August 22nd, 2007 by Dr. Val Jones in True Stories
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Dr. Sid Schwab recently wrote a wonderful blog post about what doctors feel when they treat patients who remind them of their own kids. For example, he describes how it makes the physician want to run home and hug his/her kids out of gratitude that they’re ok. His post reminded me of an experience I had in the pediatric Emergency Department where I came face to face with memories of my own childhood trauma.
I was bitten in the face by a neighbor’s dog when I was about 4 years old. It was unprovoked and completely unexpected. The dog had no history of viciousness and I had no history of tormenting the creature. I was standing in the hallway, eye to eye with the dog (we were the same height) and I reached out to gently pet him when he attacked me. My parents freaked out, blood was pouring out of my face, and apparently it initially looked as if he’d gotten my left eyes since it was covered in blood. I was rushed to the local hospital where a family physician cleaned me up and put stitches in my cheek, eyebrow, and corner of my eye. It was hard to sit still for the numbing medicine and I was crying softly through it all. I don’t remember the details of the event, but I do still have the scars on my face – scars, I am told, that would be less noticeable if a plastic surgeon had closed the wounds.
Flash forward 30 years and I’m working a night shift in the pediatric ED. A father carries in his young daughter, crying and bloody. She had been mauled by a dog – and had sustained injuries to her face only. I escort the little girl to an examining room and begin flushing her wounds with saline to get a sense of how extensive they are. Dad goes to fill out paperwork while mom holds the girl’s hand.
It was eerie – her injuries were very similar to my own. I figured she’d need a total of 15 stitches or so, all on the left side of her face. There was no missing flesh so I knew that the cosmetic result would be good. I explained to her mom that we would be able to stitch her up nicely – and that she’d likely have minimal scarring. The mom asked for a plastic surgeon – and I agreed to call one for her right away.
That night I had a new appreciation for what my parents must have felt when I was bitten. I could see these strangers’ concern – how they hoped that their little girl wouldn’t be permanently disfigured, how they wanted the most experienced doctor to do the suturing, how they held her hand as she cried. It was really tough – but we were all grateful that the injuries weren’t more severe… and I was glad that I didn’t have to do the suturing. I showed the girl my scars and she seemed comforted by how they had turned out. This experience reminded me how personal experience can add a special dimension to caring for others, and that sometimes having been a patient can make you a better doctor.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
August 20th, 2007 by Dr. Val Jones in News
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There has been some recent buzz about the health risks of nail salon workers. Two studies suggest that constant exposure to nail product fumes might impact cognition in both nail salon workers and their unborn babies. Although the workers’ exposure is estimated at 1200 times that of the average American, it does make one wonder if any woman who frequents these places may be at some risk.
The first study involved neuropsychological testing of 33 female salon workers and comparing their results to 35 women matched controls. The researchers found that the salon workers did worse on tests of attention span and mental processing speed and their sense of smell was decreased. This study was too small and non-specific to tease out which chemicals might be the culprits, but the observations were concerning.
The second study involved cognitive testing of children born to 32 mothers who were exposed to organic solvents when they were in utero. Compared to a control group, the children (whose moms had been exposed to chemicals) performed more poorly on IQ tests and various other cognitive tests. Interestingly, the participants in this study were not nail salon workers – they held jobs ranging from funeral home embalming technicians to hair stylists, to dry cleaners.
The Environmental Protection Agency issued some guidelines for nail salons, and based on my experience I’d be surprised if salons adhere to even 1/3 of these guidelines on average. If you scroll to page 12 of the brochure, you’ll see that the EPA recommends wearing a “organic vapor cartridge respirator” which looks like something out of a HAZMAT video. I doubt that any nail salons provide these for their staff… and if they did, what would clients make of it?
And so I think these small studies raise an interesting question: how safe is it to be exposed to organic solvents at all? We need to do more research to tease out the exact risks of each individual chemical, and at which concentrations. As for me, I’d urge pregnant women to minimize their exposure wherever possible, and strongly consider avoiding salons that offer acrylic nail services. Until we know exactly how harmful these chemicals are – the best thing to do is to avoid them wherever possible. The potential for solvent-related cognitive decline is worrisome enough – but allergies and asthma exacerbations are far more common. For a full list of chemicals known to be harmful (and their side effects) please review the EPA brochure, pages 4-5.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
August 18th, 2007 by Dr. Val Jones in Health Policy, Medblogger Shout Outs
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Emergency departments are splitting at the seams, uninsured patients fill the waiting rooms, and Emergency Medicine physicians are crying “uncle” on a national level. We assume that gaps in health insurance coverage force patients to seek treatment in the ED, but the reality is that many insured patients seek treatment there as well. Why? Because the ED is a crowded, but one-stop shop whose convenience cannot be denied. PandaBearMD explains why one well-insured patient (who has a regular PCP) still chose to see him in the ED:
“As my patient related to me, in order to see his doctor he has to
make an appointment which is often weeks to months in the future. On
the day of his appointment, even if he shows up on time he will usually
have to wait an hour or two because the doctor is always running late.
Then he will spend a brief ten to fifteen minutes with his doctor who
will order a slew of tests and imaging studies, many of which will have
to be completed at a different location. He may, for example, have to
drive across town for a CT scan and it is usually scheduled for a
different day, often weeks in the future.
Then, as my patient explained, he must wait several weeks for his
next appointment where his physician will explain the results and
finally initiate either definitive treatment or, as is often the case,
referral to another specialist who will repeat the time consuming
process…
My patient also confided to me that even getting the results of studies
and imaging was not guaranteed. Although we are all quick to relay bad
news, apparently follow-up is not that pressing to many physicians if
the results are normal…
Consider now a visit to the Emergency Department. First, my patient did
not need an appointment. While it is true that he was triaged to a low
acuity and had to wait a while, at certain times of the day the waiting
times are not that much longer than the typical wait for his delayed
primary care physician. Second, the lab tests he needed were drawn on
the spot and the results reported within an hour even though he was a
low acuity patient. Our goal, you understand, is to discharge or admit
as fast as possible. Likewise his imaging studies were obtained, read,
and reported quickly. Finally, if anything serious has been discovered
he would have been admitted within hours. More importantly to my
patient, since everything was all right he knew fairly quickly instead
of biting his nails for a couple of months.”
This is a perfect illustration of how Americans value convenience over cost, and how health insurance can be an enabler for inappropriate ER use. The solution here is in IT. Primary Care Physicians need the tools to automate a lot of what they do, thus making care more convenient for their patients and themselves. A common, secure PHR-EMR, synched with online scheduling, radiology suites and laboratories, health news alerts, care pages and vibrant community, chronic disease management tools, and comprehensive, credible, patient education will go a long way to keeping people out of the ER. Revolution Health is working on such a system, and we have high hopes that the creation of America’s first integrated, digital medical home will improve the quality of life of patients and physicians alike. Achieving this goal will require cooperation and patience from all sectors in healthcare. I hope we’ll find a way to work together as rapidly as possible or else the PCPs and ER docs are going to crack. Hang in there, guys – help is on the way, though it might be a few years out…This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
August 16th, 2007 by Dr. Val Jones in Medblogger Shout Outs
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In an effort to provide round-the-clock emergency care for their patients, physicians often share an on call schedule. The physician on call makes him or herself available for emergency consultation for 24 hours or more at a time. Unfortunately, patients seem to misunderstand the role of the on call physician – believing that being on call is a form of extended office hours for their convenience. Here’s one doctor’s account of the non-emergency services he provides on-call, and the attitudes that drive him crazy:
One of my biggest challenges is
understanding why patients consider an emergency as anything that they
don’t want to wait until Monday, or even daylight. They want lab
reports. They want advice on whether to get a flu shot. They want to
know what that green cough medicine was their doctor recommended 3
years ago. They want their medicines— that they only seem to know by
color—refilled. And, of course, they are not satisfied with a few pills
to get them through the weekend. They’re not going to pay a “full”
copay for less than a “full” prescription.
A related challenge is that, when I call a phone
number after being paged, the person answering the phone is almost
never the person who paged me. Sometimes it is a teen who answers the
phone with a “Yeah” or a “What?” That there is an important call
expected and that there is an emergency going on in the house is beyond
them. Eventually, I persuade them to find the sick person, and from the
amount of time they are gone, the house must be a mansion.
Sometimes a man answers the phone, and says, “Here,
I’ll let you talk to my wife.” Funny, he’s the one with the problem,
but he somehow cannot talk. I imagine him sitting in the background
like a king who cannot be expected to do his own talking, while his
servant/wife explains his symptoms. Sometimes, if the person having the
emergency is a teen, I have to talk to the mother, because the teen
won’t come to the phone (an interesting twist). The teen won’t tell Mom
exactly what the problem is either, so I have to ask the mother my
questions, then she yells them down the hall, listens for the answer,
then relays the answer to me. Example: “My daughter Susie has a cough.”
“Does she have a fever?” “SUSIE, DO YOU HAVE A FEVER?” “NO.” “No,” “Is
she bringing up any sputum?” “SUSIE, ARE YOU BRINGING UP ANY SPUTUM?”
“YES.” “Yes.” Well, I don’t need to go on, but it can, interminably.
Sometimes the person having the problem is not
available at the number when I call. “Hello, this is Dr. Constan.”
“Hello, this is Mrs. Smith, I’m calling about my mother, Mrs. Jones,
and she wants to know what to do about her abdominal pain.” “Could you
please put her on the line so that I can talk to her?”
“She’s not here, she went shopping.”
“Oh.”
Sometimes the person doesn’t answer, at all. I’ve
called back promptly, yet “there’s no one home.” What gives? They call
back later to fill me in on what happened at the ER, like I need to
know. They had called me then decided it wasn’t necessary to talk to
me, they wanted to go to the ER anyway. Then, why did you call?
Sometimes when I call back, I get a busy signal. How does that happen?
You page a doctor then tie up the line so I can’t call back! I imagine
that you figure you should first seek advice from the doctor then seek
advice from all your friends and relatives, whomever you can get on the
line. Later you say to yourself, “I wonder why that darned doctor never
called me back.”
…
The advent of Caller ID has produced its own set of
challenges. The person pages me, leaves their number, but when I call
them, they won’t answer the phone because they don’t recognize the
number displayed by the Caller ID. I imagine them standing by the
phone, staring at the number, and reasoning: “Now, I’m having a serious
emergency here, but I don’t want to take the chance of answering this
call and having to talk to a telemarketer. What do I do? Best not take
the chance.” Later: “I wonder why that darned doctor never called me
back.”
If I talk to an answering machine, I usually offer
that the patient can call me back later if they still need help. One
lady called me back and told me that she was home when I called, heard
me leaving the message on her machine, but couldn’t come to the phone
because she was doing her vacuuming. How has outrageous fortune
relegated my services below those of a vacuum cleaner?
Although all the above challenges tend to wear on me
toward the end of the weekend, I try to be professional and caring
about each call (just ask my family). It’s my job to stay the course
with no laurel wreath expected on Monday morning. It was a surprise and
joy to me recently when, at a party, I was introduced to a nice young
couple. “You’re Dr. Constan! We called you 2 years ago about our sick
child. You were so helpful. We’ve always appreciated what you did for
us.” The challenge of weekend call should have more such awards.
For a complete version of this article, please visit www.PMDLive.comThis post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
August 3rd, 2007 by Dr. Val Jones in News
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An emergency medicine physician friend of mine sent me a link to a fascinating article about why cell phones aren’t good communication devices in major disasters like 9/11. When I was in NYC during 9/11 my cell phone didn’t work (the lines were all busy). Here’s what the article had to say:
“So why do text messages get through when phone calls can’t? For one,
SMS text messages are very short, so they require very little capacity
when they are transferred over the network. The second reason is that
text messaging works by allowing messages to be stored and sent through
the network.
If there is a delay in connecting to the network, the phone will
store the message in its memory and it will continue attempting to send
the message until it gets through. By contrast, voice is a
delay-sensitive application. If a sustained connection can’t be made,
the person on the other end won’t be able to understand what you are
saying. And so the call cannot be completed.
While it’s quite common for cell phone networks to get overloaded
during serious emergencies, there isn’t much that can be done to fix
the problem. The main reason is that it just isn’t economically viable
for carriers to build their networks to handle a tenfold increase in
capacity in every inch of their footprint.
“People have to remember that this is a commercial service,” Golvin
said. “It was never designed to be an emergency network. And it just
doesn’t make business sense for carriers to try to build it that way.”This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
