I had hoped to do some comparisons, between Tassie and the US, of the prices attached to ER care – from what the patient sees.

Unfortunately, I can’t seem to be able to find anything about the payments requested of patients for emergency care in Australia – and I didn’t manage to hurt myself while in Tassie, to test the system myself. Google: nothing. Pamphlets from the various state health boards: nothing. I was never asked to generate a charge code while working in Tassie. What’s up? Don’t you guys ask the unfortunate to pay for their misfortune? How could that be? Maybe I’m missing something.

In the US, the patient might start facing billings very early on in his ER visit, and then receive a bill for charges that have no bearing on what he will be expected to pay, and never actually figure out what the medical care actually “cost.”

A maze of federal laws and regulations start the process: we must perform a “Medical Screening Exam” – an MSE to decide if there is an emergency medical condition. However, we can’t try to discourage a patient from coming to the ER by telling him how much it will cost. So, at some hospitals (most others never tried this, or have given up) the patient gets a brief exam. If no emergency condition is present, he’ll be told that to continue further evaluation, he’ll need to pay first for the MSE.

(If an emergency is likely, skip the next step and go on to ordering the CT scan – everyone in the US gets one, I believe. If you’re not sure whether his vomiting is from something in his head or something in his belly, get 2 CT scans – even if he’s vomiting from something that was in the sushi – remember, I can’t charge extra for merely making a brilliant clinical diagnosis.)

Back to the non-emergency MSE… Now, he gets the first shocker: typically $400-$500 combined physician and hospital bills. Depending on his insurance (remember in the US there are about 467 gazillion different insurance plans) – he may be required to pay anywhere from $3 to the full $400 to continue evaluation and treatment of his non-emergency condition (plus the charges for the rest of the ER visit). If he decides not to pay, and goes home, he just gets the bill for the MSE itself. $400 or so to be told there is no emergency. (I can’t for the life of me understand why more hospitals don’t do this: isn’t this a reasonable and easily administered system? Maybe it’s made less desirable by the fact that every third patient threatens a slow and painful death to the physician.)

So, the emergency patient continues on through his evaluation and treatment and then tries to figure out: how much did this actually cost, and how much do I have to pay?

Now, our hypothetical patient eventually receives a bill (in the US, a separate bill for the hospital charges and for the physician fees).

A basic but quite ill patient, but eventually discharged home, but with pathology and imaging might get a charge of $850 from the ER Doc, and something in the $2000 to $5000 range for hospital charges including pathology and imaging. But, only if you’re uninsured (and usually poor), would you actually be expected to pay that much. Various governmental and private insurance covers would pay roughly half of the physician charge and about 30% plus or minus a bit, of the hospital charges. Even if you have a very high deductible (I have a $6000 deductible – bet you can’t get that in Oz), the charges first get “adjusted” to the insurance’s contracted charge, and I pay only that much. Only the poor with no insurance have the opportunity to pay the full bill – which appears to have no relationship to the actual cost of providing their care. Isn’t America a great place! (Sorta fits in with people like Mitt Romney – sadly, I expect that many from Oz actually know who he is – making $60,000 per day but paying 15% in taxes, while people making about that much per year pay a bit more, and people making 2 days worth of his income per year pay 30% in taxes. America, the land of opportunity.)

Oops, sorry, I’m supposed to talk about medicine.

So, here’s some real life examples from my personal experience:

A mammogram. A bill is generated and sent to the patient ( my wife) for $455. If she had no insurance, like 15% of Americans, the hospital would try to get her to pay that bill (actually, the imaging department would never do the test unless she paid prior to the non-emergency test. We have insurance with a high deductible, so we’ll pay the bill – but first it goes to our insurance company for “adjustment”, and the new adjusted bill comes to us $77. We pay $77. What did the test cost? Certainly not the $455 that an uninsured person would be asked to pay? $77 that an insured person pays? Something less?

More dramatically: a little bike crash. Final diagnosis list: LeForte 2 and other facial fractures, mandibular degloving, multiple crushed facial lacerations, C5 lamina fracture, moderately bad traumatic brain injury (took a couple months to think clearly enough to return to work, but ER Doc’s have low cognitive needs, so it was pretty quick – the residents did the maths for me when needed), and a host of others. 5 days ICU, week in hospital, 6 hours theatre time plus 3 more hours by plastic surgeon debridement and initial closure in ER, multiple CTs and MRIs.

• Hospital bill: $74,348. Adjusted bill: $18,876. I paid deductible, insurance paid the rest.
• Plastic surgeon bill: $9,192, Adjusted bill: $2,013. Insurance paid that.
• Emergency physician charge: $805. Adjusted charge: $450
• Total Radiologist charges: $1083 Adjusted: $437

(As I was rounding those numbers to the nearest dollar, I was reminded: Have you Aussies ever noticed, that you have no Pennies? Where did they go? What happened? Are there no frugal penny-pinchers in Australia? If you do have frugal people, what do they pinch? Just asking. No criticism implied.)

If this had been my son, self employed without insurance, he would not get those adjustments, and, unable to pay the bills, would have filed for bankruptcy – as do many other Americans with major illnesses, each year.

Estimates suggest that about 60% of bankruptcies in the US are related to medical bills.

My insurance contract is considered by hospitals and doctors to pay reasonably well – so, I would conclude that collecting about 25% of the hospital bill, and between a third and half of the doctor bills, provides adequate compensation for the time and costs involved. Howzat?

So, it seems that the true cost is something less than the $18,876 of the adjusted bill. And, that the plastic surgeon was satisfied with the roughly $225 per hour of his time that he was paid – and didn’t really need, nor expect, to be paid the roughly $1,000 per hour that he charged. I trust that you get the point.

(Just noticed: He also charged separately for an open nasal fracture. I always thought that the nasal fracture was part of the LeForte – be pretty hard to do the LeForte and skip the nose. Maybe I’ll ask for a refund. One might conclude that scamming to increase the revenues is part of the American game. You might be right.)

Now we have a system that generates a charge that is not expected to be paid, but which can bankrupt many people. An adjusted charge, which appears to be a revenue that will pay adequately for the costs of providing care. And no ready way of understanding what care really costs. A CT scan is charged at $2000, but the expected revenue from a good insurance contract may be only $500, and the average cost of doing the CT scan may be $400, and “marginal cost” of doing one additional scan may be only $20 for a non-contrasted scan.

So, if I’m trying to make rational decisions, what number do I use? I don’t know.

It helps to explain the common “gripe” among US ER Docs that their collection rate is less than 50% of billings (about 22% in the ER at University Hospital) – the charges are inflated beyond any expectation of payment. Our expected, optimized expected payment should probably be about 50% or less of what’s actually written down. It also helps explain why some cost/benefit analysis in American medical journals is hard to fathom – the articles often just pull charge data which doesn’t relate to reality. But a federal legislative proposal to have an American version of the UK’s NICE (National Institute for Health and Clinical Excellence) is a political football with charges of “socialism” for trying to figure out the cost and benefit of various clinical care strategies.

So, I guess we might never know: It cost what?

Don’t forget to read previous installments of ‘American ER Doc Gone Walkabout‘.

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

aka American ER Doc Gone Walkabout… 009

Arriving in Tassie, I had only the vaguest sense of how the intern-resident-registrar system compared to our US system. (OK, so planning ahead has never been my strong point. Works out amazingly well. Sometimes.)

By the time I finished, I had concluded:

The system doesn’t make much difference, we all figure it out and do pretty much the same things by the time we’re done training. Interns are interns, and they all look and function pretty similarly. The residents in Oz have a much greater knowledge base than interns, but not being into the ER track, don’t have quite the mindset of ER Docs – they’re doing inpatient workups – just a little closer to the front door. The registrars in their first few years are comparable to our PGY 2 and 3 residents, and during their later years are more comparable to our fellows and junior faculty – really functioning very independently and occasionally discussing particularly challenging cases with the consultants – as two faculty members would interact on a tough case.

On to some details. In the US resident physicians are doing their specialty training. In Australia, residents are doing general training – the Americans might think of it as an extended rotating internship, while the registrar has moved on from residency to specialty training.

For you Aussies: the US system is a post-graduate medical school system: high school, then (usually) 4 years of college, 4 years of medical school, and then for ER Docs, straight into specialty training – called residency in the US. 3 or 4 years of specialty residency training right out of medical school. Many, especially if interested in academics, do another 1 or 2 years of fellowship training in a subspecialty – wilderness medicine (I think that means that you go skiing or bushwalking on your days off), ultrasound, education, etc.

During that first year of residency, you’re called an intern even though you’re already in the training program, and spend part of the year in the ER, and part of the year rotating through a variety of inpatient services. From there on out it’s all ER, all the time – a few electives thrown in.

Remember, Aussies, the Americans residents are in the EM training program and there is no such thing as a registrar in the US system (except the guy that does the paperwork at the front desk). And I’ll use the terms “attending” and “consultant” interchangeably for the fully trained, independently working, board-certified guys.

For the Yanks: some Australian medical schools are directly after high school, (though some are similar to ours with undergraduate college first) – therefore, the interns may seem pretty young. But, here’s where it gets really interesting: rotating internships for everybody, 1 year. Then, “residency” – which is still not a specialty track, and during which you continue to rotate through a variety of specialties. During your residency, you choose and apply for specialty training. Your residency can last for a few years, or for lots of years: 3-5 seems common.

(I won’t mention the brutality and lack of pertinence, except for a small number going into bench research, of the primary exams.)

Then, on to specialty training – as a registrar. Here’s where the registrars begin to function as what the Yanks consider residents. But, a few differences: the Reg already has spent time in the ER as part of his rotations during internship and residency. The Reg has several years of broad background in clinical medicine, surgery, peds, OB/Gyn that our residents don’t have. The Reg has also had several years of exposure to a variety of clinical services to assist him in making his choice for specialty training, rather than the intense pressure in the US to make your choice during 3rd year of medical school so that you can do sub-internships in that specialty during your 4th year and have your residency applications done half-way through your 4th year.

The years as registrar are a bit different from the US residency:

More years. Usually 4-5. Less defined curriculum – after the minumum required of 4 years of ‘advanced training’, you remain a registrar as long as you need until you can pass the specialty exam (Australasian College of Emergency Medicine – ACEM) – it would take me approximately 12 years, I think, to get smart enough. You don’t enter a single registrar program and stay there – you go through a variety of independent positions that are typically 6 or 12 months long. Some time on other services, like Critical Care. Some time at rural hospitals. Maybe even some time as a Retrieval Registrar – flights to bring patients from outlying hospitals in to the larger centers. Take the ACEM exam when you feel ready, and keep on with training until …….well, until you can pass the exams. And the pass rate for the ACEM is lower than for the ABEM exams – about 50-60%, if I hear correctly. Why so low? Take a look at the LITFL exam resources and try some of the ACEM questions. You’ll understand. They are insanely difficult – no way that I could pass the ACEM exam. ABEM looks simple.

That program has a great advantage: not everyone can grasp the required knowledge, nor acquire the required skills at the same pace. In the US, you’ve got 3 or 4 years depending on the program. Learn it or fail. Or fail to learn it, and get eased through. In the less defined Aussie system, take 3-4-5 (?more) years and get it done at a pace appropriate to your skills and speed of learning.

Editor’s note: There are limitations in the Australasian system on the number of times the exam can be sit, and the time taken to pass the exam — but there is a lot of flexibility.

As a Registrar, you’re pretty independent – you see patients, supervise the interns and residents as in the US, but unlike the US, often present a case to a consultant/attending only if you wish to. Particularly with the senior registrars, we would often go through several shifts without discussing a patient. Not at all sure that I liked that, how else do we learn except by sharing & discussing – even when we already know the answer. Sometimes I felt that I was asking for opinions on my patients, more than the reverse. (And there were some skills that I had long ago abandoned to our nurses and paramedics, but had to request help from the registrars – or relearn the skills for 3 months. I chose the easier route.)

The junior registrars in their first and second training year, are clearly further along than our PGY 1 and 2 – no surprise, since they’ve had 3-5 years of general clinical experience. And, by the time they’ve been registrars for a few years, they function more as we would expect of a fellow or junior faculty. Even though the junior registrars are less seasoned in emergency medicine – especially some of the procedural stuff – they commonly knew more than I did about medicine outside of emergency medicine. That broad background does indeed show up, and is useful. The knowledge required for the primary exams, however, did not ever rear its ugly head.

But, in the end, if you blindfolded me, and disguised the accents, I’d have a hard time sorting out the differences in capabilities between the trainees in Tassie, and those at home.

But, you may ask, wouldn’t 8-10 years of training, even if the hours worked are less crushing, constitute a severe personal and financial load? Well, a little context:

The Australians have contracts that call for 37 hours a week, plus 5 hours of educational sessions whereas the US it’s typically 48 hours of clinical time plus educational time – and in the realm of electronic medical records and the pressure to “move the meat”, at least at my hospital, many of the house staff are spending hours after each shift finishing up their charting. Never happened at LGH – done and gone as soon as handover rounds were done. So, the weekly work load in the US is about 25% – at least – greater than in Australia.

Americans finish medical school with a debt load perhaps 4-5 times that of Aussies finishing med school (perhaps a bit higher debt load for those finishing a graduate, rather than undergraduate medical school). An Australian intern earns 30-50% more per year – plus 5 weeks of paid vacation, plus state holidays, and some of that income can be tax-free – than American interns. And, as the Australian moves through the system, the year-to-year increase in salary is substantially greater than in the US. So, as a registrar, the Australian physician has a much more reasonable debt load, work hours compatible with a career – rather than a right of passage, and earns a comfortable living. He appears to be passing through stages of a career. Whereas the American resident is passing through an unsustainable, though prolonged and brutal right of passage – at the end of which he has a sudden transition, seemingly overnight from an underpaid, overworked trainee to a fully formed, newly omniscient, and generously compensated attending. I exaggerate, but only a little.

Think about it: if you’re an engineer or businessman, you don’t finish training, then join a firm or start your own business and become the senior partner. You gradually work your way up as you gain experience and establish the tentacles of power. But US medicine assumes that as soon as you have that certificate, you’re ready for full do-it-all medicine. Perhaps a slower and lower-angled ramp up to full certification has some advantages.

Another observation about the residents and registrars with whom I worked: diversity. In the US, we consider diversity in skin color. But, not much in backgrounds. The Australian registrars were from the big island, the little island, India, Africa, Burma, and Singapore. What’s up, can’t Oz grow their own? Consider this: in the US, about 11% of our population was born abroad. In Australia, that number is over 30%. With that kind of a rate of growth through immigration, it’s not surprising that immigrant doctors need to be part of the equation. The diversity of background was sometimes challenging – not all of our residents and registrars were starting from the same knowledge and experience base, and often enriching – both culturally and medically (“Oh, yeah, boss, we saw lots of typhoid in India – here’s how we did it……”).

If I was doing training now, I think I might like the longer but less brutal program that really felt to me, as an observer, much more as a progression through current career stages, rather than the US training that seemed more an independent step to a future career.

Don’t forget to read previous installments of ‘American ER Doc Gone Walkabout‘.

References

• Salaries in the US (pdf)
• Salaries in Australia

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

Two weeks ago, the Australasian College for Emergency Medicine (ACEM) held their Annual Scientific Meeting (ASM) in Sydney. Whilst the weather didn’t really live up to our expectations, I think most delegates would agree that a high quality conference was delivered at the Darling Harbour Sydney convention centre.

The theme was “educating for our future” and the conference featured a host of articulate medical educators including Professor Ronald Harding, chief editor of the Medical Teacher journal, Susan Promes from the USA who is affiliated with the ACGME (the national credentialing committee of the US residency programs), David Cone the Editor-in-Chief of the Academic Emergency Medicine journal, and Victoria Brazil who is an Australasian fellow and Director of Queensland Medical Education and Training (QMET). There were also talks from a team of local medical education experts like Tony Brown (Qld), Peter Cameron (Vic), Chris Curry (WA), Peter Kas (NSW) and Paul Middleton (NSW) just to name just a few. The topics covered in this conference ranged from Trauma and Disaster medicine right through to Australian indigenous health. Also of note, International Emergency Medicine was given a spot in the plenary sessions with a great talk by Chris Curry on the development of training programs in PNG and Botswana.

For a conference with such diverse content it is difficult to present an all-encompassing summary. I will provide the perspective of a college trainee with an interest in medical education rather than a compendium of all the activities that took place. For another perspective, read the daily summaries presented on the EDexam blog which are linked below:

• ACEM 2011 Day 1 Summary
• ACEM 2011 Day 2 Summary
• ACEM 2011 Day 3 Summary
• ACEM 2011 Day 4 Summary

“Trainee Tuesday” – a day for Trainee’s!

In keeping with the education theme, the organisers targeted greater trainee involvement in this year conference. “Trainee Tuesday” was an entire day of talks and activities pitched at training registrars. This day consisted of trainee focused talks including a symposium on the ACEM’s Trainee Program, a Trainee Cocktail party and of course the hugely anticipated “SimWars”.

The symposium on training led by Yuresh Naidoo (Censor-in-Chief) and Mary Lawson detailed the recommendations for change after the college’s recent training review (pdf version) and Bob Dunn updated us on advances in the trainee research requirement. Andrew Perry, the training committee chair, gave a dynamic talk on the “Trainee Perspective” highlighting the promotion of e-learning within the training process, a theme that Prof Ron Harding had described in the previous days medical education talk on “the future of education”. Andrew, who has been representing the voice of Australasian trainees for over 3 years, reminded us of the great job that college is actually doing with the massive task of coordinating the training of over 1000 trainees across Australasia. The Emergency Medicine training program is the 3rd most highly recruited specialist-training program in Australasia and arguable one of the most dynamic, especially taking to account the current re-structuring of the program based upon trainee feedback. Andrew also unleashed the Twitter hastag #ACEM2011 to the masses at the conference in his plenary session just in time for SimWars where the action hit centre stage….

Here’s the the slideshow for Andrew’s talk on the ACEM Training Program from a Trainee’s Perspective:

Sim Wars!

The much-anticipated Sim Wars went down a treat.

The event was organised on stage in the main auditorium and was presented by eloquent and charismatic hosts Neil Cunningham (VIC) and Marian Lee (NSW), and a panel of playful but experienced judges played by Susan Promes (USA), Victoria Brazil (QLD) and Stuart Diley (NSW). The scenario directors were James Kwan and Julian van Dijk, and their ideas were coordinated by the very effective support of a team of technologically and artistically-minded helpers.

There were teams of “4 registrar resuscitators” who entered an unknown scenario set in a standard emergency department with the ‘usual’ set of hazards and challenges that we face as Emergency Doctors in the real world. These challenges and/or obstacles included having to coordinate resuscitation efforts whilst dealing with hysterical friends and family, or interruptions from the police, and coping with rapidly evolving critical illness in an undifferentiated patient.

An array of scenarios were on offer ranging from the intoxicated assault resulting in a “loss of hand”, severe burns needing advanced airway interventions, to the surprise arrival of a VIP from a foreign embassy presenting with PV bleeding and a potential ruptured ectopic pregnancy…

This year there were 4 brave and enthusiastic teams who competed in the name of learning and fun from Queensland, Victoria and New South Wales., namely “The Royal Queens”, “The Liverpool lovelies”, “Thank God you’re here!”, “The Nepean Nightriders”.

The even itself was full of excitement, fun and humour, amplified by the simultaneous live twitter feed that took the event nationwide and beyond. All teams did exceptionally well in this inaugural event and were rated between 7.5 and 8 out of a possible 10 on the first round. This was followed by a play off between the two top scorers. Congratulations to Rik Wheatley, Alex Buttfield, Bellice Olima and Jimmy Bliss from the “Liverpool Lovelies” who were the winners in the final!

Life in the Fast lane – palpably present!

Finally no summary would be apt without at least mentioning the undeniable impact of the “Life in the Fast Lane” blog and others like it in “educating for our future”. The “LITFL” blog was mentioned several times (including screenshots on occasions) throughout out the conference both in the plenary sessions and parallel sessions. Whilst neither Mike Cadogan nor Chris Nickson were able to make it to the sessions they were “virtually” present with the dynamic twitter feed that was going on throughout the conference. It is also worthy of mention that Mike Cadogan received ACEM’s “Teaching Excellence Award”.

So well done to Mike for this great achievement!

Future articles….

Well that’s it for now with my quick peek at the conference from a trainee’s perspective. I hope to follow with a few posts on the future of medical education and what makes a good clinical teacher as the keynotes saw it, and a report on the events of the International Emergency Medicine Symposia on Day 1 at the conference… so much content in so little time! Thank goodness for the power of reflection and ability to write a delayed blog post!

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

I must be getting older…I find I need a little bit of inspiration on a Friday!

Maybe it is a reward for making it through another week, or motivation to get through another weekend on call…not sure – but whatever the reason, we will try to bring a little positive energy to your Fridays in the future!

This is a fantastic version of Australian artist Nick Cave’s iconic song – the Ship Song.

The Ship Song Project is a reworking of Cave’s original work with individual lines sung/performed by the most prominent acts to feature at the Sydney Opera House over 2010/2011.

http://www.youtube.com/watch?v=bG7wbAfcKUI

Artists include: Neil Finn, Kev Carmody and The Australian Ballet, Sarah Blasko, John Bell, Angus and Julia Stone, Paul Kelly and Bangarra Dance Theatre, Teddy Tahu Rhodes and Opera Australia, Martha Wainwright, Katie Noonan and The Sydney Symphony, The Temper Trap, Daniel Johns and the Australian Chamber Orchestra.

Directed by Paul Goldman.
Arranged by Elliott Wheeler.
Photography by Prudence Upton.

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

aka Prehospital Predicament 001

This is post by LITFL’s newest contributing author, Dr Minh Le Cong, a specialist in rural generalism and the current Medical Education Officer for RFDS Queensland.

Hi folks. I want to present this scenario based on a real case to highlight the challenges of dealing with critically ill pregnant women in remote Australia.

This is not just an issue for obstetrically-trained doctors but for all health providers who may have to deal with obstetric emergencies and provide resuscitation and arrange urgent retrieval. As we are all aware, emergency and critical care training lacks detailed coverage of obstetric skills and knowledge. This might be acceptable in city-based practice where specialist maternity units are available for on call support but in rural areas it falls upon the remote doctor or nurse to provide all the initial and ongoing care whilst transport is arranged. Then during retrieval it is the flight doctor, nurse or paramedic who has to continue to provide ongoing obstetric resuscitation and stabilisation of not only the mother but the unborn baby as well.

Many consider these emergencies to be ‘worst case scenarios’…

Let’s set THE SCENE

You are an RFDS doctor in Mount Isa, a remote mining city in north Queensland.

• A regional hospital with a resident obstetrician and an anaesthetist.
• HDU on site, no ICU
• RFDS base with 24 hr fixed wing retrieval service

Now you get THE CALL

• 36 yo Indigenous woman at Doomadgee (Indigenous community)
• G7 P5, currently 34 weeks gestation
• Presents with small PV bleed that has settled
• Obs stable
• Doomadgee has small hospital with resident doctor but no acute birthing service or OT

OK, now its over to you…

Q1. Regarding RETRIEVAL TRIAGE AND PLANNING:

a. What is the priority of this call?
b. What crew mix is required?
c. What special preparations are needed?
d. What further medical information do you need? 

Answer and interpretation

You obtain the further information requested.

Click to get the info!

Q2. What is your interpretation of the history and examination findings?

Answer and interpretation

Q3. What is foetal fibronectin? Is it useful in this situation?

Answer and interpretation

… SECOND CALL:

COME QUICK SHE IS BLEEDING AGAIN!!!

Q4. Regarding the PV bleeding:
a. What 3 likely causes should you consider?
b. What is the uterine blood flow at term?
c. Do you want to take blood with you, if so, how much?

Answer and interpretation

Q5. Is there an indication for tocolysis, and what would you advise?

Answer and interpretation

You arrive at Doomadgee with your retrieval team.

This is the handover:

• Woman in blood soaked bed
• Semi conscious
• BP 60/, HR 140, RR40
• SaO2 unrecordable
• Rx = IV Saline 4 litres, O2

Now, you have some decisions to make.

Q6. What is definitive care for this woman? Can you provide it as a retrieval team?

Answer and interpretation

Q7. What are your immediate management priorities? Is there a role for a ‘permissive hypotension’ resuscitative strategy in this case?

Answer and interpretation

Q8. Apart from the administration of replacement blood products, what other agents might be considered for use in the retrieval of a critically bleeding obstetric patient?

Answer and interpretation

Now, back to the case…

This is where we’re at:

• Patient given more saline and two units of O neg… BP and GCS improved.
• Fetal HR is 180/min.
• You ‘load and go’
• Portable USS inflight demonstrated abnormal vasculature of the placenta

Q9. What is your interpretation of the above clinical information?

Answer and interpretation

Well done, you’ve made it to Mt. Isa ED…

This is the situation now:

• Obstetrician waiting
• BP 90/50, HR 100, Hb 37
• Coags – borderline abnormal
• Decision made for emergency LSCS
• Husband on commercial flight to Mt. Isa… he was refused transport with wife due to her criticality.

Q10. Was it appropriate for the patient’s husband to travel separately from the retrieved patient?

Answer and interpretation

Now, the patient has made it to the operating theatre in Mt Isa:

• LSCS performed and abnormal placental anatomy is found
• The placenta is adherent to uterus and penetrated to bladder
• The baby delivered in distress
• The surgeon is unable to control haemorrhage from uterine incision and placenta

Things are looking grim…

• The anaesthetist having trouble maintaining MAP >60
• 19 Units PRBC and 19 Units FFP given
• 10 units of platelets
• The surgeon is not willing to do hysterectomy in Mt Isa due to a lack of recent experience
• The pelvis is packed…
• Mt Isa is running out of blood products…

Q11. What are your options at this point?

Answer and interpretation

Now its your job is to perform an interhospital trnsfer to the nearest ICU in Townsville.

Q12. Is this a good idea?

Answer and interpretation

It is nearly 900 km from Mt. Isa to Townsville, another 2.5h flight…

Q13. What are the key management issues for her aeromedical retrieval care  given that she is post-operative patient having sustained massive blood loss?

Answer and interpretation

You’ve made it to Townsville!

Reveal the outcome and key learning points

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

Hectic times at present…

Juggling work commitments, family life and writing can be tricky. However, new vigour and inspiration has been instilled with the arrival of some geeky new toys!

First up – Sanük

Sanük have been around since 1997 when Jeff Kelley started making sandals out of inner tubes and indoor-outdoor carpet…

These are not shoes - they’re Sandals

The guys from Sanük Australia found out that I had become inseparable from my old sidewalk surfers, but that they were a little too ‘cool’ to wear to work…so they introduced me to their new, uber-sophisticated range, super comfortable and smart enough for work! I met up with Matthew Paull, brand manager, in Canberra on the weekend to try out a few pairs  - and when he wasn’t looking slipped off into the sunset with a cool pair of pick-pockets!

Second arrival of the week was the Samson Meteor Mic – USB Studio Microphone

The Meteor Mic is the universal solution for recording music on your computer. Perfect for your home studio, Meteor Mic is also ideal for Skype, iChat or voice recognition software.

Awesome!

Although the Meteor Mic itself is quite compact, it features a large, 25mm condenser element that makes it suitable for both acoustic instrument recording or vocals. It requires no drivers and works well with almost any digital audio program, from Garageband to Skype to voice recognition software.

The Mic has a volume control knob, mute switch, stand adapter, a remarkably flat frequency response, zero-latency headphone jack built in and is capable of full 16-bit, 44.1/48kHz recording. The mic also features fold out legs to form its own stand, and can be positioned in a variety of ways. It can even work directly with the iPad (using the Camera Connection Kit), and uses a cardioid pickup pattern and captures a very flat 20Hz-20kHz frequency range.

Thanks to @fnyc I was able to pick up the Uber-Geek limited edition Gold version of this awesome USB recorder. This version of the Meteor has 4-micron thick 22K gold plate in an individually numbered mahogany box and braided gold USB cord…MMMmmm

http://www.youtube.com/watch?v=byun8WG2y1U

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

Not so long ago we featured The Intensive Care Network, a forum and collection of resources for trainees in intensive care. Now it’s the turn of ED.EXAM, a similar resource for emergency medicine trainees.
ED.EXAM is created by Melbourne-based Emergency Physician Andy Buck (and colleagues) with the stated aim of ‘leveling the playing field’. In recent years the FACEM Part 2 exam has only had a pass rate of about 60% and the creators of ED.EXAM recognise that the amount of support and preparation that trainees get across Australia and New Zealand is highly variable. Like LITFL, ED.EXAM aims to give everyone a ‘fair suck of the sav’.

The site is new, and still in the early phases of development. However there are already many useful tips and resources on self directed learning, studying for exams, living through the exam process, textbook reviews, exam courses, notes, practice questions, flashcards, and the pros and cons of technology.

For instance, it includes the following sage advice on the use of the web as a study aid:

“Think of the world wide web like a spider’s web – intricate and cleverly designed, but it’s a trap: During your year of exam study you will procrastinate, it is inevitable, and the internet is an excellent way to lose hours, days or even weeks of valuable study time.  Wasting time on facebook or twitter is clearly pointless, but be aware that you may start fooling yourself into thinking that you are learning useful content for the exam by browsing through all of lifeinthefastlane.com, when in fact it is incredibly easy to get sidetracked, and next thing you know you’re ordering one of their g-strings or hot pink y-fronts to wear as your lucky undies on exam day in the hope that this will help you get through the exam…”

Access to the site is free, but you must register. The strength of the site will come from the participation of trainees, so get in there and check it out. Also, don’t forget to check out LITFL’s FACEM exam resources, which includes links to many other great web-based resources.

For those who are 2 weeks out from the FACEM Part 2 clinical exams — Good luck!… and sorry we didn’t feature this resource sooner!

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

A new intensive care educational and networking website is being launched this week, and I invite you all to check it out:

www.intensivecarenetwork.com

The website is aimed at Australasian trainees, but is also relevant to the global intensive care community. There’s some industry sponsorship (see the disclaimer below) which won’t influence site content but will allow the site to remain free to access.

We are putting up lots of our own material for the primary and fellowship exams of the College of Intensive Care Medicine, as well as for the paediatric fellowship exam.

We also have resources to help with research, training, clinical and non-clinical areas of our practice, and much more, which we will continue to update. We will have regular podcasts on a variety of topics later in the year.

We will also post vodcasts of our bi-monthly meetings, when we host guest speakers on useful topics such as burns, ECMO, rural ICU, and exam technique. Currently these meetings are held in Sydney — the first one by Dr Hergen Buescher on ECMO is being held today at St. Vincent’s — but later this year they will be held throughout Australia.

The forum will allow open discussions on a variety of topics, and encourage interaction from intensivists and critical care trainees from all over the world in a password-protected environment.

There is also a links section on the site on which we’ve tried to collate the best of what’s out there to save you trawling the net. And finally, there’s a calendar of events, with links to ICU courses and conferences in Australasia and overseas.

Please join up (the site has even been specially adapted for smart phones!), have a look, follow us on Twitter (@I_C_N) and befriend us on Facebook.

Oliver Flower FCICM
Royal North Shore Hospital, Sydney

Disclaimer:

• I am a co-contributor to the design and maintenance of this website and its content.
• The current sponsors of this website are CSL Biotherapies and Edwards Lifesciences. The sponsors do not determine the content of the website.

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

If you’re an overseas doctor seeking to work in an Australian hospital it is vital to make a good first impression. This is not always easy to achieve. The following are verbatim excerpts from the application letters of overseas doctors seeking to put their best foot forward.

I wish to apply for an opening of a Resident Medical Officer at your hospital

Dear respected Sir could you please insert me in the most appropriate place

I have acquired clinical skills that can match any other doctor who have more experience than me

Respected Sir/ Madam, Writing you this correspondence gives me immense pleasure

I am an ambitious team player and have good regulatory compliance

Responsibilities — psycho education and execution of the patient

I am well confident now in Resuscitation

I am seeking a working slot in your hospital and will provide your hospital with a highly prolific doctor

I believe that the services I will render to you will be source of pride for you in coming future

I possess a very good command over English language as can be seen

Eagerly waiting for a positive response from your kind end

Who would you give the job to?

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

Merry Christmas dear LITFL readers!

Have a great day, however you like your bells to jingle.

Whether that’s Aussie style…

http://www.youtube.com/watch?v=S9NhL3agUaw

New Zealand style…

Or Bollywood style…

http://www.youtube.com/watch?v=MHkfPjW0aRg

From the LITFL team:

have a good one, one and all!

Life in the Fast Lane Medical Blog - Emergency Medicine education blog