Back from the MICU

The medical intensive care unit is a very difficult place for interns to work. I'm glad my month is finished.

I'm back to being a regular New Haven Resident, which includes time for writing, for studying and for kitchen renovation in the midst of learning how to intubate patients and how to look at just about everything you can imagine using ultrasound.

Here are some other things I've been working on recently:

A little article about couple's matching for residency over at Medscape. The couple's match is how medical school graduates can be guaranteed placement in a city where their partner (who must also be a soon-to-be intern) will also match.

I'm also helping kick-start some conversations over at a discussion board within Medscape, called Med Student Connect. Check out my morning report posts if you want to work through some clinical brain-teasers. #1, #2, and #3. I'm trying to kick up some controversy in the ethics section, but haven't any takers yet.

You'll need a free log-in for Medscape to read each of these. Sorry.

So not very much news from me other than these. For now...

Intensive Care

As my wife and I completed some interventions on our New Haven home this weekend (namely finishing circuitry and hanging drywall), I prepared for my month in the intensive care unit. It begins tomorrow at 06:00.

See you in a month.

Voting en bloc

Yesterday I set foot in the concrete bunker of a behemoth called East Rock School to vote. It was the first time I've voted in Connecticut. It's the fourth state I've voted in. IL, PA, WA are the others. There were three positions and one ballot measure up for review. The most important race (for District 9 alderman) included an individual who ran unopposed. Roland Lemar's frequent neighborhood updates are useful to me, and he's replied to all of my emails. I enjoyed voting for him. The other race was for a mayor who easily won his 9th term, and for a city clerk. I didn't know I was voting for a clerk so decided to let the other New Haven residents pick that job.

One of the reasons I voted was that the polling place was right across the street (in a school slated to be torn down and rebuilt next summer). Likened to a prison in its current manifestation, the new design promises to be open, friendly and better integrated with the neighborhood.


Extra points go to the person who can ID which house on the architectural design is ours. My wife and I are excited about the new park and playground area across the street.

A second reason I voted is because I appreciate the opportunity to participate in government, even as a mere voter.

Finally, if I ever participate in government as more than a voter, I think it's important to show that, yes, I have voted in every election I was able.

Which brings me to another point. Sometimes, I'll not be able to vote, except by absentee ballot, simply because I'm working 30 hour shifts. CT doesn't make absentee balloting as easy as King County, Washington does. I'll have to figure that one out later. By this time next week, I'll be a MICU intern. Remember those work hours limitations? No more than 80 hours a week or 30 hours at a time... I've heard that it's pretty hard to observe them when you're a MICU intern. Either way, you won't be hearing much from me on this blog, by emails, or frankly, in any other medium, for the next month, as I will be in the midst of my MICU schedule block. Or said another way, en MICU block.

Immune!

Look at this scary beast!

Influenza H1N1 - striking fear into the hearts of mothers and 24-hour news networks alike. Except that it's not. On the pediatrics floor where I'm working this month, there are so many parents I've talked with who just aren't sure about the new H1N1 vaccine. They're happy giving the seasonal flu shot, but are leary of the other. "Is it safe?" they ask. "I don't know," they say. Or in one case, "This is all just a damn conspiracy cover-up for a bioterror experiment gone bad."

Right.

I can't make parents give a shot to their kids, but it is awfully frustrating to hear how someone out there (the media?) has confused so many people about this. Here is some of the information I know:

• The flu vaccine was produced by the SAME technique as the seasonal variety.
• Most (in my area 99%) cases of flu are H1N1, so the seasonal vaccine will not cover you.
• The best guesses out there are that younger patients may be at increased risk.
  

If you need more reasons, check out this list posted by an infectious disease doctor on the West Coast. As I see it, my job as a medical resident working on a pediatrics floor this month and in the ICU next month, I hardly have a choice in the matter of vaccination. I owe it to the patients and families I care for to build up my resistance. So when I learned that my hospital had made the vaccine available to staff from the women's and children's departments, I was among the first in line.

Plus, if I have a bad night tomorrow on call, I can blame it on all of those flu vaccine side effects!

Interior Walls

I'm about to finish my 4th month as a resident of/in New Haven.

Let's just say I'm undergoing some remodeling. This applies to the metaphor of individual change and literally to the state of our house. Our neighbors no doubt have recognized the debris in our back yard from our kitchen project. Hopefully all of the cognitive remodeling I am pursuing in my clinical training is moving along, too.

Unfortunately, there is not as much time as in medical school to take stock of the situation and reflect. Perhaps that will change next month on my pediatrics rotation. For now, I have two more overnight shifts...

Rarely do I encounter a statement from a professional organization that I agree with en total. The following myth-busting memo from the American College of Emergency Physicians (of which I am a resident member) is one I can put my support behind. President Obama mentioned emergency medicine in his joint session, but in doing so added fuel to the fire that emergency care is at the root of our current crisis. It is not. Take a few minutes to read this well crafted letter.

An Open Letter from America's Emergency Physicians

As the physicians on the front lines of emergency care, we see the tragic problems of a failing health care system. We care for people who are ravaged by untreated disease; help worried mothers on weekends with sick children, unable to access a system that's open 9 to 5, weekdays only; and treat the victims of heart attack, stroke and injuries whose very lives depend on our care.

The role of emergency medicine has been badly misrepresented during the health care reform debate. The American College of Emergency Physicians supports comprehensive reform, including universal coverage. But it is vitally important that reform legislation not be based on erroneous perceptions, but instead address the critical problems harming emergency patients. It is time to debunk the myths, focus on the real problems and outline solutions to ensure that health care reform will protect and enhance everyone's access to quality, timely emergency care.

Myth: Emergency medical care is expensive and inefficient. Reducing emergency care will "bend the cost curve" on our nation's rising health care costs.
Fact: The 120 million annual visits made to emergency departments account for only 3% of all health care spending. In addition, emergency departments are equipped with state-of- the-art diagnostic equipment and highly trained physicians who can draw on many hospital resources quickly, providing coordinated, efficient patient care. The fixed costs of being open 24/7 are high, but the variable costs for seeing patients in the emergency department are the same as anywhere else care is provided.

Myth: Emergency departments are crowded with patients seeking non-urgent care.
Fact: Only 12.1% of emergency patients have non-urgent conditions that could wait 2 to 24 hours for medical care, according to the Centers for Disease Control and Prevention (CDC). While this percentage may be slightly higher in some hospitals, the reality is that crowded conditions and longer wait times are primarily caused by patients being "boarded," or forced to stay in the emergency department - often on gurneys lining the hallways - long after they have been seen and admitted to the hospital.

Myth: Your local emergency department will always be there when you need it.
Fact: Hundreds of emergency departments have closed nationwide because of an overburdened emergency care system. Those remaining must accommodate an average increase of 3 million more patient visits each year. Every 60 seconds emergency care is delayed when an ambulance is diverted to a distant hospital because a nearer one is unable to accept more patients. In addition, 75% of emergency department directors report significant problems getting needed on-call specialists, such as neurosurgeons and orthopedists, to provide vital on-call services to emergency patients.

Myth: The need for emergency care will decrease when health care reform is enacted.
Fact: With a growing and aging population, our role in providing care to the sick and injured any time day or night, and our front line responsibility in responding to natural and man-made disasters, will be in even greater demand in the future. Since enacting its universal health care legislation, Massachusetts has experienced an increase in emergency department patients. Emergency medicine is an essential community service that is vitally important to our nation's health care system.

To help ensure our country has a strong emergency care system, the American College of Emergency Physicians supports comprehensive health care reform that includes:

• Every person in America must have meaningful and affordable health insurance coverage provided through a combination of employer and individually mandated insurance. It should be means-tested, allowing those in need to receive coverage or financial support to buy insurance. A combination of private sector and governmental solutions may be needed to achieve universal coverage. America is experiencing a dramatically rising tide of uninsured and underinsured patients. Emergency physicians are the only doctors in the country required by federal law to treat all patients regardless of their ability to pay. It is a responsibility we embrace proudly, but many emergency departments and physician groups are closing under the burden of uncompensated care.
• Health care costs must be reduced. Significant medical liability reform is needed to eliminate unnecessary, expensive tests known as "defensive medicine." Liability reform can also help increase the availability of critically needed on-call specialists. Widespread adoption of electronic health records could substantially cut costs and improve patient care if there were complete integration of data between the emergency department and other medical settings. Administrative and overhead costs must be reduced.
• Quality and patient safety must be improved by eliminating the practice of "boarding" admitted patients in emergency department hallways until they are transferred to an in-patient hospital bed. This can be achieved by establishing quality standards that define how quickly admitted patients are moved to their appropriate care settings, with such information reported and available to the public.
• A national surge capacity plan must be developed and resources provided to prepare our nation's hospital emergency departments for public health crises such as the H1N1 pandemic, a terrorist attack or other catastrophes.

With so much at stake, America can no longer ignore the crisis in its emergency medical care system or make health reform decisions based on myths. Go to www.acep.org/realities for information on protecting your access to quality, timely emergency care.

We must act now.

Nick Jouriles, MD, FACEP
President
American College of Emergency Physicians

This Crazy Town

Everything's connected.

Earlier this month, I spent a week in the back of ambulances learning about pre-hospital medical care. As part of that, I was on the scene at two rather large fires in the city of New Haven. The first was well-reported by the New Haven Independent. I helped take care of guys that had been battling the blaze for hours. We monitored heart rates and blood pressure, gave oxygen, and transported guys with vital signs out of range to local hospitals just to be checked out. The second fire I was present for occurred early one morning and happened to be across the street from a neighborhood where both one of my senior residents and one of my professors live. The former took this photograph of me looking happy about the smoking building in the background. Really, I was just happy to be outside of the back of the ambulance cab...

The very next call that day was for a person who was feeling like she might hurt herself. She had a history of feeling suicidal and had been hospitalized before, so we took her to Yale, where she would presumably be connected with a psychiatrist who could help her. Hopefully it would not be the self-proclaimed "Savior of Death," who was arrested a few days ago about 2 blocks from my home. Evidently, a well-respected psychiatry resident was involved in an altercation in a local bar and found to have an unlicensed firearm on his person. Any person who is charged in the care of others who makes threatening gestures suggesting danger to those individuals or others in the public may be arrested and be searched without a warrant. A subsequent search of this individual's home revealed a stockpile of firearms and ammunition. He lived about a block from me. The instigating incident goes to show that everyone can be affected by alcohol or mental illness - even physicians.

The arrest was made at the same time that the news conference announcing the discovery of Annie Le, the unfortunate victim who has put Yale on the front page of the nation's newspapers and other news sources. The continued media presence around the police headquarters in New Haven has provided additional unlikely casualties in this story. No fewer than two people from the television news industry have presented to the Yale-New Haven Hospital for carbon monoxide poisoning. I treated a cameraman who was thinking slowly and just wanted to go to sleep. It's the time of year that we ER docs need to think more about that colorless, odorless gas that causes more people to wake up dead than any other poison. (Check your heaters for leaks and please don't burn kerosene or gasoline inside!) The cameraman (and his friend, a union representative) asked me what I knew about the occupational dangers of CO. I know that no significant studies have shown ambulance drivers (who often leave the rigs' engines running in closed spaces) to be at risk, but that smokers and firefighters tend to be chronically exposed and sometimes need to be monitored as such.

Which reminded me of the ambulance ride-alongs I did earlier this month.