorders in the Emergency Department, Critical Points for the Recognition and Medical Management of Individuals with Eating Disorders in the Acute Care Setting, American Academy of Eating Disorders 2012 http://feast-ed.org/Portals/0/Documents/Library/ER%20Guide%20AED_Broch.pdf
Developed in the 1980’s the Broselow Pediatric Emergency Tape is a color-coded tape measure used worldwide for pediatric emergencies. It correlates a child’s measured height to the child’s weight while providing guidelines for medication dosages, equipment sizes, and defibrillation voltages. It is designed for children up to 12 years of age with a maximum weight of 36 kg (80 lbs), and recognized as a standard of care in pediatric emergency medicine.
A recently published abstract in the Annals of Emergency Medicine sheds light on an important issue related to the use of the Broselow Tape. The study evaluated the accuracy of the Broselow Tape in an area of varying nutritional status of children in South Sudan, Africa (labeled the hungriest place on earth by the United Nations). The authors defined the largest acceptable difference between measured weight and Broselow predicted weight to be 10%.
The percent agreement between the Broselow color zones and the zone corresponding with the measured weight was just 26.6% in the adequately nourished group and only 6.1% in the severely malnourished group. The investigators discovered that the mean weight overestimation was a significant 30.2 % for the severely malnourished group, 20.6% in the moderately malnourished group, and still 16.6% in the adequately nourished group. Consequently, the majority of cases yielded overestimations of medication dosages, equipment sizes and defibrillation voltages by at least one color zone when using the Broselow system. Furthermore, overestimation by two zones ranged from 10.2 -23.6%!
As you can surmise, basing your care solely on the Broselow system in the malnourished pediatric patient can lead to significant dosage and equipment errors. Although it may seem unlikely for this to ever be an issue in the United States of America, consider the following. In 2012, approximately 22% of children in the U.S. lived in poverty. The top five states with the highest rate of food insecure children under the age of 18 were New Mexico, Mississippi, Arizona, Georgia, and Nevada.
The take home message here is to consider correlating growth and development staging on your patient when preparing to use the Broselow Tape for the acute care setting even in the USA.
1. Clark, M.C., et.al., Is the Broselow Tape Valid in South Sudan “The Hungriest Place on Earth”
A recently published study in the Annals of Emergency Medicine expounded on the patterns and predictors of whether the prescription information and services we offer at discharge improve the treatment compliance of our emergency department (ED) patients. In this study, the authors found that 88% of the nearly 4000 patients studied filled their discharge prescription. They concluded that there were no meaningful improvements achieved by offering patient-centered prescription and services.
In another study looking at the validity of self-reported prescription filling among ED patients, the authors found that self-reported prescription filling was overestimated by 16%. Reporting was more likely to be accurate if they admitted that they did not fill the prescriptions. The editor even concluded, “Something more than or in addition to this will be needed…”
We all acknowledge that the ED discharge process is inherently high-risk. Unfortunately, negative outcomes occasionally reflect on the provider with less regard to the compliance of the patient. We should introspectively look at our job performance to see how we might improve the safety of our patient dispositions. The providers’ care repertoires need to take into account the clairvoyance of this propensity for patients failing to fill their prescriptions.
What can we, as Hospitalists and Emergency Physicians, take away from the information in these studies? It is clear that the current systems in place are not getting the message through to our patients. When we speak to our patients at discharge, we need to proactively determine if they can afford the prescriptions we expect them to use. Plenty of cell phone apps are available that can instantly provide us this information. Epocrates, chief among them, is a free, downloadable app that offers useful information including costing data for most medications.
This is also the perfect opportunity to reach an understanding with our patients as to how the medications we prescribe will affect their illness and prognosis. Motivation through informed consent and collaborative agreement is the most effective way to bring the patient into partnership with the comprehensive care program. Making this a part of your discharge repertoire will help patient satisfaction soar with the physician-patient bond you will inevitably strengthen. Patient compliance will surely follow.
The quality assurance standard for Emergency Medicine Physician’s and Hospitalist’s real-time radiograph reading is achieved with radiologist’s overreads. It’s not surprising that incidental findings discovered by these experts occasionally fall through the cracks. Supplementary findings (i.e. lung nodules) are usually accompanied by a recommendation for additional follow-up imaging. The process inherently generates an onerous task for busy clinicians who are challenged to relay these recommendations for additional imaging to the patients with findings that may not be relevant to the patient’s primary evaluation. Any glitches in this process can lead to medicolegal pitfalls and diminished patient care quality.
A recently published study in the Annals of Emergency Medicine evaluated the potential of an automated detection tool for finding the radiologist’s recommendations within the medical record for additional imaging of incidental findings. They sought to validate an automated natural language processing algorithm to reliably identify recommendations for additional imaging. The authors proposed that using this innovative technology may help address the issues that exist with this quality oversight issue.
Over 3000 radiology reports (half for algorithm training and half for validation) of discharged emergency department (ED) patients were used to determine: a) the incidence of discharge-relevant recommendations for additional imaging and b) the frequency of appropriate discharge documentation of these recommendations. As the standard, they compared these results to blinded chart reviews. The authors found that discharge-relevant recommendations for additional imaging were found in 4.5% of ED radiology reports. However, 51% of discharge instructions failed to note those findings. The final natural language processing algorithm had 89% sensitivity and 98% specificity for detecting recommendations for additional imaging. Discharge-relevant recommendations for additional imaging sensitivities ultimately improved to 97%.
The authors concluded that the need for recommending additional imaging in ED discharge instructions occurs frequently and that the natural language processing algorithm’s performance provided a promising error-prevention tool.
We all acknowledge that acute care radiology reading is inherently high-risk. Imagine how helpful this algorithm could be if this technology proves effective in prompting follow-up studies on all radiologic over-reads. If the information is directed in a provider-specific format, it could be used as a real-time learning tool for the provider to learn from these additional findings. We would only have to be careful not to become complacent in failing to use the opportunity to learn from the incidental findings we missed when over-reads are brought to our attention. Trends recognized in the missed findings will also allow the provider to focus on specific areas of deficiencies in their reading skills.
To quote Alan Jackson, “Who says we can’t have it all?”
Reference: Dutta S et.al., Automated Detection Using Natural Language processing of Radiologists Recommendations for Additional Imaging of Incidental Findings, Annals of Emergency Medicine, 2013 Aug;62(2):162-9.
Hospital Physician Partners (HPP) recently received some media props in one of our newest communities, Medina, New York. We provide Emergency Medicine management and staffing services for Memorial Hospital, a 100-bed hospital in Medina. HPP recently wrote about the addition of the new contract in a news announcement in November.
HPP has been working with Memorial Hospital team members to help recruit and staff Medina’s emergency department. Emergency Medicine jobs in New York are plentiful but staffing emergency departments is an ongoing challenge across the country. HPP specializes in Emergency Medicine jobs for Emergency Medicine Physicians, Physician Assistants and Nurse Practitioners.
Emergency Medicine Physicians working during the holidays can tell you countless stories of the odd, amazing, miraculous, and marvelous. As providers of Emergency Medicine jobs for both ED physicans as well as Nurse Practitioners and Physician Assistants working in ER’s across the country, we felt it our duty to repost a story from the Thanksgiving holiday. Be forewarned, you are about to enter “bizzaro-world!”
KevinMD.com, a leading social media blog in the physician community, recently posted some of the leading stories in health and medicine from 2013 according to Medpage Today. Medpage Today is a trusted news service for physicians that provides a clinical perspective on the breaking medical news that their patients are reading.
Over the next few weeks, we will be sharing some of Hospital Physician Partners’ top news stories the year. On the clinical front, this includes Emergency Medicine physician news and Hospitalist physician news. For hospital leaders and hospital administrators, we’ll look at news related to Emergency Medicine program management Hospital Medicine program management.
Check out the latest Movers and Shakers from SHM which highlights two of HPP’s Hospital Medicine clinical leaders: Dean Dalili, MD, FHM and Robert Mickelsen, MD. Dr. Dalili is Vice President of Medical Affairs for HPP and the practicing Medical Director at Wuestoff Medical Center Rockledge. Dr. Mickelsen is the system Medical Director for Lovelace Hospitalist Services in Albuquerque, N.M. Read more about them in SHM’s latest e-newsletter.
HPP manages Hospital Medicine programs nationally providing Hospitalist jobs to Physicians, Physician Assistants and Nurse Practitioners. Click HERE to learn more about nationwide Hospitalist careers with HPP.
Hospital Physician Partners) was recently awarded two new contracts in the southeast, adding to their already strong presence in this area of the country. The Florida-based, company begins management of the Hospital Medicine Program at Gaffney Medical Center in Gaffney, SC on December 21st. On February 1, 2014, HPP will manage the Emergency Department program Southwest Mississippi Regional Medical Center in McComb, MS.
Gaffney Medical Center, part of the Novant Health System, is a 125-bed acute care facility that is less than one hour from Charlotte, NC. HPP will manage the Hospital Medicine in-patient program that currently sees 15-20 patients per day including some pediatric patients.
Southwest Mississippi Regional Medical Center designated as a Level III Trauma Center and its Emergency Department sees over 48,000 patients annually.
“Both of these programs align quite well with our business model and we have a great scope of knowledge of healthcare in Mississippi and South Carolina, having managed programs in both states for over a decade,” says Jeffrey Schillinger, HPP Chief Executive Officer. “We help hospitals improve the quality of care, enhance patient satisfaction and grow strategically. When we accomplish this, we achieve our mission of saving lives every day,” added Schillinger.
Over the past 16 months, HPP has been awarded over 25 new contracts nationwide. Most recently, HPP began oversight of the Emergency Department at Memorial Hospital in York, Pennsylvania and Knapp Medical Center in Weslaco, Texas. HPP will begin managing the Emergency Department for Medina Memorial Hospital in Medina, NY in January, 2014.
What we know about managing our jobs in Emergency Medicine and Hospitalist Medicine we learned in training, practice, or the school of hard knocks. Unfortunately, our syllabi didn’t venture into some of these salient advice side roads.
INTERVIEWING SKILLS, WHERE WAS THAT IN THE CURRICULUM?
It would help to know what to expect when you are headed into the interview for the job of your dreams. So many important career impacting skills to learn and so little time devoted to the art of being interviewed. Keen interviewing skills are the best way to determine if you’re a good fit or if they are. The land mines contained in the engrained cultures present in the institution you seek to join for your livelihood, along with the red flags that you aren’t trained to see, aren’t typically written into the job description.
The interview is a very good place to learn if this could be the last place one ever wants to work. Well-phrased interview questions can help ferret out hidden facts. There are also opportunities during the interview to save your only shot at the job you always wanted if you just know how to ask the correct questions. You’re definitely not born with the skills and tools to be the interviewer either. This lesson is best learned by not having to deal with the experience of learning how much harder it is to fire a bad resident than it is to hire one!
CAN WE LEARN SOME PEOPLE SKILLS PEOPLE?
If they can teach the importance of wearing sunscreen and how to do a craniotomy, why can’t they teach how to be skillful with handling people? Not their illnesses, their personalities. How many extra years did it take to learn that the proper evaluation and care of a child is actually achieved by treating the parent or guardian the entire time? Often, the only one needing therapy is the person that brought you the patient. In truth, some of these family members actually bring a lot of valuable information to the case. But you’ll never know that unless you get to know them while you’re entertaining the would-be patient.
WHAT IF BIG BROTHER HAS IT IN FOR YOU?
Then there is the enigmatic Data Bank, formerly the National Practitioner Data Bank (NPDB). Usually not a single “data-bank” word was uttered to us in training. Originally created by congress as a confidential information clearinghouse to improve healthcare, it was designed to help reduce healthcare fraud and abuse while protecting the naïve public. It allows authorized users, such as hospital administrators, access to collected and disclosed negative information about healthcare workers so they can effectively find out if you really were a bad guy working in the east when you “decided to move west” to practice under the same delusional pretext ostensibly with a clean slate.
When it was created, no one saw the formation of the McCarthyistic black list this animal turned into. Any ignorant or vengeful medical director can submit a permanent entry into the NPDB. No amount of complaints can force its removal if the person who filed the report followed the proper process, regardless of its accuracy. And to add salt to the wound, one must wait weeks before a rebuttal can be submitted for approval.
DIRECTIONS? WHO NEEDS DIRECTIONS?
Last, but not least, nobody taught us to read the directions, even if we didn’t intend to follow them! I have found myself terminally lost in a situation that would have been doable using the directions I never read. Unfortunately, the intuitions that I typically used to make situations like this work no longer applied to the state of affairs at hand. My kingdom for the directions!
Ultimately the lesson to be learned from all the advice that we didn’t gather before we needed it can be best summed up by an excerpt from an article entitled “Advice, Like Youth, Probably Just Wasted On The Young“ written by Mary Schmich. “Be careful whose advice that you buy, but be patient with those who supply it. Advice is a form of nostalgia. Dispensing it is a way of fishing the past from the disposal, wiping it off, painting over the ugly parts and recycling it for more than it’s worth.”
Hospital Physician Partners has transformed ED’s into community assets for more than 30 years, and is currently seeking Emergency Medicine Physicians and NPs/PAs for Medina Memorial Hospital in Medina, New York. Medina Memorial Hospital had its beginnings in 1908, when it was incorporated by a group of citizens who were interested in establishing a publicly-owned hospital. While Medina Memorial Hospital remains the hub of our community health services, growth of services outside of the acute care setting led to our name being changed to Orleans Community Health in 2009. Today, Orleans Community Health is a full-service community hospital, serving 45,000 residents with off sites in Orleans, eastern Niagara, and northern Genesee counties. It is the only full-service, acute care system in Orleans County, and is one of the largest non-government employers.
The Village of Medina is located in the towns of Shelby and Ridgeway in Orleans County, New York. Known as the “Friendly Community on the Erie Canal”, Medina offers the comfort of small town living with access to urban life with Rochester, NY and Buffalo, NY being less than an hour away. The quiet, clean and quaint Village of Medina is the perfect place to live, work, and raise a family. Medina has a low crime rate, good schools, and a friendly disposition that makes it an ideal and attractive location for anyone to live. The rich history of Medina is the first thing you will notice – beautiful old buildings, houses, and churches set Medina apart from surrounding communities. Visit Main and Center streets in Downtown Medina for a various selection of local food and beverage establishments to satisfy all your cravings!
One of the reasons you chose Emergency Medicine is because you wanted your flexibility and personal freedom and Medina, New York offers plenty of it for you to enjoy! For more information about the opportunities available at Medina Memorial Hospital, contact Josh Jeanblanc at 800-815-8377, ext. 5264.
Hollywood, Florida, November 18, 2013 – Hospital Physician Partners (HPP), one of the nation’s leaders in Emergency Department and Hospitalist Program management, has again expanded their national footprint. Over the past 90 days, the Florida-based, privately-held company has reached the furthest into the Northeast it has ever been while adding to its contract portfolio in Pennsylvania, Texas and New York
In October, HPP began its oversight of the Emergency Department at Memorial Hospital in York, PA. Memorial Hospital is a 100-bed community teaching hospital serving southeastern Pennsylvania with an annual patient volume in the emergency department of 45,000. In November, HPP took over the helm of the ED of Knapp Medical Center in Westlaco, Texas. Knapp Medical Center, serves the Mid-Valley in southeastern Texas. The 227 bed facility serves a large growing patient population in the heart of the Rio Grande Valley. HPP will begin management of the Emergency Department for Medina Memorial Hospital Medina, NY in January 2014. Medina Memorial Hospital is part of Orleans Community Health serving approximately 45,000 residents in the region.
“We continue to seek business opportunity where we can help hospitals improve the quality of care, enhance patient satisfaction and grow strategically as a company,” said Jeffrey Schillinger, HPP Chief Executive Officer. “Our expansion into the northeast is a positive step in that direction and allows us to demonstrate our capabilities to a yet untapped market for us,” Schillinger added.
HPP has been growing their emergency department and Hospitalist Medicine business lines steadily with expansions in Mississippi, Oklahoma, New Mexico, Arkansas, Florida, and Washington.
Emergency Medicine Jobs in Kentucky, Hospital Physician Partners (HPP) has a number of opportunities available for the right candidates who love Emergency Medicine and are Board Certified or Board Eligible in Emergency Medicine, Internal Medicine or Family Practice Medicine.
The “Bluegrass State” is abound with great landscapes, outdoor life, terrific communities and rich history. This week and weekend (November 14-16), the Kentucky Academy of Family Physicians (KAFP) will hold its annual meeting in Lexington and HPP will be there with you. State conferences, especially annual conferences, can present challenges to physician recruitment and staffing companies such as ours.
We know that ED clinicians such as yourself attend these meetings to get CME, network with your peers, and stay up to date on new laws and legislation affecting you in your state. No doubt, healthcare reform in Kentucky will be on a lot of your minds. While Hospital Physician Partners doesn’t have the answers, we will have some bright stars of our company on hand to meet you in the event you are in career search mode or possibly considering a change in the future.
Learn about our opportunities in Kentucky for Emergency Medicine physicians. Leslie Stockton, RN is our Kentucky Recruiter and a lifelong KY resident. Leslie is also an ER nurse who understands the field of Emergency Medicine and has worked statewide. Joining Leslie is HPP’s Residency Recruiter Toni Corleto will be attending. Toni is a dynamo of energy who can share the HP story with you. She will also be joined by Dr. Bart Francis, Regional VP Medical Affairs for Hospital Physician Partners covering the Appalachian Regional Healthcare System in Kentucky and West Virginia. Dr. Francis is a practicing ER physician who is also the Medical Director at Hazard ARH Regional Medical Center.
View more details about the event on our events page.
Hospital Physician Partners has transformed ED’s into community assets for more than 30 years, and is currently seeking an Emergency Medicine Director and staff physicians for Memorial Hospital in York, Pennsylvania. Memorial Hospital is a 100-bed community teaching hospital serving the York community for more than 65 years.
York is the home of the cultural and recreational resources of a large city and the sense of community, charm, and affordability of a small town. Located in the heart of south central Pennsylvania and just north of the Mason-Dixon Line, York is a geographic, historic, and cultural crossroads of the east coast. Forty percent of North America’s population is within a four-hour drive. With a gradually growing population of over 40,000 people within 5.2 square miles, York is proud to be the county seat of one of the fastest growing counties in Pennsylvania. In York you can find downtown farmer’s markets, parks, a premier performing arts center, a liberal arts college and university, museums, a symphony orchestra, plus downtown access to a 42-mile nature and jogging trail, and more.
One of the reasons you chose Emergency Medicine is because you wanted your flexibility and personal freedom and York, Pennsylvania offers plenty of it for you to enjoy! For more information about the opportunities available at Memorial Hospital, contact Craig Bleiler at 800-815-8377, ext. 5352.
The modern holiday of Halloween is renowned for trick-or-treating and frightening fun. But the superstitions associated with this holiday date back at least 11 centuries to the Gaelic seasonal Festival of the Dead (aka. the Samhain). Samhain was believed to be a time when the ‘door’ to the underworld opened enough for the dead to communicate with us. Families of the dead would leave treats for their dearly departed to dispirit tricks from being offered back from beyond the grave.
Superstitions are a part of our lives and have been known to permeate our jobs in Emergency Medicine and Hospital Medicine. For the superstitious, there are days in the year like Halloween which are believed to be best served as far from our workplace as is possible.
You are likely all aware of more than a few irrational beliefs slithering indolently within the hospital’s bowels. The full moon has often held the responsibility for bad nights in the hospital acute care setting. I’ve heard it sarcastically said that there is nothing like a hot, humid, summer night with a full moon to bring out the best in our inner-city community emergency departments. When the department is uncannily devoid of patients, using the ‘Q’ word (short for the word quiet) is forbidden unless you are looking to set a new record for patients seen per hour. Forget trends, metrics and statistics. Everyone knows if you have a slow night, the next night you’re doomed to get your tail kicked in. It’s like déjà vu all over again.
The Halloween curse has even shrouded my home. Kids are pretty intuitive and must know something I don’t because on the eve of all hallows they are all afraid of my “haunted house”. They’re so scared I have to ride around the neighborhood that night asking for trick-or-treaters to come up to our street. In all fairness to the entire subject, some of us are not working shifts with golden horseshoe suppositories; (which is maybe I am on the list of closet superstitious people). I believe I’m living proof that superstition is an inevitable consequence of being a victim of the scientific principal of Halloween night Pavlovian training. Happy Halloween!
One of our most important patient management jobs as Hospitalists and Emergency Medicine physicians is to create medical records that are accurate, reliable, and complete. The universal implementation of the electronic medical record (EMR) promises to do just that. It has the potential to make a lot of things better. But as far as I can tell, only a few people that have used EMRs to this point actually have found that utopia!
Just imagine however, how sad we all will be when the EMR universally eliminates the dictation transcription errors like these, (which may look familiar as I presented some of them in a previous blog)*.
- “Patient has left her white blood cells at another hospital.“
- “She has no rigors or shaking chills, but her husband states she was very hot in bed last night.“
- “Rectal examination revealed a normal size thyroid.“
- “She stated that she had been constipated for most of her life until she got a divorce.“
- “Examination of genitalia reveals that he is circus sized.“
- “Large brown stool ambulating in the hall.“
- “Between you and me, we ought to be able to get this lady pregnant.“
If these examples didn’t convince you that you are going to be missing out on a lot with the institution of the universal EMRs, I’ll share a few real-life experiences that should make you a believer. None of these situations kept me from providing proper care for the patients, but they weren’t reminiscent of the peace and serenity of a stress-free lifestyle either.
- There was the chest pain patient who looked like hell, had a left bundle branch block on ECG and the cardiologist was reluctant to come in without my first referencing an OLD ECG. When I tried to get copies of his old ECGs I was told that those records were mistakenly archived last week and they could not be accessed until next Tuesday afternoon.
- I will not miss the inability to access my acutely ill, severely mentally disabled patient’s old chart in medical records because the medical record department was closed. The medical records person did not have a home or cell phone and had gone home for the weekend, taking the only set of keys to medical records with her.
- Then there is the time that the medical records were unavailable for my same-day discharged from inpatient, bounce-back, comatose ED patient. It turned out that the patient’s attending physician took the entire medical record with him when he left earlier that night on a 19 hour flight to the Orient.
One’s life is not complete until the medical records person decides to take a box of medical records home so he can get caught up. Contained in this box just happen to be the patients’ records for my newly unresponsive, pediatric, developmentally delayed, 72-hour bounce-back to the Emergency Department(ED).
- And lastly, picture yourself being this patient. She decided to fire her doctor for sending her home from the hospital two days prior because she still felt really sick. She went to medical records and brought home what she thought was a copy of her medical records to bring to her new PMD for out-patient follow up next week. Unfortunately medical records actually gave her the originals. The following evening she returns to the ED in septic shock via EMS. There were no copies of her records in the hospital and EMS did not know to bring them with her when they transported her.
Please don’t mistake me as a frothing fan of EMRs just yet. I’ve been doing this too long to make that blunder. EMRs are under the continuous process of being reworked to allow us to efficiently ‘paint a picture of our patient in time’. The good news; when that is accomplished it will then provide us an easily accessible, and legible patient record. These can then be accessed by any qualified professional, which will facilitate better-informed and potentially cost-saving patient care decisions. You will also have the real-time power at your fingertips to prevent medical record errors that make the difference between a chart’s credibility and laughability. As disappointing as it may seem, EMRs can give you the power to make the “Dictated But Not Read” follies that rapidly go viral on the internet a thing of the past!
* Statement highlights extracted from patient records at the National Health Services, United Kingdom, and published in the Wall Street Journal.
When seeking Hospital Medicine and Emergency Medicine leaders at HPP, we always look within our organization and existing contracts/states first. Such is the case with the addition of two new team members in our Hospitalist division. HPP promoted Dean Dalili, MD, FHM recently to Vice President of Medical Affairs. Dr. Dalili has worked with HPP since 2011 and has demonstrated outstanding leadership and management.
We also recently hired Robert B. Mickelsen, MD as System Medical Director for Lovelace Hospitalist Services in Albuquerque, New Mexico. Dr. Mickelsen is a veteran clinical leader in New Mexico. He attended the University of NM School of Medicine and also completed his Internal Medicine residency at the University of NM. Most recently, Dr. Mickelsen served as Hospitalist Medical Director at Gerald Champion Regional Medical Center in Alamogordo, NM and Assistant Professor of Internal Medicine at UNMH/VAMC.
Looking within for great leadership is directly in line with HPP’s Core Values represents our commitment to hire, cultivate, promote, and retain the very best talent.
We continue to face the pitfalls of making correct patient dispositions while performing our jobs as Emergency Medicine physicians and Hospitalists. One approach has been with the use of quality metrics. A well-established emergency department (ED) metric is monitoring 72-hour returns, so-called bounce-backs. This metric has validity for maintaining patient safety and monitoring quality of care.
A recently published study in the Annals of Emergency Medicine has explored one aspect addressing ED bounce-backs. The study’s objective was to identify the patients that were hospitalized shortly after ED discharge. They hoped that this may reveal opportunities to improve ED or follow-up care. It also identified hospital and visit-level predictors of bounce-back admissions that they defined as unscheduled hospital admissions within 7 days after ED discharge.
This retrospective cohort analytical study reviewed over 5 million visits to 288 facilities in 2007. Bounce-back admission occurred in 2.6% of the visits. They found a positive association with Medicaid or Medicare insurance and, not surprisingly, the disposition of leaving against medical advice or before the evaluation was complete. They also discovered that the 3 most common ED discharge diagnoses associated with a bounce-back admission were chronic renal disease, end-stage renal disease, and congestive heart failure. Hospital characteristics associated with a higher bounce-back admission rate were for-profit status and teaching affiliations.
The authors identified these vulnerable populations as being particularly at risk and recommended that quality improvement efforts should focus on high-risk individuals as well as that of the disposition plan of patients considered to be members of vulnerable populations.
Hospital Physician Partners has a well-established, self-designed safety metric to provide oversight on ED discharges called ‘Risk Target Admission Rates’. This study offers research-based findings that suggest how we can proactively address the most appropriate disposition of these patient populations as well as rationally confront the resistance to admit these high risk cases. This can aid in improving the performance on this important metric while simultaneously improving patient care and patient safety by potentially decreasing bounce-backs to your hospitals.
References; Gbayan, G. et al., Factors Associated With Short-Term Bounce-Back Admissions After Emergency Department Discharge, Annals of Emergency Medicine Volume 62, Issue 2, Pages 136-144.e1, August 2013
Occasionally there is a topic that is presented in the literature which reminds us that some of the processes we hold as truths in diagnostic studies are not always perfect truths. Supine computed tomography (CT) and magnetic resonance imaging (MRI) are modalities we as Emergency Medicine Physicians and Hospitalists regularly rely on as standards for injury assessment of the spine. So much so that we often forge standard radiographs and disregard the physiologic effects of position in lieu of these studies.
A recently published study pointed to another value of positional radiography in the evaluation of C-spine stability. The authors described four cases in which unstable C4-C5 or C5-C6 injuries were missed by supine radiographs, supine computed tomography (CT) and/or magnetic resonance imaging (MRI). Subsequently, at a later date unstable cervical spine injuries were found that were only demonstrated on erect radiographs. CT and/or MRI identified bony injuries that were present but failed to make a definitive assessment of the stability of the cervical spine. The authors concluded; “The controlled use of erect radiographs to test for clinical instability in cervical spine injuries should be considered except in cases in which instability is already evident on other imaging modalities and/or surgical treatment is already indicated.”
What we can take away from this study is that the seldom considered effects of physiological loading on radiographic findings may need to be factored into the process of clearing patients with cervical spine injuries. This is not going to radically change any of our practice management patterns as hospitalists or emergency medicine specialists. But it does remind us that the human bodies’ structure and function are intimately related and this principal must remain an integral part of the thought process in the evaluation and treatment of our patients.
References: Erect Radiographs to Assess Clinical Instability in Patients with Blunt Cervical Spine Trauma Simon Humphry, et.al., J Bone Joint Surg Am, 2012 Dec 05;94(23):e174 1-4. doi: 10.2106/JBJS.K.01502
At Hospital Physician Partners (HPP), we practice Emergency Medicine and Hospital Medicine nationally in more than 20 states and over 100 hospitals. Recently, our scope briefly expanded to Haiti as our President and Chief Medical Officer, Dr. David Schillinger and two of HPP’s Senior Vice President’s of Medical Affairs, Dr. Andy Pacos and LaMon Norton, RN, MSN, FNP, completed a mission trip. The following is a reflection on the experience as shared by LaMon Norton, RN, MSN, FNP.
Pictured l to r: Dr. Schillinger, LaMon Norton RN, MSN, FNP, Dr. Pacos
Many of us started in medicine or nursing to “make a difference” or to “help people.” Some of us were legacies into the medical service, but learned of the originating antecedent motivation from stories or observed experiences. HPP was offered the opportunity to partner with a medical mission group early in 2013. Eagerness would be an understatement to describe the mood and emotion associated with our trip. Anxiety was another ready companion. I had no worries about security and safety, though I was assured by many others we should be concerned. But I was unsure what kinds of diseases and injuries would we be called upon to treat? What kinds of supplies and process would be involved? Our partner and guiding physician was quick to assure us that security was not a big problem, advise on immunization precautions and malarial prophylaxis, and alleviate some of the anticipatory angst in describing some common endemic presentations. I elected to obtain and bring with us a small supply of injectable Rocephin and Toradol, thinking they might have some use. Another provider brought some sutures and kit material. Both of these would turn out to be most fortuitous to have in our bag of tricks. I was not prescient enough to bring needles or syringes (I may not be very bright, but I AM teachable!). I won’t make that mistake again.
Our target destination was a remaining tent city kind of camp in Port Au Prince. Travel in the city was accomplished by a locally hired van on streets that were more like dirt roads with potholes, rocks, piles of debris that would be made into cement or impromptu walls and barriers.
Tent city camp in Port Au Prince and the “Waiting room”
The morning we arrived was spent setting up inside a worn tented structure. Privacy was absent. Four providers and three benches. Two of us shared a bench, but we each had our own translator. The pharmacy consisted of two long tables and literally piles of donated medicines; piled by type of problem to be treated and therapeutic group. An intake desk is set up to register and triage patients and notecards are used as charts. Each patient is evaluated and attempts are made to place the sickest patients at the head of the waiting chairs. The cacophony can be very disruptive to the examination process and the majority of the waiting crowd is held at bay outdoors.
The “Pharmacy” and patient treatment “room”
Many of the patients are as well as can be expected in the circumstances and come seeking minor medications and reassurances, but some have bona fide medical issues and a few have critical issues requiring immediate care. Both the ability to examine and medication selection were limiting factors. We may not have practiced standard of care medicine, but it was GOOD medicine. Hypertension, vaginal discharge and cough were common. Malnutrition and intestinal parasites are endemic from contaminated water and frequently the same sources are used for washing and personal consumption. One elderly woman had journeyed three hours into the city because she heard the doctors were coming to the tent city. The patients are usually very orderly and appreciative and always present themselves in their sole set of Sunday-best clothes. The experience in Haiti is a humbling one because exposure, comparison and reference inevitably result in a recalibration of American values and priorities. This provider was reminded anew how easy American life is in comparison to SO many others. I can’t wait to go again.
While doing our jobs as Hospitalists and Emergency Department physicians, we frequently get exposed to incidental radiation working with our patients. A patient receiving a CT scan of the head will get 2 mSv and a CT of the abdomen receives 8 mSv. Additionally, we occasionally find ourselves in the position to receive our own doses of radiation while caring for our patients. Now for perspective, a jetliner pilot receives 5 mSv/year. A radiologic technologist in a hospital is allowed 50 mSv/year and their life-time permissible dose is calculated by the formula: (Your age – 18) x 5 in REMs (where 1 rem = 10 mSv)
There was a study performed in 1989 that evaluated the potential hazard of ionizing radiation exposure to health care workers who routinely stabilize the necks of trauma patients during cervical spine radiography. A clinical trauma model was developed to simulate an actual patient with radiation monitors placed where a health care worker’s exposed anatomy would be located. Standard cervical spine radiographs were taken. The mean exposure to the finger for a single cross-table lateral radiograph was 1.74 mSv. For a single cervical spine series consisting of lateral, antero-posterior, odontoid, and swimmer’s views, the total mean measured exposure to the finger nearest the radiographic tube was 6.81 mSv and the exposure to the finger of the opposite hand was 2.30 mSv. Under the assumption that the simulated exposures were comparable to actual exposures, a health care worker holding the head of a trauma patient 4 times a week would receive over twice the maximum allowable annual occupational radiation exposure to the extremities alone! The authors of the study concluded that health care workers who stabilize the necks of trauma patients during cervical spine radiography may sustain a radiation exposure risk. Hand shielding dramatically reduces these exposures.
Remember, radiation exposure is inversely proportional to the square of the distance from the source. So, standing 6 feet from the source, you would receive 1/36th of the dose compared to the dose at the source. The “rule of thumb” for personnel who are within 6 feet of the primary x-ray beam, is that they should wear leaded aprons when a portable x ray is taken. Radiation levels at distances over 6 feet are low and do not require additional shielding.
But if you think your job is placing you at risk or if you were planning to be a flight surgeon for NASA, try this on for size. An astronaut on the international space station is exposed to 200 mSv/year. The recently launched Mars Science Laboratory had a Radiation Assessment Detector (RAD) on board. It found that a passenger traveling to mars would receive a radiation exposure of 1.84mSv/day, plus 24.7 mSv from five solar events during the journey, PLUS 662.4 mSv from galactic cosmic rays. (Who needs LED lights if you have these guys with you in a dark room?)
From a health-impact standpoint, a 360 day round trip to mars translates to an increased risk for fatal cancer in males by 4% and females risk by about 5%. Compared to that, what are a few c-spine x-rays amongst friends?
Singer CM, et al. Exposure of Emergency Medicine Personnel to Ionizing Radiation During Cervical Spine Radiography. Ann Emerg Med. 1989 Aug;18(8):822-5.
Hospital Physician Partners is assuming the management and staffing of eight Emergency Department programs in Mississippi over the next 60 days. Thus, we are featuring these contracts over the next few months in a Blog series called “Magic In Mississippi.” In this series, we explore some of the more aesthetic sides of these opportunities. Next up, Gilmore Memorial Regional Medical Center in Amory, MS.
Located just a short drive from the recreational and entertainment attractions in Tupelo (Birthplace of Elvis) and Oxford, MS (27 mins), Amory blends the charm of quiet country life and small town Main Street with social, artistic, and educational opportunities for citizens of all ages. Through the efforts of organizations such as the Gilmore Memorial Regional Medical Center, The Gilmore Foundation, local school systems, various non-profit organizations, as well as many other individual and business projects, citizens can experience great innovations in health care, education, artistic endeavors, state-of-the-art communication, and industrial technology. Antique stores, old-fashioned barber shops, New Age spas, hair salons, modern designs in fashion for both home and clothing, home-town cooking, international and gourmet cuisine, home and garden shops, and much more are all within a small radius.
One of the reasons you chose Emergency Medicine is because you wanted your flexibility and personal freedom and Amory, Mississippi offers plenty of it for you to enjoy! For more information about the opportunities available at Gilmore Memorial Regional Medical Center, contact Christina Plain at 800-815-8377, ext. 5295.
We all know that feeding our patients in the emergency department (ED) is one way of getting them to come back to see us. Occasionally they even return for their daily three squares. Even though it is a two edge sword, the treatment of chronic alcoholic withdrawal includes feeding the patient to help prevent alcoholic ketoacidosis (AKA) as this condition is related with a high morbidity and mortality rate. One study indicated ketoacidosis was present in 25% of alcoholics brought to the ED and it is estimated that 10% of deaths in alcoholics are due to AKA.
With the current rate of patients being brought to the ED for acute alcohol intoxication we as Hospitalists and Emergency Medicine Physicians must find ways to get these patients safe for discharge after ruling out an EMC. Since these patients contribute to over-crowding in the department, we could all use an extra trick to more expeditiously get these patients ETOH levels down to an acceptable level. The current methods available such as hydration, followed by the tried and true “sit on them and wait”, is one of the mainstays of management unless we can find a responsible party to take them home. Included in this process, we often need to document a serum alcohol level to support a sobriety level safe for discharge… (And the practice of diluting the serum sample we send to the lab is still considered unethical.)
Recent research suggests there is a specific food-induced effect on the activity of alcohol metabolizing enzymes in intoxicated patients. With that in mind a recent study was published in the Annals of Emergency Medicine abstract to determine the effect of eating a meal on the rate of ethanol elimination from blood over a 4 hour time period. The investigators enrolled 26 subjects of which 96% were male. The mean length of stay was 9 hours! The average ETOH level was 326 mg/dl. Subjects were given a meal as soon as they were able to feed themselves. Comparison of mean alcohol elimination rates (AER) before eating and 2 hours after eating showed that food increased the elimination rate by 86%. Unfortunately the 4 hour AER returned to pre-consumption levels. They concluded that food intake temporarily but dramatically increased clearance of ethanol. This finding was supported by a previous study which found that the AER showed a significant average 45% increase following a meal, regardless of food composition, compared with AER in patients that were monitored while fasting.
Studies have indicated that the food effect is not due to specific interactions with what type of food they are provided. The postulated mechanisms for the increased AER include food-induced increases in hepatic blood flow and in the activity of alcohol-metabolizing enzymes.
There is an experimental alcohol antagonist that competes with and antagonizes the actions of low to moderate concentrations of alcohol. Essentially this represents a potential competitive receptor treatment that may mediate some of alcohols effects. However, until the FDA offers us a nonreversible competitive ethanol receptor site inhibitor that can be used to safely sober our patients up, feeding our acute alcohol intoxicated patients when feasible is a start!
Jones, J.S. et al., Effect of High-Carbohydrate Meals on the Rate of Ethanol Metabolism, Annals of Emergency Medicine, Volume 60, Issue 4, Supplement, Pages S125-S126, October 2012
Ramchandani VA Effect of food and food composition on alcohol elimination rates in healthy men and women. J Clin Pharmacol. 2001 Dec;41(12):1345-50.
Paul, S., Alcohol-sensitive GABA Receptors and Alcohol Antagonists, Proceedings of the National Academy Science May 30, 2006 vol. 103 no. 22
Hospital Physician Partners is assuming the management and staffing of eight Emergency Department programs in Mississippi over the next 60 days. Thus, we are featuring these contracts over the next few months in a Blog series called “Magic In Mississippi.” In this series, we explore some of the more aesthetic sides of these opportunities. Next up, Madison River Oaks Medical Center in Canton, MS.
Located about 10 miles from Barnett Reservoir and the Natchez Trace, Canton is the perfect stop for the equine and nature enthusiast. The Multipurpose & Equine Center offers overnight stables and a variety of year-round events. At milepost 114.9 of the Natchez Trace Parkway, access can be gained from the Highway 43 trailhead to a 24 mile trail used for horseback riding and hiking that passes through a variety of areas of historical significance and natural beauty. The Reservoir and the Pearl River offer opportunities to enjoy canoeing, swimming, fishing and boating. Annual activities include the Championship Hot Air Balloon Race, Victorian Christmas Festival and the Gospel Fest Homecoming.
One of the reasons you chose Emergency Medicine is because you wanted your flexibility and personal freedom and Canton, Mississippi offers plenty of it for you to enjoy! For more information about the opportunities available at Madison River Oaks Medical Center, contact Christina Plain at 800-815-8377, ext. 5295.
Hospital Physician Partners is assuming the management and staffing of eight Emergency Department programs in Mississippi over the next 60 days. Thus, we are featuring these contracts over the next few months in a Blog series called “Magic In Mississippi.” In this series, we explore some of the more aesthetic sides of these opportunities. Next up, Natchez Community Hospital in Natchez, MS.
Natchez has a vast amount of diverse year-round events. Some of the area’s best wildlife watching, including superb birding and alligator sighting, can be found at the Bayou Cocodrie National Wildlife Refuge and St. Catherine Creek National Wildlife Refuge. For the adventure seeking individuals, during the 3rd week of October, enjoy the Great Mississippi River Balloon Race, voted Best Festival in Mississippi, a hot air balloon race and world renowned musical acts. For individuals seeking a laid back setting, take part in the most anticipated three-day event in Natchez at the Food & Wine Festival offering terrific wine and cheese tastings. Explore the Native American culture events for the family such as the Krewe of Indians Mardi Gras Parade and the Krewe of Phoenix Mardi Gras Parade. Visit the Natchez Pilgrimage, where you can tour some of the area’s best-preserved mansions and estates in the nation.
One of the reasons you chose Emergency Medicine is because you wanted your flexibility and personal freedom and Natchez, Mississippi offers plenty of it for you to enjoy! For more information about the opportunities available at Natchez Community Hospital, contact Christina Plain at 800-815-8377, ext. 5295.
Hospital Physician Partners is assuming the management and staffing of eight Emergency Department programs in Mississippi over the next 60 days. Thus, we are featuring these contracts over the next few months in a Blog series called “Magic In Mississippi.” In this series, we explore some of the more aesthetic sides of these opportunities. Next up, Northwest Mississippi Regional Medical Center in Clarksdale, MS.
Clarksdale is full of numerous exciting music festivals. The Friday at the Stage is a weekly concert series held each spring in downtown Clarksdale. Enjoy entertainment to another level at The Sunflower River Blues & Gospel Festival, held annually in August which features live entertainment by America’s blues legends. The three-day event is held on Blues Alley in downtown Clarksdale and features workshops which focus on the life and work of individual Delta blues artists. For the more tranquil events, visit the Delta State University’s Bologna Performing Arts Center, an entertainment calendar filled with world-class performances ranging from the best of theatre, dance, and music. Memphis Tennessee is located just hour away where residents may enjoy professional and major college sports, upscale dining, live blues events, and nationally known barbecue lining at Beale Street.
One of the reasons you chose Emergency Medicine is because you wanted your flexibility and personal freedom and Clarksdale, Mississippi offers plenty of it for you to enjoy! For more information about the opportunities available at Northwest Mississippi Regional Medical Center, contact Christina Plain at 800-815-8377, ext. 5295.
Hospital Physician Partners is assuming the management and staffing of eight Emergency Department programs in Mississippi over the next 60 days. Thus, we are featuring these contracts over the next few months in a Blog series called “Magic In Mississippi.” In this series, we explore some of the more aesthetic sides of these opportunities. Next up, Tri-Lakes Medical Center in Batesville, MS.
Located in northwestern Mississippi, Batesville is made up of diverse communities, and industries offering unlimited opportunities to America’s Fertile Crescent, the Delta. Recreation opportunities abound at places like John W. Kyle State Park at Sardis Reservoir, and George Payne Cossar State Park at Enid Reservoir. Golf, water sports, fishing and hunting is enjoyed throughout the County. Health care facilities, thriving businesses, competitive educational institutions, and numerous civic organizations offer advance services to individuals rooted in Panola County and attract travelers in search of a vibrant and healthy community.
One of the reasons you chose Emergency Medicine is because you wanted your flexibility and personal freedom and Batesville, Mississippi offers plenty of it for you to enjoy! For more information about the opportunities available at Tri-Lakes Medical Center, contact Christina Plain at 800-815-8377, ext. 5295.
We are all aware that the total number of visits to emergency departments (EDs) has increased while the total number of emergency departments (ED) in the United States has declined. In fulfilling our jobs as Hospitalists and Emergency Medicine practitioners we have first-hand experience with the resultant overcrowding, delays in treatment, patient dissatisfaction, and potential for worse clinical outcomes. Here’s a perspective worth looking at.
A new study published in the Annals of Emergency Medicine has evaluated the effect of ED overcrowding on outcomes of admitted patients using a somewhat different vantage point. Typically overcrowding is measured as a metric of ED patient census, patient length of stay, and various ED patient registration parameters. In this study, the investigators instead used a statistically normalized value of ambulance ED diversion hours on the day of admission from the ED. They defined ambulance diversion as occurring when “ED staff can no longer safely care for new patients” and thereby divert these patients to another facility. The investigators used retrospective evaluation of nearly a million patients admitted from the ED to see if there was any effect of ED crowding on inpatient mortality, hospital length of stay and costs.
They found that patients who were admitted on days with high ED crowding had a 5% greater odd of sustaining inpatient death! Furthermore there was nearly a 1% increase in length of stay and a 1% increase in costs per admission. Additional sensitivity analyses yielded up to 9% greater odd of in-hospital death within 3 days for those admitted during diversion times.
While the investigators admit ambulance diversion may be an imperfect measure of ED overcrowding and represent a potential limitation to the studies’ sensitivity, they site contemporary peer reviewed published studies that support the use of this parameter for assessing ED crowding. In spite of the data being obtained from a somewhat less common information source, the study is capable of demonstrating that ED overcrowding is associated with increases in patient mortality, length of stay and costs. This strengthens the arguments to eliminate ED boarding which also has also been associated with poor patient satisfaction when compared to boarding in in-patient ward hallways.
This information can be part of any persuasive argument with ‘those accountable’ to compel them to make changes that prevent ED overcrowding and boarding thereby eliminating this unwanted, costly and potentially dangerous practice plaguing our EDs.
References: 1. Benjamin , S. et.al., Effect of Emergency Department Crowding on Outcomes of Admitted Patients, Annals of Emergency Medicine Vol 61 No 6 : June 2013 P 605- 611
Hospitalists and Emergency Medicine specialists have patients that present for care, speaking a language with which they are not fluent enough to obtain an adequate history or safely define their problem. A recently published study in the Annals of Emergency Medicine broadens the scope of concern for the problem to include the triage person and ultimately, patient satisfaction.
This study’s goal was to evaluate the language discordance as reported by both the patient and the triage nurse and to see if it had effect on door-to-room time or patient satisfaction in the triage setting. Seventy five patients completed a survey of which slightly less than half identified themselves as English speaking. The study found that triage nurses somewhat overestimated their patients’ English speaking skills. Furthermore, for the 32 patients who identified themselves as speaking Spanish or mostly Spanish, an unlicensed translator was used in only seven encounters, a printed translation tool was used in two encounters, and a language line was used in one interaction.
Patients speaking Spanish and mostly Spanish felt less well understood by the triage nurse. There was a trend for these patients to also report feeling less satisfied with the triage process. (a median score of 4 versus 5). However, there were no differences in triage acuity level or time-to-room between the groups.
The investigators concluded that triage nurses underestimate of the language barrier may not offer the translation services deemed to be the standard of care as compared to their English speaking counterparts. They noted that most patients are still relatively satisfied with their triage experience.
This study did not evaluate if there were any retrospective errors in the triage categorization of these patients. Considering the importance of the history in the clinical evaluation of these patients, this is some useful information provided in this study we should factor into the equation when working with these patients. The finding that there was no difference in triage acuity level or time-to-room between the groups is perhaps an effect of the lack of procurement of translation services during the triage process. Though this study shows some insight into some nuances of the areas affecting patient satisfaction, the concern for standard of care in the evaluation of these patients may be a more compelling reason to address this issue formally in our work environments.
Reference: K. Cossey, R. Jeanmonod, Impact of Language Discordance on Door-to-Room Time and Patient Satisfaction in Triage Annals of Emergency Medicine Volume 60, Issue 4, Supplement, Pages S113-S114, October 2012
According to a report from the US Centers for Disease Control and Prevention, every year, one in five Americans makes at least one trip to the emergency department (ED). They also revealed that children and adults with Medicaid coverage were more likely than uninsured Americans and those with private insurance to make at least one visit to the ED. According to the Department of Health and Human Services, the percentage of Americans visiting the ED each year is stable. However, the total number of visits to EDs increased 34% between 1995 and 2010. Compounding the problem, the total number of ED facilities available for offering emergency care in the United States has declined by about 11%. This is resulting in overcrowding, delays in treatment, patient dissatisfaction, and worse outcomes.
Hospital Physician Partners continues to offer improved comprehensive programs committed to enhancing professional skills in the administration of patient care. Our fully accredited on-line CME training is expanding prolifically to address the ever changing requirements for physician licensure. There is a consistent commitment for individualized, personal attention focused on improving physician performance, ED management and efficiency. This approach is leading the way to handling these challenging aspects we face in the world of patient care while improving the job we do as Hospitalists and Emergency Medicine Physicians.
Hospital Physician Partners is assuming the management and staffing of eight Emergency Department programs in Mississippi over the next 60 days. Thus, we are featuring these contracts over the next few months in a Blog series called “Magic In Mississippi.” In this series, we explore some of the more aesthetic sides of these opportunities. Next up, Central Mississippi Medical Center in Jackson: “City with Soul!”
The city of Jackson is Mississippi’s largest city, and also its most treasured. The slogan for Jackson, Mississippi is “City with Soul.” Jackson is ranked 3rd out of America’s 100 largest metro areas for the best “Bang for Your Buck” city according to Forbes magazine.
Jackson offers a full range of entertainment activities for all ages! Experience the cheers of the crowd at the Mississippi Sports Hall of Fame and Museum – named among the Top 10 “Most Amazing Baseball Museums in America” by ESPN. Take the kids to see the enchanting animals at the Jackson Zoological Park. Learn about the wonders of nature at the Mississippi Museum of Natural Science. See a memorable performance by the world-class Mississippi Symphony Orchestra, or grab a drink and a bite to eat at an authentic blues “juke joint.”
One of the reasons you chose Emergency Medicine is because you wanted your flexibility and personal freedom and Jackson, Mississippi offers plenty of it for you to enjoy! For more information about the opportunities available at Central Mississippi Medical Center, contact Christina Plain at 800-815-8377, ext. 5295.
We all enjoy positive reinforcement, don’t we? A recently published abstract in the Annals of Emergency Medicine has just done that for an innovative process Hospital Physicians Partners (HPP) uses to improve patient satisfaction in the Emergency Department.
The study’s objective was to quantitate the reduction in formal complaints by emergency department patients using a real time patient satisfaction survey tool and provider-driven service recovery. This was performed with a third party surveyor using a nine question survey taken in real time. One of the questions specifically asked if the patent he/she had any concerns about their care. After the survey was administered, the surveyor would notify the provider of any concerns.
With an N of 5969, the survey found a 5.6% complaint rate regarding the care these patients received. The surveyor notified the provider only 53.4%% of the time, for reasons not well established in the document. The provider returned to the patients’ room to address the patients concerns 74.2% of the time. 2.9% of these patients filed a complaint with the hospital after patient discharge. Of the 54 instances when the provider failed to return to the room to address the patient concerns, 22.2% OF THESE PATIENTS SUBSEQUENTLY FILED A FORMAL COMPLAINT WITH THE HOSPITAL.
The investigators concluded that they showed an 87% reduction in the number of formal complaints made by patients, demonstrating the value of service recovery before patient discharge. They added that this also served to reduce costs of handling the complaints by $900.00/patient complaint. This study reiterates the well-established precept that service recovery opportunities have a profound effect on patient satisfaction.
Though this study looks at its data from a slightly different perspective than an overall change in patient satisfaction percent, it supports the survey recovery process that HPP offers to our partners. Furthermore, the methodology we use allows us to eliminate the ‘3rd party’ which gives the providers directly caring for the patient the opportunity to review all of the feedback in real time. We can then self-determine which situations would benefit from another visit with the patient. Our method also offers the surveyee the potential perception that feedback can be more candidly provided, as they are in a less judgmental situation while responding to the survey.
Ultimately, this gives the opportunity to have the real issue addressed, leading to building a more favorable relationship between the patient and the provider. This will translate into happier patients, leading to better patient aftercare compliance and subsequently improved patient outcomes. There are some less obvious, but more significant, financial benefits that can come from this success. Namely, the potential for less litigant situations and an increase in the emergency department census generated from the more satisfied community service base.
Reference: Landsburg. J.M. Et.al, Utilizing Real-time Patient Satisfaction data to Perform Service Recovery for Dissatisfied(PATIENTS) Who Present to the Emergency Department., Annals of Emerg. Med Volume 60 No4s, Oct. 2012, P S112
My summary of the 2013 Hospital Physician Partners (HPP) Medical Directors Conference: Nashville Tennessee, April 21-25 2013
Hospital Physician Partners sponsored and produced its annual director’s conference the week of April 21st. The physical setting was a good environment to foster productivity. The conference was graced with a series of lectures and demonstrations focusing on concepts and methods to bring the directors up to date on subjects we can use to meet the demand s of the continuous changes in the business and science of medicine. The academic lectures were state of the art and thought provoking.
As has been customary in the past, the attendees were required to create and perform a self-learning exercise. (see pic below) They again found themselves being placed a bit out of their comfort zone to learn and critique the intricacies of adapting to unique situations.
The ultimate goal of these conferences is to provide our HPP family of doctors and mid-levels with innovative tools to make their jobs more satisfying, rewarding and productive. Once again it is clear this conference was productive based on the feedback. The utility of the information gathered at the program showed in the participant’s motivation and satisfaction. They were inspired by the content and plan to bring these revolutionary ideas and ideals back to the practitioners in the trenches.
It would be hard to walk away from this event without finding yourself better prepared to bring leadership to HPP. Most of the attendees were engaged to the point that the content presented in this conference will generate benefits for all HPP providers throughout the country.
To read more about this year’s conference and HPP’s Medical Director award winners, click here.
Hospital Physician Partners is assuming the management and staffing of eight Emergency Department programs in Mississippi over the next 60 days. Thus, we are featuring these contracts over the next few months in a Blog series called “Magic In Mississippi.” In this series, we explore some of the more aesthetic sides of these opportunities. Next up, Crossgates River Oaks Hospital in Brandon: A City of Growth & Stability!
Located in central Mississippi just 14 miles from Jackson, Brandon is in the amazing Pine Region, also referred to as the Black Prairie because of its rich, dark soil, white-tailed deer, and large flocks of turkey. This region has over 200,000 acres of land open for public hunting, fishing, and other outdoor recreations in the pines. Geographically, it’s just outside of Jackson in Rankin County, voted the tenth best place to live in America by Progressive Farmer Magazine. Brandon has a total area of 21.3 square miles and a population of 21,705. In the past three years, assessed valuations have increased by 26% and the population has grown from 115,327 to 121,758.
If you love the country and being outdoors, then you’ll discover the beauty of Brandon’s country-side and be able to experience the cities exclusive and unique farm tours including shrimping tours, U-pick farms, catfish farm tours, & Christmas tree farms. Other popular venues to visit include the local fairs, festivals, and farmer’s market. End the night dancing under the stars in a clear night at the many private “Barn Dances.”
One of the reasons you chose Emergency Medicine because you wanted your flexibility and personal freedom and Brandon, Mississippi offers plenty of it for you to enjoy! For more information about the opportunities available at Crossgates River Oaks Hospital, contact Christina Plain at 800-815-8377, ext. 5295.
Picture this surprising but realistic, documented patient care scenario: You have a patient that presents who is currently in a clinical trial for treatment of depression. She has intentionally overdosed on her study medication. After she overdoses, she begins to feel pre-syncopal and calls 911. EMS arrives to find that her blood pressure is 70/40 and has to institute standard ALS protocols including a substantial fluid bolus to normalize her vital signs. A through inpatient hospital evaluation fails to determine any pathophysiological diagnosis. Ultimately it is determined that her pills were placebos.
The positive influences of doctor–patient communication, treatment expectations, and sham treatments (termed the placebo effect), have been demonstrated scientifically for subjective symptoms such as pain and nausea. Many of us have seen the efficacy of a placebo.
As Emergency Medicine Physicians or Hospitalists, patient self-induced illnesses caused by internet medical care recommendations and treatment/medication noncompliance are etiologies that may cause these patients to seek medical evaluations. Then there’s the nocebo effect defined as the induction of a symptom perceived as negative by sham treatment or by the suggestion of negative treatment expectations. A nocebo response is a negative symptom caused by the patient’s own negative expectations or by negative suggestions from clinicians in the absence of any treatment. In fact, information about possible complications and negative expectations on the patient’s part has been found to increase the likelihood of adverse effects.
A recently published study from Germany was designed to determine the impact of nocebo effects on adverse events (AEs) in drug trials for fibromyalgia syndrome (FMS) and painful diabetic peripheral neuropathy (DPN). There were a total of 5065 patients in the placebo groups. The pooled estimate of the event dropout rate due to AEs in placebo groups was 9.6 in placebo and 16.3 in true drug groups of FMS trials; and was 5.8 in placebo and 13.2 in true drug groups of DPN trials. The investigators concluded that nocebo effects accounted for substantial numbers of AEs in drug trials of FMS and DPN. They recommended the need for development of strategies to minimize nocebo effects in both clinical trials and clinical practice. With any acute patient complaint presentation, our job is to rule out an emergency medical condition without introducing personal biases, minimizing the chief complaint or attributing the problem to potential nocebo effects.
Care standard requires us to inform patients of the potential complications of our proposed treatments. Concurrently we should make a conscious effort to minimize the likelihood of complications caused by a potential nocebo effect. When we place a patient on a new medication, it has been suggested that we should emphasize the fact that the proposed treatment is usually well tolerated. Another suggestion is to obtain the patient’s permission to incompletely inform them about the treatments’ possible side effects.
Words are one of the most powerful tools we have in our armamentarium. Communication lessons provided during training and with continuing medical education are ways that we can learn to more effectively utilize the spoken word. We need to remember that doctor–patient communications and the patient’s treatment expectations can influence the course of their medical therapy.
1. Häuser, W et.al. Adverse Events Attributable to Nocebo in Randomized Controlled Drug Trials in Fibromyalgia Syndrome and Painful Diabetic Peripheral Neuropathy: Systematic Review, June 2012 – Volume 28 – Issue 5 l
2. Häuser, W et.al. Review Article Nocebo Phenomena in Medicine Their Relevance in Everyday Clinical Practice; Dtsch Arztebl Int. 2012 June; 109(26): 459–465. Published online 2012 June 29.
As we announced last week, Hospital Physician Partners will be assuming the management and staffing of eight Emergency Department programs in Mississippi the next 90 days. Thus, we will be featuring these contracts over the next few months in a new Blog series called “Magic In Mississippi.” In this series, we will explore some of the more aesthetic sides of these opportunities. First up…Biloxi: The Playground of the South!
Biloxi Regional Medical Center in Biloxi is the first touch of Mississippi Magic we are highlighting. Residents can enjoy the sugar-white sand beaches, great deep-sea, freshwater fishing and various outdoor activities. The city is within minutes from the ocean waters where you can ride a ferry out to Ship Island by the historic Fort Massachusetts, discover dolphins swimming in the ocean, or visit several delicious seafood restaurants overlooking the Crystal clear waters. Choose from landing “the big one” on one of the many fishing charters or sinking a 40-footer at a professional-grade tough southern golf course.
Biloxi is a great city of entertainment and thus its nickname: The Playground of the South. Enjoy the “Grillin on the Green” every March; a family fun event featuring a BBQ competition, arts & crafts vendors, live entertainment, and children’s activities. Mississippi’s Gulf Coast offers weekend’s FILLED with events, parades, festivals, & FUN! And of course, for those who love games of chance, win big at the nationally known Biloxi Hard Rock Hotel & Casino open 24/7 a week.
You chose Emergency Medicine because you wanted your flexibility and personal freedom and Biloxi, Mississippi offers plenty of it for you to soak up! For more information about the opportunities available at Biloxi Regional Medical Center, contact Christina Plain at 800-815-8377, ext. 5295.
As I was writing the news release today announcing that HPP was taking the reigns for eight Health Management Associates Inc. (HMA) contracts in Mississippi over the next 90 days, I got pretty excited. This new portfolio of business triples our Emergency Medicine programs in the state. Then I looked at the growth stats since January 1st and was shocked again to see that since the start of the year, we have begun 22 new Emergency and Hospital Medicine contracts. I was blown away. Although I am the VP of Marketing and know that we have started a number of new contacts recently, it was the first time I looked at everything in aggregate and frankly, I was just blown away.
Why was I blown away? Honestly, it is because while we have earned all this new business, are growing steadily, and dealing with all the pressures that come with such growth; here was my CEO, Jeffrey Schillinger, leading a “huddle” with our management team and asking how WE were doing. Earlier in the day, I spoke to our President and Chief Medical Officer, (and Jeffrey’s twin brother) Dr. David Schillinger, who was fresh off working a 24 hour clinical shift with about 4 hours sleep. He was returning my call from the day before to discuss some minor details about our upcoming Medical Director’s conference. He’s flying all over the country, working crazy hours on shifts, leading our clinical operations team, and oh yeah, helping run a national medical management company. Yet, he took the time to call me back promptly and personally. This is the culture of Hospital Physician Partners.
That’s why I am blown away. We have the opportunity to now save even more lives in Mississippi and help provide quality care for the communities we will be serving throughout the state. It feels awesome knowing that leading the way are two ordinary people, twin brothers no doubt, who care as much about their employees as our physicians do about their patients. Here at HPP, there are no ivory towers or “gates to the C-Suite.” We are a family whose mission is Saving Lives. We are guided by a simple premise: What’s Important to YOU…Is What Matters to US!® and we look forward to proving it to our patients and our new hospital partners in Mississippi.
Patient handoffs serve a critical function. They constitute a major responsibility with patient management while performing our jobs as Hospitalists and Emergency Medicine physicians. A recently published abstract in the Annals of Emergency Medicine evaluated the frequency of errors made during transfer of patient care.
The focus of the study was to describe the prevalence of errors related to communicating abnormal vital sign findings from the ED provider to the receiving physician. Specifically, hypotension and hypoxia were studied since these conditions are independently associated with poor clinical outcomes. Of the 434 patients studied, 58% of the handoffs took place in a critical care unit and 42% in the emergency department. The primary outcomes sought were errors of omission in the communication of an episode of hypotension (defined as systolic blood pressure <90 mm of Hg) or hypoxia (defined as oxygen saturation < 92%). A secondary analysis attempted to identify predictors of handoff errors which included: interruptions for patient care, verbal interruptions of primary communicator, and requests for vital signs by other providers.
The investigators found that nearly 20% of hypotensive episodes occurring in the emergency department were not reported during patient handoffs. They also found that there was a failure to report the history of hypoxic episodes 4.4% of the time. Interestingly, no predictors of handoff variables were found to be significant. Furthermore, the experience of the primary communicator (Residents, P.A.s, Attending physicians) was not determined to be a factor.
Since this aspect of patient care is a National Patient Safety Goal, this study’s findings are magnified by the patient’s need for this information being relayed without errors. The historical, diagnostic, therapeutic and medicolegal relevance of relaying the occurrence of an abnormal or life threatening vital sign finding during the handoff cannot be understated. We have to admit these findings represent a serious deficiency in communicating to the receiving physician salient observations relevant to our patient’s care. This study should remind us to concentrate on attention to important details during patient handoffs.
Reference: Venkatesh, K et al. Effectiveness of Communicating Vital Signs at Emergency Department Handoffs, Annals of Emergency Medicine, Volume 60, Issue 4, Supplement , Pages S49-S50, October 2012
When we as Emergency Medicine specialists and Hospitalists find ourselves working through long stretches of routine care of patients, have you ever heard a newbie say “it’s quiet in here “ or “we need an good trauma”. I have looked at them in abject horror and at the very least wondered ‘what they will be wanting next’? Then the curve ball hits. A legitimate disaster is now on its way to the hospital with 40 hikers being brought to your ED as was the case recently at one of HPP’s contracts, Whitesburg ARH Hospital in Whitesburg, Kentucky.
What does that do to the doctor? There is a myriad of thoughts and feelings coursing through your veins to decide how to best prepare for this challenge. Is it the excitement of the challenge, or just wanting to cut the throat of the person that used the taboo word “Quiet” just before the emergency medical services calls this in trauma? Is it the sense of responsibility or the sense of dread? Then there is fear, logic, and anxiety. You tell yourself to get a grip. And you’re off to the races.
For some of us it is the memory of a lifetime. For others it is Deja vu. And for a few it’s the nightmare of the century. Either way we are there for the duration and can take pride in making a difference in as many of those people’s lives as we possibly can. We will be what we need to be selflessly, for each and every one of those people injured. We’ll be proud of the fact that we will perform better than we ever have because that’s what makes us whole. Now you have had a glimpse of the rest of the story…a view from the heroes.
Every day, we can usually find examples of teamwork and partnership around us. As a matter of fact, as Emergency Medicine practitioners, we see it and live it every day because it is how we get things done and save lives. That said, every once in a while, we see something wonderful that grabs us and demands our attention. Such is the case last week at Whitesburg ARH Hospital in Whitesburg, Kentucky. Last Thursday night, around 11:00pm, the ARH CEO called with a local disaster; 40 college students out for a day hike in the mountains got lost. The search for them was on as the night got colder and wetter. With dropping temperatures and as the hour grew later, the hospital was alerted that there would be an influx of patients, however the arrival time was unknown; but it was clear that more physician staff would be required.
The HPP Physician Services team feverishly began making calls. The hour was late and many were putting children to bed and getting ready themselves for lights out. However, they stepped away from what they were doing to help strangers miles away. In the end, within an hour, assets were marshaled and the HPP staff, in coordination with the Whitesburg nursing staff and administration, were able to find doctors to be on standby and ultimately come in to help the students as soon as they were found.
One hospital nursing staff leader said, “The teamwork involved was wonderful. All of our resources were utilized and implemented with great success. It was breathtaking to see our administration and department managers at the bedside offering comfort measures and advocating for our patients as they communicated our patient’s needs. I want to add thanks to HPP for providing us with the doctors in the ER. They arrived promptly and were awesome.” Of course, most important was the fact that all 40 of the college students were safe and okay.
At HPP, our tagline is “Partnering For Results.” Sometimes, taglines and marketing slogans can be viewed as fluff. However, this is one time where we can all stand a little taller. Everyone teamed together to save lives and partner for results!
Intraosseous infusion (IO) routes are well touted to provide some significant advantages over intravascular (IV) infusion in the proper setting. It is considered as efficient as an IV route and can be inserted quickly, even in the most poorly perfused patients. It represents a non-collapsible infusion route providing access in difficult patients with obesity, burns, or edema. It is reported to have a low complication rate, and considered to be safer and easier than central line placement. In truth it does the job while potentially decreasing morbidity and mortality in the critical pediatric patient and can be accomplished without interrupting CPR.
However, a study abstract published in the Annals of Emergency Medicine reveals a very significant morbidity and mortality consideration for this modality. The study was designed to compare flow rates of blood administered through an IO needle in various extremity sites under high pressure in an adult hypovolemic swine model. The striking finding from this study was that histopathologic lung examination of the study participants revealed fat emboli present in 14/14 (100%) of the tibia study arm, 10/11 (91%) of the humerus study arm, and 8/14 (57%) of the femur study arm group. They concluded that the rate of IO infusion of blood through the swine humerus was greater than the femur and tibia but that fat emboli were detected in the lungs of MOST of the study animals.
We all know that patients with increased mass, age, multiple underlying medical problems, and/or decreased physiologic reserves have worse outcomes than other patients with fat emboli. Paradoxically these are often the people that may need IO access the most.
What practical lessons can Emergency Medicine and Hospitalist specialists take away from this study? A lot of bacon gave its’ all to show us something could be happening in our patients with IO infusions that many of us probably didn’t know about. Considering the mortality rate of fat embolism is 10-20% 2, we have a significant reason for adhering to the indications for this method of infusion instead of defaulting to the IO modality too quickly. Our prehospital crews should also be reminded of this significant morbidity and mortality as a reason to place these lines according to their protocols.
1. Lairet, JR et al. Comparison of Intraosseous Infusion Rates of Blood Under High Pressure in an Adult Hypovolemic Swine Model in Three Different Limb Sites. Annals of EM, Vol. 60 NO48 Oct 2012 page S75
2. Kirkland,L., Fat Embolism, Emedicine.medscape, Sep 8, 2011
Hospital Physician Partners (HPP) announced recently that they have expanded their management agreement with Lovelace Health System to manage an extended portfolio of contracts throughout New Mexico.
HPP, which partners with more than 90 hospitals in over 20 states, currently has the responsibility of managing and recruiting Emergency Medicine clinical providers Lovelace Health System’s Albuquerque campuses: Lovelace Medical Center, Lovelace Women’s Hospital, Lovelace Westside Hospital and Heart Hospital of New Mexico at Lovelace Medical Center. This footprint has now grown to include the Hospital Medicine programs those facilities as well as the Emergency Department at Lovelace Regional Hospital-Roswell.
This expansion of services is an honor says HPP Chief Executive Officer, Jeffrey Schillinger. “We have enjoyed a strong partnership over the past four years,” said Schillinger. “The expansion into Roswell and addition of the Hospitalist services is a great opportunity to help improve the quality of care for Lovelace patients.” HPP’s clinical leadership team actively practices in New Mexico and has a keen understanding of the market which is key to achieving the goals Lovelace has for attaining quality patient outcomes.
“This partnership will enhance care coordination at our hospitals,” said Dr. John Cruickshank, Chief Medical Officer at Lovelace Health System. “By having the Emergency Department physicians and hospitalists working together as one team we will be able to improve quality, service and efficiency for our patients.”
HPP’s growth 12 new additions to its portfolio in the Emergency and Hospital Medicine industries between fourth quarter 2012 and first quarter 2013 with more set to begin in the second and third quarters this year. “HPP’s experience and size provides valuable resources in the form of recruiting physicians, billing and management, to the hospitals, physicians, and communities we serve,” says Schillinger. “My brother, who is an actively practicing ER physician, and I strongly believe success comes from being accessible, in touch, and involved. Our entire company is constantly focused on the one thing that keeps us grounded – We Save Lives.”
About Hospital Physician Partners
Hospital Physician Partners (HPP) is a physician-led, privately held Emergency and Hospital Medicine Management company that partners with hospitals and clinical providers to deliver quality patient care and physician recruitment services. HPP contracts with over 1,200 providers and will treat more than 2 million patients in 2013; maintaining corporate headquarters in Hollywood, Florida with offices in Jacksonville and Ft. Lauderdale, Florida as well as Durham, North Carolina. More information is available at www.hppartners.com.
Occasionally, Hospitalists and Emergency Medicine clinicians have patients who present for care, speaking a language with which they are not fluent enough to obtain an adequate history or safely define their problem. It seems reasonable to find anyone willing to help us with language translation in lieu of locating a professional translator. We might need to think twice before using this easy way out! A recently published study in the Annals of Emergency Medicine sheds some light on the risks of errors of medical interpretation in the management of these patients.
This study’s goal was to compare interpreter errors and the potential consequences involving encounters using professionals, ad-hoc interpreters, or no interpreters. The proportion of errors that may cause potential consequences was significantly lower for professional (12%) versus ad hoc interpreters (22%) versus no interpreters (20%). Additionally, professional interpreters with greater than 100 hours of training committed a significantly lower proportion of errors of possible consequence (2% versus 12%) in every error category.
The investigators concluded that the use of a professional interpreters skills results in a significantly lower likelihood of significant errors than other interpreters. They further stated that requiring at least 100 hours of training for interpreters could have a significant impact on reducing interpreter errors and their consequences in health care while improving care quality and patient safety.
Considering the importance of the history in the clinical evaluation of these patients, this is valuable information we should factor into the equation when working with these patients. This significance would also have an impact on the ever important after care instructions, which may influence their care plan, treatment compliance, and subsequent case liability concerns.
Reference: 1. Flores, G et.al., Errors in Medical Interpretation and Their Potential Clinical Consequences in Pediatric Encounters. Annals of emergency medicine, Vol. 60 Number 5, Nov. 2102 pages 545-553
There have been recent EMTALA cases brought forward with the physicians clinging to the hopes of defending themselves by using the argument, “But I didn’t even know about that patient being here.” How surprised would you be to find a federal inspector arriving in your department or office handing you a bill for $50,000 due immediately accompanied by the threat of cutting off all your institution’s Medicare payments? This could be a real scenario if you are found in violation of the terms of the Federal Emergency Medical Treatment And Labor Act. (EMTALA) It’s possible to violate this law without knowing it, but “ignorance of the law is no excuse.” It is fact that a person engaged in work that is not common for a normal person, is obligated to be familiar with the laws necessary to do that job. If they do not, they cannot complain about subsequent liability. Furthermore, if you feel like complaining about the inconvenience of EMTALA compliance, frankly you’ll find that the Federal Government and the general public just don’t give a darn.
An emergency medical condition is defined as manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in placing the individual’s health (or the health of an unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs. There have even been EMTALA cases charging that physicians have discharged the patient before adequately treating their pain thereby not satisfying the EMTALA requirement of stabilization. How these cases are treated is still under consideration by the courts.
What does this situation mean for you? If you perceive that the processes in place at your institution may allow the aforementioned scenario (or any other EMTALA violation) to take place, it is incumbent upon you to address these deficiencies immediately. Ultimately, being well-informed about EMTALA law is a mandatory requirement for anyone who treats hospital patients in an emergency situation. We must continually maintain a healthy respect for the laws of the EMTALA. The safest approach is to know the laws well. Additionally we must always do the right thing by placing the health and welfare of the patient as paramount practice goal. Anyone may file a claim. But if we are doing our jobs correctly as emergency physicians and hospitalists (along with good documentation), we can practice with confidence… as long as there are no violations in our practice.
1. Zibulewsky J. Ignorance of the law is no excuse. Knowledge of the statute by the medical staff of a large, tertiary-care hospital. Ann Emerg Med (submitted for publication, May 2001).
2. Zibulewsky J.Proc The Emergency Medical Treatment and Active Labor Act (EMTALA): what it is and what it means for physicians, (Bayl Univ Med Cent). 2001 October; 14(4): 339–346.
Much is published in the literature regarding the risks of signing patients over to the admitting physician, especially if they aren’t coming in to evaluate the patient in a timely manner. Subsequently, if the admitting physician is reluctant to see the patient until his hospital bylaw grace period is nearly over, that usually portends more work for the Emergency Medicine physician regarding the admission of the patient.
Speaking of increased work, many of us can relate to a law taken from the Samuel Shem book, “The House of God”. The law states, “Show me a medical student that doesn’t triple my work and i’ll kiss your feet.” An abstract recently published in the Annals of Emergency Medicine has examined an aspect of this law in some detail. Their findings may someday play a roll in the way we function with our jobs as emergency medicine physicians and hospitalists.
The investigators looked for factors associated with and the rate of adverse events caused by medical errors made by emergency physicians while caring for, managing, and admitting their patients. The authors concluded that emergency physician’s adverse events are common for patients hospitalized from the ED. Of the 225 patients included in the study, 130 errors were detected. Of these errors, 34 were categorized as adverse events (defined as medical errors that caused harm to the patient). They noted only two factors that lowered the risk of adverse events in this study: a) the transition of care involving a handoff within the ED, and b) the involvement of a Junior Doctor (resident) in addition to the senior physician. Essentially, instead of tripling their work they found that the residents were improving patient safety. The French investigators went on to say that crosschecking every major decision is mandatory in many other professions and could be beneficial in emergency medicine. Imagine the consequences and permeations of this becoming a Joint Commission standard.
Our post-graduate training programs have reinforced this paradigm for many of us, effectively hardwiring this method into our care plan. This is especially true in the highly litigious specialties. But as for the studies newly recognized value of the “junior doctor,” I guess I better not believe everything I have read in “The House of God” to be the gospel I thought it was. I should probably just stick to Rosens, Tintinalli and Harrisons.
Reference: Goulet, F. et al., Factors Associated with Adverse Events Resulting from Physician Medical Errors in the Emergency Department: Two Doctors Safer than One. Hausfater P/Freoupe Hospitalier Pit`e-Salpentriere, Paris France.
Often our jobs as Hospitalists and Emergency Medicine Physicians are to face the questions patient have regarding their fears of dying from nicotine addiction. I have repeatedly been asked if there are any good things about nicotine. There are approximately 44.5 million adult smokers in the United States. No one will dispute the cardiovascular risks of smoking. While the risk of cancer from smoking is well established, there is no clinical evidence that therapeutic nicotine products create a risk of cancer when used as directed. More than 20 years, over 110 studies involving more than 35,000 participants have shown no increased risk of heart attack, stroke or death among therapeutic nicotine users even in populations with specific health conditions, such as diabetes, high blood pressure, lung disease, and existing heart disease.
The American Journal of Pathology in 2003 reported findings that nicotine accelerated wound healing in diabetic mice. Interestingly, these effects are mediated by neuronal nicotinic acetylcholine receptors nAChRs and that nicotine-induced wound healing is mediated, at least in part, by its effects to increase wound angiogenesis. Other studies including a study published in the Annals of Medicine, 2004 also reported nicotine as a potent angiogenic agent. The Journal of Cardiology 2007 concluded intramuscular administration of nicotine for 3 weeks was capable of significantly promoting intramyocardial angiogenesis. Nicotine has also been found to accelerate intimal proliferation and thickening of balloon catheter denuded iliac artery injury.
Current evidence about the therapeutic potential of nicotine is strongest for ulcerative colitis. The Department of Gastroenterology at the, University Hospital of Wales, in the U.K concluded that ulcerative colitis (UC) is predominantly a disease of non-smokers and nicotine is thought to be the agent responsible for this association. Transdermal nicotine was shown to improve disease activity and sigmoidoscopic appearance in active disease patients. Attempts to reduce systemic levels and improve drug tolerance have been let to colonic delivery systems of nicotine (also an ancient treatment for resuscitation of drowning victims!). Preliminary observations with nicotine enemas in UK have been shown to be clinically beneficial.
Tebanicline, developed by Abbott as partial agonist at nAChRs, showed potent analgesic activity against neuropathic pain in human trials. It was designed to be a less toxic analogue of a potent frog-derived compound which is some 200x stronger than morphine as an analgesic. It was dropped from development due to an unacceptable incidence of gastrointestinal side effects. The development of new nAChR agonists continues. Several new nAChR agonists have advanced to Phase II clinical trials demonstrating efficacy in Alzheimer’s disease, attention deficit hyperactivity disorder, cognitive deficits of and schizophrenia. Nicotinic receptors and Parkinson’s disease studies done between 1961 and 2000 demonstrated that there may be nearly a 50% decrease in the incidence of Parkinson’s disease in tobacco users.
Ultimately how one acquires their nicotine has a lot to do with its risk versus benefit. A cigarette contains 9-30 mg of nicotine. Cigars can contain up to 40 mg. Chewing tobacco carries 6-8 mg per gram, gum is 2-4 mg per piece and patches 8.3-114 mg. The fatal dose of nicotine has been estimated to be 0.5-1.0 mg/kg in an adult. The lethal dosage for adult humans according to the CDC is 5 mg/ m3 based on oral toxicity data in humans. It is pretty unlikely that any studies will ever conclude that those intriguing contraband habanos Cuban cigars are going to be “healthy” or a” one a day” staple to the fountain of youth. However they do contain at least one chemical with multiple potential therapeutic indications and perhaps will one day offer benefits beyond the cigar aficionados’ universally purported “relaxing, flavorful, enjoyable” appeal.
As a marketer, I spend a great deal of my day supporting our recruiting team efforts to locate emergency department physicians, nurse practitioners, and physician assistants for Emergency Medicine jobs and Hospitalist jobs nationwide. As such, my team researches communities to provide optimal background for our Recruiters, job postings, and advertising efforts. Hospital Physician Partners provides Emergency Medicine management and Hospitalist Medicine management services in 23 states at more than 80 hospitals. We recently had the opportunity to expand our footprint into Oklahoma thus providing my team with an exciting project and serving as a reminder why I love my job!
Hospital Physician Partners is now providing Emergency Medicine staffing and management services for six hospitals in Oklahoma including five from the INTERGIS system; Blackwell Regional Hospital, Clinton Regional Hospital, Marshall County Medical Center, Mayes County Medical Center, Seminole Medical Center, as well as Medical Center of Southeastern Oklahoma. Researching these cities and communities has not only been fun as I learn about new parts of the country I probably would not have looked at previously, but it is also educational. Long gone are the history and geography books from my aging and forgetful mind so a little refresh was a good thing. For example, I forgot that Oklahoma was part of the 1803 Louisiana Purchase and is one of the nations youngest states. I didn’t know that Oklahoma has more man-made lakes than any other state, is the third largest gas-producing state in the nation, and that forests cover approximately 24 percent of Oklahoma. Now, while all this may do is make me sound more intelligent during the next Trivial Pursuit family challenge, it has driven me to learn on the job which is what we all should be doing anyway isn’t it?
Hospital Physician Partners is now a new partner in the care of patients in the Oklahoma communities we serve. In addition to providing Emergency Medicine jobs in Oklahoma, we will be caring for ten’s of thousands of patients across the state. As an employee of Hospital Physician Partners, I am proud of this. In our day to day jobs, (especially in our industry) it is easy to get lost in the crush of work as we staff, recruit, manage, and most importantly, save lives everyday. However, this new venture into Oklahoma has reminded this marketer that part of the excitement of what we do is also engaging in new communities, developing new recruitment strategies, and expanding our scope of knowledge as purveyors of quality patient care.
For thousands of years, humans have been over eating regardless of the presence of enough food. The definition of “abnormal eating patterns” as “eating disorders” was developed about 20 years ago. I am one of those who has eaten too much and felt like I was going to die for the next few hours, surviving on the principal of living to eat instead of eating to live. According to the Calorie Control Council, the average American consumes about 4,500 calories and 229 grams of fat on Thanksgiving Day. Dr. Pamela Peeke, a well published author on obesity, has been quoted saying this meal is like a tsunami of fat coming into the body. In fact, studies have shown that there was a 4-7 time increase in heart attack risk of heart attack risk after eating too much at one sitting.
On the other hand, if you’re not one of those individuals with one foot on the banana peel and the other one in the grave, there are some differing opinions on this. Some fitness experts suggest why should we restrict this feast at all? Since a Thanksgiving Day feast happens only 1 day a year, why not just eat as much as you want? If you are healthy enough, one day of feasting out of a full year is NOT going to make or break ones’ fitness routine.
Even if you decide to feast on every holiday that you celebrate throughout the year, this is still only going to be 5 or 6 feasts per year. That calculates out to only about 1 feast every 2 month which they say is certainly nothing that is worth worrying about in terms of a fitness plan. And if you have been fasting prior to this onslaught, occasional overeating may have the benefit to revamping your metabolic rate via the leptin hormone response, which has been suggested to up-regulate your metabolism. This physiologic concept actually originated from studies in the 1950s on obese mice that showed when this subset of mice was treated with injections of leptin, they lost their excess fat and return to normal body weights. So if you’re healthy enough to withstand the stress test at the dinner table, dig in. After all its better to burn out than to fade away. (Neil Young from the song: My My, Hey Hey)
Pamela Peeke, MD, MPH, FACP, Assistant clinical professor at the University of Maryland School of Medicine
Ingalls AM, Dickie MM, Snell GD (December 1950). “Obese, a new mutation in the house mouse”. J. Hered. 41 (12): 317–8. PMID 14824537.
We all realize how important a job it is as Emergency Medicine Physicians and Hospitalists to generate an accurate medication list for the care and safety of our patients at their hospital admission. It is vital to prevent medication errors and adverse drug events during the hospital stay and after discharge. Unidentified errors can result in the patient receiving harmful, inaccurate treatment. As such, in todays clinincal environment where more and more ER physicians and Hospitalists travel to work locums-based Emergency Medicine jobs and Hospitalist jobs, the challenge is even greater.
A recent study published in the British Medical Journal attempted to describe the frequency, type and predictors of errors in the patients medication history, and to evaluate the extent to which standard care corrected these errors. They also tried to determine the degree to which standard care identified errors in the medication history when the pharmacists performed a medication reconciliation. In the study, the medication list generated at admission was compared with the patient’s medication list in the hospital medical records. The errors were identified by pharmacists performing medication reconciliations for patients admitted to a Swedish hospital, and generated predictors for those medication errors. Addition, withdrawal of a drug, or changes to the dose or dosage form in the hospital medication list was considered a medication discrepancy. Medication discrepancies for which no clinical reason could be identified were considered medication history errors.
The study population constituted 670 patients. At least one medication history error was identified by pharmacists conducting medication reconciliations for 313 of these patients, (47%)! The most common medication error was an omitted drug, followed by an incorrect dose. Analysis showed that a higher number of prescribed drugs listed at admission, and the patient living in their own home without any care-givers were predictors for medication history errors. The results indicated that the usual care by non-pharmacist patient care staff partly corrected the errors in affected patients by four days after admission. However, a considerable proportion of the errors made in the initial medication history at admission remained undetected by standard hospital operating procedures.
The investigators concluded that medication history errors generated at hospital admission are common. This highlighted the importance of introducing processes for ensuring that the medication lists are accurate and complete as soon as possible to reduce the risk of medication errors. They concluded that clinical pharmacists conducting medication reconciliations have a high potential for correcting errors in medication history. They noted that there is limited potential for predicting which patients are at highest risk of experiencing errors in their medication history. They recommended that systematic medication reconciliations should be conducted in all patients admitted to hospital and noted that older patients being prescribed many drugs could benefit the most from admission medication reconciliations by clinical pharmacists.
As purveyors of Emergency Medicine management and Hospitalist Medicine management, clearly we should educate the staff caring for our patients on the critical nature of this portion of the patient assessment and encourage them to acquire an accurate valuation of the patient’s medication list. Those of us who are writing admit orders as part of our patient management must be vigilant for this error potential and be diligent with our medication orders. At the very least, we can write an order to contact the patient’s personal pharmacy for their medications and dosages.
Lina M Hellström; Åsa Bondesson; Peter Höglund; Tommy Eriksson, Errors in Medication History at Hospital Admission: Prevalence and Predicting Factors., BMC Clinical Pharmacology BMC Clin Pharmacol. 2012 Apr 3;12:9
Occasionally, our job as Hospitalists and Emergency Medicine physicians is to decide who should return to work and who really needs a work note. Sometimes we need to decide if WE are too sick to make it through the shift. I personally have worked shifts while enduring an active GI bleed, an acute pulmonary embolus and a stroke in evolution. That is not saying that I demonstrated or used the common sense God gave a tack. But I’m admittedly on the other end of the extreme and in my defense, most of these weren’t infectious. A recent article by Sue Shellenbarger in the Wall Street Journal brought up a few salient items for us to ponder about calling in sick. Surveys have disclosed that 1 in 7 women and 1 in 5 men have called into work and lied about being sick. With that, the following are the results of a survey listing the most creative excuses for missing work.
- The employee’s toe was stuck in a faucet
- The employee’s dead grandmother was being exhumed for a police investigation.
- The employee got sick from reading too much.
- The employee was suffering from a broken heart
- The employee was upset after watching Hunger Games
- The employee’s bird bit her
- The employee’s hair turned orange while dyeing her hair.
- The employees sobriety tool wouldn’t allow the car to start
- The employee’s dog was having a nervous breakdown
In truth, these statements fail to document the details that may make the difference between credibility and laughability. Maybe they just want to take Halloween off to spend with their kids. Still, we have all have heard patients tell us things that are nearly as outrageous as these statements.
We can easily convince our diehard patients in our ED that they are too sick to work. Some may need some prodding by asking them, to paraphrase an office manager from New York; “You don’t look very good. What kind of flowers do you want at your funeral?” Or perhaps, ‘Would you like me reserve you a horse-drawn U-Haul behind your hearse’? Considering the years’ projected outbreaks of whooping cough, and the concerns for outbreaks of hantavirus and norovirus, we need to be diagnostically vigilant. Not to mention the occasional patient sauntering into the ED or our office with the chief complaint of ‘a cough’, hacking away in our faces with multidrug resistant TB!
We all have an obligation to not gift our own infectious diseases to our susceptible patients. Additionally, our patients and their coworkers count on us to not allow highly contagious people to bring said diseases to the workplace. And in reality, in this day of a cornucopia of information technologies, patients can now work at home or Skype into the meetings from home.
So, let’s just say I made these things up. Maybe they just want to take Halloween off to spend with their kids. What can we take away from these ingenious but inane justifications for skipping work? We must wade through the various presentations and complaints in an attempt to weed out the malingerers. There must be a happy medium where we serve the patient and the communities best interest by using a modicum of common sense, a good physical exam and the applicable testing available to these patients at our health care facilities.
Hospital Physician Partners brought their team earlier this month to the American College of Emergency Physicians (ACEP) Scientific Assembly in Denver, Colorado with the goal of introducing the quality of our company to those potentially interested in joining the HPP family. Some of Hospital Physician Partners top administrative staff and clinicians were present to offer ACEP participants the benefits and advantages of joining one of the premier ED management organizations in the country. The success of their interactions was evident in the sheer volume of productive leads that were acquired.
The American College of Osteopathic Emergency Physicians (ACOEP) Scientific Assembly was attended by two of HPP’s physician recruiters who engaged the participants at every opportunity with personable and meaningful dialogue. The interest Scott Bradford and Benny Rossner generated in HPP was remarkable. They offered a nearly unique presentation format from the recruiters at this conference by genially engaging the participants in front of booth, demonstrating the personal touch that HPP offers to its members. The resulting quality of the responses from the participants was readily apparent and well received.
The ultimate goal of HPP presenting ourselves at these conferences is to offer to the attendees the chance to become a part of the HPP family of health care providers and learn about our nationwide opportunities. We introduce them to the prospect of experiencing a more satisfying, rewarding and productive career in Emergency Medicine.
Now I’m sure some of you are saying this is another review dripping with syrupy propaganda. But the interest generated at these conferences will clearly bear fruit which will be realized by HPP facilities throughout the country. And, as a physician myself, I can full appreciate the value of a meaningful conversation with a recruiter versus mindless banter about the weather and how nice the conference is. HPP’s team did a great job and made it fun for attendees who visited their booths
Multiple CME courses presented at Hospital Physician Partners’ On-Line University have touted the virtues of Emergency Medicine Physicians and Hospitalists care of themselves as a key to improving our management of our on-the-job performance. We have all heard the recent earth-shattering statistics about the modern world’s obesity rate. How many times have I eaten too much and felt like I was going to die for the next few hours? More than I care to admit, and I’ll bet I am not alone. I have even done it under conditions where activity is compromised such as in clinical practice. Clearly however, gorging oneself is not unique to humans. So we logically need to study the gorgers in our world to see where that vice fits in the big picture. Here is a new take on the world of those that are firmly braced in the rank of a gothopotamus.
A python can eat a meal equaling 75% of its body mass. When one does this, (with the exception of the brain), all of its organs increase in size 30-100% to take on the meal! With this astounding change, their basic metabolic rate increases 40 times! Interestingly these organs including their hearts will shrink back to normal size within 10 days. Now grant it they may only eat like this once a year but this adaptation is worth studying.
A study published in Science found that Burmese pythons display a marked increase (40%) in heart mass after a large meal. They found that heart growth in pythons is characterized by hypertrophy. Even with this overt lipemia, the python heart does not accumulate triglycerides or fatty acids. Instead, there is robust activation of metabolic pathways including activation of a cardioprotective enzyme. They identified three fatty acids in python plasma that promote physiological heart growth when injected into either pythons or mice.
These findings may lead to development of therapeutic agents that could confer the benefits of a python overeating as a cure for some common heart diseases. Could there be a cure buried in gluttony? The future holds hopes in these findings that an atrophic scarred heart may he rejuvenated or that diseased hypertrophic hearts may be able to regress to a healthy size. In the meanwhile we owe it to our patients to take better care of ourselves. Based on these findings, maybe some of our morbidly obese, hyperlipidemic colleagues and patients really have a glimmer of optimism. After all, on those tough nights in the hospital when we have overeaten to keep going, we may not be merely overfed “snakes in the grass all coiled up and hissing”.
REFRENCE: Cecilia A. Riquelme, C., Leinwand, L et. al., Fatty Acids Identified in the Burmese Python Promote Beneficial Cardiac Growth Science 28 October 2011: Vol. 334 no. 6055 pp. 528-531, DOI: 10.1126/science.1210558
A summary of the 2012 Hospital Physician Partners (HPP) Medical Directors Conference in Dallas Texas, September 9-12
Hospital Physician Partners sponsored and produced its annual director’s conference recently. The conference was graced with a series of lectures and demonstrations focusing on preparing the directors to educate our providers in the field on concepts and methods we can use to meet the demands of the continuous changes in the business and science of medicine. The program also presented tools that we all will find valuable and easy to implement into our practices. Most of these concepts have proven in practice to increase patient, staff, administrative and provider satisfaction while increasing work environment efficiency. There was even a drizzle of LLSA focused academia to round out the curriculum.
The attendees were treated with a captivating presentation from a guest speaker, Colonel Mark Tillman, the former commander of Air Force One who was at the helm on 9/11. He actually outperformed the stellar line up of conference speakers and received a well-deserved, extended standing ovation from the attendees. Colonel Tillman’s clever delivery and entertaining content provided valuable insight to the unique situational challenges he faced while working in his position. He then pointed out concepts that fascinatingly parallel those in the hospital environment. He offered eye opening revelations of shared operational principals that both his and our professions utilize which allow specialists to achieve success in our respective fields.
The attendees were also required to create and perform in a self-learning exercise based on a loosely scripted emergency department setting. They found themselves being placed entirely out of their comfort zone to learn and critique the intricacies of adapting to unique, albeit artificial, clinical situations.
The ultimate goal of these conferences is to provide our HPP family of doctors and mid-levels with innovative tools to make their jobs more satisfying, rewarding, and productive. The result was clearly on the mark. The participants were inspired by the content and showed a lot of motivation to bring these revolutionary ideas and ideals back to the practitioners in the trenches.
Now I’m sure some of you are saying this review is syrupy propaganda. But the content presented in this conference will clearly bear fruit which will be reaped by HPP providers throughout the country. To quote one of the attendees, “After attending the conference, I feel that my passion for emergency medicine and my role as medical director has been renewed. I am excited to take back the information I have learned and share it with my colleagues, so that we may all perform at our highest level.” And so, prepare yourselves to be dazzled even by the little things that will make big differences.
“The hair of the dog”: We all have heard it, said it or done it. Where did it come from? How does it apply to us? The hair of the dog is classically a shot of alcohol sucked down to mitigate a hangover. In reality, the phrase “hair of the dog” was originally related to how people that were bitten by rabid dogs attempted to treat themselves. They did so by killing the animal and applying the hair of the dog to the wound. In the seventeenth century, it was believed that to fry such a hair and place it with rosemary on the bite wound was protection against rabies! Other attempts to treat rabies included eating the hair, or the rabid animal’s liver or heart.
New trends and lore must be validated by the scientific method. Where would we be if medicine stuck with that 17th century unproven medical care plan of sewing rabid dog hair into the wound? Theoretically though, if the rabies virus was licked onto the fur and became inactivated by drying before the patient applied the hair into the wound, one could actually inoculate one’s self with the dead virus and generate an immune response without producing disease. But the variables would be hard to scientifically define and the scientific method would be heavily compromised. Pasteur solved these concerns by killing the virus before inoculation.
Nickerson, Barilla et. Al., biologists from the Arizona State University Biodesign Institute, recently revealed a discovery that Salmonella becomes several times more virulent while living in space! Interestingly this increased infectivity disappears within hours after being brought to normal gravity; (a process thought to be dependent upon gravity’s effect on stress gene expression). This infectious disease discovery madness is brought to us on a daily basis. When faced with these amazing scenarios both 17th century and space shuttle based, it’s no wonder how difficult it is for the clinician to not jump on any bandwagon a drug company sends at us.
One of the most recent trends that have backfired for our patients was the heavily touted use of third generation fluoroquinolones for acute sinusitis. Clinical experience has later revealed the significant increased risk of tendonopathies and retinal detachments incurred by this cavalier, trendy indication. The seventh commandment of emergency medicine: ‘trust no one believe in nothing’ contains a subset of wisdom: Always maintain an element of skepticism about old adages or new trends. The travesty generated by this indiscriminant antibiotic sales pitch really gives Emergency Physicians and Hospitalists a reason, as part of our patient management job, to heed this commandment for our patients’ best interest.
While there is a theory that a hangover is a form of withdrawal, and that another stiff drink will relieve the hangover, the only part of this that is validated scientifically is that additional alcohol can have sedating and anesthetic effects. In support of this, I’ve never met any journeyman alcohol drinker that denied the benefits of “the hair of the dog that bit you” after tying one on the night before. Without question, this practice has been validated for hundreds if not thousands of years. Alas, I still cannot find one scientific publication or rabies research study that references this acclaimed, ‘off label’, best practice point of care use for “the hair of the dog that bit you.”
As Emergency Medicine physicians, we are always asked to make the patient care plan for our patients more efficient. This quandary is consistently handed to us by the hospital and the groups we work for. And if it isn’t these groups that actually have any steak in the care plan, its JACHO or core measures raining on our parade. A study finally offers a potentially real solution to this age old concern. How can we order ancillary diagnostic studies without causing massive increases in length of stay? You asked for it and you got it! A recently published study evaluated the emergency department strategy of eliminating routine use of oral contrast for abdominal and pelvic computed tomography. The investigators sought to determine if this process could reduce ED length of stay without compromising diagnostic accuracy.
The N of the study was 2001: the study group N was 987 with a control N of 1014. The study was structured so that oral contrast was still ordered for patients with history of inflammatory bowel disease, gastrointestinal tract altering surgery or extremely lean body habitus. Patients were typically excluded if they would not have typically received oral contrast regardless of the intervention (i.e. CT for renal stone protocol). The authors note that the study found no statistically significant difference in the rate of return to the ED in the 72 hours after discharge for patients who received CAT (computerized axial tomography) without oral contrast compared to those who had conventional abdominal pelvic CAT scan with contrast. No patient with a CAT scan negative for acute findings required an additional, subsequent scan within 72 hours. The mean time from order to performing CAT was decreased by 66 min. And the most notable finding for throughput times; the mean emergency department length of stay among oral contrast patients decreased by 97 min. They concluded that “eliminating routine oral contrast use for abdominal-pelvic imaging in the emergency department may be successful in decreasing length of stay and time from order to CAT scan without demonstrated compromise in acute patient diagnostics”.
The take home message: (the impact on patient management and our jobs as emergency medicine physicians and hospitalists): Improved patient throughput times, a potential decreased morbidity with oral contrast use in patients, increased patient satisfaction, decreased cost to the patient, and decreased hospital costs. All of these will lead to better patient satisfaction survey scores and the potential for increased revenue for you as a provider.
Reference:eliminating routine oral contrast use for CAT scan in the emergency department: impact on patient throughput and diagnosis. Levinso, B., et al., Energ. Radiol. 2012, DOI:10,1007/s10140-012-1059-7. Itry65
Numerous articles have been recently written on the risk of sleeping pill use, one of which contained potentially earthshattering news. One of the article’s conclusions reads: “Receiving hypnotic prescriptions was associated with greater than threefold increased hazards of death even when prescribed <18 pills/year”.
Considering the estimates that an estimated 6%–10% of US adults took a hypnotic drug for poor sleep in 2010, the potential permutations are enormous. Furthermore, we all know a few physicians we work with that occasionally use hypnotics for shift work. Our patients read and watch the news. When they get wind of this article publishing the alleged lethality of sleeping pills, we need to be prepared to answer for the public concerns of this medical journalistic luridness.
Fortunately there is a clarifying, common sense, logical discussion that brings reason to this mayhem. An article in Emergency Medicine News, 6/2012, takes a realistic view of this on-line published research. This author’s approach to interpreting this study is a method we all should undertake when we encounter these studies that have been produced for ‘shock and awe’ instead of legitimate research-based knowledge dissemination.
Dr Gussow breaks down the article published in the British Medical Journal Open (BMJO) which appears to baselessly purport the incredible risks for anybody even being prescribed a sleeping pill, whether they have taken it or not. You really need to read it just to see how far over the line this paper went when it comes to publishing research conclusions without basing all of them on scientific facts. Dr Gussow states, “Holy moly, if sedatives and hypnotics, taken a dose of 1.5 pills a month, can quadruple one’s risk of death they must be among the most toxic substances known to man. If sleeping pills kill at least four times as many people in the United States as gunshot wounds and automobiles combined, there is an unprecedented and unappreciated ongoing public health catastrophe”; and he is spot on!
We as physicians have an obligation to be current with research in the medical field. Particularly since it affects our patients and ourselves, (depending on where we fit in the subject matter). Our jobs as Hospitalists and Emergency Medicine physicians also require us to make sure the current research presented to the public makes sense and is sensible. To do this we have to be scientifically critical in our interpretations of what is published.
The learning value of this discussion for us is that Dr. Gussow’s article, in combination with the information from the BMJO, brings some utility to this egregious publication. The two articles together total 3 pages. After reading these you will see how the BMJO publishers’ urge to make the news overrode the standard of peer reviewed medical research publications. You can then appreciate his critical analysis of the flawed conclusions presented in the BMJO article. His perspective reveals the unscientifically based deductions that will unfortunately bring the patients in by the hordes asking legitimate questions about their concerns regarding the safety of the hypnotics doctors have prescribed for them. Reading both of these articles will improve your scientific critical thinking while getting you well prepared for the public’s questions.
It will also undoubtedly help everyone sleep better.
- Gussow, Leon MD., Toxicology Rounds: Sensational Claims Aside, Can Sleeping Pills Really Lead to Earlier Death? Emergency Medicine News: June 2012 – Volume 34 – Issue 6 – p 8 Toxicology Rounds
- Kripke, D., Langer, R. Kline, L. Hypnotics’ association with mortality or cancer: a matched cohort study BMJ Open doi 10.1136/bmjopen-2012
Here we-go again. (And you won’t be lucky enough to have your dog WE-GO bring you a beer while you’re reading this either). I know you’re saying “Not another discussion on quality metrics, patient flow, and patient satisfaction”. They’re shoved down your throat every time you turn around. You have to hear about it from hospital administration, your bosses, and the companies you work for. Furthermore, we see these process improvement plans passed to and from hospital administration with variable success. Now you have some new ammunition supported by newly released research to help convince the doubters that direct bedding and bedside triage are a key component in making things work better in your hospital.
A recently published study from the Society for Academic Medicine’s Research Forum presented more direct evidence which supports having these processes in place in your institution. The authors measured the effect of direct bedding, bedside registration and patient pooling on pediatric ED wait times, length of stay, and patient satisfaction. The proof is in the pudding. The study found that the mean time to be seen by the Emergency Department physician decreased by 20%, length of stay for discharge decreased by 15% and the median time until admission decision was lowered by 10%. The real kicker: Press-Ganey satisfaction scores increased by five points. Interestingly, during the study there was even a decrease in attending physician coverage and increase the patient volumes! HPP is a leader in the Emergency Medicine industry in trying to achieve these goals. Our policies support the practice processes of provider in triage, direct bedding for patients when empty beds are available (bypassing triage), and bedside patient registration.
In hospitals where HPP has both Emergency Medicine and Hospitalist Medicine programs, there are coordinated efforts to reduce boarding and expedite disposition of patients to in-patient beds and we have even established a discharge staging area to free up beds where the situation permits. HPP offers comprehensive strategies consistent with protocols by current Emergency Medicine industry research and remains committed to enhancing the quality of care in the management of our patients!
Reference: Niel F. Miele, Neelam R. Patel, Rachael D. Grieco, Ernest G. Leva. Direct Bedding, Bedside Registration and Patient Pooling To Improve Pediatric Emergency Department length of stay., SAEM Annual Meeting Research Forum, Abstract #217, May,2012
Hospital Physician Partners manages excellent Emergency Medicine facilities throughout Arkansas and these Arkansas Emergency Medicine jobs are open right now:
- In Forrest City at a newly renovated state-of-the-art facility we have emergency medicine job openings for both physicians and NP/PAs. Forrest City Medical Center is a full-service 118-bed hospital and here flexible scheduling and custom reward bonuses are available. Forrest City is just 45 minutes west of Memphis so all the amenities of a big city are just a short drive away, yet there is also plenty for the outdoor enthusiast to enjoy at nearby Village Creek State Park, the state’s largest park.
- At Helena Regional Medical Center there is an immediate opening for a full or part-time Emergency Medicine Physician. This is an excellent facility, offering a full-range of services and the latest in technology. Flexible scheduling is available for 12 and 24-hour shifts plus there is access to full benefits and there are bonus opportunities. Possible relocation assistance is also available. Helena, Arkansas is located on the Mississippi just one-hour southwest of Memphis and is known for its music, culture, history and beautiful scenery.
- In Newport, Arkansas we have another full or part-time Emergency Medicine job opening for a physician at Harris Hospital. You can take advantage of full-benefits, flexible scheduling and competitive compensation at this 133-bed acute care facility. Harris Hospital plays a very important role in the community as it’s the county’s only inpatient and outpatient healthcare services provider. Here’s your chance to enjoy life while making a real difference in the health of your neighbors in this wonderful town located 80 miles northwest of Memphis. It’s home to eighteen-hole golf courses, a state park and museum, two annual festivals and has a host of community cultural activities for the family.
There are nearly 795,000 stroke cases in the U.S yearly and nearly a quarter of are patients under the age of 65. Recent research found that nationwide, hospitalization rates for ischemic strokes increased over 30% among people ages 15 to 44 in the last 10 years. And then THERE IS THE TREND that Americans are becoming fatter, more frequently hypertensive, and more often acquiring diabetes with the consequential atherosclerotic changes they develop at an earlier age. Lastly, data shows an increase in strokes during pregnancy and in the post-partum period.
In adults, minor acute infections are considered a risk factor for stroke. However the issue had not been adequately explored in pediatrics. Now, according to Nancy Hills, PhD, of the U.C. San Francisco reporting at the ASAs International Stroke Conference, acute infection appears to be associated with an increased likelihood of ischemic stroke in children who were at least 29 days old. This retrospective cohort study found an increased risk if the individual had had an outpatient visit for acute infection within the previous 30 days, and especially within two days of the stroke. (N = 126 pediatric ischemic strokes, study population of 2.5 million, 1993- 2007). A prospective study to verify these findings — The Vascular Effects of Infection in Pediatrics (VIPS) trial — will likely to be published within two years.
So what’s bubbling up in the literature that may be good news? Dr. D. Manawadu from the King’s College Hospital in London presented data at the ASA in New Orleans suggesting that it may be safe to give rTPA to people who wake up with stroke symptoms. Almost 25 percent of strokes have their onset during sleep. The investigators used a stroke registry comparing 326 patients treated with rTPA within 4.5 hours of symptoms to 68 “wake-up” stroke patients. In the study, the death rates, risk of ICH and recovery rates after three months were similar in both groups of stroke patients. “Administering rTPA to ‘wake-up’ stroke patients matched for clinical and imaging features as those treated within current guidelines appears feasible and safe.” It could make sense that our technology has finally improved to the point that it can finally begin to tell us something the patient can’t about when they started having problems. Future studies will likely tell us more.
The bottom line still remains, the earlier the treatment is started the better. So, what can we do for these people? Foremost, we have to tell the general population that it is time to take better care of themselves! (maybe not by telling them, “you’re a fat unconditioned slob”, take it from me). We also need to start teaching our patients at all ages about stroke signs and symptoms. They need to be familiar with the following: sudden unilateral numbness or weakness in the face, arm or leg; sudden difficulty speaking or understanding speech, trouble seeing or walking, a sudden onset-severe headache. And finally, the general public needs to understand TIAs are a warning of imminent stroke.
References: Hills N, et al “Timing of infection and risk of arterial ischemic stroke in children” ASA 2012; Abstract 39.
Source: Feb. 1, 2012, presentation, American Stroke Association meeting, New Orleans, LA
In Mount Vernon and Dayton, Ohio, we have rewarding Emergency Medicine jobs waiting for you at top medical facilities in the Buckeye State:
- Knox Community Hospital is located in Mount Vernon and this modern, well-equipped and professionally staffed facility offers a full range of medical and surgical services. It’s a busy emergency room, seeing 25 to 35 thousand patients a year and you’ll have a chance to apply and deepen your skills while working with a highly qualified and supportive staff. We have Emergency Medicine jobs here for physicians, nurse practitioners and physician assistants take advantage of this excellent professional opportunity in one of Ohio’s most livable communities.
- Grandview Medical Center and Southview Medical Center in Dayton, Ohio are part of the Kettering Health Network and are Dayton’s only osteopathic hospitals. We have immediate Emergency Medicine job openings for physicians at both of these great facilities. Grandview is a top Emergency Medicine teaching facility and has a busy emergency department, seeing 25 to 35 thousand patients a year. Southview is Grandview’s sister hospital and this 12-bed ED sees between 15 and 25 thousand patients a year. Both opportunities at Grandview and Southview give qualified physicians a chance to work in a region that’s ranked #3 nationally for hospital quality. Dayton’s strong industry base and low cost of living also make it a great place to live and work.
As with of our all of our Emergency Medicine jobs and Hospitalist jobs that we have available across the country, these Ohio Emergency Medicine jobs come with full benefits and there are possible bonus opportunities.
Included in multiple CME courses presented on line at Hospital Physician Partners On-Line University have been the virtues of Emergency Medicine Physicians and Hospitalists taking care of themselves off the job as a key to improving our management of our on-the-job performance. Scientists from the Laboratory of Neuroscience at the National Institute on Aging have recently attempted to study whether changes in muscles prompted by exercise affect the brain’s cognitive functions. They investigated the effects of endurance factors, (a peroxisome proliferator-activated receptor δ agonist and AICAR, an activator of AMP-activated protein kinase) on memory and neurogenesis. The premise for their research was based on the finding that lab animals and people have been found to perform better on tests of cognition after several weeks of exercise. Furthermore studies have shown that endurance exercises increase the number of neurons in portions of the brain devoted to memory and learning.
Their published results showed that muscle endurance enhancing compounds improved spatial memory in sedentary mice. The behavioral enhancement may be due at least in part to increased dentate gyrus neurogenesis. In other words, the experimental animals’ brains contained far more new neurons in brain areas central to learning and memory than the brains of the control mice. These findings may lead to development of therapeutic agents that confer the benefits of exercise in conditions where activity is compromised such as in clinical practice. (Especially ones with challenging EMRs!)
In the meanwhile we owe it to our patients to take better care of ourselves. Based on these findings, exercise may make our brains better able to deal with the complex situations that pop up in many clinical cases. Maybe some of our muscle-headed colleagues really have something going after all. At the very least, science has proven that regular exercise will help prevent us from literally blowing a gasket…take it from me.
REFRENCE: Kobilo, T., Chunyan Yuan, C., van Praag, H., Endurance Factors Improve Hippocampal Neurogenesis and Spatial Memory in Mice., Journal Learn Mem., 2011 February; 18.
What has more become more of an influence on our jobs as Emergency Medicine physicians or Hospitalists than the issue of ED wait time quality metrics? A recently published blog in Health Leaders Media expounds the on two ED wait time quality metrics and the potential consequences for these published parameters which are now posted on the Hospital Compare website. The first metric is the median time between when patients enter the Emergency Department door until they leave the ED for an inpatient bed (ranging in minutes from 52 – 387). The second metric is the median time between the moment an Emergency Department doctor decides to admit patients to an inpatient bed and the time the patients actually leave the Emergency Department for that bed (ranging from 0 – 170 minutes).
Hospital Physician Partners (HPP) is very proactive, working toward leading the Emergency Medicine industry in achieving these goals by implementing the following process improvement scenarios:
1. Provider in triage; (Mid-Level Provider in triage to screen patients and make quick dispositions on simple cases while beginning workups for patients to be brought to the back for further evaluation and treatment).
2. Direct bedding for patients when empty beds are available (bypassing triage).
3. Bedside patient registration.
4. Encouraging the hospital to move to Point of Service lab testing (bedside tests available include: urine; pregnancy test; BMP;CBC; ABG; Troponin).
5. Instituting a virtual scribe program for ED’s with an Electronic Medical Record.
6. Providing specific education targeted for efficient practice methods offered on the Hospital Physicians University Continuing Medical Education and in their Provider Manual under the section: “Moving Patients in the ED”.
7. In hospitals where HPP have both ED and hospitalist programs, there are coordinated efforts to reduce boarding and expedite disposition of patients to in-patient beds.
8. We have even established a discharge staging area to free up beds where the situation permits.
The world of transparency for the efficiency of medicine is running straight into the practice of Emergency Medicine for all to see. HPP offers a comprehensive program to enhancing professional skills in the management of our patients!
With a combination of competitive compensation, an enjoyable lifestyle and excellent facilities, these exciting Emergency Medicine jobs in Arizona are great opportunities for qualified physicians:
- In Mesa, Arizona, just 20 minutes east of Phoenix, there is an opening for an Emergency Medicine Physician at a fairly active emergency department. Mountain Vista Medical center has 30 ED beds and the department sees between 25-35 thousand patients each year. Mesa is known for its focus on the arts and offers something for the entire family, including playgrounds, picnicking, local sports action, world-class resorts and plenty of fine dining. It all adds up to a great place to both make your home and further your professional career.
- At St. Luke’s Medical Center in Phoenix proper we have an immediate opening for a qualified physician. Volume at St. Luke’s is relatively light, between 15-25 thousand patients annually, but its Phoenix location will give you plenty of opportunity to utilize and expand your skills. Phoenix is also one of the most exciting cities in the West to live in, with world-class resorts, fine dining, exhilarating adventure, trendy shopping, modern nightlife and enriching culture. The area’s natural beauty offers rugged mountain ranges, Saguaro cacti that tower over relaxing hiking trails and spectacular, breathtaking sunsets.
- In Tempe, Arizona we have an emergency medicine job opening with excellent pay at a state-of-the-art facility. Tempe’s St. Luke’s Hospital has 19 ED beds and is a fairly active emergency department at 25-35 thousand patients annually. Nestled in southern Arizona with Phoenix to the west, Mesa to the east and Scottsdale to the north, Mesa is close to everything that this area of Arizona has to offer. With history, culture, shopping, dining, nightlife and more, Tempe has something for everyone.
Often our jobs as Hospitalists and Emergency Medicine physicians are to create and manage a medical record that is meaningful. With that in mind, the following are sentences extracted from patient records exactly as typed by medical secretaries in the N.H.S. (National Health Service – Greater Glasgow). The N.H.S. is the largest health board in the United Kingdom, providing healthcare to over 1.2 million people and employing more than 40,000 staff members.
1. The patient has no previous history of suicide.
2. Patient has left her white blood cells at another hospital.
3. Patient’s medical history has been remarkably insignificant with only a 40 pound weight gain in the past three days.
4. She has no rigors or shaking chills, but her husband states she was very hot in bed last night.
5. Patient has chest pain if she lies on her left side for over a year.
6. On the second day the knee was better and on the third day it disappeared.
7. Discharge status: Alive, but without my permission.
8. Healthy appearing decrepit 69- year old male, mentally alert, but forgetful.
9. Patient had waffles for breakfast and anorexia for lunch.
10. She is numb from her toes down.
11. While in A&E, she was examined, X-rated and sent home.
12. The skin was moist and dry.
13. Occasional, constant infrequent headaches.
14. Patient was alert and unresponsive.
15. Rectal examination revealed a normal size thyroid.
16. She stated that she had been constipated for most of her life until she got a divorce.
17. Both breasts are equal and reactive to light and accommodation.
18. Examination of genitalia reveals that he is circus sized.
19. The lab test indicated abnormal lover function.
20. Skin: somewhat pale, but present.
21. Large brown stool ambulating in the hall.
22. Patient has two teenage children, but no other abnormalities.
23. When she fainted, her eyes rolled around the room.
24. The patient was in his usual state of good health until his airplane ran out of fuel and crashed.
25. Between you and me, we ought to be able to get this lady pregnant.
26. Patient was seen in consultation by Dr. Smith, who felt we should sit on the abdomen and I agree.
27. The patient was to have a bowel resection. However, he took a job as a stock broker instead.
So, let’s just presume I made this whole thing up. Still we have all likely read things in others medical records that are nearly as outrageous as these statements. It is ideal, within the functionality of a medical record to “paint a picture of your patient in time.” This allows for an accurate, reliable and complete record that can be referred to and translated by any professional needing to make good decisions about the patient they are evaluating using the information within the records provided. What can we take away from these invaluable misquotations?
These statements are not particularly defensible in a court of law, and they fail to document the details that may make the difference between credibility and laughability. Undeniably, “Dictated but not read” can be a recipe for a medical record disaster that may find its way to a viral internet publication!
Hospitalist medicine is one of the fastest-growing disciplines across America today and North Carolina is no exception. Hospital Physician Partners has rewarding Hospitalist jobs throughout the state for physicians, nurse practitioners and physician assistants. We also have Medical Directorship opportunities available in North Carolina and across the United States. Here’s a sample of the exciting jobs that are open right now:
- Brevard, North Carolina is located in the western Blue Ridge Mountains and is just 30 miles southwest of Asheville and all the entertainment, dining and cultural activities that Western North Carolina destination has to offer. Here in the heart of Transylvania County against the breathtaking backdrop of the Pisgah National Forest is Johnston Medical Center-Smithfield. This 94-bed facility has openings for physicians, nurse practitioners and physician assistants. It delivers a full range of services, including: cardiology, ICU/CCU, anesthesiology, OB/GYN, home health, radiology, speech/language therapy, respiratory therapy, laboratory, wound care/ostomy and podiatry.
- Johnston Medical Center-Smithfield is located on the Coastal Plain in Smithfield, NC and the 199-bed facility also has openings for physicians and NP/PAs. This affordable community is just 30 miles east of the Research Triangle city of Raleigh. With behavioral health, urgent care, surgical services and a cancer center, the Center plays an important role in the well-being of this friendly community.
- In Louisburg, North Carolina At Franklin Regional Medical Center we have Hospitalist jobs for a full or part-time physician. Here’s your chance to work for a state-of-the art medical system that delivers comprehensive services such as cardiac care, ultrasound, radiology, laboratory, critical care, plastic surgery, imaging, OB/GYN, nephrology, orthopedics, gastroenterology, urology and pediatric. Louisburg is located in the upper Piedmont plateau of North Carolina just 30 miles northeast of Raleigh and 45 miles northeast of Durham, so it offers close proximity to the resources and great quality of life of the Research Triangle.
Remember, we also have Medical Directorship opportunities at great facilities across the country. If you’re interested in Directorships, email us at Recruiting9@hppartners.com or call us at (800) 815-8377. Click here to view the complete list of North Carolina Hospitalist jobs or view all of our Hospitalist and Emergency Medicine jobs.
A recently published study evaluated the utility of sidestream quantitative end-tidal carbon dioxide (ETCO2) measurement as a triage tool to rule out serious illness in the emergency medicine triage process. NOW STAY WITH ME AS THIS IS ACTUALLY INTERESTING AND REALLY PERTINENT TO YOUR PRACTICE!
This adequately controlled and designed study collected ETCO2 samples from every other patient presenting to an ED that had been assigned triage acuity levels of 2 through 4. Using 30 control subjects and 320 study subjects they collected data and subsequently correlated vital signs, discharge diagnostic criteria (i.e. respiratory, metabolic etc.) ETCO2, and patient disposition data. The highlights of this study’s findings included the results that one in two subjects with normal vital signs and abnormal ETCO2 were admitted. One in 6 (10 with adjusted data) subjects with normal vital signs and normal ETCO2 were ultimately admitted. Lastly, ETCO2 readings outside the accepted range correlated with the need for patient admission. They concluded that ETCO2 may be a sensitive indicator of illness or injury and is predictive of the need for admission. Additionally, “Routine measurement of ETCO2 may contribute predictive information about severity of the disease process that may be missed by current standard vital signs.”
Let’s consider how this can fit into the Emergency Medicine and Hospitalist’s management of our patients. We are the providers ordering the measurement and interpreting its results. Certainly this gives us first hand insight on the potential severity of illness of the patient we will be caring for. Furthermore it can give us the awareness that there may be a need for more aggressive, attentive or individualized patient care. Clearly the discovery of an abnormal level in the patients’ evaluation produces an obligation to relay the significance of this data to the admitting MD for these patients.
The take home message: Here is scientific evidence of another potentially valuable use for ETCO2 in our diagnostic armamentarium. Make sure you are the most knowledgeable and accurate resource for both obtaining and interpreting this critical physiologic data point as you are often the resource that can save the patient’s life or at the very least are responsible for improving the efficiency of their evaluation and their overall quality of care.
Reference: Sidestream Quantitative End-Tidal Carbon Dioxide Measurement as a Triage Tool in Emergency Medicine, D. Williams, T. Morrissey, D. Caro, R. Wears, C. Kalynych : Annals of Emergency Medicine – ANN EMERG MED , vol. 58, no. 4, pp. S212-S213, 2011
Hospital Physician Partners has three immediate openings in West Virginia for qualified physicians seeking a rewarding job in Emergency Medicine. All of the jobs come with full benefits and also may have bonus opportunities. The openings are in these areas of the state:
- In Beckley there is an exciting opportunity at the Beckley ARH Hospital. The 26-bed emergency department treats 22,000 people annually and this full-time position requires that you work 144 hours per month. The Beckley market area includes over 200,000 people and offers beautiful state and national parks, great dining and shopping.
- Over in Oak Hill there is an immediate opening for an Emergency Medicine Physician at the Plateau Medical Center. Services available to ER patients include, but are not limited to, Respiratory Therapists, Laboratory and Diagnostic Imaging. Oak Hill is a growing city with a small-town feel and is home to some of the best-know attractions in West Virginia, including the New River Gorge Bridge.
- At the Greenbrier Valley Medical Center in Ronceverte, West Virginia, there is an opportunity for an Emergency Medicine Physician at a facility that offers an extensive array of medical, surgical and outpatient services. ER patient volume is between 15 and 25 thousand annually, providing an essential service to this historic city situated on the gently flowing Greenbrier River.
Throughout the Tar Heel State, in some of the best places to live in North Carolina, we have Emergency Medicine jobs available for physicians, nurse practitioners and physician assistants:
- In Brevard, North Carolina, near the beautiful Blue Ridge Mountains, we have an opening for an Emergency Medicine Physician at a state-of-the-art emergency department. Transylvania Community Hospital has 10 ED beds and 94 hospital beds and sees between 15-25 thousand patients a year in its ED. Brevard is just 30 miles southwest of Asheville, NC and within a couple of hours of Charlotte so you’ll have the best of all worlds – breathtaking scenery, outdoor activities and plenty of entertainment nearby.
- At the Johnston Medical Center-Smithfield in Smithfield, NC we have great emergency medicine job opportunities for physicians, nurse practitioners and physician assistants. This is a fast-paced, professional environment with an annual emergency department volume of more than 50 thousand and the career rewards are many. Smithfield offers you comfortable and affordable accommodations, outstanding “Southern-style” restaurants, five area heritage museums, annual festivals and the largest selection of outlet stores in the state at Carolina Premium Outlets.
- In Washington, North Carolina we have an excellent emergency medicine job opening for a physician at a recently renovated facility with great mid-level support – and that means a rewarding job with less stress for you. Beaufort County Hospital has 149 beds and delivers a full range of services while its Eastern Carolina location offers affordable living, culture and a wide range of activities.
- Blue Ridge Regional Hospital, as its name implies, is located in the heart of the Blue Ridge Mountains in Spruce Pine, North Carolina. This facility has emergency medicine jobs available for qualified physicians, nurse practitioners and physician assistants. Spruce Pine is just an hour’s drive from Asheville and has plenty to offer close to home, including craft studios and galleries, the renowned Penland School of Crafts and the Museum of North Carolina Minerals.
- We have even more opportunities in great North Carolina communities such as Linville, Louisburg, Thomasville and Wilson, so be sure to check out all of the Emergency Medicine jobs available in North Carolina.
All of our North Carolina Emergency Medicine jobs come with full benefits and many have bonus opportunities. Click here to see the complete list of North Carolina Emergency Medicine jobs or browse our entire list of Emergency Medicine and Hospitalist Medicine jobs.
The National Hockey League postseason playoffs have started. Even pro ice hockey offers us some published scientific research we can chew on. A recently published study in the Annals of Emergency Medicine expounded on the results of 1,300 consecutive fights to determine if there is a different rate of metacarpal fractures when punches are thrown by 2 professional hockey players on ice compared to a control sample of similar patients who traded punches on land. (Now stay with me on this as we do see both groups of patients in our practices and this article will get more interesting.) How did they faire? The injury rate was 1.12% (17 injuries) and only 5 of the 17 were metacarpal injuries for an injury rate of 0. 33%, while the land fighting metacarpal injury rate was a whopping 81%!!! Combatants in the NHL group landed 11.5 punches per fight compared to only 3.5 in the land cohort.
Additionally, the concussion rate was 0.39% for on ice fighting compared with the nearly 4.5% relative closed head injury risk per game from checking (aka ‘hitting’; defined as a number of defensive techniques used to separate the player from the puck).
Yet the rash of head injuries plaguing the sports world and the community is large and of importance to both of our professions. Since a head injury happens every 15 seconds and a patient dies of a traumatic brain injury (TBI) every 12 minutes we have a lot to learn from this venue for our patients.
So what has ice hockey research proposed? A group of scientists (Dr. Fisher, senior scientist in human physiology at Toronto General Research Institute, Univ. of Toronto; Dr. Smith, Univ. of West Virginia, Dr. Bailes brain injury expert for NFLPA, whose findings have been accepted for publication in the medical journal “Neurosurgery”), are working to develop a collar that would ‘increase’ blood flow to the head and keep the brain movement to a minimum. This collar slightly restricts venous return from the brain which would effectively give the brain an increased volume allowing less room to “slosh around” The pressure being applied by this collar is no more than a “tight collared shirt”. When they fitted rats with these collars and inflicted a “standard TBI” to the rats, the ones wearing collars had an overall brain injury reduction of 82.7% compared to the non-collared TBI rats!
In speaking with contemporary respected neurosurgeons at a regional trauma center in Southern California, the primary concern was the consequences due to the established alterations in the normal circulatory balance and its localized effects on intravascular pressures and venous/capillary/blood brain barrier permeability with these collars in place at the time of the TBI. In particular they have concerns over the short and long term sequelae related to the potential pathophysiology induced by said collars on significant TBIs. This is especially concerning to these surgeons since TBIs are not standardized.
So sit back and enjoy the Stanley Cup Playoffs in high definition (the only way to watch ice hockey unless you’re there in person) while personally gathering the real time study data the players continue to develop for you during the games. Perhaps even ice hockey can teach medicine a couple of things these days.
Results of 1,300 Consecutive NHL Fights: Fists of Fury with Minimal Injuries
Annals of Emergency Medicine, Volume 58, Issue 4, Page S330
K. Pasternac, D. Weiner, D.P. Milzman
First, let me say congratulations to the Society of Hospital Medicine (SHM) for a great 2012 national conference. SHM is a professional medical society representing more than 10,000 of the 30,000 practicing hospitalists in the United States. They recently held thier annual national conference April 1-4 in San Diego, California. If you have been to or participated as a vendor in these types of conferences, you know it’s sort of a cross between speed dating, a county fair, lunch at Charlie Palmers (a power broker place to meet in Washington DC), the lecture hall, and the hallways of your hospital. In otherwords, there is alot of meetin’, greetin’, sellin’, and learnin’ going on. As an exhibitor and sponsor, Hospital Physician partners’ primary goal at the conference was to meet and network with Physicians, Nurse Practitioners, and Physician Assistants either currently or soon to be seeking Hospitalist Jobs. In short to recruit new team members for our programs across the country and introduce the HPP brand to practitioners in the industry.
I can only speak for our company, but hats off to SHM for setting up the conference so we could accomplish our goal. This was by far the most successful conference we have attended with SHM. The weather was amazing. (It is San Diego afterall!) The exhibit hours were pretty good. The conference hall was navigable and easy to access and the SHM staff was easy to work with. Most importantly, we met alot of quality Hospital Medicine Physicians. Admittedly, we had a great location. (Booth 201 right up front)
I won’t spill our secrets, less our competitors read this (haha), but we actually had doctors hanging out in our booth. There was a general interest not only in our services, but also in talking about the industry. This is something I have noticed about Hospitalists, especially at Hospital Medicine conferences such as this, they are much more willing to engage exhibitors than many other clinical professions. Perhaps it’s the natural tendency towards bedside manner, patience, friendliness, and subsequent gentle touch. Or maybe we just had really cool giveaways. Either way, the attendees at this years Hospital Medicine 2012 were considerate, engaged, enthusiastic, and interested.
Again, thank you to SHM and all of the Hospitalist Physicians, Nurse Practitioners, Physician Assistant and administrators who visited us. We look forward to Hospital Medicine 2013 in National Harbor, MD. Guaranteed, Hospital Physician Partners will bring our swag (promo items), our great team, our energy, and our unique brand of approachability; and hopefully we’ll attain even greater success than we had this year.
As an Emergency Medicine physician, you probably know that of the nonfatal, unintentional, non – fire-related carbon monoxide (CO) poisoning cases treated in emergency departments, most are caused by furnaces. The remainders are followed by motor vehicles, stoves, gas lines, water heaters, and generators. Males represent an overwhelming 74% of unintentional non – fire-related deaths. Interestingly, intentional fatalities seem to show that race-specific rates for all racial groups are 87% lower than for whites. Fatality rates increase with age and are highest in the population greater than 65. Nonfatal exposures are more common in older teens and young adults (15-34) and are most common in young children (0-4). Patients with chronic obstructive pulmonary disease tolerate CO intoxication poorly and it is harder for them to tolerate treatment. Neonates and fetuses are more vulnerable to CO toxicity because of the leftward shift of the dissociation curve of fetal hemoglobin, a lower baseline PaO2, and levels of HbCO at equilibration that are 10-15 higher than maternal levels.
CO toxicity impairs oxygen delivery and utilization at the cellular level. It therefore has the most profound impact on the organs with the highest oxygen requirement. Toxicity is caused primarily from cellular hypoxia due to impairment of oxidative phosphorylation and electron transport. CO reversibly binds hemoglobin which effectively causes a relative anemia. It binds hemoglobin 230-270 times more strongly than oxygen. A room with a CO level of 100 ppm can cause a HbCO of 16% at which is enough to produce clinical symptoms. The binding of CO to hemoglobin causes an increased binding affinity of oxygen molecules on the other 3 hemoglobin oxygen-binding sites. This causes a leftward shift in the oxyhemoglobin dissociation curve further lowering the availability of oxygen to the issues. CO binds to cardiac myoglobin with an even greater affinity than to hemoglobin resulting in myocardial depression and worsening hypotension. Studies have shown that CO may cause inflammatory changes in the brain. Following severe intoxication, patients do display central nervous system (CNS) pathology, including white matter demyelination. This leads to edema and focal areas of necrosis.
Symptoms typically begin with headaches at levels around 10%. Levels of 50-70% may result in seizure, coma, and death. Misdiagnosis is common. Because of how vague and varied the complaints are, symptoms often are attributed to a viral illness. Therefore, asking about possible exposures is important. This is even more important in the winter months. Another clue can be recognizing when more than one patient in a house presents with the same complaints. Remember, severity of symptoms may not correlate well with HbCO levels. The most common symptom is usually headache (37%) followed by dizziness (18%) and nausea (17%).
Physical examination is not very helpful because there is no one defining feature pointing to the diagnosis. Inhalation injury or burns should always make one consider the possibility of CO exposure. Vital signs would be consistent with a nonspecific acidosis and metabolic derangement; tachycardia, hypertension or hypotension, hyperthermia, and tachypnea. The classic skin sign of cherry red is rare because pallor is actually more common. The chest x-ray may be negative or show non-cardiogenic pulmonary edema. The most common abnormality on an electrocardiogram is sinus tachycardia. Arrhythmias may be secondary to hypoxia, ischemia, or infarction. Patients may have memory problems including retrograde and anterograde amnesia and may even confabulate. They demonstrate emotional lability, impaired judgment, and decreased cognitive ability. Stupor, coma, gait disturbance, movement disorders, and rigidity may be present. Long-term exposures or severe acute exposures can lead to long-term neuropsychiatric problems. Some individuals even develop delayed neuropsychiatric symptoms several days to weeks later. Patients with preexisting heart disease can experience increased exertional angina with HbCO levels of just 5-10%. At high HbCO levels, even young healthy patients develop myocardial depression. Nontraumatic rhabdomyolysis can result from severe CO toxicity and can lead to acute renal failure. Lactic acidosis, hypokalemia, and hyperglycemia may be seen with severe intoxication. Methemoglobinemia should be considered in the differential diagnosis of cyanosis with low oxygen saturation but normal PaO2. Chronic exposures may present with a loss of dentition, gradual-onset neuropsychiatric symptoms, or recent problems with cognitive ability. Two thirds of all acutely exposed patients eventually recover completely.
HbCO absorbs light almost identically to that of oxyhemoglobin. Although a linear drop in oxyhemoglobin occurs as HbCO level rises, pulse oximetry will not reflect it. Pulse oximetry gap, (the difference between the saturation as measured by pulse oximetry and one measured directly), is equal to the HbCO level. Pulse CO-oximetry units are available which can screen for CO toxicity at the bedside. Patients need immediate and continuous 100% oxygen therapy until the patient is asymptomatic and HbCO levels are below 10%. In patients with cardiovascular or pulmonary compromise, lower thresholds of 2% are recommended. One can calculate an estimate of the necessary therapy duration by using the initial level and half-life of 30-90 minutes at 100% oxygen FIO2. In uncomplicated intoxications, measuring venous HbCO levels and oxygen therapy are sufficient. HbCO analysis requires direct spectrophotometric measurement in specific blood gas analyzers. Bedside emergency department pulse CO-oximetry requires a special unit and is not a component of routine pulse oximetry. Elevated levels are significant; however, low levels do not rule out exposure, especially if the patient already has received 100% oxygen or if significant time has elapsed since exposure. Individuals who chronically smoke may have mildly elevated CO levels as high as 10%. Presence of fetal hemoglobin, as high as 30% at 3 months, may be read as an elevation of HbCO level to 7%. When interpreting an arterial blood gas, PaO2 levels should remain normal. Oxygen saturation is accurate only if directly measured, not if calculated from PaO2, common in many blood gas analyzers. One can estimate PCO2 levels by subtracting the carboxyhemoglobin (HbCO) level from the calculated saturation. PCO2 level may be normal or slightly decreased.
CO is eliminated through the lungs. The half-life of CO at room air temperature is 3-4 hours. One hundred percent inspired oxygen reduces the half-life to 30-90 minutes. Hyperbaric oxygen therapy (HBO) for the treatment of CO poisoning is controversial. There is a true, increased rate of elimination of HbCO. Certain studies demonstrate large reductions in delayed neurologic sequelae, cerebral edema and pathologic central nervous system (CNS) changes. But with all those positive findings, systematic reviews have not revealed a clear benefit of HBO, so no clear guidelines for its use have been determined. Furthermore universal treatment criteria do not exist. The most common selection criteria for use of HBO (regardless of HbCO level) include coma, transient loss of consciousness, ischemic ECG changes, focal neurologic deficits, and abnormal neuropsychiatric testing. HBO at 3 atm raises the amount of oxygen dissolved in the serum to 6.8% which can maintain cerebral metabolism. This reduces the elimination half-life to 15-23 minutes. Treatment regimens are usually provided at FIO2 of 100% at 2.4-3 atmospheres for 90-120 minutes Hyperbaric oxygen at 2.5 atm with 100% oxygen reduces it to 15-23 minutes. Hyperbaric therapy should be considered immediately for patients with levels above 40% or cardiovascular or neurologic impairment. Additionally, persistent impairment after 4 hours of oxygen therapy necessitates transfer to a hyperbaric center. Pregnant patients with carboxyhemoglobin levels above 15% should be considered for hyperbaric treatment.
Since sudden death has occurred in patients with severe arteriosclerotic disease at HbCO levels of only 20%, all patients require continuous monitoring. Serial neurologic examinations, including funduscopy, CT scans, and, possibly, MRI, are important in detecting the development of cerebral edema which require intracranial pressure and invasive blood pressure monitoring to guide therapy. Head elevation, mannitol, and moderate hyperventilation to 28-30 mm Hg PCO2 are indicated in the initial absence of ICP monitoring. Acidosis should improve with oxygen therapy. Patients with HbCO levels of 30-40% or above 25% with associated symptoms will usually be admitted.
We have Emergency Medicine jobs available for doctors, nurse practitioners and physician assistants in four great Mississippi communities — Bay St. Louis, Booneville, Columbus and Oxford:
- Hancock Medical Center is a new state-of-the art facility located in Bay St. Louis, a beach community on Mississippi’s Gulf Coast. This beautiful, quaint, beach town has both a fantastic cost of living and a solid economic base, with employers that include: NASA, 2 casinos, 2 plastic plants, Calgon Carbon and Dupont Chemical. Doctors and nurse practitioners and can enjoy rewarding emergency medicine jobs while working with a great team and a highly educated and insured patient population.
- In the Northeast corner of Mississippi in the town of Booneville we have an opening for an Emergency Medicine Physician. Booneville is just 100 miles southeast of Memphis and is near the Bay Springs Lock and Dam area where there is plenty of swimming, boating and fishing to enjoy. With breathtaking beauty along the Natchez Trace Parkway and exciting history throughout nearby Tishomingo State Park, Booneville offers area residents plenty of things to do year-round.
- Oxford is the home of the University of Mississippi and here we an opportunity for an Emergency Medicine Physician at beautiful facility — Baptist Memorial Hospital – that is situated just off the Ole Miss campus. Oxford has plenty of activities for the entire family, from Ole Miss football games on campus to fun city festivals downtown.
- For physicians and nurse practitioners we have Emergency Medicine jobs available at Baptist Memorial Hospital in the vibrant town of Columbus. Columbus is located 120 miles west of Birmingham, AL and was named one of Mississippi’s Dozen Distinctive Destinations. It’s a vibrant town that preserves the past and promotes the future with historic homes, a great Southern atmosphere and community events.
Full benefits are available and many of these Emergency Medicine jobs come with bonus opportunities. Click here to browse Hospital Physician Partners’ entire list of Emergency Medicine and Hospitalist Medicine jobs.
Located just 60 miles west of the First Golf Course in the US, Beckley is the largest city in southern West Virginia and its market services more than 200,000 people. Beautiful state and national parks offer plenty of skiing, hiking, fishing, and camping; with all that, Beckley also offers great dining, shopping and the lowest crime rate in the country. Did we mention the climate? Enjoy near perfect temperatures of high 70s in the summer & high 30s & 40s in the winter. Not too hot and not too cold! It’s easy to see why the city Beckley is a great place to live and work! Learn more about Beckley here
Beckley ARH is a 173 bed Acute Care Hospital & Level IV Trauma Center with 26 ED beds – 10 of which are for patients pending admission. It plays a critical role in the health of the local community and you’ll be working with a great staff. Services here include: AIDS complex, CT scan, Alcohol/Chemical Dependency – Inpatient Home Health, ICU, Lithotripsy, MRI, PET, Nuclear Medicine, Pediatrics, Ultrasound, and Inpatient Wound Care.
For our Emergency Medicine Job the Beckley ARH Hospital ED will be treating 22,000 patients annually. You would have the benefit of certified mid-level coverage from noon to midnight daily. The combination of access to full group Health & Benefits working at a distinguished 173-bed facility and the chance to live in a friendly community make this an opportunity you won’t want to miss.
For our Hospitalist Medicine Job you can work a 7 on and 7 off schedule and have a variety of services at your fingertips including AIDS complex, CT scan, Alcohol/Chemical Dependency-Inpatient Home Health, ICU, Lithotripsy, MRI, PET, Nuclear Medicine, Pediatrics, Ultrasound and Inpatient Would Care. Enjoy living in this affordable community, working with a top-notch staff and our attractive benefits
These Emergency Medicine & Hospitalist jobs in Beckley, WV are exceptional opportunities that won’t last long! Apply Now or contact a recruiter firstname.lastname@example.org . To see all of our Emergency Medicine and Hospitalist jobs throughout the United States, click here.
A recently published study evaluated the ability of CT to detect clinically significant injuries missed on chest X-Rays in blunt trauma patients1. In this study they found chest CT detected significant intra-thoracic injury in 13.6% of cases not seen on plain CXR. Forty percent of these injuries required chest injury management changes! After crunching the numbers they found that 5.5% of all cases where chest CT was performed led to chest injury management changes not seen on CXR.
They concluded that “although chest CT frequently detects injuries missed on CXR in blunt trauma patients, it rarely changes patient management. Given this low yield and the concerns for radiation cost and ED crowding they are developing a clinical decision instrument for selective chest CT in blunt trauma.” We all acknowledge that trauma medicine is inherently high-risk (especially for the patient). Furthermore, none of us want to hear THAT QUESTION: “Remember that patient you saw the other night?” Let’s consider the potential consequences if one was to take away from this study that since the CT findings rarely lead to management we should consider not performing that CT. Which one of us would like to be a member of the 40% patient group which would not receive management changes to a significant intra-thoracic chest injury if our doctor decided to take the conclusion prematurely to heart?
The take home message: Within all of the fine emergency medicine peer reviewed literature, one must still beware of new trends and old traditions. We have to place studies like these into perspective. It is our responsibility to practice in a method which has been shown to be best for the patient until a new clinical decision instrument becomes the standard of care. Otherwise we could find ourselves in a TICU from a car accident, wondering if we were unfortunate enough to be one of those 5.5% of all cases that the trauma service was no longer looking for due to a new protocol that hasn’t met the test of time.
Reference: Does Chest CT Detect Clinically Significant Injuries Missed on Chest X-Rays in Blunt Trauma Patients? — B. Kea, San Francisco General Hospital; University of California, San Francisco, School of Medicine. Scientific Assembly 2011 Conference, 10/15-10/18. ACEP
Hospital Physician Partners has a great Hospitalist job opportunity in Michigan that you’ll want to check out in Three Rivers — offering a compensation package worth up to $285,000 with bonuses and benefits.
Three Rivers Health, a 60-bed community hospital, has an immediate need for a Hospitalist Physician who is board-certified in Internal Medicine. This excellent facility offers a full range of services, including allergy & immunology, anesthesiology, cardiology, gastroenterology, family practice/GP, infectious disease, neurology, internal medicine, oncology, pediatrics, orthopedics, radiology, urology and OB. You’ll have a chance to have a real impact on the health of the community and work with a great support staff.
Best of all, you can take advantage of Hospital Physician Partners’ “Base Pay Plus” monthly bonus payouts. With this incentive program you get predictable income and bonuses paid within 30 days, putting cash in your pocket quickly and consistently.
While performing our jobs as Hospitalists and Emergency Medicine physicians, we are often required to estimate a patient’s weight to order medications for critical situations such as during management of a resuscitation or a time-critical case. I have always felt confident in my own and my colleagues’ ability to look at that patient and come efficiently close to the actual weight.
Perhaps this confidence is unfounded. An abstract published in the Annals of Emergency Medicine: Accuracy of Body Weight Estimates in Acute Emergency Department Stroke Patients, compared actual versus estimated weight determinations performed by the EDMDs and Neurologists caring for these patients. While 90% of the estimates were within +/- 0.20 mg/kg, the study concluded that 10% of patients enrolled in the study had the potential to receive a clinically relevant overdose or under-dose of TPA. Furthermore, the patients had an equal potential to be overdosed versus under-dosed. The authors went on to say that based on this initial analysis, they recommended all patients have their weight measured by scale prior to receiving that weight sensitive medication. Of note, the total patient sample number was low (N = 61).
The study raises a valid point for the physician ordering medications with narrow therapeutic indices. Obviously, the Hospitalist or EDMD needs to generate these orders accurately while maintaining care standards. Maybe “the eyes are bigger than the stomach” idiom applies to ordering for these patients too!
1. RAIO C et al., Accuracy of Body Weight Estimates Acute Emergency Department Stroke Patients. North Shore-LIJ, Manhasset, New York
A few weeks ago, I read a blog post which raised a discussion about hand washing in the ED. It was prompted by an article published in EP Monthly in which the author discussed concerns on regulations related to how much hand washing should be required of an Emergency Medicine Physician or Hospitalist as part of their job.
It has been stated by experts in the field of microbiology and immunology that 80% percent of all infectious diseases are transmitted by direct and indirect contact; direct meaning such as kissing and indirect meaning such as shaking someone’s hand. On the other hand (pardon the pun), many studies have found that only a small portion of bacteria on donor hands is recovered on the recipient’s hands. With this information to consider, we need to take a close look at the other side of the coin. A 2011 study from Case Western Reserve University School of Medicine titled, Evaluation of Patient Hygiene Practices During Emergency Department Visits, sheds light on the hands we shake in the ED.
The conclusion was that patient-reported hand washing following potential contact with their bodily fluids after vomiting, urinating or defecating during their ED visit was low. This included only 13% after defecating at bedside and 62% after defecating in the ED restroom. With that in mind, one can see the landmines faced trying to treat people with respect, warmth, and decency through a warm handshake while practicing favorable customer service practices.
That friendly handshake truly has the potential to provide a gift that keeps on giving to you, everyone, or everything you touch until you decontaminate your appendage! This study’s findings certainly support the recommendations from the CDC regarding hand washing following each patient contact even if it is no more than a hello thank you or goodbye. If this knowledge doesn’t propagate self-motivation for the practice of frequent hand washing after casual friendly handshake, nothing will.
Luz J Cydulka et al/ Case Western Reserve University School of Medicine, Cleveland OH: MetroHealth Medical Center, Cleveland, OH
Over the past week, we have once again been reminded of the terryifying power tornados possess. The tornadoes in West Virginia and the shock of the level of destruction throughout the midwestern and southeastern parts of the Unites States has still not worn off for many. For those in the affected town, cities, and communities, the wounds are still so raw, it may be months before the trauma fades and some sense of normalcy resumes. In times like this however, resiliency finds its way into the voices, hearts, minds and bodies of the survivors and our citizenry. People can do extraordinary things in extraordinary times. Communities rise, people plant thier feet firmly in the foundation of service, and healing begins.
(Photo: Scott Olson/AFP)
One of the affected communities was West Liberty, Kentucky, home to Morgan County ARH Hospital, a long-time HPP client. While damage is still being assessed, the destruction is extensive. As a company, we are assisting in providing additional clinical support. At times like this, we appreciate the desire for our partners to provide support and assistance to those in need. Should you desire to help, there are two links available to you which are safe and secure:
The Hospital Physician Partners family sends our deepest thoughts and prayers to all who have been affected by the recent tornadoes.
Hospital Physician Partners has great Emergency Medicine jobs available for physicians, nurse practitioners and physician assistants at emergency departments we manage throughout the Sunshine State. These opportunities in communities like Sebring, Milton and Lake Wales combine easy access to Florida’s attractions with affordability and a great lifestyle:
- In the historic community of Sebring, world-renowned for its Formula One racing, we have Emergency Medicine job openings for both physicians and NP/PAs. This full-service, 126-bed facility plays a critical role in the health of the local community and you’ll be working with a great staff. Sebring’s central location gives you easy access to Orlando, fun water activities on hundreds of lakes and all that Florida has to offer.
- Also in Central Florida, physicians and nurse practitioners can take advantage of exciting Emergency Medicine job opportunities at Lake Wales Medical Center. Lake Wales is rich in Florida culture and history with unique architecture, diverse accommodations, charming shops and restaurants along with outdoor and recreational attractions. The chance to live in this friendly community and work at this excellent 160-bed facility is an opportunity you won’t want to miss.
- In the town of Milton on Florida’s Panhandle we have Emergency Medicine jobs for physicians, nurse practitioners and physician assistants. Twenty minutes from Pensacola, the Milton/Pace area has the nearby Gulf beaches to the south and beautiful countryside for fishing, hunting camping, canoeing and hiking. Also, access to great dining and shopping is only a short drive away. Enjoy living in this affordable community and working with a top-notch staff.
If you’re looking for Emergency Medicine Jobs in Kentucky, we have immediate opening for physicians, nurse practitioners and physician assistants at emergency departments that we manage across the Bluegrass State:
- At Jennie Stuart Medical Center in Hopkinsville, Kentucky we have emergency medicine jobs available for physicians, nurse practitioners and physician assistants. Hopkinsville is located at the Kentucky-Tennessee border just 45 minutes from Nashville and maintains its small-town charm while proactively pursuing initiatives to ensure a skilled workforce, attractive opportunities for business, residential and tourism growth and a safe, clean community that everyone is proud to call home. Here you’ll have a chance to join an expert team of caring medical professionals at a first-class facility.
- In Hazard, Kentucky, we have Emergency Medicine jobs for both physicians and nurse practitioners. At Hazard ARH Medical Center we have an excellent opportunity for an Emergency Medicine Physician. ARH Medical center is a 308-bed, acute-care and psychiatric hospital and enjoys a reputation of excellence as a patient-oriented, rural health facility. Also in Hazard, Kentucky, we have emergency medicine job openings for nurse practitioners and physician assistants at ARH Hospital. This facility has a 13-bed emergency department with an annual volume of approximately 26,000 patients. Here’s an excellent opportunity for new graduates looking to pursue an Emergency Medicine career as candidates will be considered without any prior emergency medicine experience!
- Over in Middlesboro, Kentucky, at Middlesboro ARH Hospital we have an immediate job opening for an Emergency Medicine Physician. This 96-bed facility offers an aeromedical heliport, case management, CT scan, home health, ICU, laser surgery, MRI, labor & delivery and outpatient services, plus pediatrics and ultrasound. Middlesboro is located in southeastern Kentucky, just a short drive from Knoxville and its shopping, dining and big city events, while at the same time has breathtaking views of the Cumberland Gap National Historic Park and Pine Mountain State Park.
We also have Kentucky Emergency Medicine jobs in Fulton, Hyden, McDowell, South Williamson, West Liberty and Whiteburg. In addition, we have Emergency Medicine jobs and Hospitalist jobs available across the United States. Click here to view.
As if our jobs as Hospitalists or in the field of Emergency Medicine couldn’t get any more interesting…on 12/29 the USA Today published an article that is beckoning us to welcome the informed public. Advertised as “may be the difference between life and death when it comes to medical emergencies”! It goes on to tell the reader that stroke victims who get the proper treatment “within 60 minutes could reduce or even prevent lasting damage”. So now there’s an app to help you locate the emergency medical center closest to you anywhere in the world. The Emergency Medical Center Locator is a free i-Phone app that uses GPS in your phone to offer the user a list of names and addresses of the closest medical centers. The app contains addresses for hospitals in 101 countries including Europe and South America.
Interestingly only medical centers certified by the American College of Cardiology and American College of Surgeons are included. The app offers recommendations for facilities with the best patient outcomes in the fields of trauma, stroke, eye, pediatric, cardiac and burns. The writer touted the app as “vital when emergency rooms are equal distances in order to allow you to choose the center that specializes in treating your particular health problem”.
How many times have you been at work and begin having an acute vertebral artery dissection with a brainstem TIA and a cerebellar stroke and decided to dive into your i-phone to determine which hospital has the best invasive neuro-radiologist on staff to stent your artery? In point of fact, who knows, maybe the general public will all have this app and we will never have to worry about EMTALA or transfer a high acuity patient again.
I dare you to find me more than a handful of Hospitalists or Emergency Medicine Physicians that haven’t, on occasion, had coffee on the job or somewhere related to working a shift. Caffeinism manifests as anxiety, agitation, restlessness, insomnia, nausea, vomiting, diarrhea, palpitation and a fast heart rate. Because caffeine can have addictive potential, its withdrawal can produce headaches, irritability, lethargy and occasional nausea. Heartburn and reflux are commonly accepted side effects (even I’ll attest to that). Old studies showed high consumption of unfiltered coffee was associated with mild elevations in cholesterol levels and that two or more cups of coffee a day could increase the risk of heart disease in people with a specific, fairly common genetic mutation that slows the breakdown of caffeine in the body.
But have no fear as a study in Fudan University in Shanghai found that one extra cup of coffee a day correlated with a 3% reduced risk of a broad list of cancers. It turns out that steaming cup of java is the number one source of antioxidants in the U.S. diet according to a study by researchers at the University of Scranton, PA. Coffee came out on top, on the combined basis of both antioxidants per serving size and frequency of consumption (interestingly, of all the foods and beverages studied, dates actually have the most antioxidants of all based solely on serving size).
Furthermore, for the male sex, the Harvard School of Public Health relayed results of the 20-year look at nearly 48,000 men which showed that those who drank 6 or more cups of coffee daily were 18% less likely to get prostate cancer than non-drinkers and 60% less likely to die from it. Drinking even one to 3 cups daily lowered the risk of dying by 29%. The good news is that caffeine was not the secret ingredient. Men drinking decaf benefited equally as those drinking caffeinated coffee.
So in addition to the reported reduced risk of type 2 diabetes (Australian research) and the slowing of cognitive decline, males may have found a therapeutic reason to Joe before, during, and after work. Who knows, maybe this profession will show the male cadre the management keys to longevity as opposed to the doctors aging before their time.
Hospital Physician Partners has immediate Hospitalist Job openings at three emergency departments that we manage in Kentucky:
- In Flemingsburg, Kentucky at Fleming County Hospital there is an excellent Hospitalist job opportunity for a physician Board Certified or Board Eligible in IM or FP. This facility was established in 1962 and a new replacement facility opened in 2008. The new hospital features many private rooms, expanded operating rooms, a larger Emergency Department, new state-of- the-art MRI equipment and many other improvements. The friendly town of Flemingsburg is located in northeast Kentucky in the heart of Fleming County, just two hours from Cincinnati. A city that’s full of heritage, it’s surrounded by historic buildings, beautiful rolling farmland, lovely old wooden covered bridges and antique shops. There are plenty of outdoor activities as well, including golf, fishing, camping, swimming, tennis, hiking, hunting and boating.
- At Appalachian Regional Medical Center in Hazard, Kentucky, we have Hospitalist jobs for both physicians and nurse practitioners. This center is a 308-bed, acute-care and psychiatric hospital and enjoys a reputation of excellence as a patient-oriented, rural health facility. You’ll enjoy working with a great team and living among the beautiful mountains of Hazard on the North Fork of the Kentucky River. Hazard has everything from great fishing, hunting and camping to a wonderful heritage, strong education system and low cost-of-living.
- In Middlesboro, Kentucky, at Middlesboro ARH Hospital we have an opening for a Hospitalist Physician. This 96-bed facility has services that include aeromedical heliport, case management, CT scan, home health, ICU, laser surgery, MRI, labor & delivery, outpatient services, pediatrics and ultrasound. Middlesboro is located in southeastern Kentucky, just a short drive from Knoxville, and is a great place to call home. The city offers beautiful views of both the Cumberland Gap National Historic Park and Pine Mountain State Park.
All of the Hospitalist jobs we have available in Kentucky come with full benefits and there are possible bonus opportunities. We also have Emergency Medicine jobs and Hospitalist jobs available across the United States. Click here to view.
Often our jobs as Hospitalists and Emergency Medicine Physicians involve having to face patient questions stemming from their fears of contracting and dying from west Nile virus, the bird flu or the swine flu. We know they are all victims of the press telling them how deadly these illnesses are to the public because they are constantly bombarded with sensationalism in the mass media effectively designed to induce frenzy and hysteria.
To put these diseases into perspective for these people, tuberculosis (TB) is one of the world’s deadliest diseases. It is estimated that one-third of the world’s population are infected with TB (according to the CDC). In 2010, nearly 9 million people around the world became sick with TB. There were around 1.4 million TB-related deaths worldwide. Malaria i s another deadly disease, causing about 250 million cases of fever and approximately one million deaths annually.
Attempt to allay the fears of the relatively rare, inconsequential, over-hyped diseases by bringing these ideas into the forefront of knowledge for these patients. Of the 690 West Nile Virus cases reported in the US in 2011, there were ONLY 43 deaths. The “deadly” strain of bird flu known as H5N1 has infected 565 people worldwide since 2003. Of these, only 331 have died. Official figures show there were about 562 deaths linked to the H1N1 virus during the most recent “season” , compared with 474 deaths in the global outbreak of 2009.
Something of encouragement to us all was recently reported regarding the global management of malaria. In October of 2011, GlaxoSmithKline announced that, as noted in a large trial which will run until 2014, its new malaria vaccine has cut infection rates in half. Its effectiveness appears to be due to the combining of the hepatitis B vaccine with the malaria vaccine which appears to boost the immune response to the malarial particles in the vaccine by 50%.
Hospital Physician Partners has rewarding Emergency Medicine Jobs at two excellent emergency departments that we manage in Ohio:
- In Dayton, Ohio, we have Emergency Medicine job openings for physicians at Southview Medical Center plus Grandview Hospital and Medical Center. Grandview is the more active of the two rooms, seeing 25 to 35 thousand patients a year. The Emergency Medicine job opening at Southview can be either full or part-time and this 12-bed ED sees between 15 and 25 thousand patients a year. Dayton is home to several Fortune 500 companies and encourages innovation, with more patents per capita than any other city in the nation. Its own international airport and a lower than average cost of living are among a long list of benefits that make Dayton a great place to live and work.
- At Knox Community Hospital in Mount Vernon, we have Emergency Medicine jobs for physicians, nurse practitioners and physician assistants. This modern, well-equipped facility has an active emergency room, seeing 25 to 35 thousand patients a year. It offers a full range of medical, surgical and rehabilitation services and has state-of-the-art laboratory and radiology equipment. Just 44 miles from Columbus, the city of Mount Vernon is considered to be one of Ohio’s most livable communities with a low cost of living, affordable housing, a pleasant climate, light traffic and low crime rate.
These Ohio Emergency Medicines jobs come with full benefits and there are possible bonus opportunities. Click here to view the Emergency Medicine jobs and Hospitalist jobs that we have available across the country.
Hospital Physician Partners has immediate job openings for Emergency Medicine Physicians in the cities of Atmore and Russellville in Alabama. The two facilities, Atmore Community Hospital and Russellville Hospital, have relatively low ED volume, seeing less than 15 thousand patients a year. Still, both of these excellent facilities play a central role in the health of their communities and both communities are great places to live and work.
Atmore is located in the southwest corner of Alabama between the metropolitan areas and beautiful beaches of Mobile, Alabama and Pensacola, Florida. With its great location, host of activities and beautiful scenery, Atmore is comfortable and affordable living at its best.
Russellville is within easy reach of Huntsville, Birmingham and Nashville. With a small town atmosphere, a fine educational system and a low crime rate, it’s a great place to call home. Russellville also has some of the cleanest recreational waters in Alabama and award-winning lakes for bass fishing.
As with all of our Emergency Medicine jobs, these opportunities in Alabama come with full benefits and there may be bonus opportunities. You can also browse our entire list of Emergency Medicine and Hospitalist jobs to view great job opportunities in other parts of the country.
When it comes to Emergency Medicine jobs, exciting opportunities abound in the Peach State. Hospital Physician Partners has seven immediate Emergency Medicine Job openings for physicians at great locations throughout Georgia, including:
- Just one hour north of Atlanta in the scenic mountain village of Dahlonega, we have an emergency medicine job opening at Chestatee Regional Hospital. This modern facility plays an important role in the health of a community that’s rich in history and a great place to live and work.
- Thirty minutes southwest of Macon in the small community of Fort Valley, Georgia, there is a full or part-time EM job opening at Peach Regional Medical Center. This excellent facility has a more active emergency room, seeing 15 to 25 thousand patients a year.
- Hartwell is in northeastern Georgia, just a few miles from the South Carolina border. Here we have a great emergency medicine job available at Hart County Hospital.
- In what Travel Holiday magazine called the “#1 Small Town in America”, we have an excellent EM job opportunity at Morgan Memorial Hospital. The six-bed emergency department sees about five thousand patients annually.
- In the heart of the Georgia Piedmont is the historic town of Monticello. Here we have an excellent opportunity for an Emergency Medicine Physician at Jasper Memorial Hospital.
- At another Northeastern Georgia location, this time at Cobb Memorial Hospital in Royston, we have an immediate EM job opening. Known as the Home of the Georgia Peach, Ty Cobb, it is home to the Ty Cobb Museum honoring the legendary baseball Hall of Famer and is only 100 miles from the excitement of Atlanta.
- Just 70 miles south of Atlanta lies the small southern town of Warm Springs, Georgia, where we have another great emergency medicine job opening. You can enjoy life in this warm town that has mix of hospitality and heritage. Warm Springs was home to President Franklin Delano Roosevelt.
All of these Emergency Medicines jobs in Georgia come with full benefits and there are bonus opportunities. We also invite you to browse Emergency Medicine jobs and Hospitalist jobs that we have available across the United States.
Hospital Physician Partners has immediate Emergency Medicine Job openings at three emergency departments that we manage in Michigan:
- In Dowagiac, Michigan, there is an excellent emergency medicine job opportunity for a physician Board Certified in EM or IM and FP with significant Emergency Medicine experience. The facility, Borgess Lee Memorial Hospital, has 11 ED beds and the hospital has delivered comprehensive, personal healthcare for over 85 years and consistently scores high in customer-service rankings. Nestled in the rolling hills of southwestern Michigan, Dowagiac carries the feel of a rural community with close proximity to major metropolitan areas like South Bend, Indiana, and Chicago.
- At Sturgis Hospital in Sturgis, Michigan we have another great Emergency Medicine job opportunity for a physician. This emergency department is a little more active and sees 15 to 25 thousand patients a year. Located just one hour from South Bend, Indiana, Sturgis is a great Midwest location with a diverse economic base; a wonderful assortment of people; one of Michigan’s finest school systems; several international businesses; excellent healthcare and beautiful, affordable homes.
- In Three Rivers, Michigan we have emergency medicine jobs for physicians, nurse practitioners and physician assistants. In this moderately active ED physicians work 12 hours shifts and NPs/PAs work eight hours shifts. Here’s a chance to apply your skills at a great facility and live in a wonderful community. Three Rivers is located approximately 20 miles South of Kalamazoo where the Portage and Rocky Rivers flow into the St. Joseph River. It’s surrounded by many lakes and the local economy is a diversified mix of service, tourism and industry.
All of the Emergency Medicines jobs we have available in Michigan come with full benefits and there are possible bonus opportunities. We also have Emergency Medicine jobs and Hospitalist jobs available across the United States. Click here to view.
Hospital Physician Partners has an immediate job opening for a full or part-time Emergency Medicine Physician at Lock Haven Hospital in Pennsylvania. This ER has relatively low volume (less than 15 thousand patients annually) and 10 beds. Since Lock Haven is Clinton County’s only city, this is your chance to have a real impact on the health of a community at a great facility.
Close to 37,000 people live in Clinton County. A friendly and natural environment, Clinton County has five Pennsylvania state parks and parts of five state forests cross into the county. With mountains as far as your eyes can see and the crystal-clear waters of the West Branch Susquehanna River beckoning for a boating ride, Lock Haven is perfect for the outdoor enthusiast and a great place to live and work.
As with all of our openings, this Emergency Medicine job in Pennsylvania comes with full benefits and there may be bonus opportunities. You can also browse our entire list of Emergency Medicine and Hospitalist Medicine jobs to view great job opportunities in other parts of the country.
When it comes to rewarding Emergency Medicine jobs in the Show-Me State, Hospital Physician Partners delivers the goods. Check out three great Emergency Medicine Job opportunities now available in Missouri:
- At St. Alexius Hospital in St. Louis, Missouri, we have Emergency Medicine job openings for both physicians and nurse practitioners. The physician positions can be either full or part-time and the full or part-time nurse practitioner positions give you the chance to work independently and enjoy a high rate of pay. Not much more needs to be said about the great city of St. Louis — the Gateway to the West offers jazz, blues, archeology, culture and history plus is home to the World Champion St. Louis Cardinals.
- In southeastern Missouri is the small, historic community of Dexter. At Missouri Southern Healthcare in Dexter we have an excellent opportunity for an Emergency Medicine Physician. In this five-bed ED you can make a difference in this low-volume room while earning up to $200k per year! With St. Louis and Springfield just a few hours away, Dexter is a great place to live and work, with a warm small-town community; outdoor activities like fishing, water skiing, hunting and boating; plus museums like the Heritage Museum and the Stars and Stripes Museum.
Many of the Missouri Emergency Medicine jobs have bonus opportunities and all of the jobs we have available come with full benefits. To see the complete list of Missouri Emergency Medicine jobs click here, or browse our entire list of Emergency Medicine and Hospitalist Medicine jobs.
Hospital Physician Partners manages Emergency Departments at great facilities throughout Arkansas and the Untied States. Here are a few of the excellent Emergency Medicine Job opportunities that we currently have available in Arkansas:
- In Helena, Arkansas, just one-hour southwest of Memphis, there is an immediate opening for a full or part-time Emergency Medicine Physician. There is flexible scheduling for 12 and 24-hour shifts and although ED volume at Helena Regional Medical Center is relatively low, this excellent facility delivers a full-range of services through the latest in technology. There is access to full benefits and there are also bonus opportunities and possible relocation assistance. In addition to Helena’s proximity to the culture and attractions of Memphis, the town that Mark Twain once called the “prettiest situation on the Mississippi River” is home to plenty of culture and attractions of its own, including the famous Arkansas Blues and Heritage Festival.
- Another town in Arkansas with easy access to Memphis is Forrest City, just 45 minutes to the west. Here we also have a full or part-time job opening for an Emergency Medicine Physician. Flexible scheduling and custom reward bonuses are available in this full-service facility that has 118 beds. Forrest City is home to the famous singer and minister Rev. Al Green and to John W. Henry, principal owner of the Boston Red Sox. Forrest City is a great place to live and work.
- We have another full or part-time Emergency Medicine job opening for a physician at Harris Hospital in Newport, Arkansas. This 133-bed acute care facility is the county’s only inpatient and outpatient healthcare services provider and has a strong focus on customer service and quality patient care. Full benefits and custom reward bonuses are also available here.
Hospitalist medicine continues to be a fast-growing and rewarding discipline. Hospital Physician Partners has Hospitalist jobs at these excellent facilities throughout North Carolina:
- Johnston Medical Center-Smithfield is a 199-bed facility located on the Coastal Plain in Smithfield, NC and has openings for physicians and physician assistants. This hospital has behavioral health, urgent care and surgical services plus a cancer center. The facility plays an important role in the well-being of this friendly community and the town is known as a great place to live and work.
- At Franklin Regional Medical Center in Louisburg, North Carolina there is an opening for a physician at this 85-bed facility. Services include: cardiac care, ultrasound, radiology, laboratory, critical care, plastic surgery, comprehensive imaging, OB/GYN, nephrology, orthopedics, gastroenterology, urology and pediatric. Louisburg is located in the upper Piedmont plateau of North Carolina just 30 miles northeast of Raleigh and 45 miles northeast of Durham, so it offers close proximity to the resources and great quality of life of the Research Triangle.
- Transylvania Community Hospital in Brevard, North Carolina has an opening for a part-time physician. This hospital has 94 beds and delivers a full range of services, including: cardiology, ICU/CCU, anesthesiology, OB/GYN, home health, radiology, speech/language therapy, respiratory therapy, laboratory, wound care/ostomy and podiatry. The facility is located in the heart of Transylvania County in the western Blue Ridge Mountains, just 30 miles southwest of Asheville, and is near the beautiful Pisgah National Forest.
From Texarkana to San Antonio, over in Houston to Odessa, there are excellent Emergency Medicine jobs available for physicians, nurse practitioners and physician assistants:
- Wadley Regional Medical Center (WRMC) has been servicing the city of Texarkana and surrounding communities for 100 years and today has grown into a modern facility with cutting-edge technology and 370 beds. Rewarding jobs are available for physicians, nurse practitioners and physician assistants in this active emergency department that treats 35 to 50 thousand patients annually.
- Down in San Antonio there is an exciting emergency medicine job opportunity a physician looking to make a difference in a fast-paced urban environment. The emergency department at Southwest General Hospital sees 35 to 50 thousand patients annually and this state-of-the-art facility has 28 beds in its ED. The most visited state in Texas, San Antonio is also a great place to live, home to many historic sites, attractions, the San Antonio River Walk and major league sports with the San Antonio Spurs of the NBA.
- Over in Houston at St. Joseph Medical Center there are Emergency Medicine Job openings for both physicians and nurse practitioners, The Center is staffed by over 650 board-certified physicians and more than 1,800 medical professionals. The hospital facility covers eight city blocks and is conveniently located on the edge of Houston’s downtown. Houston is the fourth largest city in America and offers a rich, diverse culture, world-class museums, plenty of entertainment options and is home to more than 40 universities and colleges.
Many of the Texas Emergency Medicine jobs have bonus opportunities and all the jobs we have available come with full benefits. To see the complete list of Texas Emergency Medicine jobs click here, or browse our entire list of Emergency Medicine and Hospitalist Medicine jobs.
Repeatedly we hear from administration that our customer service scores are not what they want them to be. Sure, there is nothing wrong in making the emergency department experience as pleasant as possible for our patients and their visitors. But the ED has one experience more shocking than other areas of the hospital and certainly more than the average person is accustomed to. We see dead people. Most people would run out of the room screaming if they found themselves in a room with a dead person. Not us. We continue to talk about movies, family or whatever else has our fancy at the time. Some of us continue eating lunch shortly after a code. By and large we are standing by death. This is not normal — but it is absolutely necessary. Building mental silos, as it were, helps us cope with bad outcomes. We create a wall between the patients and us. We, on one side, separate ourselves emotionally from the patients on the other side. We need that wall to make it through the day. Who could possibly go on with their work after witnessing the death of a child in the emergency department without that wall?
But perhaps the wall is too high. Perhaps once in a while we need to look over the wall to see who is there. It is important for us to remember that there are in fact people over the wall, and they are not all dead. We need to lower that wall whenever we can to allow us to associate with our patients as living people who are experiencing a difficult time — that is why they are in the emergency room. These are the patients filling out those patient surveys. It is often not our sickest patients (when admitted that have their complaints validated) who complete these surveys. It is those not-so-sick patients; the urgent and not-so-urgent patients that complete surveys. These are the ones who “pay” for the construction of the wall. They pay with the emotional detachment of the staff from their needs. They sense our “compassion fatigue”.
It is time to reconstruct the wall at a lower height. We in Emergency Medicine cannot make it go away but we can make it so we see those people on the other side that are not dead.
Hospital patients in the U.S. acquire nearly 2 million infections each year (approximately one in 20 patients) according to the Center for Disease Control. Hand hygiene has been established as one of the most important ways to prevent the spread of infections. A recent satirical article was published in EP Monthly in which the author developed a valid point about how much hand washing would be required of an Emergency Medicine Physician during a shift. The author based his calculations on the requirements he apparently summarized from JCHAO recommendations.* The author calculated that if an emergency physician sees an average of 2.5 patients per hour, (assuming a conservative average of touching each patient twice) he/she would be required to perform hand hygiene about 10 times an hour (about once every 6 minutes) and about 100 times in a 10 hour shift.
(Here’s a link to the actual CDC guidelines and indications for hand washing and hand antisepsis in the health care setting for you to reference at your convenience. The CDC’s recommendations are valid and sensible but the list itself is onerous.)
A key factor in successfully running an emergency department is time management. Assuming the author is correct in his calculations, he raises a valid point for the physician working shifts in an emergency department. The Emergency Medicine Physician is obliged to comply with an immense set of requirements from regulators while performing his or her professional obligations and maintaining care standards. These responsibilities fill up the shift and add to the time-management challenge in the emergency room. The skill of “Managing the ED” and its nuances will be spotlighted as one of our CME lectures available to you soon from the HPP University website.
*Reference: R. Bukata, MD, In my opinion Death by Regulation: Enough is Enough, EP Monthly, 10/7/11.
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