ACEP NowACEP Now https://www.acepnow.com Thu, 21 Mar 2019 19:47:20 +0000 en-US hourly 1 https://wordpress.org/?v=5.1.1 Hurricane Florence and the Use of Telemedicine https://www.acepnow.com/article/hurricane-florence-and-the-use-of-telemedicine/ https://www.acepnow.com/article/hurricane-florence-and-the-use-of-telemedicine/#respond Tue, 19 Mar 2019 19:14:23 +0000 https://www.acepnow.com/?post_type=article&p=21023 Hurricane Florence struck North Carolina as a Category 1 storm on Sept. 14, 2018, bringing with it...

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A boat washed ashore in New Bern, North Carolina, by Hurricane Florence.
FEMA/Liz Roll

Hurricane Florence struck North Carolina as a Category 1 storm on Sept. 14, 2018, bringing with it record rainfalls and flooding, an estimated $50 billion in damages, and a death toll of 51.1,2 

Coastal Evacuation

Mandatory evacuations forced thousands of residents from their homes. To help those affected, Wake County created six shelters serving 1,100 people. Many of the evacuees had multiple chronic medical conditions, such as diabetes, high blood pressure, heart conditions, and kidney failure. In their flight to safety, many forgot their medications. Additionally, due to the stress of the circumstances, many of the shelter residents developed acute medical conditions, and their only access to physician care was through EMS and local emergency departments. The added call volume from the shelters strained the Wake County EMS system and taxed the already crowded emergency departments in Wake County.

Wake Emergency Physicians and RelyMD

Staffing six different shelters simultaneously with individual qualified providers was beyond the human resources capabilities of the stressed Wake County infrastructure. Wake County EMS and North Carolina Department of Health and Human Services contacted a local telemedicine company, RelyMD, and asked it to deploy its services to the shelters. RelyMD is a telemedicine service that is 100 percent owned and staffed by Wake Emergency Physicians, PA (WEPPA). With more than 160 emergency medicine and telemedicine specialists, WEPPA is a private, independent emergency medicine practice based in Raleigh, North Carolina, that staffs nine different emergency departments across three health care systems. RelyMD provides thousands of annual online medical evaluations via mobile app and internet-enabled computers. Its providers are available 24-7-365 in an on-demand model.

One of the shelters set up for those affected by Hurricane Florence.

One of the shelters set up for those affected by Hurricane Florence.
Bobby Park

Telemedicine Workflow

Just before the storm hit, the RelyMD team provided a one-hour in-service covering the basics of the platform, which operates on an iPad. During a 10-day hurricane-related period, RelyMD cared for 95 shelter patients, with 67 percent of the care delivered during the first three days of Florence making landfall. The medical issues included respiratory conditions, chest pain, wound care, minor injuries, mental health issues, dialysis coordination, and medication refills. Nurses would evaluate the patient’s needs, take vital signs, review medication lists, and transmit 12-lead ECGs, after which they contacted the RelyMD provider, who would get the “quick story” from the nurse. Then using synchronous real-time audio and video, a physical exam would be performed through the camera of the iPad, with the nurse acting as the provider’s hands. Of the 95 telemedicine consults, nine patients were evaluated and advised to go to the emergency department for further care (see Table 1). The diversion rate of patients who said they would have gone to the emergency department if the telemedicine consult hadn’t been available was 33 out of 41 cases, or 80 percent. (See “Telemedicine Response, By the Numbers” for a summary of this telemedicine initiative.)

Table 1: Patients Evaluated by Telemedicine and Directed to Go to the Emergency Department

(click for larger image) Table 1: Patients Evaluated by Telemedicine and Directed to Go to the Emergency Department

The Advantages of Telemedicine

The Hurricane Florence telemedicine shelter project is an illustration of how necessity is the mother of invention. Hurricane Florence strained the medical system in Wake County, and the RelyMD telemedicine initiative provided a needed solution. Traditionally, having multiple shelters means requiring multiple medical providers, one for each facility. Through telemedicine, one provider was able to be efficiently deployed to all of the shelters simultaneously.

From a logistical standpoint, the service was deployed quickly, despite the need to go on-site to deliver the iPads, introduce the concept, and show the nurses how to perform the telemedicine visits. The program was up and running in the busiest shelter in less than eight hours.

In a resource-constrained environment, the right care was delivered. Of those patients who said they would have gone to the emergency department for their medical care, the data show that there was an 80 percent emergency department diversion rate. This resulted in significant savings with respect to overall cost and EMS worker hours (see Figure 1). Of the nine patients who were sent to the emergency department after initially being evaluated by RelyMD, three required admission to the hospital.

FIGURE 1 Cost Savings from Telemedicine Program

Figure 1. Cost Savings from Telemedicine Program

Beyond the Shelters

RelyMD recognized that there were people affected by Florence all across North Carolina, not only in the shelters. To help those populations, RelyMD offered a coupon code for a free patient-initiated telemedicine evaluation. Patients were able to obtain treatment using the RelyMD app or an internet-enabled computer. RelyMD was able to evaluate and manage more than 100 patients across North Carolina.

Future Disasters

Unfortunately, devastating natural disasters will continue to affect the nation. In this case, telemedicine was a useful tool that helped manage patients quickly and in a high-quality manner. One provider was able to take care of patients across eight different shelters. At one point, there were more than 100 shelters set up for Hurricane Florence victims across North Carolina. Telemedicine has the capacity to take care of all of these patients with a fraction of the usual medical resources.


Dr. Park is the director of RelyMD, a North Carolina–based telemedicine company, and a partner at Wake Emergency Physicians. Ms. Raegen and Mr. Caflisch are executives at RelyMD. Dr. Granovsky is president of LogixHealth, a national coding and billing company.

References

  1. Scism L, Ailworth E. Moody’s pegs Florence’s economic cost at $38 billion to $50 billion. The Wall Street Journal. Sept. 21, 2018.
  2. Borter G. Hurricane Florence death toll rises to 51. Reuters. Oct 2, 2018.

Get Involved

ACEP has an active telemedicine section. Learn more.

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Toxicology Q&A Answer: Castor Beans Can Kill, and the Oil Is Iffy, Too https://www.acepnow.com/article/toxicology-qa-answer-castor-beans-can-kill-and-the-oil-is-iffy-too/ https://www.acepnow.com/article/toxicology-qa-answer-castor-beans-can-kill-and-the-oil-is-iffy-too/#respond Tue, 19 Mar 2019 19:13:14 +0000 https://www.acepnow.com/?post_type=article&p=21051 See question Answer: Both! The castor plant is a beautiful, large semi-woody shrub that can grow to...

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© Jason Hack (Oleander Photography)

See question

Answer: Both!

The castor plant is a beautiful, large semi-woody shrub that can grow to 40-feet tall in the right environment. The star-shaped leaves can grow more than 2.5 feet across. Each lobed leaf has serrated edges and prominent central veins that vary in color from green to red to white. Many species have glossy green leaves; others can be purplish, dark red, or maroon. The stems are often a striking red color.

The female flower develops a bundle of seed capsules, each about the size of a large walnut, which are covered with soft flexible spines after pollination. They have notable colors of coral pink or red that fade to brown with maturity.

To protect and defend themselves from herbivores, some plants develop innate immune systems. These defense mechanisms include lectins and proteins that act to make the threatening animals ill after ingestion, resulting in future plant avoidance.

Properties

The castor plant has been recognized for thousands of years as having properties that can be used for health benefit but may also be harmful. The two major components are castor oil and ricin.

Ricin: The Poison

Castor Bean Plant Ricinus Communis Common names: locoweed, angel’s trumpet, thorn apple, devil’s trumpet, mad apple, stinkweed, sacred datura, green dragon, and devil’s trumpet

Castor Bean Plant
Ricinus Communis
Common names: locoweed, angel’s trumpet, thorn apple, devil’s trumpet, mad apple, stinkweed, sacred datura, green dragon, and devil’s trumpet

Ricin is a poison found naturally in castor beans. A nonmalicious exposure might occur if a castor bean is chewed and swallowed. Mastication releases ricin and causes injury.

Ricin is a natural product that is created from waste material when processing castor beans. It is a heat-labile powder, dissolvable in water or weak acid.

Ricin is a toxalbumin (protein toxin) that is composed of two chains, A and B (the “killer” and the “key”). As a group, they are referred to as ribosome-inactivating proteins (RIPs).

The B chain (key) is a lectin that binds to cell membrane surface glycoproteins and glycolipids, which causes endocytosis and allows ricin to access the cell. Once inside, the A chain (killer) irreversibly inactivates RNA, stopping protein synthesis, leading to cell death.

Ricin is estimated to be 6,000 times more poisonous than cyanide and 12,000 times more poisonous than rattlesnake venom.

One milligram of ricin can kill an adult. The symptoms of human poisoning begin within a few hours of ingestion.

Exposure Route

After ingestion, nonspecific symptoms—including nausea, vomiting, diarrhea, and abdominal pain—develop after approximately 12 hours. Ultimately, this progresses to hypotension, liver failure, renal dysfunction, and may progress to death due to multiple organ failure or cardiovascular collapse. After inhalation, symptoms develop within eight hours and include cough, dyspnea, arthralgias, and fever, which may progress to respiratory distress and death, without other organ system manifestations.

Castor Oil

Castor oil, historically known as Oleum Palmae Christi, comes from the seeds of the Ricinus communis plant and has been used therapeutically for centuries. No ricin is thought to remain in the oil and it would be inactivated during extraction due to heating of the oil.

Castor oil is metabolized to ricinoleic acid, which is absorbed in the intestine. This acts as a strong laxative that has been used medicinally dating back to ancient cultures. Castor oil can also induce labor but has a poor safety profile and thus is not used clinically.

Treatment

There is no antidote and no specific treatment for ricin poisoning. The treatment is supportive for the organs affected.

Interesting Facts

The name Ricinus is a Latin word for tick because the seed of the plant has markings and a bump at the end that resemble certain ticks.

This plant is commonly regarded as one of the most poisonous in the world.

Four seeds can kill an average-sized adult, while ingestion of lesser amounts has resulted in gastrointestinal symptoms and convulsions.

Ricin is suspected to have been the poisonous agent used to assassinate Georgi Markov, a Bulgarian journalist who spoke out against the Bulgarian government, in 1978. He was stabbed with the point of an umbrella while waiting at a bus stop in London. His autopsy revealed a perforated metallic pellet embedded in his leg that presumably contained ricin.

It is advisable to keep children away from the castor bean plant or necklaces made with its seeds.

Ricin has been used experimentally in medicine to kill cancer cells.

Resources for Further Reading


Dr. Hack (Oleander Photography) is an emergency physician and medical toxicologist who enjoys taking photographs of beautiful toxic, medicinal, and benign flowers that he stumbles upon or grows in his garden. Contact him at ToxInRI@gmail.com.

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Toxicology Q&A Question: What’s Poisonous on the Castor Plant? https://www.acepnow.com/article/toxicology-qa-question-whats-poisonous-on-the-castor-plant/ https://www.acepnow.com/article/toxicology-qa-question-whats-poisonous-on-the-castor-plant/#respond Tue, 19 Mar 2019 19:11:11 +0000 https://www.acepnow.com/?post_type=article&p=21047 QUESTION: Which causes toxicity from this plant: the beans or the oil? Click here for the answer.

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© Jason Hack (Oleander Photography)

© Jason Hack (Oleander Photography)

QUESTION: Which causes toxicity from this plant: the beans or the oil?

Click here for the answer.

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High-Yield Ocular Ultrasound Applications in the ED, Part 1 https://www.acepnow.com/article/high-yield-ocular-ultrasound-applications-in-the-ed-part-1/ https://www.acepnow.com/article/high-yield-ocular-ultrasound-applications-in-the-ed-part-1/#respond Tue, 19 Mar 2019 19:10:05 +0000 https://www.acepnow.com/?post_type=article&p=21060 Part 1 of a 3-part series. The Case Monday, 23:00—Your first patient of the night is a...

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Part 1 of a 3-part series.

The Case

Monday, 23:00—Your first patient of the night is a 65-year-old male with “no medical problems” who reports loss of vision in his right eye for the past two days. He thought it might just “go away,” but now that it hasn’t, he has placed his vision in your hands. A quick visual acuity test reveals 20/200 in the affected eye, and your attempt at a funduscopic exam reveals what you would describe as a blur of yellow and red. You have a sense of what is going on with this patient. However, you want more objective information before you speak with the ophthalmologist.

Discussion

The use of ocular ultrasonography for the evaluation of emergency patients has been well-established in the emergency medicine literature. The anatomy of the eye is very complex, but luckily, point-of-care ultrasound (POCUS) can identify the key structures. The eye is a fluid-filled structure, which makes for an easy organ to visualize. With practice, POCUS can easily be incorporated into the workup of patients with ocular complaints to avoid lengthy consultation or other diagnostic tests.

The first application of diagnostic ocular ultrasound was reported by Mundt and Hughes in 1956 when diagnosing an eye tumor. Prior to ultrasound, in vivo ocular lengths and other measurements proved difficult to obtain. However, all the measurements of an eye can now be obtained by a handheld transducer.1 Today, POCUS is beyond savvy and can essentially replace the dilated funduscopic eye exam for emergency physicians. We will review the normal eye anatomy on ultrasound, techniques for the exam, as well as some high-yield ED applications on our tour of the globe!

Anatomy

When discussing anatomy, the eye is divided into two segments: anterior and posterior. The anterior segment is composed of the cornea, iris, ciliary body, and lens, while the posterior segment contains the vitreous body, posterior layers of the eye (retina, choroid, sclera), and the optic nerve (see Figure 1).

Figure 1: Anatomy of the eye.

Figure 1: Anatomy of the eye.

Figure 2: The fluid-filled vitreous body should appear anechoic (black) on ultrasound.

Figure 2: The fluid-filled vitreous body should appear anechoic (black) on ultrasound.
ILLUSTRATION: shutterstock.com | Photos: Nicole Yuzuk

When utilizing POCUS, the majority of your time will be spent visualizing the posterior segment. It is important to note that since the vitreous body is a fluid-filled structure, it should appear anechoic (black) on ultrasound. Hyperechoic (bright white) densities, if not artifact, should alert you to potential pathology (see Figure 2).

Ultrasound Technique

  1. Figure 3: Place a Tegaderm film dressing over the patient’s closed eye, gently press out any pockets of air, and apply a copious amount of gel directly over the Tegaderm.

    Figure 3: Place a Tegaderm film dressing over the patient’s closed eye, gently press out any pockets of air, and apply a copious amount of gel directly over the Tegaderm.

    Explain this bedside procedure to your patient prior to starting. As this is a dynamic scan, the patient will have to move his or her eyes side to side and up and down to allow complete visualization of the posterior segment.

  2. The orbit is a superficial structure. Therefore, a high-frequency linear transducer should be used.
  3. For comfort and to prevent a mess, place a Tegaderm film dressing over the patient’s closed eye and gently press out any pockets of air. Remember, air is the enemy of ultrasound.
  4. When performing ocular ultrasound, a copious amount of gel should be used, which will prevent contact of the transducer with the eyelid and minimize direct pressure. The gel can be applied directly over the Tegaderm (see Figure 3).
  5. Figure 4: Transverse visualization of the orbit.

    Figure 4: Transverse visualization of the orbit.

    Visualize the orbit in both transverse (see Figure 4) and longitudinal planes. After scanning through, the patient should be asked to move his or her eye right to left and up and down. A combination of still images and dynamic scanning clips will best document your exam.

  6. Repeat these steps on the unaffected eye.
  7. Contraindications to the exam include high suspicion of globe rupture.
  8. Always supplement your ocular POCUS exam with a visual acuity and intraocular pressure measurement for a well-rounded emergency eye exam.

Tips & Tricks

Figure 5: Stabilize your scanning hand by placing your pinky finger on the bridge of the patient’s nose.

Figure 5: Stabilize your scanning hand by placing your pinky finger on the bridge of the patient’s nose.

Stabilize your scanning hand by placing your thumb or pinky finger (whichever is medial) on the bridge of the patient’s nose (see Figure 5). This will also prevent you from applying too much pressure.

 

 

 

 

 

Common Emergency Department Application

Structure: Retina

Evaluate for: Retinal Detachment

The retina is a crucial structure to evaluate for patients with visual complaints. In a normal eye, the retina cannot be distinguished from the other posterior layers, appearing as one homogenous structure.2 The retina is anchored at the ora serrata laterally and the optic nerve posteriorly. This will be important later on when distinguishing retinal versus vitreous detachments.

Figure 6 (LEFT): In retinal detachment, the retinal membrane will be lifted off of the posterior or lateral globe and appear as a hyperechoic (bright white) and sometimes serpiginous membrane. Figure 7 (RIGHT): A detached retina may take on a funnel-shaped appearance.

Figure 6 (LEFT): In retinal detachment, the retinal membrane will be lifted off of the posterior or lateral globe and appear as a hyperechoic (bright white) and sometimes serpiginous membrane.
Figure 7 (RIGHT): A detached retina may take on a funnel-shaped appearance.

A normal retina should be closely attached to the posterior wall of the globe such that on ultrasound there will be no distinction between the two. In the case of retinal detachment, the retinal membrane will be lifted off the posterior or lateral globe and appear as a hyperechoic (bright white) and sometimes serpiginous membrane (see Figure 6). Because of its firm attachment to the optic disc, a detached retina may take on a funnel-shaped appearance, and you will see it tethered to the optic nerve (see Figure 7). The retina’s attachment to the optic nerve posteriorly will be preserved even in the case of a retinal detachment, which is an important detail when distinguishing it from other detachments. With patient eye movements, the membrane may undulate or wave.

Involvement of the macula, in the case of retinal detachment, is a critical piece of information to obtain. The macula contains structures specialized for high-acuity vision and is located perpendicular to the lens. Once you have obtained a clear image of the retinal detachment with the lens included in the image, draw a straight line connecting the middle of the lens to the posterior wall of the globe. The area you encounter is the macula, and if it is still attached, your consult to ophthalmology becomes emergent rather than urgent. Preventing further detachment of the macula is paramount and could be a vision-saving act.

POCUS for retinal detachment has been shown to not only be possible but also accurate and precise among emergency physicians. According to a systematic review of the literature, sensitivities range from 97 to 100 percent, and specificities range from 83 to 100 percent. In a study by Blaivas et al, all retinal detachments diagnosed by ocular ultrasound performed by emergency physicians were later confirmed by a formal, masked ophthalmology evaluation, demonstrating its high specificity.3,4,5

Tips and Tricks: Be sure to scan through the entire retina and encourage eye movement while scanning as there may be small detachments of the peripheral retina that are easily overlooked.

Case Resolution

So what about the 65-year-old man with acute vision loss? After performing your funduscopic exam, you bring the ultrasound bedside and scan your patient’s eye. You immediately notice a retinal detachment and call the ophthalmologist, who is able to see the patient immediately in her office. On the way out, your patient thanks you for your quick diagnostic skills.

Ocular ultrasound is easy to learn and can rapidly assess ocular emergencies. With practice, you can easily incorporate POCUS into your diagnostic algorithm and rule in or out important ocular pathology.


Part 2 will appear in the April issue. 

References

  1. Lizzi F, Coleman DJ. History of ophthalmic ultrasound. J Ultrasound Med. 2004;23(10):1255-1266.
  2. Lyon M, Blaivas M. Ocular ultrasound. In: Emergency Ultrasound. 2nd ed. New York: McGraw Hill; 2008: 449-462.
  3. Jacobsen B, Lahham S, Lahham S, et al. Retrospective review of ocular point-of-care ultrasound for detection of retinal detachmentWest J Emerg Med. 2016;17(2):196-200.
  4. Blaisvas M, Theodoro D, Sierzenski PR. A study of bedside ocular ultrasonography in the emergency department. Acad Emerg Med. 2002;9(8):791-799.
  5. Vrablik ME, Snead GR, Minnigan HJ, et al. The diagnostic accuracy of bedside ocular ultrasonography for the diagnosis of retinal detachment: a systemic review and meta-analysis. Ann Emerg Med. 2015;65(2):199–203.e1.

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ACEP Members Receive Order of International Federation for EM Award https://www.acepnow.com/article/acep-members-receive-order-of-international-federation-for-em-award/ https://www.acepnow.com/article/acep-members-receive-order-of-international-federation-for-em-award/#respond Tue, 19 Mar 2019 19:06:32 +0000 https://www.acepnow.com/?post_type=article&p=21041 Ashley Bean, MD, FACEP, and Gary Gaddis, MD, PhD, FACEP, were honored with the Order of the...

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Ashley Bean, MD, FACEP, and Gary Gaddis, MD, PhD, FACEP, were honored with the Order of the International Federation for Emergency Medicine (IFEM) during the Congress on Emergency Medicine in Mexico City in June 2018. The Order of the IFEM is given biennially to individuals who have demonstrated an extensive and continuous commitment to the emergency medicine specialty in their country while supporting the development of IFEM. IFEM is an international consortium of more than 60 emergency medicine organizations, including ACEP.

Dr. Bean, associate professor at the University of Arkansas for Medical Sciences in Little Rock, is involved in global health initiatives. She has presented emergency medicine and ultrasound lectures and workshops across five continents and has completed medical service trips to Latin America and Haiti. Dr. Bean serves as a reviewer for the European Journal of Emergency Medicine and the African Journal of Emergency Medicine, and she’s an ACEP International Ambassador.

Dr. Gaddis, a professor of emergency medicine and resident research director at Washington University in St. Louis, is a longtime contributor to emergency medicine in North America, South America, Europe, and Asia. He has chaired conferences, reviewed manuscripts, directed courses, and served on international scientific committees. Dr. Gaddis serves as course director for Emergency Medicine Basic Research Skills (EMBRS).

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ACEP Is Launching New EM Journal, Seeks Editor-in-Chief https://www.acepnow.com/article/acep-is-launching-new-em-journal-seeks-editor-in-chief/ https://www.acepnow.com/article/acep-is-launching-new-em-journal-seeks-editor-in-chief/#respond Tue, 19 Mar 2019 19:06:32 +0000 https://www.acepnow.com/?post_type=article&p=21039 ACEP is launching a new open-access journal in 2020 and is seeking applicants for editor-in-chief. The editor will...

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ACEP is launching a new open-access journal in 2020 and is seeking applicants for editor-in-chief. The editor will participate in the full-scale launch of the journal, including creation of the editorial board and strategic editorial plans. Applications are due March 25. Find more details.

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For One Medical Student, a Job as a Scribe Was the Pathway to Emergency Medicine https://www.acepnow.com/article/for-one-medical-student-a-job-as-a-scribe-was-the-pathway-to-medicine/ https://www.acepnow.com/article/for-one-medical-student-a-job-as-a-scribe-was-the-pathway-to-medicine/#respond Tue, 19 Mar 2019 19:06:32 +0000 https://www.acepnow.com/?post_type=article&p=21032 I turned 18 in the emergency department. The charge nurse surprised me with a cake, and as...

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ILLUSTRATION: Chris Whissen & Shutterstock.com

ILLUSTRATION: Chris Whissen & Shutterstock.com

I turned 18 in the emergency department. The charge nurse surprised me with a cake, and as the clock struck midnight, I celebrated my entry into adulthood, and legal overtime, with my emergency department family.

I began work as a scribe roughly two weeks after I graduated from high school. I suppose that I, more or less, grew up in the emergency department. My father was the medical director of our local department, and I was quite familiar with afternoons spent at “Daddy’s house.” My first shift in the emergency department was filled with sheer excitement rather than nervousness; I was finally working among the heroes. I had so much to learn! Over the course of four years and 4,500 hours in our hospital, I would forgo many other life events. I have no regrets; working is learning, and learning is addictive. Each shift and each physician brought a new set of skills and life lessons. Scribing reaches beyond thorough documentation and increased efficiency. It has become a necessity to both emergency departments and aspiring premed students. As time goes on, their mutual reliance and integration will only increase.

My favorite emergency cases occurred outside of the emergency department. When a good friend crashed his vehicle and laid unconscious, not breathing, it was an emergency physician who met him on the side of the road and provided lifesaving interventions. When a local house collapsed down a mountain and rescue technicians rappelled into the rubble to ensure that children had not been present, it was an ED doc they had waiting on standby. An emergency physician provides their community with the best when they are experiencing their worst. Through these circumstances, I saw that emergency medicine reaches outside of the walls of a hospital and, perhaps, could be the practical field I had dreamed of.

As a scribe, I learned many lessons that prepared me well for medical school. I saw firsthand how to approach a patient with objectivity and deductive reasoning to narrow the differential diagnosis, and I learned how to develop a plan of care based on those considerations. I know the value of thorough documentation, and I am familiar with many of the charting regulations (ICD-10). When I’m faced with a “challenge question” (eg, “Will I need surgery?” “Do I have cancer?” “Am I going to die?”), my professors are always impressed with my emergency medicine approach, encouraging the patient that they are in the right place and we will work together through the history and physical exam to get them to the next correct place.

At times, scribing went beyond documentation. I often assisted in log rolls and other activities that helped the transitional processes for an emergency department to run more smoothly. I am convinced that manipulating a wheelchair and driving a hospital bed should require a license. Other times, I found ways to implement my skills as a scribe outside of a chart. During codes, I often grabbed a marker and recorded times of medications and procedures on the room’s whiteboard. I learned to spike fluids and fetch a crash cart. I became part of a team and tried to use my time to fill in the gaps.

Truthfully, I trailed my physician and tried to provide any assistance required. This path took me all over the hospital. I remember the feeling in the pit of my stomach when we walked into the morgue to attempt to draw blood from an exsanguinated patient. I remember the fascination of suiting up in lead for a cardiac catheterization lab intubation, and I remember joy when the stent was placed, seeing the dye once again wrap around the myocardium. I remember the sadness of helping clean up a room after calling a code, and I remember offering coffee to the family in a desperate attempt to provide some form of comfort as they sat with their lost loved one. I spent hour upon hour in exam rooms, cringing at the sight of chest tube placements and the sound of bone drills. I learned to identify Clostridium perfringens from Clostridium difficile simply by smell, and I learned that, sometimes, opening a bag of coffee can help with those smells!

To the physician, I was an extra set of eyes that noted a bruise here, swelling there, or clear fluid draining from an ear in a trauma patient. I was the one who wrote down “left” versus “right.” Often, there were things that the physician picked up on that they did not state aloud. These things appeared as gaps in the history, but through inquiring about those details, I learned that you can glean a lot of information without speaking.

While I have gained invaluable clinical experience, the most valuable lessons came from the doctors themselves. Through simple observation, I learned how to break bad news with honesty and tact. I learned to remain calm and collected in the face of urgency. I sat with souls as they slipped from this earth, and I watched soon-to-be parents receive the news of their pregnancy. I saw that a kind word and small act of service can mean the world to someone.

I gravitated most to the physicians whom I found to be willing instructors. Though I came out of my first ECG introduction remembering only the letters “PQRST,” I had identified a teacher, and I followed his lead (and his shifts). Often, those willing to take the time to pass along wisdom were also willing to spend time with their patients and the staff. They got water glasses and pillows rather than recommending an aide for the job. Difficult diseases were explained in colloquial terms, and families were allowed to ask questions. They fought for a patient’s best interest while still retaining respectful professionalism with peers.

The most valuable thing you can do as a physician is to demonstrate the role of a physician. Be a healer, teacher, and leader. Be astute and analytical and show a propensity for lifelong learning. Be correctable, willing to admit mistakes, and take time to teach those following you all the lessons you’ve learned. You never know—you just might influence a young kid like me to follow in your footsteps.


Skyler E. SmithMs. Smith is a second-year medical student at Edward Via College of Osteopathic Medicine in Spartanburg, South Carolina.

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New ACEP Framework Protects Patients from Out-of-Network Billing https://www.acepnow.com/article/new-acep-framework-protects-patients-from-out-of-network-billing/ https://www.acepnow.com/article/new-acep-framework-protects-patients-from-out-of-network-billing/#respond Tue, 19 Mar 2019 19:06:32 +0000 https://www.acepnow.com/?post_type=article&p=21037 On Jan. 28, 2019, ACEP released a framework of proposed solutions to protect emergency patients from surprise...

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On Jan. 28, 2019, ACEP released a framework of proposed solutions to protect emergency patients from surprise billing. The proposed solutions include:

  • Prohibit balance billing
  • Streamline the process to ensure patients only have a single point of contact for emergency medical billing and payment
  • Ensure the patient responsibility for out-of-network emergency care is no higher than it would be in network
  • Require insurers to more clearly convey beneficiary plan details
  • Require insurers to more clearly explain policyholders’ rights related to emergency care
  • Take the patient out of insurer-provider billing disputes

Read the full release with more details about this framework.

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ACEP Suspends Physician for Expert Witness and Ethics Code Violations https://www.acepnow.com/article/acep-suspends-physician-for-expert-witness-and-ethics-code-violations/ https://www.acepnow.com/article/acep-suspends-physician-for-expert-witness-and-ethics-code-violations/#respond Tue, 19 Mar 2019 19:06:31 +0000 https://www.acepnow.com/?post_type=article&p=21058 The ACEP Board of Directors suspended Diane M. Sixsmith, MD, FACEP, from ACEP membership for a period...

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The ACEP Board of Directors suspended Diane M. Sixsmith, MD, FACEP, from ACEP membership for a period of 12 months beginning Jan. 1, 2019, for violations of ACEP’s Expert Witness Guidelines for the Specialty of Emergency Medicine and the Code of Ethics for Emergency Physicians.

Pursuant to ACEP’s Procedures for Addressing Charges of Ethical Violations and Other Misconduct, any ACEP member may transmit to the Executive Director a request for information regarding the disciplinary actions taken by the College. Such letter shall specify the name of the member or former member who is the subject of the request.

Procedures for Addressing Charges of Ethical Violations and Other Misconduct

ACEP has a formal procedure for reviewing complaints and addressing charges of ethical violations or other misconduct. The procedures can be found online.

The following is a summary of the procedures:

  • A complaint of ethical violations and/or other misconduct may be initiated by an ACEP member, chapter, committee, or section.
  • The ACEP Executive Director, in consultation with the ACEP President and the chair of the Bylaws or Ethics Committee, reviews the complaint and determines whether it is frivolous or alleges conduct that may constitute a violation of ACEP Bylaws or a policy or principle included in ACEP’s Code of Ethics. If the complaint meets this criterion, it is forwarded to the Bylaws or Ethics Committee, or an appointed subcommittee, for review.
  • The respondent is provided with a copy of the complaint, along with any attachments, and has 30 days to respond and submit evidence in his or her defense.
  • The appropriate committee, or its subcommittee, will consider whether the alleged action(s) violates the ACEP Bylaws or current ACEP ethics policies, such as the Code of Ethics, which includes ACEP’s Expert Witness Guidelines. If it is determined that a violation has occurred, the group will make a recommendation to the Board of Directors as to whether the alleged conduct warrants private censure, public censure, suspension, or expulsion from ACEP.
  • The Board of Directors then receives the recommendation of the appropriate committee, the complaint, response, and any submitted supporting documentation, and at a Board meeting determines whether a violation has occurred and if disciplinary action is warranted. The respondent is notified of the decision and may either request a hearing or accept the Board’s decision.
  • If a hearing is requested, the complainant and respondent each may be represented by counsel or any other person of their choice at the proceedings. The Board will then render a final decision based on the hearing and provide written notice of its decision, along with its basis, to the respondent.

Possible Disciplinary Actions and Disclosure to ACEP Members

  • Censure
    • Private Censure: A private letter of censure informs a member that his or her conduct does not conform with the College’s ethical standards. ACEP may confirm the censure at the request of an ACEP member. However, contents of the letter will not be provided.
    • Public Censure: A letter of censure shall detail the manner in which the censured member has been found to violate the College’s ethical standards. The censure shall be announced in an appropriate ACEP publication. The published announcement shall also state which ACEP bylaw or policy was violated by the member and shall inform ACEP members that they may request further information about the disciplinary action.
  • Suspension from ACEP membership shall be for a period of 12 months, after which the suspended member may request reinstatement. The suspension shall be announced in an appropriate ACEP publication. The published announcement shall also state which ACEP bylaw or policy was violated by the member and shall inform ACEP members that they may request further information about the disciplinary action.
  • Expulsion from ACEP membership shall be for a period of five years, after which the expelled member may petition the Board for readmission to membership. The expulsion shall be announced in an appropriate ACEP publication. The published announcement shall also state which ACEP bylaw or policy was violated by the member and shall inform ACEP members that they may request further information about the disciplinary action.

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Reduce Opioid Duration and Quantity to Limit Use, Avoid Addiction https://www.acepnow.com/article/reduce-opioid-duration-and-quantity-to-limit-use-avoid-addiction/ https://www.acepnow.com/article/reduce-opioid-duration-and-quantity-to-limit-use-avoid-addiction/#respond Tue, 19 Mar 2019 19:06:31 +0000 https://www.acepnow.com/?post_type=article&p=21082 Editor’s Note: This is the seventh part of an ongoing series on what emergency physicians can do...

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Editor’s Note: This is the seventh part of an ongoing series on what emergency physicians can do to combat the opioid epidemic. 

The opioid epidemic initially revolved around abuse of prescription opioids. Since then, the epidemic has evolved, with the majority of deaths now associated with fentanyl and other synthetic opioids. Still, the majority of people initiate opioid use with prescription opioids before switching to illicit, and potentially more dangerous, drugs.1 As such, physician prescribing habits continue to be scrutinized. Not only is this evident from articles in the lay press but also with guidelines such as those from the Centers for Disease Control and Prevention (CDC) or hospital organizations.2,3 In some situations, laws were even passed governing prescribing practices. For instance, in Missouri, a seven-day prescribing limit for acute pain was passed during the latest legislative session.4

This scrutiny has led to considerable debate regarding emergency physicians’ prescribing practices and their association with long-term opioid use—and potentially abuse. The easy answer is to keep patients opioid naive when possible. After all, you can’t get addicted if you’re never exposed. Resources are available to help emergency physicians appropriately manage pain in situations where they should avoid opioids. The ACEP Pain Management and Addiction Medicine Section has developed the Managing Acute Pain (MAP) bedside tool (acep.org/map) that can be used in real time.

Of course, there are still times when an emergency physician will need to prescribe an opioid. While scoring systems such as the Opioid Risk Tool (ORT) are readily available on your smartphone and easy to use, they are limited. Sure, a high score should probably make you think twice, but a low score doesn’t eliminate the chance of developing a substance use disorder; this is the crux of the problem. Even though the rate of developing an opioid use disorder is low, we simply don’t know who is going to be fine and who will start down the deadly and destructive path toward addiction.

This is exemplified by the current U.S. Surgeon General, Jerome Adams, MD, MPH. Dr. Adams is an incredibly accomplished physician and public health official. Yet his brother, with similar genetics and raised in similar circumstances, is serving time in federal prison for drug-related crimes due to his substance use disorder.5

How Dangerous Are Prescriptions?

What evidence is there that a prescription from the emergency department is going to lead patients down this path? It’s an important question. The emergency department certainly can’t be the source for the majority of prescriptions when compared to internists, family medicine physicians, and pain physicians. However, this doesn’t mean we don’t need to prescribe responsibly. A study published in the New England Journal of Medicine in 2017 investigated this by reviewing claims data from a national sample of Medicare patients.6 The authors explored individual prescribing practices among emergency physicians in the same practice to determine if their prescribing was associated with long-term opioid use over the next year. Emergency physicians were separated into “high-intensity” and “low-intensity” prescribers based on the total number of prescriptions and total number of pills prescribed.

The authors found the high-intensity group was 3.3 times more likely to prescribe opioids than the low-intensity group (7.3 percent versus 24.1 percent, P<0.001). Shockingly, this corresponded to a number needed to harm of 49. Or, to put another way, for every 49 prescriptions written, one resulted in long-term use.

There were multiple and significant limitations that have been discussed elsewhere—most important, long-term use does not equal addiction and the prescriptions themselves were not necessarily inappropriate.7 Still, this study is not unique in associating new prescriptions in opioid-naive patients with long-term use and is not the only ED-based study to do so.8-10 A similar study from the CDC also concluded that the probability of long-term use increased starting on day three of the prescription.11 This was also a review of opioid-naive patients in a large claims database and has many of the same limitations as the New England Journal of Medicine study. Other non-ED-based studies also demonstrate long term persistence of between 5 and 10 percent following an initial prescription.12,13 Once again, long term use does not equal addiction. However, even factoring in their limitations, these findings are important.

Possible Solutions

What is the emergency physician who is concerned about contributing to long-term use—and potentially addiction—but still believes that an opioid is indicated to do? The good news is that evidence shows patients may only need a very short course of opioids for many conditions.

A recent study offered another solution. It looked at the use of digital pills to evaluate ingestion patterns of ED patients.14 Digital pills are gel caps containing a medication (in this case, oxycodone) and a biosensor. In the stomach, the gel cap is dissolved, releasing the pill and activating the biosensor. A reader is attached by a sticker to the abdominal wall and transmits ingestion data to a cloud-based server. A convenience sample of opioid-naive patients diagnosed with an acute fracture was included.

Only 15 patients completed the study, but what it found was still very interesting. Patients only required a mean of six pills (range of three to nine pills), with nearly 82 percent of the dose taken in the first 72 hours. Nearly half of patients stopped taking opioids by day three. Patients who required operative repair did use more medication (median of eight pills with a range of six to 11) but required small dosages by 24 hours. Importantly, 12 of the 15 patients reported that their pain was well controlled.

A study evaluating opioid requirements following surgery also suggests that patients’ pain can be controlled with smaller amounts of opioids.15 While there were multiple limitations, the authors determined that the median number of opioids consumed following laparoscopic cholecystectomy, appendectomy, colectomy, hernia repairs, small bowel resections, and vaginal hysterectomies was fewer than 10 tablets. To be balanced, some procedures such as an abdominal hysterectomy required more. Perhaps as interesting, the authors discovered that the quantity of pills prescribed had the strongest association with opioid consumption (0.53 pills consumed for every one prescribed [95% CI, 0.40–0.65]), which was stronger than the association with patient-reported pain in the week following the procedure. Availability of follow-up appointments and other patient-centered factors still need to be considered when determining the prescription duration.

While emergency physicians aren’t responsible for the current epidemic or the majority of opioid prescriptions, our actions may still have long-term repercussions. The good news is that it appears we can still achieve appropriate analgesia while limiting patients’ opioid exposure. For most patients, prescribing between three and four days of opioids, or approximately 10 to 15 pills in addition to non-opioid analgesics for acute pain, should be enough. Of course, patient-specific circumstances and follow-up availability should be factored into prescribing practices.


Dr. Schwarz is associate professor of emergency medicine and medical toxicology section chief at Washington University School of Medicine in St. Louis.

Dr. Waller is a fellow at The National Center for Complex Health and Social Needs and managing partner at Complex Care Consulting LLC.

References

  1. https://www.cdc.gov/drugoverdose/data/heroin.htmlHeroin overdose data. Centers for Disease Control and Prevention websit. Accessed Feb. 22, 2019.
  2. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain–United States, 2016. JAMA. 2016;315(15):1624-1645.
  3. Opioid use in Missouri: opioid prescribing guidelines. Missouri Hospital Association website. Accessed Feb. 22, 2019.
  4. S 826, 99th Leg, 2nd Sess (Mo 2018). Accessed Feb. 22, 2019.
  5. Joseph A. The surgeon general and his brother: a family’s painful reckoning with addiction. STAT website. Accessed Feb. 22, 2019.
  6. Barnett ML, Olenski AR, Jena AB. Opioid-prescribing patterns of emergency physicians and risk of long-term use. N Engl J Med. 2017;376(7):663-673.
  7. Schwarz E. Unpacking the opioid blame game. Emergency Physicians Monthly website. Accessed Feb. 22, 2019.
  8. Alam A, Gomes T, Zheng H, et al. Long-term analgesic use after low-risk surgery: a retrospective cohort study. Arch Intern Med. 2012;172(5):425-430.
  9. Clarke H, Soneji N, Ko DT, et al. Rates and risk factors for prolonged opioid use after major surgery: population based cohort study. BMJ. 2014;348:g1251.
  10. Butler MM, Ancona RM, Beauchamp GA, et al. Emergency department prescription opioids as an initial expsoure preceding addiction. Ann Emerg Med. 2016;68(2):202-208.
  11. Shah A, Hayes CJ, Martin BC. Characteristics of initial prescription episodes and likelihood of long-term opioid use – United States, 2006-2015. MMWR Morb Mortal Wkly Rep. 2017;66(10):265-269.
  12. Marcusa DP, Mann RA, Cron DC, et al. Prescription opioid use among opioid-naive women undergoing immediate breast reconstruction. Plast Reconstr Surg. 2017;140(6):1081-1090.
  13. Brummett CM, Waljee JF, Goesling J, et al. New persistent opioid use after minor and major surgical procedures in US adults. JAMA Surg. 2017;152(6):e170504.
  14. Chai PR, Carreiro S, Innes BJ, et al. Oxycodone ingestion patterns in acute fracture pain with digital pills. Anesth Analg. 2017;125(6):2105-2112.
  15. Howard R, Fry B, Gunaseelan V, et al. Association of opioid prescribing with opioid consumption after surgery in Michigan. JAMA Surg. 2018:e184234.

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