aka American ER Doc Gone Walkabout 020
Well, ACEP is over and the Convention Center is being taken over by a beer fest. There’s gotta be some cosmic symmetry there.
Strolling the exhibit hall, I continued to be struck by the progressive miniaturization of the technology: smaller video laryngoscopes, smaller ultrasound, smaller everything. But bigger capabilities – your smart phone is still small, but with bigger screens, longer battery life, and with continuing expansion of the medical apps available.
There continues to be large interest in recruiting Americans to work abroad – 3 Middle Eastern Recruiters, and 4 locums companies recruiting primarily for Australia and NZ (but no direct recruiting from Australian Health Authorities this year). I hope that they have great success – I think the US will benefit greatly by seeing how it’s done when you don’t have that constant overhang of figuring out how your patients will pay for care that is needed. (On the overnight shift that I worked during the conference, I spent much unproductive time “discussing” with my ENT colleagues how we would care for a nice, but poor, gentleman with a mandible fracture. I learned yesterday that the conversation was continuing – 2 days later, with the dental school finally pitching in to care for him. I’m not proud.)
If any of you ever get to hear Ravi Morchi talk about EM in the poor world – do it. It will expand your mind, and the pictures are worth the price of admission (check out his course syllabus on the ACEP SA web site – all the slides are here: http://webapps.acep.org/meetings/download.aspx )
My favorite topic during the last sessions was the management of chaos session. The speaker reviewed the article that followed ERP’s and noted an average of 17 interruptions per hour. 10 of them were brief and didn’t require a cessation of the task at hand, but 7 required a diversion of attention to a new task, thus leaving the original task. (I noted that during the discussion of degradation of performance and learning caused by multitasking that over 1/4 of the attendees were multitasking on their smart phones and tablets.) My theory is that this is an exponential function: as you manage more patients, the interruptions “stack” – just like an autopeeping asthmatic on a vent – at some point interruption #3 is actually interrupting interruption #2 which in turn has interrupted interruption #1 – leaving the original patient and task forgotten. And, leaving one with many tasks that must begin again from the beginning with massive decreases in efficiency. (I await the day when a resident asks: “Where’s the transvaginal ultrasound?”. Rather than replying “In room 3”, I will have the awful epiphany that the correct answer will be: “Uh, oh, it’s still “in” patient 3, – no, not in the room, in the patient. I think you can just explain that you need to borrow it for a moment, and gently remove it. Just be sure to put it back where you got it when you’re done.”)
The multitasking gets worse when interruptions come not only from direct patient care, but from ancillary tasks: the waiting room ECG, the EMS call for a no-transport or a DOA, the referring Doctor call, (my favorites are the calls from the specialty clinics with a problem unique to that clinic, but being sent to ER: Hi, this is the hematology clinic, and there’s a patient who is bleeding so we’ll send him to the ER.). I’m convinced that at some point ER’s must have an MD floor manager who handles all those issues not involving direct patient care. Specialization within each shift to improve efficiency.
Beyond the direct ACEP activities I had some interesting personal interactions: spent some time with an ERP who is an ultradistance cyclist – his most recent ride was 1600 km in just under 135 hours, with 6 hours of sleep, and entirely fueled by Ensure liquid nutritional supplements. He was interested in research projects to look at nutrition and endurance: visualize the research protocol: 10 subjects in a crossover design with standard diet for 5 and Ensure for 5. Ride on a stationary cycle in the lab for 100 hours, with limited sleep, minimal breaks to pee, and fueled by the selected diet with metabolic measurements during the ride. Then a week washout and another 100 hours in the lab on a stationary bike. Got any volunteer subjects out there? And then several months in a psychiatric hospital afterwards.
Finally, my mate from France spent time at ACEP, at home with me, and in the U Colorado ER. Always an excellent exercise in comparing systems of care (MD’s as EMS first responders with the transport ambulance arriving as secondary response – but the on scene MD able to initiate, for instance, direct transfer of STEMI’s to the cath lab – more than half of STEMI’s in Rouen go that route.)
He also noted that his English is pretty good but he can’t understand accents from Glasgow, Texas, or New Zealand (In fact, I’m not sure that he realized that Kiwi-ish was a form of English).
Hopefully I can reciprocate the internationality with a visit to the big SMACC-down in Sydney in France – working on the scheduling and hope to see you there.