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Tuesday, May 29, 2012

another question about rationing, without an answer

Today I met a man whose liver is failing. He drank way too much alcohol for many years and quit in February when he finally realized his liver was toasted, pickled, scarred, hardened, cirrhotic. He had begun to build up fluid in his belly that had to be drained with a needle because the medicines designed to help reduce it didn't work and made him feel terrible. Because the liver clears toxins created by metabolism, and his didn't, he began to be loopy and tired all the time. Today the fluid had built up again and when over 8 quarts of it was drained from his belly he was too weak to walk and had to stay in the hospital.

The single solution to his problem, barring the invention of a time machine so he can go back and not drink so much, is liver transplantation. He is not insured for a liver transplant. We talked about this and about his prognosis with the technology available to him, which is terrible, while he struggled to keep his eyes open. I am pretty certain he will remember none of the conversation. He made the comment that it is terrible that things like money and insurance determine who will live and who will die. When you put it that way, it is terrible. But it is so very not that simple.

Many physicians are intelligent, motivated and inventive. They see a problem and use their knowledge of anatomy, physiology, pharmacology, plumbing, that sort of thing, to solve it. Amazingly creative solutions arise, many of them wildly complex, expensive and prone to spectacular failure. Liver transplantation is just one example of this. If a liver is failing and needs to be replaced and livers in folks dying of non-liver disease are just fine, why not replace failing livers with unspent, perfectly good used livers? Nearly 6000 liver transplants are performed every year, a very involved and expensive procedure costing nearly a quarter of a million dollars for each patient treated (those numbers vary widely depending on many factors.) The donor liver needs to be matched by blood type and must be removed, preserved, reattached and must withstand the body's immune response. Families of the not-quite-dead must agree to harvesting the organ while the body that holds it is still capable of nourishing it. There are living donors, because livers are quite good at regenerating themselves even after more than half of their volume is removed. These living donors go through a major operation to save someone else, from which it can take months to recover. Some donors die. After transplant, the recipient of the donated liver must take medications that suppress immune function, sometimes for years, in order to avoid rejection.

Getting a liver transplant is a really big deal. Only a fraction of people who are on transplant lists get transplanted and many die waiting for a new liver. The sickest of those waiting get preference. Active drinkers or drug abusers are not candidates, and people whose conditions are very likely to cause death despite a liver transplant are not put on the list. A person must be abstinent from alcohol for at least 6 months and have a good support system to maintain sobriety to be eligible for transplant.

So, I ask, in the case of liver transplant, is it terrible that something like money and insurance coverage helps make the decision about who will have the opportunity for a cure for liver failure? What should make the decision? Should the medical profession have an essay contest? Should we judge each candidate's likelihood of contributing to society? Should we value the unusual, and transplant those with red hair, odd names, unusual syndromes? Should we measure who deserved to get sick and who did not? What about the fact that some people can drink like fish and never get liver disease? Should we absolutely refuse to transplant people whose own actions directly lead to liver failure, like those who overdosed on acetaminophen in a suicide attempt, because we most certainly do transplant these, and they often go to the head of the list because their livers get so sick so fast.

And what about other resource intensive treatments that we invent for dire illnesses? Should we just not invent them because we don't have the resources to offer them to everybody? Should we invent them in scientific studies, then discard them because they are not universally effective or their cost benefit ratio is unfavorable, even though increased familiarity will most certainly lead to modifications that benefit at least some people?

If and when my patient wakes up, we will perhaps discuss it again, and I will listen to what he has to say, and I will not have any truly satisfactory answers.

Wednesday, May 23, 2012

Why don't doctors want to do primary care anymore?

I really loved doing primary care, taking care of patients in my community in a medical office and in the hospital when they needed that. I practiced primary care internal medicine for over 20 years, first as part of a health care cooperative and then in private practice, and it was very gratifying, never boring and fed my soul. This last year, across the country, almost no internal medicine residents chose to go into primary care. Graduates of family medicine residents were more likely to go into primary care, but many of them, too, chose specialties or hospital medicine. Though family medicine residency positions mostly did fill, over half of them were taken by foreign medical graduates who traditionally are less competitive for residency slots. Why?

An article in the New England Journal of Medicine discussed some of the challenges of being a primary care doctor and some of the changes in reimbursement that are expected to ease the shortage of those absolutely essential regular doctors who take care of real people in health and disease through sizable portions of their life spans. This is the link:

So why, if it is such a great job, don't medical school graduates want to do it? Medical school professors teach medical students and residents, and they are our role models. They don't do primary care. They are professors of medicine. We do some work in outpatient clinics as students, but most of our teachers there, the real primary care docs, are pretty busy and when they have medical students, they are even busier because then everything takes longer. So medical students learn that the really important people don't do primary care and that primary care docs are always busy and harried. And it is often true. Primary care docs are busy and harried, and getting moreso because less people are doing it and so they have to see more and sicker patients, and now they need to use increasingly complex computer systems to document visits and since insurance company evaluations of quality are based on proving that in addition to curing a person's rash or counseling them on their failing marriage, we also need to harangue them about their cholesterol and vaccinate them for pneumonia and tell them how to lose weight and quit smoking, and and and... I loved it because I got good at it, but most new graduates are totally out of their element and, compared to specialty or hospital medicine, they get paid pittances.

Various payment incentives are being put forth by private and government insurance agencies which offer a partial solution to the salary problem, but fail entirely to deal with the inherent difficulty in doing the job as it is now defined. These include not reducing payments to primary care docs, while reducing them to specialists (Medicare), increasing pay by 10% (Wellpoint) and paying primary care docs an extra $3 per patient per month as an incentive to see patients (several private insurance companies.) My personal experience going from office based primary care to hospitalist medicine points out how ridiculously too-little, too-late these schemes are. Practicing full time as a hospitalists means working 12 hours a day, seven days a week, every other week. With that schedule I can make what was an entire year's salary in my office job in 5 months. I can also work a little on my weeks off and make more than that. I am really truly not working on my weeks off, plus I can take real vacations without feeling guilty about leaving my patients in the lurch. I don't have to take telephone calls at night when I am not working. The work is faster moving and more intense, with more people threatening to die if I don't do everything right, but that is what I was trained to do.

For physicians to go into primary care it will need to be delicious. It will need to satisfy the very human needs for competence, by having work loads be within reason, for meaning, by allowing us to use our own creativity to solve patients' problems, and for connection by giving us time to talk to patients, colleagues and engage with our families and friends. It wouldn't hurt if it also paid even close to what hospital medicine does.

Waste avoidance and "rationing" in health care: how much money can we actually save?

Two articles in today's New England Journal of Medicine address waste and rationing. Rationing in health care is an emotion fraught term meant to awaken visions of long lines of people waiting for loaves of bread in grainy black and white photographs, but bearing the faces of sick loved ones instead of long dead strangers. Arrrgh. The first article, entitled "From an Ethics of Rationing to an Ethics of Waste Avoidance" is written by Howard Brody MD, an infectious disease specialist who was in clinical practice for many years and now is known as an ethicist. He makes the point that we need to pull ourselves away from the issue of rationing truly valuable medical care to focus on realizing that the procedures and treatments that we do that are truly not helpful are not only expensive but harmful and therefore unethical. He further suggests that using population studies to decide what works or does not work for an individual is inherently in error, and that if we successfully cut most of our truly wasted medical costs, real people will suffer who presently make their livings off of our health care behemoth. His bottom line, as I read it, is that it would be easy, using the evidence we now have and our own good sense, to do many less useless things and save lots of money, but that we need to be very aware of our patients' individual needs and also of how vulnerable our economy is to major changes in medical spending.

The other article, by Dr. Gregg Bloche MD, JD, seems to be another article about how there is really no easy way to save money in medicine unless we make major painful changes. He cites the statistic that 30% of medical spending is wasted, then goes from there to estimate that perhaps 3% per year could reasonably be saved by cutting waste and that since medical care just naturally gets more expensive every year that means we could just about break even. I really dislike this 30% number. It comes from nowhere. It might be right, but is based on no actual figures and so extrapolating to an invented 3% per year from the invented 30% per year is one of the most flagrant examples I can imagine of the truism that 73% of all statistics are made up on the spot. It is interesting that this article is written by a professor of law who also happens to be an MD, rather than someone who has practiced much medicine. The people who write articles in the New England Journal who say that there is no easy way to save money in the practice of medicine usually don't practice medicine. Most of us who do practice medicine feel like huge and avoidable waste is right there, within easy reach and that with some small changes in culture and incentives we could realize it.

Dr. Bloche goes on in his article to say that we really do need to realize that we can't afford all of the expensive and actually helpful things that medicine has to offer or will have to offer in the future and that we eventually do need to think of rationing in some way. I probably agree with him on this, though I think it is truly out of order to talk about cutting back what is actually useful before making changes that drastically reduce real waste.

Links to the two articles are:

Monday, May 14, 2012

Re-certification in Advanced Cardiac Life Support--the ethics and practicality of wrenching people from the jaws of death

My Advanced Cardiac Life Support (ACLS) certification expires in June of this year. At least that's how it used to be. Now my card says that June 2012 is the "recommended renewal date." These re-certification dates always sneak up on me, and if I go over two years between certification I need to take a two day class rather than a one day class, which is more expensive and time consuming.

ACLS is a protocol based set of guidelines published by the American Heart Association to standardize the treatment of cardiac arrest, heart attacks, strokes and heart rhythm disturbances. The first guidelines were published in 1974 and have been updated 6 times since then, most recently in 2010. ACLS is meant to help physicians deal with situations that require very quick action in order to have good outcomes, sort of like soldiers used to need to be able to take apart and reassemble a rifle quickly. ACLS often follows bystander cardiopulmonary resuscitation (CPR), also known as Basic Life Support (BLS.) Neither BLS nor ACLS is particularly intellectual or subtle. In BLS (as of 2010), when a person has ceased to respond (usually they are on the ground, could be in bed) the responder checks to see if they can talk or wake up and if they are breathing, then  calls for help and for a defibrillator, then checks for a pulse, then starts chest compressions if there is no pulse, with rescue breaths every 30 compressions if that is practical. Compressions with no rescue breaths also works, almost as well, and is recommended for very inexperienced providers and when rescue breathing puts the provider at risk. If an automatic defibrillator is available, that is attached as soon as possible and it recommends and delivers shocks to the heart when appropriate. ACLS is done by either EMTs or physicians, and involves administration of medications, continuing cardiac compressions and delivering more shocks as appropriate. To certify in ACLS one must be proficient in both ACLS and BLS.

So when I heard that my certification was (sort of) expiring, I first called my hospital and found out, as usual, that there was a class in ACLS but that it was already full and I would have to wait for a few months for another one. I got online and started to look for other classes within driving distance or in places that I was going to go anyway and found that the American Heart Association website has a central location for finding ACLS classes. This is the site: I went on the site, found a class that I could take, signed up for it and was contacted by the instructor about a week later saying that it had been postponed to a time when I couldn't take it. I then looked further and found several sites that looked legit that offered certification fully online. I became suspicious of these when they said they required no in-person demonstration of skills. The most difficult and relevant part of ACLS for me is the "megacode" part of the test in which the course instructor takes me through an scenario with a manikin and a cardiac rhythm generator and makes me demonstrate that I know what I'm doing and can respond to the usual flow of a cardiac arrest situation. This hands on evaluation has also involved demonstrating that I know how to use a defibrillator, know how to intubate a plastic person and know how to provide effective chest compressions.

The question exists, then, regarding the legitimacy of these sites. There are actually several of them, and they have nothing to do with the American Heart Association. This is one: Although ACLS guidelines are heavily researched and involve hard work and creativity of many doctors and nurses via the Committee on Emergency Cardiovascular Care, the committee did not copyright the algorithms or the recommendations. I may be wrong in my thinking, but it seems to me that anyone could legitimately teach from the text of the recommendations and provide certification of proficiency, and it would be up to the hospital or clinic or emergency medical provider agency requiring certification to decide whether that certification is adequate. For me, doing an online course just sounded too flaky so I went back to the American Heart Association. For some providers, especially emergency physicians who are doing this stuff all the time, less than the full deal might be quite adequate.

It is possible, through the American Heart Association at this website: to buy a really well designed online course called Heartcode ACLS, part 1, which provides video teaching of all of the components of ACLS including actual simulations of dying patients. It is also possible to buy the official ACLS book from which the course material is drawn and a little spiral bound handbook that has the grubby essentials, called "2010 Handbook of Emergency Cardiovascular Care". After completing the heartcode thing, I can take my certification to any of the folks at any of the hospitals who teach ACLS and they can put me through parts 2 and 3 which are the hands-on tests, including the megacode. Then I will be set, again, for 2 years.

Certifying for ACLS is something I have to do, but I'm not entirely sure that it is a good thing to have my hind brain hardwired to start pummeling and shocking someone who, unmolested, may actually be beginning their final rest. We attempt resuscitation of nearly anyone whose heart stops, even though most of these attempts come to no good end. Response to resuscitation varies, but a recent review article quoted about 6.4% survival after out of hospital cardiac arrest and 17.6% for in hospital cardiac arrest. This is to say nothing of the level of disability or brain damage after recovery. Some cultures, specifically I have been reading about Tibetan culture, believe that death is an important transition and that an opportunity for peace and contemplation at the time of death is important. Even though I am not at all sure about either reincarnation or the existence of an immortal soul, it does seem that major transitions in our lives, such as birth and death for instance, should ideally be associated with some level of dignity. When we attempt resuscitation, as physicians, we think of that one in 20 (or 1 in 6 in hospital) who goes on to live a longer life and we count the brutality of the procedure, with its broken ribs and myriad tubes and helplessness, as a necessary cost. It is also true, conversely, that many more people lose the opportunity of a peaceful death than have a chance to walk out of a hospital, and they will never again have an opportunity to do that death over. ACLS and resuscitation are the defaults. Barring a specific request of a patient not to have these things, we do them. But ACLS is also a procedure, similar to an appendectomy or chemotherapy. Statistics as dismal as the ones for ACLS would certainly make us think several times before doing surgery or starting a new medication.

Monday, May 7, 2012

Choosing Wisely--a campaign to save healthcare resources by not doing stupid things

The most recent edition of the Journal of the AMA features an opinion article about a campaign to highlight the top 5 probably useless, dangerous and overused medical interventions for various medical specialties. This is the link:, The authors,  Dr. Christine Cassel, the CEO of the American Board of Internal Medicine and Dr. James Guest, the CEO of the Consumer's Union, discuss the process that has led up to this approach.

In 2002 US and European internists came together to create a document entitled "Medical Professionalism in the New Millennium: A Physician Charter." This put into print a set of goals that were intended to spark various projects to improve what physicians do.  The primary principles were that patient welfare goes first, that patients have the right to autonomy in defining their medical care and that physicians should be held to behave in a way that promotes social justice, including fair distribution of limited and finite medical resources. Out of the charter rose a growing impetus towards determining and promoting high value and cost conscious care.

The Choosing Wisely campaign is aimed at physicians and patients and is readable and understandable, not talking down to either group, but sufficiently well worded and detailed to be of use. The groups that worked on this decided that instead of tackling all of the things that we do that are useless, choosing the top 5 most egregiously stupid interventions in each participating specialty would be an excellent start and could save billions of dollars. The website is and it doesn't run very well on Google Chrome, but seems to do great on Internet Explorer. The egregiously bad top 5 for internal medicine are that doing plain film x-rays for low back pain without red flag symptoms adds nothing, that getting a preoperative chest x-ray when a person has no lung symptoms is a bad idea, that doing cardiac stress testing just to make sure everything is ok in a person with no symptoms and low cardiac risks is liable to give bad information and that doing a head CT or MRI scan because someone faints makes no sense and doesn't help. The final one is that a normal d dimer blood test is good enough to rule out a pulmonary embolus in someone felt to be at low risk, without performing imaging studies. Oncology has their own set of don't-do's as does nephrology and a total of 9 medical specialties. Some of them overlap. Some are obvious and probably don't go far enough, like the nephrology recommendation that the patient and family should all sit down and discuss options before the patient starts dialysis. My guess is that consensus finding guided the wording in many of these. The recommendations are intended not just to avoid wasting resources, but also to limit risk to patients including radiation exposure and intrinsic risks of medications and invasive procedures.

This website adds a great deal to the resources available for good shared decision making about medical interventions between patients and providers. It's an excellent start.

Sunday, May 6, 2012

A day in the life: mostly how doing bedside ultrasound as a hospitalist is cool, and how charity care fosters community stewardship

I've been doing 12 hour shifts at a regional medical center that serves a predominantly blue collar community in Washington. My job as hospitalist involves showing up at 7AM on a Monday and meeting and taking care of about 16 new patients on the medical and surgical services as well as admitting a few more, usually from the emergency department. My shift ends at 7 PM or whenever I'm actually done. Mondays are big, but I do get to meet lots of people. The first two transitional days involve reviewing lots of data and I become gradually less dependent on my predecessor's clinical judgement. It would be ideal for patient care if the physician who admitted the patient stuck around until discharge, but that would logistically mean that physicians worked every day, all day and all night. Nobody would sign up for that, and if they did, they would be toasted to a crisp very soon and patient care would suffer. Transitions are inevitable, but always involve increased patient risk. Sometimes it's good that care transitions, and I pick up something that the previous doctor hadn't noticed. Sometimes it takes awhile to understand the rationale behind treatment and sometimes I probably drop the ball without even noticing it. Eventually everything is rolling along nicely and then I go off service, usually 7 days after starting. Signout routines for the organization that employs me are good. Not only does the physician write assessments and plans in the patient's chart, but a more casual and concise signout is part of the organization's website and is kept up to date by routine to help the night physicians with care and for the change of service. All places are not like this. Some have terrible or non-existent signouts, and the places that are smaller and have 24 hour shifts (like my own community hospital) have face to face signouts that are really excellent. But that wasn't actually what I wanted to talk about.

I have been doing more and more ultrasounds as part of my examination routine as a hospitalist, with the little GE Vscan ultrasound that I keep in my pocket. Using "point of care" ultrasound in the hospitalist setting is a slow starter. I read an article about training hospitalists to do ultrasound of hearts that was dated 2007, concluding that they weren't as good as echo technicians after doing 35 ultrasounds. The authors were surprised. Why would they be surprised? Learning to do an echocardiogram well, obtaining pictures and interpreting them, takes more than 35 ultrasounds, and echo technicians do at least hundreds before considering themselves competent. Hospital physicians do use ultrasound pretty often for doing procedures involving placing needles in internal structures, but apparently not often for diagnosis. Many emergency physicians use ultrasound frequently and there is quite a bit of precedent for this, but once the patient is admitted to the hospital, bedside ultrasound for making diagnoses becomes less common. In the two hospitals I work in there are no other physicians other than intensivists routinely using ultrasound they do themselves for diagnosis. Which is too bad, because it is really fun and really good for the patients. I now ultrasound everybody I examine, unless I have already done it and there is no conceivable reason to think that they have changed.

Here are some examples of how my little ultrasound machine makes a huge difference in how effective (and happy) I am. Echocardiography is an obvious application. A few days ago I admitted a man who presented with fatigue and a fast heart rate. His EKG showed atrial fibrillation at about 150 beats per minute. His rate slowed somewhat with a diltiazem drip but then he began to feel worse. My ultrasound said that he had a severely weakened left ventricle, probably from prior heart attacks, and so diltiazem was a bad drug for him. I could adjust his medication appropriately knowing what his physiology was, not waiting for an official echo. He got his official echo eventually, but he was also treated appropriately right away. I could also see with a lung ultrasound that he was in congestive heart failure, which helped guide therapy as well, since I could follow that along day by day to look at how adequate treatment had been.

Then there was the 92 year old woman who came in with a hip fracture from a fall the previous evening. It was unclear how much hydration she would require before surgery, but my bedside echo showed that her cardiac function was normal and that her inferior vena cava was very decompressed and collapsible, consistent with dehydration, so she needed lots of fluid. And I could watch that vena cava with hydration to see when her tank was full. So nice to know rather than guess.

And there was the 88 year old man whose foley catheter I had had removed so he could go home. But he didn't pee. He said he didn't feel the need. My handy dandy ultrasound is also useful below the navel, and I could tell that his bladder was about the size of Texas, so he needed the catheter back. The nurses have a version of the ultrasound called a bladder scan, but I was right there and could show the patient the picture without delay, which was good for him since he could tell what I was worried about.

This was a big week for pancreatitis. Pancreatitis can be caused by gallstones, but in our population it is much more likely to be caused by drinking alcohol to excess. Still, you can be a drunk with gallstones. The 49 year old drinker with pancreatitis got his cardiac ultrasound to document how well he would tolerate vigorous hydration, plus I could see his gallbladder which was healthy looking and stone free. I could also see that he didn't have free fluid in his abdomen which would have suggested more severe pancreatitis or coexistent cirrhosis of the liver. But even better than all that, I could show him his organs, which he loved, and made him much happier, more cooperative and appreciative. That was incredibly cool, since apparently appreciation wasn't his usual MO.

And then there was the guy with diverticulitis who had had more pain the night before I came on service, then felt better by the time I saw him. He was bloated, with no bowel sounds, but not all that tender, not all that sick seeming, and with a normal white blood count. I ultrasounded his heart--couldn't see a thing, not a single thing, all air. Then I checked his intestines, because diagnosis of small bowel obstruction by ultrasound is really not very difficult. Couldn't see a thing. When you can't see a thing what you are really seeing, barring that the machine is broken, is air. Air looks like a gray screen, like an old tv when the programming was all over. Not ever having seen absolutely nothing, I was stymied and ordered an x-ray, which confirmed that I had in fact been seeing air, inside the belly, that is to say free air from an intestinal perforation. Now I know. Air everywhere is free air and means a perforation (or recent laparoscopic surgery, but that would be obvious.) The patient had emergent surgery and is doing pretty well.

I have come to appreciate the larger hospital I am working in for various things, most importantly that they make absolutely no fuss about treating patients who are uninsured. They do over 14 million dollars in charity care per year, and the primary physicians and specialists all treat these patients without whining about not being paid. A hospital can't run in the red for very long, though, so it is paying customers, in some way or another, who finance those who can't pay. This hospital runs in the black, but is a not for profit organization, so money left at the end of the year gets funneled into either community programs or capital improvements. They donate generously to the local YMCA which has all sorts of popular wellness programs. I'm not sure what all else they do, but it is clear that promoting health in the community for the poorest people can impact the likelihood of those people needing expensive hospital care. This model seems like a good one for making natural consequences for a hospital favor good health for a community. This incentive only applies to patients who have no or low paying insurance, since hospitals will always thrive on the well insured who have repeated need for high cost and well reimbursed care. If hospitals were paid per capita to care for the insured, they would also have a good reason to attempt to keep these patients well, which would mean even more effort spent on prevention and health promoting programs and probably more aggressive research into high value and cost effective inpatient care.

Wednesday, May 2, 2012

Ultrasound education and why ER physicians are different (Castlefest) (CORRECTION)

(CORRECTION PART: WOOPS. WHEN I FIRST PUBLISHED THIS, NOT ONLY DID I LEAVE IN ALL SORTS OF WEIRD STUFF, BUT I ALSO SPELLED MIKE MALLIN'S NAME WRONG AND GOT THE WEB ADDRESS OF HIS AND MATT'S SITE WRONG. I THINK IT'S ALL FIXED NOW.) Northern Kentucky is lushly, jaw droppingly beautiful in the spring. Green fields of grass stretch out from smooth highways and thoroughbred horses graze languidly. (Also I got some mild version of influenza and am hideously allergic to whatever particular grass pollen collects here so I’m thinking and seeing everything through a small amount of edema fluid.) The town of Versailles (pronounced ver-sails) has a small castle on its outskirts that was originally partially built by someone whose love grew cold before he could finish it. It stood partially finished for years, changed hands, burned down and was rebuilt, so it now exists as a venue for weddings and things like that. It was the location of an emergency and critical care ultrasound course sponsored by the University of Kentucky and organized by Mike Mallin and Matt Dawson who have produced an excellent website, podcasts and smartphone apps to share the good news of how useful and cool and profoundly game changing the practice of bedside ultrasound can be.

This course was the third one I have attended since November 2011 in bedside ultrasound, also known as point of care ultrasound.  The first was at Harvard Medical School, put on by their department of emergency ultrasound (yes, there is an actual department there.) Before that course I had been mostly unaware of ultrasound applications but had heard a few things about it and chose to go to the Harvard course because I figured that an institution like that would be likely to be on the leading edge in terms of research and teaching. It was an excellent course, organized by Vicki Noble MD who has been involved in developing the field and doing the hard work of both research and communication with physicians of all types who are set in their ways but also needing the boost that being able to do ultrasound can give them in terms of job and patient satisfaction.  I learned enough in the course to start doing ultrasounds with the machine that non-radiologists share in my hospital, looked at more stuff using various online resources, bought myself a pocket ultrasound, scanned anyone who got within arm’s length of me and went to another course, one given by Yale University emergency physicians, scanned more parts of more people and just now returned from course number three.

Castlefest was delightful. The instructors, beside Matt and Mike, were Chris Fox MD who heads the emergency ultrasound department at University of California at Irvine and, according to Matt, is something like the father of emergency ultrasound. He amended that to say “creepy uncle of ultrasound,” which seemed to fit a little better. Cliff Reid MD came from Australia where he practices emergency medicine and teaches and flies helicopters to remote areas to save people (also has a website and podcast called  and Vicki Noble MD came from Massachusetts General Hospital. Dr. Tim Jang came from the USC department of emergency ultrasound and taught us about techniques for diagnosing intestinal maladies such as small bowel obstruction that are simple and surpass x-ray and rival CT scans in accuracy. Medical student volunteers were models and there were lots of machine reps who brought their nifty and expensive ultrasound machines so that we could learn to find the organs and structures that we heard about in lecture, visualize them (which is really tricky) and interpret their abnormalities.  There was also good food and Kentucky themed activities such as visiting a whiskey distillery and touring a thoroughbred farm owned by the ruler of Dubai. The subtext of the conference was that you could do excellent medicine, care about your patients, do new things and also not take yourself too seriously. As conferences go it was kind of expensive, probably because of the extra activities, but worth it because of the excellent faculty.

I learned lots of stuff:  new ways to put in central venous catheters that reduce risk and discomfort, new ways to look at the heart and evaluate its function, how to evaluate the appendix and small bowel with ultrasound, how to find that pesky gallbladder and what to do with it once I do find it. Most of the things I learned will impact the way I practice medicine, which is really unusual in medical education. The new and interesting stuff I learned really deserves its own post, so I’ll save it for a bit.

Besides learning about ultrasound I also got a chance to observe my fellow doctors, almost all of them emergency physicians. There was quite a variety--men and women, mostly from the US Southeast, but also from Australia and Canada and the Midwest.  Some had been in practice for as long as 40 years, some were pretty fresh, having practiced only a few years. They all knew how to deal with an emergency room full of people, sometimes acutely dying, most presenting with problems that were time sensitive and with some level of mystery. Most of them worked 12 hour shifts, a few still did 24 hour shifts, and most were on some sort of salary, either paid by a hospital or by an incorporated group of emergency physicians.  There was a nurse practitioner who had trained in emergency and critical care medicine who did just about everything that an MD would do in the hospital including most critical care related invasive procedures and also ultrasound. He had done it for years and was probably as capable as most physicians and more capable than others. There was a young woman who practiced in Canada after having finished her family practice residency. Apparently in Canada it is rare for emergency physicians to have completed an emergency medicine residency, much like it was here 10 or 20 years ago. She had gotten bedside ultrasound training on her own after residency because she thought it would be important. Her ER was always full, she saw 14-30 patients per shift, made a flat fee of $30 per patient or $86 if they took more than 30 minutes with an extra $14 for every 15 minutes more after that. She worked for a few hospitals and was self employed, responsible for billing the state health insurance and buying her own malpractice insurance. Patients she cared for would wait weeks for a non-emergency CT scan and months for an MRI scan. A surgical consultation for a condition that did not require surgery immediately would be scheduled 2-4 weeks out or more.  They would wait in the waiting room to see her for 8-24 hours.  I’m sure this isn’t representative of all of Canada, and, other than the financial arrangements, I think that similar wait times may apply to some inner city hospitals in the US. Still, it was interesting to hear about what she considered normal.

Emergency Medicine is really popular in the US. After medical school a sizeable number of graduates want to be emergency physicians. It’s not too hard to see why. The pay is good. When you work you get a chance to treat all kinds of things, cure people, send them home, resuscitate near dead people and then send them to the intensive care unit for another doctor to take care of the details and clean up the numerous loose ends. When you are not working you are really and truly off, no patients calling in the middle of the night, no waiting for the cell phone to ring while hanging out with the family.  Maybe this is why the emergency medicine docs I have been meeting at these ultrasound courses seem to be overall happier than the internists at the internal medicine conferences. Maybe it’s just that the folks who choose something fast moving and demanding have more self confidence. It can also really suck to be an ER doctor. Patients respect them when they reduce a dislocated shoulder or treat a pneumonia.  Other physicians are grateful to them because they are on the front line and so we don’t have to be there. But then they call us because the patient really can’t get what they need in the ER, either needs to see us in followup or be admitted to the hospital and then sometimes we are not at all nice to them. We ask if we really have to come in now, at 2 in the morning, for this. We wonder why they couldn’t figure out that the patient had this, not that, which is so clearly obvious to us who have a much narrower specialty and are only seeing one patient at a time. We share our unhappiness with them as we emerge from sleep to their phone calls. They also deal with patients who are very unhappy with them because they have waited for hours to see anyone and now it turns out that their problem is not that dire and only requires some reassurance.  The ER is where the patient who is addicted to prescription pain killers comes to get a fix, complaining of some kind of pain that may be real or may be imaginary, hard to tell since pain is truly subjective, and angry at the ER doc who won’t give out pain meds for non-surgical pain on principal, to keep from feeding the system. They get sued pretty often. They get lots of complaints from patients because the patients don’t know them very well and they don’t have the time to establish a good doctor patient relationship. Perhaps it’s all this adversity that makes them interesting.

For whatever reason, my experience of the medical education courses that I’ve attended that are coordinated by emergency physicians and for an ER audience are interesting, fast paced, practical and make me smile.  In bedside ultrasound they are also the ones who are most involved in pushing the limits of what the technology can do and making the advances practical and accessible.