aka American ER Doc Gone Walkabout 004
LITFL Editior’s note:
- 001 — Why are there so many emergencies here? This is an ER!
- 002 — What is that stuff you give for a fever?
- 003 — Who’s Gonna Insert That Cannula, Place That Urinary Catheter, Whatever?
How do you deal with that specialist?
Among the consultants that we love to hate, where should we begin? Dermatology? Naah, dermatologists don’t really exist, do they. Hospitalists? No, they’re actually our friends. Psychiatry? Hmmmmm there’s a potential.
Remember that in US usage a “consultant” may be a resident or registrar from a specialty service – and what you would call a consultant, the specialist who has completed his training, is the “attending”. I might mix the usage here a little bit.
I almost hate to bring this up. The variation between my US experiences and Tassie, when it came to psych, was imperceptible. I once went to an “Emergency Psychiatry” course run by the Department of Psychiatry at Harvard (a small University near Boston). I knew I was in trouble when the Psychiatrist course director defined an emergency in Psychiatry as the first month of Psychiatric evaluation and treatment. My expectations fell further when another shrink talked about dealing with the violent patient and pointed out that every time a patient threatened him, he became so frightened that he vomited – and that had always set back the patient enough for him (the shrink, not the patient) to run out of the room and get help. Now, there’s some real helpful information for an ER Doc in a busy ER on any continent. (It does make me wonder what universe we were talking about.) HTFU.
The consulting psychiatrists and registrars on both continents seem to have the same inability to think in terms of organic needs of the ER society: allowing patients to be out of control for many hours isn’t feasible. We can’t take large proportions of our staff to spend lots of time while some slow acting antipsychotic takes place – we’ve got stuff to do. Now – or even sooner.
A larger difference is not between Oz and the US but between a hospital that does and does not have dedicated ED social workers/psych evaluators. Where we have psych workers in the department, they work so much better with the ED Docs in taking a “quick look,” to see what the baseline behavior is, and then come back after adequate chemical control to further evaluate a patient who can now communicate in somewhat more understandable terms.
Like other ER’s, some of the ER folks in Lonnie seemed intimidated and worried that if they took the behavioral bull by the horns and chemically restrained a patient, they might not get the help they needed from the psych reg (i.e., they worried that the psych reg wouldn’t come to see a tranquilized patient). However, my experience was comparable to the US: give the haldol or droperidol, and provide the consultant with a conversant rather than violent patient , and there’s a better chance of a mutually satisfactory disposition – and, a quieter ER. (And, as often happens, the patient later says something to the effect: “Good on ya, Doc. I felt so out of control and feel better now after that vitamin H that you gave me.”)
How about something different medically?
OK we know about jackjumper ants, leeches, tiger snakes – not much of any of those east of the pacific. Toxicology in Tassie is just downright interesting.
Let’s try some dysrhythmias: I was surprised at how many people we saw with symptomatic bradycardias, but who were not on a digoxin or a beta blocker or calcium channel blocker. This was moderately common in the US 25 years ago, but is pretty rare now: I think everybody over here must get an implanted pacer for their 65th birthday. But saw a few virgin bradycardias in Tassie. More interesting was the locally preferred mode of treatment: isoprenaline infusion until an expedited but elective permanent pacer implantation can be done – usually within 24 hours. As an intern and during the first few years in practice, that was typical in the US. But, the frequency of tachydysrhythmias was substantial. So, more and more of us got reasonably adept at floating a temporary pacer wire (easier with the newer technology) or we’d use drugs for very temporary control and a cardiologist would pop in the temporary wire. With the advent of transcutaneous pacing, that became the bridge – temporary transcutaneous pacing with some sedation, and an urgent temporary transvenous pacer to bridge to permanent pacer (or while waiting for the toxicity of beta blocker/digoxin/CCB to wear off).
I thought it was pretty retro at first, but after some thought came to a few conclusions. First, I’m not sure anyone has good data as to which has higher complication rates – isoprenaline infusions, or pacer wires placed by inexperienced personnel (occasionally into truly unforeseen parts of the human anatomy), or prolonged sedation for transcutaneous pacing. Of course, in the US where a major portion of our health care “industry” is driven by economics – the more expensive the better – the high tech approach gets pushed.
Isoprenaline is a cheap, off-patent medication, so no one will ever get funding to do a study to see how well it works. But, the electronics companies are glad to fund the studies that show how well an electronic device works: with all the latest bells and whistles, and selling for tens of thousands of dollars. So, it seems highly likely that a relatively inexpensive medication-based approach will be used where low cost is a driving force, and high tech electronics (and high fees for the ER Docs and cardiologists using the technology) will be used in a incomprehensibly expensive system of medical care.
New, nonvalvular A Fib was mostly managed similarly in Tassie, as long as you didn’t consult cardiology before treating the patient. In the US, one hour of procainamide followed by electrical cardioversion,if needed, is pretty common (though I usually skip the procainamide – doesn’t seem to work as often for me as the literature suggests, or I’m too impatient to wait an hour to see if the patient is one of the 50% who will convert). Some ER Docs like propafenone – but it commonly takes 4-6 hours to convert. (For a while ibutilide was popular until we all got tired of having people collapse, and sometimes die, from the distressingly common polymorphic V Tach that it induced.)
At LGH, if one got a cardiology consult first, they spent 18 hours or so giving amiodarone (never worked), then ran off to do something interesting while we cardioverted. So, the registrars seemed to like having a supervising consultant who would support managing the patient in the ED, without consultation: quick sedation, quick little buzz, quickly out the door and home. Cardioverted more folks at Lonnie than I have in the past 5 years at University of Colorado Hospital – all of our patients at UCH have complicated AF: valvular disease, cardiomyopathy with EF’s of 10%, prior heart transplant, etc, etc. So, a true paroxysmal lone AF patient is truly unusual. Bummer.
Working with internal medicine was not dissimilar compared to home with the sole exception that the medicine registrars were more willing to do a consult and discharge when appropriate. A medicine consult in the US seems to be a guaranteed admit except in rare instances.
Orthopedics (orthopaedics I believe is the antipodean spelling?) was pretty comparable (including the similar rapid conversion to the “Captain Morgan” – such a cool descriptor – technique for reducing dislocated hips and hip prostheses) with some limited exceptions . The ED Docs – consultant and registrar level – did more of the fracture reductions than is typical in larger US hospitals. And, of course, since the US residents then get little experience with the hands-on “Feel” of proper fracture reduction, when they move out into smaller hospitals where fracture reduction by the ER Doc would be a good idea, they have little experience. When I work at the little ER on the Navajo reservation, I don’t always have ortho available, and it’s kinda fun to do the reductions – and, I enjoyed the ortho experience at Lonnie. Timing of operative orthopedics was pretty similar to the US. For example, bi- and tri-malleolar ankle fractures would be reduced, splinted, and discharged for surgery at a later date (though, I did note that patients with private insurance would be offered operative fixation within a day or two by a consultant at one of the private hospitals – same as in the US).
OK BUT HERE’S WHERE US MEDICINE SUCKS:
At many US hospitals (including University of Colorado I am ashamed to say), if you are one of the 52 million Americans with no (no,none,nada) health insurance (what’s that – about thrice the population of all of Australia?), you will have the fracture reduced and splinted. And then, advised to do your best to find a surgeon who will do the fixation within a week or two. (Or, maybe you could rob a bank, or sell a kidney, or something. Have to be a big bank – $15,000 or so price tag.) So, if you happen to have a job, but no insurance – say a hair dresser, or burger flipper – you have to find the money, mortgage your soul, or you’ll find that you’ve got a really messed up leg that will not permit you to go back to work. Ever. Ward of the state. On the dole. That kind of stuff. Remind me of how that crap is good for society. (Or, as happened in Denver recently, you get reduced and splinted, but the reduction – surprise – doesn’t hold, and actually shifts enough that it converts to an open, infected fracture. That then becomes a “limb-threatening” emergency, and under US law has to be treated.) I often feel like our discharge instructions should include, for the uninsured and unfortunate: “HTFU”.
The pictures below show how American bicycle racers try to get our kids (in my case grandkids) to HTFU:
More on the truly bizarre world of US health financing in the near future (check out the 5th episode of ‘American ER doc gone Walkabout’ here). After writing the last paragraph, I’m all worked up and need a drink. Later, Mates.