ERCAST Rant-Off 2011

It’s open mike time for whatever get’s your goat (in medicine, that is) – sit up, listen and take notice – it is time for our Featured Rants…

Direct Download

The RANTS

  • Cliff Reid [Resus.me] – “The Propofol Assassins”
  • Dave Peaslee – “Do you know what medicines you’re on, sir?”
  • Andy Neill [Emergency Medicine Ireland – “Are we thinking about PE the right way?”
  • Mike and Matt [Emergency ultrasound podcast] – “USS vs CT for appendicitis”
  • Resident Jim: “How I feel about attendings who do a full H&P before I get in the room”
  • Dan Gromis: “Can you really be allergic to iodine? I think not!”
  • Gerry O’Malley: “Why do we teach residents defensive documentation?”
  • Steve Ayers: “When can you really say someone has HTN?”
  • Mike Jasumback…wants an emergency medicine forum. Email him at EMforum@live.com

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Comments

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  3. EM Basic

    Any chance of getting a direct download link posted? I’m a luddite who burns these to CD and listens to them in my car and it’s easier than going through iTunes (waiting for the iPhone 5 to come out to join the iPhone masses…)

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      Author
  4. Paramedic

    Rob makes a really good point regarding documentation: read the nurse’s AND paramedic’s reports.
    And be nice to the paramedic! Simply asking for a brief report, rather than getting the information through a game of telephone with the nurse, might be a very good use of your time. Even, “Anything serious?” may clue you into the fact that the paramedic is going to put something concerning into their report.
    And whatever you do, don’t blow off the paramedic who approaches you with a concern: “Do you know which doctor is going to see the patient in room 14?” The correct answer is NOT, “Nope.” How about trying, “Nope. Anything interesting?” You might find out the patient was incontinent before we cleaned them up, was complaining of saddle paresthesia at the scene, and had to be assisted to the cot. Probably you’ll get all that while you’re taking care of the rest of your patients, but if you don’t you’ll look pretty silly when the plaintiffs attorney points out that the paramedic mentioned the possibility of cauda equina syndrome in his or her report, or simply documented those symptoms. Loss of quality of patient’s sex life can sure be expensive…
    Show some interest in the medics and they will really respect you. They’ll often be wrong because they are looking for classic signs of disease, and as Amal says, “classic” is Latin for 10-15% of the time. But at least you’ll have some forewarning that they are likely to have something in their report worth addressing in your documentation.
    If you have time to teach-great, if you can only listen briefly-fine, but don’t ignore or ridicule (to our faces at least)!
    That’s my rant Rob. Love your podcasts and this last rant podcast was great!

    1. Post
      Author
      emergencypdx

      Truer words never spoken. Paramedics are one of our best resources for getting the ‘boots on the ground’ history. The initial ED evaluation is shortened by at least 50% by listening to the paramedic report and asking questions as to scene management, the patient’s social situation, etc. Keep up the good work!

  5. Steve

    I’ve been meaning to comment on this episode for a while…

    Cliff Reid= my hero. This one clinical situation is a metaphor for everything else we do in EM. When will other specialties realize that what they do in their office, the OR, the ICU is a different ballgame than what we do in the ED or the resuscitation bay? Anesthesia can say that they are the experts of the airway…fine- we are the experts of the emergent airway. Surgeons aren’t the experts of undifferentiated abdominal pain- we are. Critical care doctors aren’t the experts of the undifferentiated crashing patient- we are. I can go on…and saying these things are not to make us cocky or pompous or to say that we don’t need our consultant’s help- its to say that we have our own set of unique skills that should be respected. We should stand up for our patients when certain specialties come to our playground, treat it like their own, and don’t do the right thing for the patient. Rant over

    Dr O’Malley’s rant- I agree with the crux of his argument- what you write down won’t matter much if something bad happens. I also agree that we need some serious malpractice reform so that we aren’t pawns in a chess game between the lawyers and our insurance company. While we shouldn’t be charting defensively, I don’t think this should be confused by saying that we should be ok with poor charting. I know he has heard all the arguments on this but what about this…The one area I can see is with documenting times and decisions when you talk to consultants. Making sure that you document that you talked to a consultant in a timely manner or that they are taking too long, don’t want to take someone to the OR, etc. can be the difference between being simply deposed and being dragged to trial as a defendant. Isn’t that a good enough reason to do good (but not defensive) charting?

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  8. T Doc

    Currently wondering how emergency docs cope with the dislike and insulting comments from inpatient teams suggesting they are lesser doctors because they haven’t done this or that, work so hard everyday with minimal information to begin with and it’s not appreciated only ridiculed..

    1. Rob Orman

      What you mention is one of the master skills of emergency medicine. Nobody likes getting calls from the ED because it invariably means more work for them. They will also apply their own standards to your workup, which is of course, ridiculous since they have unlimited time and we must make major decisions based on insufficient information. When the type of derision you speak of raises its head, my response to the inpatient team is that I’ve either 1)ruled out the life threats or 2)made the diagnosis -- what comes after that is why they did an entire residency learning a specialty. A consultant will always prefer that an entire hospital stay’s worth of tests be completed during the emergency department stay. When an admitting doc offers derision for not ordering this or that test, I politely thank them for their input and ask if they’d like to have that added to the admitting orders. I have found that responding in a snarky or sarcastic tone will only escalate tensions. Trust me, I’ve had plenty of escalation to learn from.

      You are the most versatile doc in the hospital but will never have the specialized fund of knowledge that an admitting doc has in their field. It can be a hard pill to swallow, but that is honestly what inspired this podcast. There is so much to be learned from each other!

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    1. Rob Orman

      My apologies. There is now a link for direct download of the episode. Let me know if there are any problems. Thanks!

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