actually, blood supply is the key to healing. Jagged vs smooth/linear wounds have more impact on the cosmesis of the resulting scar.
Wounds on the face and head almost always heal because of the blood supply (anyone who's ever split their scalp will attest that it bleeds like stink). Plastic surgeons will often revise the wound margins of a jagged wound to improve the final cosmetic result (ie. they cut the wound edges back with a scalpel, thereby creating a nice scalpel-smooth wound edge, then they undermine the wound edges to create some slack, and then sew the edges together).
To be fair, some of the poor cosmesis with jagged wounds may also have to do with how those wounds are usually created. Jagged wounds tend to be created by ripping and/or splitting by blunt trauma. The greater tissue trauma from those mechanisms may further inhibit good wound healing.
The biometric safe might not work if you've got a particularly hard-up prostitute on your hands.
According to one of my hand surgeon colleagues, muggers in NYC have on occasion used trauma shears (we use them in the ER to cut clothes, watches, belts, chains, etc off of people. They cut almost anything) to cut off your finger at the base in order to get any rings you might be wearing.
Instead of being horrified at the story, the hand surgeon was actually commenting about the nice clean cuts trauma shears produce... makes repairing the amputation much easier, apparently.
Prostitutes will often work in tandem with male associates to "roll" their client. As you may or may not know, as humans approach orgasm, they lose peripheral vision, their hearing becomes less sensitive... easy to get snuck up on.
One knock on the head and a pair of trauma shears later... so much for the biometric safe.
I don't know about that... I don't shop that way, and I'll bet you don't either.
Bear with me for a second.
When you know quality, and quality is important to you (and I work hard for my money, as I'm sure you do), you shop for it. I'll pay more for quality, whether it's cars, computer products, or expertise.
I have my taxes done by a tax attorney every year... I could go to HR Block, but I'm willing to pay that highly-educated professional for his expensive expertise, and it's WORTH IT.
I have several RAIDs, and I use 3ware cards for them. Yes, they are more expensive than the Promise/highpoint cards, but they are better, the drivers are open-source, and they are WORTH IT.
If I'm going to have a LASIK procedure, I'm going to go to the best, most well-trained (and likely most expensive) eye surgeon I can find. You only get one set of eyes... It's WORTH IT.
It sometimes takes a while to learn that little life's lesson... but I figured it out. I'll look for a bargain, but I don't go as cheap as possible for everything, and I'll bet you don't either.
people want high-quality products as cheaply as they can get them. Period. If a company can get a similar service for a cheaper price in another country, it makes them that much more competitive. If the company's new workers make cheap, substandard crap, people won't buy it, and the company loses... so you can't go too cheap.
Also, don't overlook the fact that these moves often benefit the workers in the host country. Their people need jobs, and the industry needs people to do those jobs. Now, I'm not polyanna... you do have to look out for sweatshop-like exploitation... although just defining exploitation can be tricky (particularly if we apply western standards to a third-world subsistence-living standard).
It's all about efficiency, and the market is driving this. Naturally, you non-capitalists may disagree...
I've practiced in Ohio, and medical non-competes don't tend to hold up there either.
I can't speak to the rest of your tirade on the Ohio legal system, with the exception of the malpractice situation. I happen to think that tort reform is a good thing... of course, you may disagree.
Non-compete clauses used to be common in medical contracts, and most physicians will attempt to get them removed from the contract during negotiations.
It's usually not a serious bone of contention, because the unspoken reality is this: non-competes, particularly geographic ones (ie. you cannot practice within a 60-mile radius) are generally viewed negatively by the courts, and do not hold up.
As for programmers... that might be a different story.
C'mon... isn't this a little too escapist-fantasyish, even for slashdot? I know every geek dreams of hitting it off with a Ms.(insert state of choice here), but isn't living it through the eyes of her lawyer Ex-BF a bit much? Talk about living vicariously through others...
So her intelligence is not Ph.D-in-number-theory Slashdot elite... that's really no excuse for her class-deficient Ex-BF to write a kiss-and-tell website about their entire relationship. Frankly, I'd say it's pretty weak. I understand wanting to do it; everyone's lived in bimbo limbo at some time in their life. Everyone who's ever had a bad breakup, whether they saw it coming or not, has wanted to do the same thing; it's actually doing it that's over the line. Be an adult and walk away, thankful that the other person is out of your space.
There's something to be said for being the bigger man about these things. Let it go... such people tend to get what's coming to them anyway; all it takes is time.
Leave it to a geek
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PeltierBeer
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· Score: 3, Funny
I have to echo the above poster's comment about the racially-tinged reference.
It's ironic indeed that the same comment could not be made about african americans or other racial groups without setting off the Al Sharptons of the world.
I'm not claiming some kind of conspiracy or anything of the sort, but it's interesting what we as americans find acceptable targets of our derision. Whether this is due to socialization, collective guilt, peer pressure... who knows. IANAS (I am not a sociologist).
rather than slashdotting
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Alien Case Mod
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· Score: 4, Funny
Hah... medicine would be easy if it wasn't for the politics...
No, my medics do not do RSI. The flight medics on our helicopter crews do... but they have their own medical director (I work as their control sometimes, but I generally give them pretty free rein... they've proved their worth)
I like RSI... I'm a real fan. Problem is, you have to select your patients VERY carefully. As you alluded above, Sux will sometimes require you to bag them for few minutes, but then they're back breathing again (and you can clean out your trousers). I've had one RSI go horribly wrong, to the point that I had to crich the patient (the crich tray was in the pyxis... thankfully we had asked for it earlier. That whole pyxis thing drives me crazy... but I digress). The patient survived, but I'm not in a hurry to do that again anytime soon.
My favorite drugs are etomidate and Sux (I would even use Sux in a trauma patient... just be careful of the long-term paralysis patients, high K+ folks, etc). Sux is the fastest, hands down, and it wears off quickly. Fast on, fast off... what could be better? I use the longer acting paralytics if there is a contraindication for a depolarizing blocker, or the patient needs to be down for a while. If you know what you're doing, RSI saves lives, and studies bear that out. You just have to know what to give, and to whom (premedication for head injury patients, for instance. I hope to hell they still have Lido in your rigs for that).
I think RSI is incredibly valuable in properly-trained hands, but I'm just not sure it's ready for widespread prehospital deployment.
I should clarify... we do use amiodarone in the emergency department.
It's in the algorithms, so you should have a good reason for using something different. Can't you just hear the lawyer "Doctor, have you ever heard of the ACLS protocols?"
Still, I have to be honest... that whole dogmatic "it's in the protocol, you must use the protocol, the protocol is your friend" approach that some people use bugs me. It's almost like people start resuscitating and stop thinking. Protocols are a framework, and you should be able and willing to work outside them, particularly as a physician (I'm not sure I want a medic or EMT doing that). I only say that because the buck really does stop with me... after all, it's my medical license and professional reputation I'm risking. I encourage my residents and medical students to protocol-bust if they think the patient REALLY needs something other than what the protocol asks.
Then again, maybe that's just the iconoclast in me.
Heh... how many non-geeks do you know who read slashdot? I can't think of any...
We're not really on the amiodarone train here yet, particularly not prehospital. We've been over and over this at our EMS council, and the consensus seems to be that the studies are just not there yet (it's always the old "do you base your practice on a single study?" question). It's like thrombolytics for strokes... I've personally seen that kill a few people, and despite the quality of the NINDS trial, some docs are very, very cautious about using it (can't really say that I blame them... lytics are dangerous drugs, best to use them with extreme care). Personally, if there's ANY contraindications to be had, relative or absolute, I urge the patient and family to consider other options.
Last time I checked the literature on Amiodarone, it was improving survival to ICU admission, but not to hospital discharge. Heheheh... Some of the docs were really waving the bullshit flag when the ACLS protocols were rewritten a few years back to include amiodarone in virtually every algorithm. Like I say, opinions differ... I'm not as passionate about that issue, though some of the other directors are pretty adamant.
I always hate it when it gets busy to the point that I'm nothing but triage. Some days, it just comes down to figuring out who gets admitted and who doesn't, and let the internists sort it out... It's a shitty way to do business, I know... but some hospitals just aren't serious about supporting their EDs, and we get chronically short-staffed and behind the eight ball.
Personally, as a specialist my own right, I fancy myself as something more than a glorified intern... I like coming up with the correct diagnosis as much as the next physician, and I pride myself on being able to do it quickly. Some days though, too much chaos and nobody's satisfied; patients, consultants, nurses... not even me. I hate those days.
I always try to provide good service to my consultants; maybe I'll bring a case of bawls up the ICU for you sometime;)
God... you know, I've racked my brain on this issue over and over... I don't know what the magic answer to the malpractice crisis is. Our insurance went up 100% this year; painful.
I like the tort reform idea... but that's only one piece of the puzzle. If we take away the financial punishment patients can theoretically levy on "bad doctors," we need to replace it with something. Perhaps giving the state board more teeth to pull licenses... I don't know. If you take away punitive malpractice awards, there has to be another way to weed out the incompetents.
The NPDB keeps track of suits... but it doesn't tell the whole story. Was the suit frivolous? settled? dropped?
I want to protect the public, but I also want to protect medicine from rapacious malpractice attorneys (every city has a group of them... advertising all over TV and radio... "have you been injured? no bill if no settlement!"). Bottom feeders like that make me want to vomit...
I don't know. I've had colleagues sued over the most ridiculous stuff... every suit I personally know of against an ER doc should have never been filed. Scary thing is, one of them was almost successful, on a totally bogus case.
It's driving the OB/GYNs out of business left and right... the neurosurgeons are starting to go bare... Scary.
Something has to be done... citizen/doctor/lawyer review board before a suit can be filed? I like that idea... let the ones with objective merit go forward.
I'm a medical director for an EMS agency, so I know the difficulty in interpreting stuff coming from the field. Getting a really good tracing on your 12-lead in the back of a moving rig is a challenge, to be sure. Now, my medics are not doing thrombolytics in the field or anything like that... maybe someday.
It would be nice to know a little more about the innards of the stuff we use/buy, particularly from an objective measurement standpoint. I'd love to know where Dr. Ornato gets that kind of info... might make purchasing decisions much more objective. I'd rather have that to throw at the reps than the "oooo! look at the shiny brochure!" that they're hoping for...
heheh... I should have figured you for a hospitalist... Internal Medicine, or FP?
Yes, you are exactly right. An EKG only helps you if it's positive... a normal or near-normal tracing buys you nothing; the negative predictive value for AMI is miserable.
Now, if only I could convince the internists I call to admit patients of that reality... they still want to believe the "normal" or "non-acute" EKG and send the patient home... it's a neverending battle.
I have to disagree with my colleague on the size of the malpractice problem, at least as far as my specialty is concerned.
The good doctor is quite right that happy patients don't sue... studies bear that out. This is good info, but only applicable if you have the ability to make them happy, and/or have a long-term relationship with them.
In my specialty of emergency medicine, this is a big problem... we get sued like nobody's business. We don't like it, but much of it is out of our control. Allow me to explain:
1. we take care of sick, sick, sick patients, and sometimes they die. Unrealistic expections about medical care fall squarely on us. We are often the first target of grief-turned-to-anger... there's a reason why I sometimes have big cops standing by when I notify family members of a death... I've had those situations turn ugly in a hurry, to the point where I had to flee.
2. We are pressed for time. I love to chat, but the MI in the next bed, and that incoming trauma on the helo, and that eclamptic mother of twins can't wait... gotta run. Patients perceive this as neglect, and I often don't have time to explain it to them. They leave with the erroneous conclusion that we don't give a shit, which couldn't be further from the truth. ERs are busy places, and statistically, we are getting busier every year. It's only going to get worse.
3. Nobody likes to wait. In the ER, sicker patients come first. Naturally, this annoys the patient who has been waiting for 4 hours in the lobby, some of whom think it's 1st come 1st served. I've had patients call 911 FROM THE WAITING ROOM, because they noticed that patients arriving by squad were brought back right away. I can't make this stuff up, folks.
4. Environment. ERs are the medicine of last resort for most people... almost nobody WANTS to come to the ER. I take care of corporate CEOS, college professors, regular joes, and society's dregs, all in the same room. Nobody likes to be sandwiched between a puking drunk and a meth user who's fighting with six cops... when they ask to be moved to another bed, I often cannot oblige in a full department. People resent it, and I don't blame them, but I also can't help them.
5. Relationships. Apart from "frequent fliers," I seldom see anyone more than once. Regardless of any "winning personality," making friends in that short amount of time, with someone in terrible pain, or a parent worried about their child, is pretty tough. My frequent fliers are often people you don't want to see again: Drug users shopping for party supplies, street people looking for a place to sleep, gangbangers... I'd love to help them, but that's not what the ER is for... and many of those folks have chronic problems/situations I'm not equipped to treat.
I also agree that honest mistakes should be held harmless... everyone makes them, and I've made my share and then some. Blatant malpractice, egregious breach of the standard of care, malice... those folks should never touch another patient.
The armed response units are what I was referring to... also, are you certain that some supervisors are not carrying weapons in their vehicles? I do recall reading that... I'll try to get you a reference.
No no... I appreciate the input of you guys that actually make the equipment function... the Biomed guys regularly save me (by keeping my equipment running). I couldn't do my job nearly as effectively if it wasn't for the biomedical engineers. I don't mean to make fun of anyone's hard work, and I'm probably being too hard on the people that program these things. Maybe it's the case that the interpretation software is simply in its infancy.
Perhaps I should expand on my initial comments. A previous poster pointed out that the first thing you are taught in medical school is to ignore the machine read... that's true, and medical students are still taught that way (I teach in an academic setting, and I teach my students the same thing).
As I understand the machine's algorithms (if somebody who programs these things wants to correct me, please do), they interpret the waveforms based on an ideal model, and attempt to interpret current-of-injury patterns, based on deviation from an expected baseline.
Many situations make the machine read useless (and to be fair, extraordinarily difficult)... any patient in a paced rhythmn (pacemaker, single or dual chamber), the machine will default, and not give a read. An excellent call for the engineer that designed the machine... reading injury on some paced rhythms can be very sticky, even for an experienced clinician. Some of these machines regularly read "digitalis effect".. a difficult call, particularly in a suspected ischemic or strain-induced ST depression. A noisy baseline (in a patient who's shaking, for instance)will often throw off the machine. Many patients who have known cardiac disease have EKGs that are difficult to interpret, and injury that can only be discovered based on comparison to a previous EKG.
What I'd like to see is a program that compares old EKGs to new ones, and automatically gives you a change summary (in addition to the tracings themselves, naturally). I could see that being very useful, particularly if it uses the previous EKG tracings to redefine "normal" for itself. That might help the over-sensitivity problem. Many people are walking around with tracings that are nowhere near the classic "normal," but are normal for THEM. What I'm saying is that I'd like to see a program with a dynamic "normal;" one it can redefine on the fly.
It's not to say that I don't read the machine's interpretation... I do, but I subordinate it to my own clinical interpretation. To be fair, I have the luxury of knowing the history... something the machine may never know, and as any physician will tell you, history makes the diagnosis 80% of the time; the tests are simply to confirm what you suspected all along.
Maybe if you frame it like that, EKG machine reads don't really need to be perfect... they are, after all, just an adjunct... A human still makes the decisions.
I disagree... EKG reading can be quite challenging, and unless you understand the nuances of why everything on that tracing happens like it does... you will miss important findings, particularly subtle ones.
Dale Dubin has a book on EKG reading that I'd recommend as an excellent starting point. It's hardly exhaustive, but well-loved by many paraprofesionals.
I can tell you that many of us clinicians laugh out loud at some of the machine "interpretations" that ECG machines generate.
NEVER trust a physician who allows his ECG machine to interpret your tracing... run for the door... I'm quite serious about that. If the guy doesn't have the expertise to read your tracing himself, don't trust your cardiovascular health to him.
I've sent people home with ECGs that read ****ACUTE MI***** in large, upper-case font on the top, because the machine was totally, completely wrong. The only thing it's sometimes useful for is in reading QT intervals, and occasionally rate (though the machine can be easily fooled on this one as well).
Have a doc read it, preferably a cardiologist. Of course, if you don't want to pay a guy like that for his expertise you don't have to... but you get what you pay for.
Slashdot Mirror
actually, blood supply is the key to healing. Jagged vs smooth/linear wounds have more impact on the cosmesis of the resulting scar.
Wounds on the face and head almost always heal because of the blood supply (anyone who's ever split their scalp will attest that it bleeds like stink). Plastic surgeons will often revise the wound margins of a jagged wound to improve the final cosmetic result (ie. they cut the wound edges back with a scalpel, thereby creating a nice scalpel-smooth wound edge, then they undermine the wound edges to create some slack, and then sew the edges together).
To be fair, some of the poor cosmesis with jagged wounds may also have to do with how those wounds are usually created. Jagged wounds tend to be created by ripping and/or splitting by blunt trauma. The greater tissue trauma from those mechanisms may further inhibit good wound healing.
Heheh... I don't amputates 'em... I just fixes 'em
The biometric safe might not work if you've got a particularly hard-up prostitute on your hands.
According to one of my hand surgeon colleagues, muggers in NYC have on occasion used trauma shears (we use them in the ER to cut clothes, watches, belts, chains, etc off of people. They cut almost anything) to cut off your finger at the base in order to get any rings you might be wearing.
Instead of being horrified at the story, the hand surgeon was actually commenting about the nice clean cuts trauma shears produce... makes repairing the amputation much easier, apparently.
Prostitutes will often work in tandem with male associates to "roll" their client. As you may or may not know, as humans approach orgasm, they lose peripheral vision, their hearing becomes less sensitive... easy to get snuck up on.
One knock on the head and a pair of trauma shears later... so much for the biometric safe.
I don't know about that... I don't shop that way, and I'll bet you don't either.
Bear with me for a second.
When you know quality, and quality is important to you (and I work hard for my money, as I'm sure you do), you shop for it. I'll pay more for quality, whether it's cars, computer products, or expertise.
I have my taxes done by a tax attorney every year... I could go to HR Block, but I'm willing to pay that highly-educated professional for his expensive expertise, and it's WORTH IT.
I have several RAIDs, and I use 3ware cards for them. Yes, they are more expensive than the Promise/highpoint cards, but they are better, the drivers are open-source, and they are WORTH IT.
If I'm going to have a LASIK procedure, I'm going to go to the best, most well-trained (and likely most expensive) eye surgeon I can find. You only get one set of eyes... It's WORTH IT.
It sometimes takes a while to learn that little life's lesson... but I figured it out. I'll look for a bargain, but I don't go as cheap as possible for everything, and I'll bet you don't either.
people want high-quality products as cheaply as they can get them. Period. If a company can get a similar service for a cheaper price in another country, it makes them that much more competitive. If the company's new workers make cheap, substandard crap, people won't buy it, and the company loses... so you can't go too cheap.
Also, don't overlook the fact that these moves often benefit the workers in the host country. Their people need jobs, and the industry needs people to do those jobs. Now, I'm not polyanna... you do have to look out for sweatshop-like exploitation... although just defining exploitation can be tricky (particularly if we apply western standards to a third-world subsistence-living standard).
It's all about efficiency, and the market is driving this. Naturally, you non-capitalists may disagree...
and I can see sooo many slashdotters running out to find a copy of Wired to buy, just so they can get the code to that 1337 3xpl01t...
free advertising alright... to the wrong audience.
I've practiced in Ohio, and medical non-competes don't tend to hold up there either.
I can't speak to the rest of your tirade on the Ohio legal system, with the exception of the malpractice situation. I happen to think that tort reform is a good thing... of course, you may disagree.
Non-compete clauses used to be common in medical contracts, and most physicians will attempt to get them removed from the contract during negotiations.
It's usually not a serious bone of contention, because the unspoken reality is this: non-competes, particularly geographic ones (ie. you cannot practice within a 60-mile radius) are generally viewed negatively by the courts, and do not hold up.
As for programmers... that might be a different story.
C'mon... isn't this a little too escapist-fantasyish, even for slashdot? I know every geek dreams of hitting it off with a Ms.(insert state of choice here), but isn't living it through the eyes of her lawyer Ex-BF a bit much? Talk about living vicariously through others...
So her intelligence is not Ph.D-in-number-theory Slashdot elite... that's really no excuse for her class-deficient Ex-BF to write a kiss-and-tell website about their entire relationship. Frankly, I'd say it's pretty weak. I understand wanting to do it; everyone's lived in bimbo limbo at some time in their life. Everyone who's ever had a bad breakup, whether they saw it coming or not, has wanted to do the same thing; it's actually doing it that's over the line. Be an adult and walk away, thankful that the other person is out of your space.
There's something to be said for being the bigger man about these things. Let it go... such people tend to get what's coming to them anyway; all it takes is time.
To not even know how to spell "breast"
I have to echo the above poster's comment about the racially-tinged reference.
It's ironic indeed that the same comment could not be made about african americans or other racial groups without setting off the Al Sharptons of the world.
I'm not claiming some kind of conspiracy or anything of the sort, but it's interesting what we as americans find acceptable targets of our derision. Whether this is due to socialization, collective guilt, peer pressure... who knows. IANAS (I am not a sociologist).
We should nuke the site from orbit.
It's the only way to be sure.
"turning it into a secure pubic server"
That's truly a noble endeavor... From my experience, most insecure pubic servers are loaded with viruses and trojans.
Hah... medicine would be easy if it wasn't for the politics...
No, my medics do not do RSI. The flight medics on our helicopter crews do... but they have their own medical director (I work as their control sometimes, but I generally give them pretty free rein... they've proved their worth)
I like RSI... I'm a real fan. Problem is, you have to select your patients VERY carefully. As you alluded above, Sux will sometimes require you to bag them for few minutes, but then they're back breathing again (and you can clean out your trousers). I've had one RSI go horribly wrong, to the point that I had to crich the patient (the crich tray was in the pyxis... thankfully we had asked for it earlier. That whole pyxis thing drives me crazy... but I digress). The patient survived, but I'm not in a hurry to do that again anytime soon.
My favorite drugs are etomidate and Sux (I would even use Sux in a trauma patient... just be careful of the long-term paralysis patients, high K+ folks, etc). Sux is the fastest, hands down, and it wears off quickly. Fast on, fast off... what could be better? I use the longer acting paralytics if there is a contraindication for a depolarizing blocker, or the patient needs to be down for a while. If you know what you're doing, RSI saves lives, and studies bear that out. You just have to know what to give, and to whom (premedication for head injury patients, for instance. I hope to hell they still have Lido in your rigs for that).
I think RSI is incredibly valuable in properly-trained hands, but I'm just not sure it's ready for widespread prehospital deployment.
I should clarify... we do use amiodarone in the emergency department.
It's in the algorithms, so you should have a good reason for using something different. Can't you just hear the lawyer "Doctor, have you ever heard of the ACLS protocols?"
Still, I have to be honest... that whole dogmatic "it's in the protocol, you must use the protocol, the protocol is your friend" approach that some people use bugs me. It's almost like people start resuscitating and stop thinking. Protocols are a framework, and you should be able and willing to work outside them, particularly as a physician (I'm not sure I want a medic or EMT doing that). I only say that because the buck really does stop with me... after all, it's my medical license and professional reputation I'm risking. I encourage my residents and medical students to protocol-bust if they think the patient REALLY needs something other than what the protocol asks.
Then again, maybe that's just the iconoclast in me.
Heh... how many non-geeks do you know who read slashdot? I can't think of any...
We're not really on the amiodarone train here yet, particularly not prehospital. We've been over and over this at our EMS council, and the consensus seems to be that the studies are just not there yet (it's always the old "do you base your practice on a single study?" question). It's like thrombolytics for strokes... I've personally seen that kill a few people, and despite the quality of the NINDS trial, some docs are very, very cautious about using it (can't really say that I blame them... lytics are dangerous drugs, best to use them with extreme care). Personally, if there's ANY contraindications to be had, relative or absolute, I urge the patient and family to consider other options.
Last time I checked the literature on Amiodarone, it was improving survival to ICU admission, but not to hospital discharge. Heheheh... Some of the docs were really waving the bullshit flag when the ACLS protocols were rewritten a few years back to include amiodarone in virtually every algorithm. Like I say, opinions differ... I'm not as passionate about that issue, though some of the other directors are pretty adamant.
Those debates are always entertaining...
I feel your pain...
;)
I always hate it when it gets busy to the point that I'm nothing but triage. Some days, it just comes down to figuring out who gets admitted and who doesn't, and let the internists sort it out... It's a shitty way to do business, I know... but some hospitals just aren't serious about supporting their EDs, and we get chronically short-staffed and behind the eight ball.
Personally, as a specialist my own right, I fancy myself as something more than a glorified intern... I like coming up with the correct diagnosis as much as the next physician, and I pride myself on being able to do it quickly. Some days though, too much chaos and nobody's satisfied; patients, consultants, nurses... not even me. I hate those days.
I always try to provide good service to my consultants; maybe I'll bring a case of bawls up the ICU for you sometime
God... you know, I've racked my brain on this issue over and over... I don't know what the magic answer to the malpractice crisis is. Our insurance went up 100% this year; painful.
I like the tort reform idea... but that's only one piece of the puzzle. If we take away the financial punishment patients can theoretically levy on "bad doctors," we need to replace it with something. Perhaps giving the state board more teeth to pull licenses... I don't know. If you take away punitive malpractice awards, there has to be another way to weed out the incompetents.
The NPDB keeps track of suits... but it doesn't tell the whole story. Was the suit frivolous? settled? dropped?
I want to protect the public, but I also want to protect medicine from rapacious malpractice attorneys (every city has a group of them... advertising all over TV and radio... "have you been injured? no bill if no settlement!"). Bottom feeders like that make me want to vomit...
I don't know. I've had colleagues sued over the most ridiculous stuff... every suit I personally know of against an ER doc should have never been filed. Scary thing is, one of them was almost successful, on a totally bogus case.
It's driving the OB/GYNs out of business left and right... the neurosurgeons are starting to go bare... Scary.
Something has to be done... citizen/doctor/lawyer review board before a suit can be filed? I like that idea... let the ones with objective merit go forward.
I'm a medical director for an EMS agency, so I know the difficulty in interpreting stuff coming from the field. Getting a really good tracing on your 12-lead in the back of a moving rig is a challenge, to be sure. Now, my medics are not doing thrombolytics in the field or anything like that... maybe someday.
It would be nice to know a little more about the innards of the stuff we use/buy, particularly from an objective measurement standpoint. I'd love to know where Dr. Ornato gets that kind of info... might make purchasing decisions much more objective. I'd rather have that to throw at the reps than the "oooo! look at the shiny brochure!" that they're hoping for...
heheh... I should have figured you for a hospitalist... Internal Medicine, or FP?
Yes, you are exactly right. An EKG only helps you if it's positive... a normal or near-normal tracing buys you nothing; the negative predictive value for AMI is miserable.
Now, if only I could convince the internists I call to admit patients of that reality... they still want to believe the "normal" or "non-acute" EKG and send the patient home... it's a neverending battle.
I have to disagree with my colleague on the size of the malpractice problem, at least as far as my specialty is concerned.
The good doctor is quite right that happy patients don't sue... studies bear that out. This is good info, but only applicable if you have the ability to make them happy, and/or have a long-term relationship with them.
In my specialty of emergency medicine, this is a big problem... we get sued like nobody's business. We don't like it, but much of it is out of our control. Allow me to explain:
1. we take care of sick, sick, sick patients, and sometimes they die. Unrealistic expections about medical care fall squarely on us. We are often the first target of grief-turned-to-anger... there's a reason why I sometimes have big cops standing by when I notify family members of a death... I've had those situations turn ugly in a hurry, to the point where I had to flee.
2. We are pressed for time. I love to chat, but the MI in the next bed, and that incoming trauma on the helo, and that eclamptic mother of twins can't wait... gotta run. Patients perceive this as neglect, and I often don't have time to explain it to them. They leave with the erroneous conclusion that we don't give a shit, which couldn't be further from the truth. ERs are busy places, and statistically, we are getting busier every year. It's only going to get worse.
3. Nobody likes to wait. In the ER, sicker patients come first. Naturally, this annoys the patient who has been waiting for 4 hours in the lobby, some of whom think it's 1st come 1st served. I've had patients call 911 FROM THE WAITING ROOM, because they noticed that patients arriving by squad were brought back right away. I can't make this stuff up, folks.
4. Environment. ERs are the medicine of last resort for most people... almost nobody WANTS to come to the ER. I take care of corporate CEOS, college professors, regular joes, and society's dregs, all in the same room. Nobody likes to be sandwiched between a puking drunk and a meth user who's fighting with six cops... when they ask to be moved to another bed, I often cannot oblige in a full department. People resent it, and I don't blame them, but I also can't help them.
5. Relationships. Apart from "frequent fliers," I seldom see anyone more than once. Regardless of any "winning personality," making friends in that short amount of time, with someone in terrible pain, or a parent worried about their child, is pretty tough. My frequent fliers are often people you don't want to see again: Drug users shopping for party supplies, street people looking for a place to sleep, gangbangers... I'd love to help them, but that's not what the ER is for... and many of those folks have chronic problems/situations I'm not equipped to treat.
I also agree that honest mistakes should be held harmless... everyone makes them, and I've made my share and then some. Blatant malpractice, egregious breach of the standard of care, malice... those folks should never touch another patient.
The armed response units are what I was referring to... also, are you certain that some supervisors are not carrying weapons in their vehicles? I do recall reading that... I'll try to get you a reference.
It does seem, however, that some units are starting to carry firearms on patrol as late as last year.
Sign of the times.
No no... I appreciate the input of you guys that actually make the equipment function... the Biomed guys regularly save me (by keeping my equipment running). I couldn't do my job nearly as effectively if it wasn't for the biomedical engineers. I don't mean to make fun of anyone's hard work, and I'm probably being too hard on the people that program these things. Maybe it's the case that the interpretation software is simply in its infancy.
Perhaps I should expand on my initial comments. A previous poster pointed out that the first thing you are taught in medical school is to ignore the machine read... that's true, and medical students are still taught that way (I teach in an academic setting, and I teach my students the same thing).
As I understand the machine's algorithms (if somebody who programs these things wants to correct me, please do), they interpret the waveforms based on an ideal model, and attempt to interpret current-of-injury patterns, based on deviation from an expected baseline.
Many situations make the machine read useless (and to be fair, extraordinarily difficult)... any patient in a paced rhythmn (pacemaker, single or dual chamber), the machine will default, and not give a read. An excellent call for the engineer that designed the machine... reading injury on some paced rhythms can be very sticky, even for an experienced clinician. Some of these machines regularly read "digitalis effect".. a difficult call, particularly in a suspected ischemic or strain-induced ST depression. A noisy baseline (in a patient who's shaking, for instance)will often throw off the machine. Many patients who have known cardiac disease have EKGs that are difficult to interpret, and injury that can only be discovered based on comparison to a previous EKG.
What I'd like to see is a program that compares old EKGs to new ones, and automatically gives you a change summary (in addition to the tracings themselves, naturally). I could see that being very useful, particularly if it uses the previous EKG tracings to redefine "normal" for itself. That might help the over-sensitivity problem. Many people are walking around with tracings that are nowhere near the classic "normal," but are normal for THEM. What I'm saying is that I'd like to see a program with a dynamic "normal;" one it can redefine on the fly.
It's not to say that I don't read the machine's interpretation... I do, but I subordinate it to my own clinical interpretation. To be fair, I have the luxury of knowing the history... something the machine may never know, and as any physician will tell you, history makes the diagnosis 80% of the time; the tests are simply to confirm what you suspected all along.
Maybe if you frame it like that, EKG machine reads don't really need to be perfect... they are, after all, just an adjunct... A human still makes the decisions.
I disagree... EKG reading can be quite challenging, and unless you understand the nuances of why everything on that tracing happens like it does... you will miss important findings, particularly subtle ones.
Dale Dubin has a book on EKG reading that I'd recommend as an excellent starting point. It's hardly exhaustive, but well-loved by many paraprofesionals.
I can tell you that many of us clinicians laugh out loud at some of the machine "interpretations" that ECG machines generate.
NEVER trust a physician who allows his ECG machine to interpret your tracing... run for the door... I'm quite serious about that. If the guy doesn't have the expertise to read your tracing himself, don't trust your cardiovascular health to him.
I've sent people home with ECGs that read ****ACUTE MI***** in large, upper-case font on the top, because the machine was totally, completely wrong. The only thing it's sometimes useful for is in reading QT intervals, and occasionally rate (though the machine can be easily fooled on this one as well).
Have a doc read it, preferably a cardiologist. Of course, if you don't want to pay a guy like that for his expertise you don't have to... but you get what you pay for.