Akutsjukvården är i kris. Det har den varit så länge jag kan minnas. Som vanligt tvistar man om vems fel det är. Populärast är att skylla på politikerna. På andra plats kommer 80- och 90-talisterna som springer till akuten så fort de fått en sticka i foten. De som aldrig pekas ut som skyldiga är de fantastiska sjuksköterskorna, om man bortser från de som jobbar på vårdguiden och hänvisar alla till akuten.
Jag tror att ansvaret delas av alla inblandade, men jag tycker att det är viktigt att vi i vården, och då framför allt läkarna, erkänner vår egen skuld i den ständigt återkommande bristen på vårdplatser. Att skylla på resursbrist är orimligt, med tanke på hur vi slösar med de resurser vi har.
Störst problem med att få fram vårdplatser på sjukhuset verkar det vara på universitetssjukhusen. Att dessa sjukhus skulle ha svårast att klara variationer i antalet sökande är ju märkligt, eftersom de har störst volymer och därmed borde ha större marginaler än de mindre sjukhusen. I stället är det tvärtom och de beror på att sjukhusen delat upp sig i allt mindre, specialiserade enheter som inte vill ta hand om de som råkar bli sjuka, utan vill spara platser till just sina patienter. Det är förstås inte konstigt att man på en högspecialiserad avdelning vill ta hand om patienter som behöver just högspecialiserad vård. Problemet är att ingen avdelning är specialist på allmänt skröpliga, multisjuka patienter. På Karolinska i Huddinge och Solna finns inte ens internmedicinska kliniker. För att veta vilken klinik patienten ska ligga på måste man utreda dem på akuten, vilket leder till långa väntetider och allmänt kaos. Vissa patienter passar inte in någonstans och var man än lägger in dem, vet man att mottagande läkare kommer att 1. bli missnöjd och 2. skicka hem patienten så fort denne kan stå på benen. Ofta läggs patienterna först in på akutvårdsavdelningen, för att sedan flyttas över till en annan avdelning. Resultatet blir ett evigt flyttande och förlängda vårdtider av dålig kvalitet.
Att blanda elektiva och akuta flöden leder till problem. Patienter som har planerats för inläggning och någon form av ingrepp eller utredning, kan få detta inställt för att någon akut inlagd patient har tagit sängplatsen. Dessutom kan någon av klinikens egna patienter bli akut sjuk och då behöva bli inlagd på just den avdelningen. Jag vill ju gärna tro att det är därför sköterskorna ibland förnekar att de har lediga platser. Otaliga gånger har jag hört om jourläkare som gått runt på huset och hittat lediga sängplatser trots att sköterskorna förnekat att sådana funnits.
Sjukhusen har organiserats utifrån läkarnas intressen, snarare än utifrån patienternas behov. Högspecialiserad vård har haft högre status än den sjukvård som majoriteten av våra patienter behöver och vi läkare har tagit oss friheten att definiera vilka patienter vi anser tillhöra vårt kompetensområde. Det går alltmer mot att vi inte ens tar oss an dessa patienter, utan bara den kroppsdel av dem som ingår i vårt specialintresse.
Samtidigt lever vi i en kultur där sjukdomar är något som sjukvården förväntas råda bot på. Acceptansen för att det tar dagar, veckor eller till och med månader att återhämta sig efter en rejäl virusinfektion blir allt lägre. När vårdcentralen ”inte gör något” söker man akuten för att man är trött på att hosta. För att röntgen finns så lätt tillgängligt och för att det verkar så besvärligt att låta vårdcentralen ombesörja en remiss, gör vi utredningarna akut. Ett lågt förtroende för primärvården från både patienter (de som väljer att söka akuten i stället för vårdcentralen) och sjukhusläkarna, gör att vi på akuten gör för omfattande utredningar, till en betydligt högre kostnad.
Det är inte bara patienterna som ställer höga krav på akutsjukvården. Även vi som arbetar där känner ett stort ansvar för att utesluta att det bakom de lindriga symtomen döljer sig en allvarlig sjukdom. Eftersom vi tänker att det nog är säkrast att vara på sjukhus, lägger vi in patienten för säkerhets skull. Det är verkligen inte riskfritt att vara på sjukhus, men i och med att man lägger in patienten överförs ansvaret till en annan läkare.
I England har man gjort försök med akutsjukvård i hemmet. I stället för att läggas in har patienten fått regelbunda besök av sjuksköterska som haft stöd av läkare. Randomiserade studier visar att detta skulle kunna minska dödligheten. Hur många fler patienter skulle vi kännas oss trygga med att skicka hem om det alternativet fanns, att någon kunde kontrollera om vitalparametrarna om fyra timmar, eller ens om vi visste att patientens husläkare kunde se patienten nästa dag?
Det är dags att tänka om i akutsjukvården och anpassa vården efter patienternas behov. Det innefattar att prioritera de patienter som behöver akut utredning och behandling. Att veta vilka dessa är kan förstås vara svårt både för patienterna och för sjukvårdsrådgivningen och hellre ett akutbesök för mycket än ett för lite. Men våra välutbildade ambulanssjuksköterskor måste kunna få göra bedömningen om patienten behöver åka ambulans, sköterskorna på akuten måste få hänvisa vissa patienter till en lägre vårdnivå och vi läkare på akuten måste våga låta primärvården sköta sitt uppdrag och inte konsumera de resurser som skulle kunna gå till dem.
This is my second post in three days. Again it is about something Rob Orman said on his podcast on suicide risk assessment. He said that when it comes to suicide risk assessment, there isn’t a clinical decision aid to lean on, only a structure to go by. There are no binary, yes or no answers, that can say with certainty if the patient will commit suicide or not in the future. Patients are different and you just have to rely on whatever information you get out of them and weigh it all together.
This is all well. What surprised me, however, was that the above statement was made with reference to the literature. It more or less sounded as if he had expected to find a study that showed Yes, all depressed patients who are male, in their late sixties with suicide ideation end up killing themselves and No, borderline females who slice their wrists from time to time never ever actually complete their suicide attempts.
Of course Rob Orman knew he wouldn’t find any studies of that kind. What he did find was studies showing that old patients with suicidal ideation were more likely to complete suicide than young ones, indicating that old age is a warning flag, or studies showing that a lot of hospitalized patients deny intent, but still kill themselves, indicating that your assessment has to be more detailed than just asking the patient if they are suicidal.
But, and this might be why I sometimes find myself lost in the EBM community, Rob Orman said that this is something that makes the risk assessment of a potentially suicidal patient different from the risk assessment of a patient with e.g. chest pain. And I can’t see that difference.
Let me give you an example.
A junior doctor presents the following case to you:
A 54 year old man presents to the ED with a diffuse feeling of not being well. He has no known risk factors for CAD and has never experienced chest pain at rest or on exertion. His physical capacity has been reduced over the last few months, but he hasn’t noticed any deterioration during the week previous to this visit. There are no pathological findings on the physical exam, except for a BP of 165/95. His ECG and cardiac enzymes are within the normal range. He is now symptom-free and wants to go home.
How likely is it that this patient has an acute coronary syndrome? I dislike the usage of percentages, since it gives a false sense of certainty where there is none. Instead I like to use very low, low, medium, high and very high. Make your estimate.
Since it’s an unusually quiet day in the ED and you feel an overwhelming urge to show off your history taking skills, you decide to take the history all over again. You grab two chairs for your young colleague and yourself and start from the beginning.
Twenty minutes later, this is the patient’s history:
He is 54 years old. Since he was adopted as a child he doesn’t know if heart disease runs in his family. He dislikes hospitals and hasn’t seen a doctor for the last 40 years. A friend with hypertension checked his blood pressure on her device ten years ago and told him it was high, but he never followed up on it. He has never checked his blood sugar or cholesterol levels. After a while he reluctantly admits that he smokes a couple of packs per week.
A few months ago he experienced a burning sensation in his jaws when he was running to catch a bus. This was the first time it happened. At first he didn’t think much of it, but there were recurrent episodes. Gradually it got worse and he had to stop at first once, then twice when walking up the stairs to his office. It wasn’t just the pain, in fact he doesn’t even want to refer to it as pain, he also felt nauseous and a bit dizzy. Since walking up these stairs is the only exercise he gets, he stubbornly kept going. But a week ago he sprained his ankle and had to start taking the elevator. During this week the jaw sensation has been more or less absent, until today when it suddenly came back as he was limping back to the office after a heavy lunch. It was much more intense than he had ever felt it before and he got scared enough to go to the hospital for the first time in his adult life. The sensation subsided almost immediately once he got here and he is very pleased with your younger colleague’s assurance that all is well and he can be discharged home, without having to wait all day for a second round of that non-high-sensitivity troponin that you still use in your emergency department.
Does this additional information change your estimation of this patient’s risk of having an acute coronary syndrome? Of course it does! Does it change his TIMI score? No! The boxes still have to be ticked the same way.
Emergency physicians preaching evidenced based medicine sometimes give the impression that science, in the form of research, gives us exact answers. As if there were an absolute truth and the more you standardize medical practice, the better your outcomes will be.
The patient, with a strong family history of thromboembolism, who presents with a swollen lower leg, measuring 2,5 cm more than the other leg, who was curatively treated for testicular cancer 7 months ago and who has now been immobilized for two days, is not at a very low risk of having a DVT, just because his Wells score is 0. The scientific evidence suggests that all these circumstances increase the risk of a DVT. In order to make a clinical decision aid, there had to be cutoffs for continuous variables. The collective body of science, including all kinds of studies on all different aspects, is what gives us the knowledge needed to decide how to treat our patients.
A drug which is commonly used and works well in one setting, may be less beneficial in a setting where it is only prescribed by a few specialists and the rest of the medical community doesn’t know what side effects and interactions to look out for.
To practice evidence based medicine is not to uncritically apply even the most prominent researchers’ recommendations, based on excellent randomized controlled trials. EBM doesn’t obviate the need for critical thinking. I think most doctors agree with that statement. But I wonder how many agree when I say that a fair amount of humility is needed in the discussion on what’s to be considered best practice and evidenced medicine in a setting you know nothing about.
I listened to the ERCast today, the episode where Rob Orman goes through his method for making a suicide risk assessment. It was, as always, very structured and well prepared. I was surprised, however, when he said that this was one of the most downloaded episodes of his show. This was a topic, unlike most of his other EM stuff, where I felt that I already had a good understanding. Maybe that’s because we have a three month rotation in psychiatry as a compulsory part of our internship in Sweden.
It was not until now in the evening, when I started to think about a patient I met some years ago, that suddenly understood what I had to learn from this episode.
The patient was a 60 year old man, who presented to the emergency department with right-sided lower thoracic/upper abdominal pain. There was nothing acute about his pain. He had had it for weeks and had already been seen by his primary care physician, who had ordered an ultrasound of the upper abdomen, which turned out normal. Since the pain got worse with certain movements, the physician has assured him that the pain was musculoskeletal. The patient was not satisfied with this explanation and decided to seek further help in the ED.
It don’t remember the exact details, but there was something about this patient that made me worried. He had rather intensive pain and couldn’t work because of it. His right upper quadrant was tender and I believe he was a smoker. The work-up in the ED, ECG and labs, were unremarkable. So I referred him to his primary care physician with a suggestion that he undergo a CT of the thorax and abdomen, looking for an underlying malignancy.
A couple of months later, I was signing my notes. It should of course have been done much earlier, but I have a tendency to accumulate unsigned notes. Anyway, when doing so the dreaded pop-up showed up: My patient had died. I immediately started thinking that maybe this was a pulmonary embolism or something else that I had missed. Since we use the same electronic medical records system for most of the health care system in our county, I was soon assured that the patient had been well when he followed up with his PCP. I got a bit annoyed that only a CT of the thorax had been ordered and that when that also turned out normal, no other investigations had been made. The patient had been back a second time and had had his sick leave for musculoskeletal pain extended. All visits were to different doctors, unfortunately a common problem in primary care in Sweden.
And then there was a note saying that the patient was dead and that a forensic investigation had been performed. I was upset, thinking that we, his doctors, had missed some pathological process. And now this man was dead. To find out what could have been done differently, I called the forensic department to ask what had happened. Within a few days, I had the autopsy report.
There was no malignancy, nor were there any other signs of disease. The patient had killed himself. I was relieved, thinking that I had been wrong in assuming that his doctors hadn’t taken his pain seriously enough and given him a thorough work-up.
It was not after listening to this podcast today that I suddenly realized that I hadn’t been wrong. Anyone of us doctors who saw this patient could have made a suicide assessment. And if we had done it as thoroughly as Rob Orman suggests, we could have picked up that this patient actually had access to a gun, which is quite uncommon in the southern part of Sweden where hunting isn’t the everyman’s sport it is in the north.
There were things we could have done differently, which may very well have saved this man’s life. Preventing a suicide is no less important than diagnosing a pulmonary embolism. We have to look for risk factors even when it’s not an obviously suicidal patient. Thank you, Rob and Casey, I’ll do my best to remember that lesson.
The first time I came in contact with CV hunters was during a four week extracurricular clinical rotation in Prague. I went there for the fun of it and to improve my Czech and was surprised to see how other medical students were asking everyone for recommendation letters. It has not until now occurred to me that a rotation like that could be used on your CV when you are a recent graduate from medical school. I’m however not the only one who thinks like this. When discussing CVs with a Swedish friend of mine, he thought his brother was embarrassing for mentioning on his CV that he used to be a football coach.
From my international experience I have learned that CV hunting is a common thing in many countries. People will do things, or a least volunteer for positions, that look good on their CV. I see on Twitter how American educators recommend everyone to keep detailed portfolios of everything they ever do. Even though I think that might be valuable and interesting to yourself, I don’t see how anyone else can get anything out of a long list of lectures, seminars, courses, assignments or whatever it is that you put there. Trying to assess what you know and who you are based on a list, seems to me like getting to know people in your community by reading the phone book.
So, I wrote an alternative CV, focusing on what I have learned through the years, instead of what I have done. Please leave a comment and let me know what you think.
The lesson learned based CV of Katrin Hruska
Lessons from education
- If you are supposed to do a presentation and don’t prepare, you might experience nausea, dizziness and mutism to such an extent that you have to return to your seat with mission unaccomplished.
- However embarrassing and uncomfortable this experience might be, the sun will still rise the next day.
How: Religion class in grade 8.
- People don’t only disagree with you because they don’t understand your arguments. They might actually understand all your arguments and come to a different conclusion.
How: Local leader of the youth wing of a political party.
- You may win the debate but still lose the issue if you are not in power.
How: Political representative in a local council for one of the opposition parties.
- Sometimes making irrational choices will change your life for the better.
How: When I quit half way through my last year of high school to go and live in Prague with my boyfriend for half a year. I doubt we would have been married today if I hadn’t and I am far from sure that I would have gone on to study medicine.
- If you don’t go to the lecture, you have to read the book, otherwise you won’t learn anything and you won’t pass the exam.
How: First year of medical school. Attendance wasn’t compulsory and the books were so heavy I had to read them in bed and so boring that I feel asleep.
- If you have been to a lecture that gave you nothing because the speaker was so bad, there is no use going to his second lecture even if it is called ”All you’ll ever need to know as a doctor”.
How: Medical school. Revised at conferences by dull professors with heavy accents.
- Socializing in a foreign language will make you seem less smart and more shy.
- If you are used to talking a lot, this can be a good experience.
- Studying in a system that stresses memorizing details doesn’t make you smarter, but it does make you remember more details. At least for a short while.
- If you stay up all night playing pool, you will be tired the next day.
- If all shops close at noon on Saturday and are closed on Sundays, you will be very hungry if you don’t do your shopping on Fridays.
How: Exchange student in Germany for my second year of medical school.
Lessons from work experience
- Taking responsibility for a patient is different from being a medical student.
- Even if lab results improve, it doesn’t mean that the patient is doing any better.
How: Summer job as some sort of medical assistant in a geriatric clinic. While I was looking at the creatinine that just came back and finally started to decrease after a steady increase, the nurse came to tell me the patient died.
- To feel better patients need to eat, pee and poop. Then they need to get on their feet and regain their balance so they don’t fall and hurt themselves.
- Doctors can’t fix this, but a team of doctors, nurses and physiotherapists can help the patients fix it for themselves.
- Patients are not only patients, they are people. Even old patients have been young and lived exciting lives. Some have even taken part in interesting happenings such as recovering the Wasa Ship, Sweden’s most popular tourist attraction which sank on its maiden voyage in 1628.
How: Junior officer in the above mentioned geriatric clinic.
- If you do research you need to be in a group that understands your work and can discuss it with you. You need a supervisor who can teach you how to conduct studies and how to interpret results.
How: Research assistant, trying to write a paper on a study conducted by someone else for another purpose, but where a lot of blood tubes were saved and stored.
- Primary care is the most difficult specialty and not something inexperienced doctors should be doing without proper supervision.
- Doing something you think is right doesn’t mean it is.
- If you don’t ask and admit you were wrong, it is possible that no one will find out. It is also highly likely that you won’t learn anything from it.
How: Junior officer at a primary care clinic.
- Doctors from different specialties have different priorities. Anesthesiologists see a need for more fluids, where cardiologists see a need for diuretics. Chest pain in a psychiatric patient can be cardiogenic. Chest pain in a cardiology patient can be anxiety related.
How: 21 months of internship, rotating through internal medicine, surgery, anesthesia, primary care and psychiatry.
- Anyone can start a fight. Anyone can also take the first step towards ending it.
- Try to dislike people’s actions instead of disliking them personally.
How: Bringing up three children with strong wills.
- If you don’t delegate well and clearly, you will either end up doing everything yourself, or frustrate people who want to help out.
- Starting up a new business is a lot of work.
- Even the best employees will not perform well, if the group doesn’t work well together.
- The best result you can get as a founder, is something that will work just as well without you.
How: Starting up a cooperative daycare together with two friends but no money. The school is celebrating its tenth anniversary next year.
- Taking care of three small kids is a hand full, even if you are two to share it. Allowing yourselves five months leave in a foreign country will make it more interesting and give you the chance to learn a new language.
How: Spending five months in Argentina with no other agenda than being with my family.
- The emergency department is the most interesting place in the hospital. It is also where you will have to work most intensely.
- If no one really knows what emergency physicians do, if there are no specialists and not even a recognized specialty, you cannot specialize in emergency medicine.
How: Started to work at Sodersjukhuset, one of the first hospitals in Sweden to employ doctors for full-time work in the ED, instead of doing occasional shifts.
- Primary care can be a lonely specialty.
- If you try to solve all you patients’ problems, your ToDo-list will continue to grow.
- If you don’t have a supervisor who is a roll model for the kind of doctor you want to be, learning to tackle these issues is very hard.
- If you start going into the restroom to bang your head against the wall in tears, it is time to move on to another workplace.
How: Resident in family medicine.
- Being an expert in one field of medicine, says nothing about your ability to treat patients with diagnoses outside of that field.
- A resident who takes a good history and does a literature search, can provide better care that a specialist who cares more about his research than about his patients.
- Patients need care even if no specialist thinks that it should be provided in their department.
- If the head of your department doesn’t address important issues, someone has to bring those issues up. If he fails to do what he has promised to do, someone has to hold him responsible.
- If that person is your friend and you agree, you have to stand by her, even if it decreases your chances to get promoted.
- If the conflicts can’t be solved constructively, one of you might have to leave.
How: Resident in Internal medicine. Specialist training concluded.
- Replacing ”I don’t have time to…” with ”I don’t prioritize to…” makes it harder to trick yourself.
- Introducing a new medical specialty is difficult and requires perseverance.
- A well working group of people will come up with better solutions than any single person.
- Even if that group decides on something after a long discussion, the work still has to be done in order for things to change.
How: Secretary of the Swedish Society for Emergency Medicine.
- Medical evidence only applies to settings that are similar to where the data was collected.
- Well’s score for pulmonary embolism is useless if it takes a whole day to get a d-dimer and the hospital doesn’t have a CT scanner.
- Patient safety is a concept that needs to be taught, understood and become part of your culture.
- For sick patients you need a team of doctors and nurses who work well together.
- Excellent care in the emergency department, followed by inadequate care in the wards, can be life prolonging, but probably not for very long.
How: Clinical rotation in the emergency department of the university hospital in Botswana.
- Transferring a concept like lean production will not solve the problem that the hospital hasn’t decided whether or not emergency physicians should run the emergency department.
- You have to choose your battles and avoid unnecessary conflicts.
- If everyone is wrong and your are the only one who is right, there is nothing to be gained by insisting.
- Every person has a good side. If you can’t see it, you have to try harder.
- If you want to learn well in a non-ideal environment, you have to take great responsibility for your own learning.
- The best way to learn is to teach. It will even make you realize how much your learned in medical school but never understood.
- When you have fully understood something, you don’t have to revise it to remember it.
How: Resident in Emergency medicine (Still pending). Responsible for the education of junior doctors who had not yet started residency.
- Global health is extremely complicated.
- Political organizations develop cultures that are hard to change, but that change people who come to work there.
- If you want big impact, you have to work through powerful channels.
How: Volunteer at WHO Headquarters in Geneva.
- If you make your blog posts too long, people won’t read them. (Maybe not yet fully learned)
How: Tweet from the Swedish minister of health saying he started to read my blog post but put it aside when he realized how long it was.
Note to potential employer:
I am not very interested in money. Just give me the average salary for that particular position.
If you show your trust in my capability to do a good job, I will probably exceed your expectations. I won’t hesitate to tell you my opinion in the most friendly and honest way I can. NB! If your department is a mess and you don’t intend to do anything about it and won’t let me try either, please don’t offer me a job. I will make both of us miserable.
I assume most of my previous employers will give me excellent references. The only one who probably won’t, and hence would be the most interesting for you to contact, is the former head of the department where I did my internal medicine residency. He is also, by far, the one with the most impressive looking CV.
Du kommer till jobbet på morgonen och slår på datorn för att börja jobba. En liten ruta poppar upp med en hälsning från chefen: ”Du har väl rätt att kolla på de här dokumenten. Annars kommer vi att polisanmäla dig.” Det är ett slumpmässigt genererat meddelande som dyker upp flera gånger under arbetsdagen. De ser vad du gör. Du kan aldrig känna dig säker.
Att hotas av polisanmälningar från chefen har blivit vardag för alla som arbetar med sammanhållna journaler, i Stockholm i form av journalsystemet Take Care. Och det är inga tomma hot. Läkare polisanmäls för att de öppnar journalen hos en tidigare patient som nu går hos en annan läkare, för att de vill följa upp hur det har gått. Sköterskor polisanmäls för att de vill se om blommorna en patient skickade till avdelningen var till dem eller en annan sköterska med samma namn.
Själv är jag vaneförbrytare och borde antagligen förbjudas att verka inom vården, eftersom jag regelbundet bryter mot journallagen. Den där patienten som verkade så sjuk på akuten, vad visade uppföljningen senare? Jag tittar för att lära mig. Genom att se hur det går för patienten, förstår jag bättre vad jag ska göra på akuten. Om jag ser att något har missats har det hänt att jag har skickat iväg en remiss, eller ringt upp patienten för att försäkra mig om att hon mår bra och är omhändertagen. Tidigare i min karriär hände det att jag följde vissa patienter vars öde särskilt berört mig. Den unga kvinnan där jag hittade en tumör på akuten, hur går det för henne? Tolererar hon cellgifterna? Sprider sig cancern? Jag har slutat att följa patienter på avstånd på det här sättet. Delvis för att jag inte har tid, delvis för att man med åren blir mer luttrad och inte har samma behov av att följa med i patientens lidande. Men framför allt för att jag tycker att det är oetiskt. Patientens journal är inte till för att tjäna mina syften, utan hennes egna.
Alla journaler slogs samman för att det skulle bli lättare att få information. När jag öppnar journalen hamnar alla anteckningar i datumordning och jag kan inte undgå att se att patienten har en anteckning från psykiatrin tidigare. Utan att mer än öppna upp journalen kan jag se att det finns ett tidigare beslut om psykiatrisk tvångsvård, eftersom den anteckningen har en särskild rubrik.
När jag vill läsa om patientens tidigare sjukhistoria, klickar jag på den rubrik som jag tror ger mig mest relevant information. En anteckning från en inskrivning eller ett nybesök är ofta mest heltäckande, oavsett vilken klinik detta skett på. Jag har försökt få klarhet i vilka anteckningar jag får öppna, om det bara är de från min egen klinik, de från sjukhuset eller alla som står där? Om patienten har lämnat ”samtycke till sammanhållning journalföring” i kassan, får jag titta då? Det är svårt att få klara besked, ens från den där chefen som kommer att polisanmäla mig om jag gör fel. Nu ska det visst ändras så att vi bara kan se det egna sjukhusets anteckningar och måste fråga patienten innan vi öppnar resten av journalen. Det betyder att vi lätt kan se gynanteckningar, men ska fråga om vi vill se vad husläkare skrivit.
Vissa läkare är mer stringenta än jag. När jag skrev en remiss till geriatriken på ett annat sjukhus angående en 80-årig dam, som tidigare vårdats på deras klinik, blev remissen väldigt kortfattad. De har samma journalsystem som vi. När de öppnar remissen i datorn, kan de klicka på journalfliken och läsa vad som hänt henne både hos oss och hos dem. Men damen fick inte komma till dem. De avslog remissen och skrev att eftersom det inte stod i remissen att patienten samtyckte till att de läste hennes journal, kunde de bara basera sin bedömning på den kortfattade remissen.
När patienter remitteras in från vårdcentralen, brukar läkare skriva remissen i datorn. Efter att jag har behandlat patienten ska jag besvara remissen. För att undvika merarbete, brukar man bara hänvisa till den journalanteckning man har gjort. Problemet är att om jag inte uttryckligen skriver i journalen att patienten godkänner att den inremitterande läkaren läser min anteckning, så har denne inte rätt att gå in i journalen. I dessa fall skriver våra sekreterare ut anteckningen och skickar den på posten. För att kunna skriva att patienten lämnar sitt godkännande, måste jag förstås fråga patienten: ”Är det okej att den doktor som skickade in dig, som själv har skrivit i din journal, nu går in i din journal igen och ser vad jag har skrivit, så att han vet hur han ska följa upp det här?” Det här låter ju så märkligt, att jag måste lägga ytterligare tid på att förklara hur systemet fungerar.
Fram till nyligen hade jag tillgång till Läkemedelsförteckningen, där man kan se vilka läkemedel patienten hämtat ut på apoteket. Man var tvungen att kryssa i en ruta att man hade patientens tillåtelse, eller också markera att det var en nödsituation, i vilket fall anledningen skulle dokumenteras i journalen. Funktionen var ovärderlig. Jag kunde se vilka läkemedel den medvetslösa patienten hade hämtat ut nyligen. För den som inte hade sin medicinlista med sig, kunde jag skriva ut en kopia, som vi gick igenom tillsammans. I de fall jag misstänkte överkonsumtion av narkotikaklassade läkemedel, hände det att jag bad att få titta i läkemedelsförteckningen och kunde antingen ta upp problemet med patienten, eller avskriva misstankarna och se till att denna fick de läkemedel hon behövde.
Numera har jag inte tillgång till läkemedelsförteckningen. Det kräver en inloggning med legitimationsbricka och vi har inga sådana apparater. Vården har blivit osäkrare och jag förstår inte varför.
Om jag skickar hem en patient som sedan dör för att hon inte fick rätt behandling, blir jag inte straffad på något sätt. Men låt oss säga att jag skickar hem patienten och en veckas senare läser i anteckningen från hennes husläkare att hon är sämre, ringer upp henne och ber henne komma till akuten. Då kan patienten polisanmäla mig för dataintrång. Och även om inte patienten vill göra det, kan min chef göra det.
Ibland är det svårt att göra rätt, men i de här fallen är det faktiskt lätt. Vi ses i tingsrätten!
The best way to learn a subject is to teach it. This has become obvious to me during the last few months, when I have been responsible for the teaching of the new doctors in our emergency department. Since they are not enrolled in any residency program, it has been all up to me to decide how and what to teach.
Not only have I had to revise all the subjects we have been discussing, I have also tried to learn how to become a better teacher. Therefor we have concluded every four-hour session with an evaluation. In general no one has anything negative to say. I don’t think they like to be critical when they can see how much effort I put into this, but something that does come up frequently is the request for more interactivity. Saying interesting things is just not enough to keep people awake and receptive. So I decided to try a concept I had come up with before: Brainstorm for meducation.
Brainstorm is a quiz-style board game, that I play with my friends. The question takes the form of a topic, and the playing team has to rapidly mention as many things fitting under that topic as possible. When the time is up, the players’ answers are checked against a checklist on the question card. Every answer found on the checklist is worth one point, or two points for more difficult ones. The original game has topics like ”Things you eat at a birthday party”. My version has topics that we have covered during earlier sessions, such as ”Signs and symptoms of hypocalcemia” or ”Possible causes of lower back pain”.
So, this is how it works. A team should have three or four members and I think it is hard to handle more than four teams. To involve as many people as possible in every question I let someone from the opposite teams read the question and mark the correct answers on the card. Every card has a topic with five to ten correct answers. I choose relevant answers from Medscape, so that it is easy to go back to the source if there is any controversy. To avoid unnecessary frustration and endless debates, I thoroughly inform the participants that if an answer is correct, but not on the card, they won’t get any points. Another person writes all the answers on the white board. I have tried both two and three minutes per question and I think two minutes are usually enough.
So for two minutes the whole team is brainstorming around the subject, creating an atmosphere where saying the right thing is less important than coming up with many suggestions. Often wrong answers are corrected by other team members, but it is somehow less intimidating and embarrassing to say stupid things when you are playing a game. And misconceptions are always important to bring out, so they can be replaced by a deeper and more correct understanding.
When time is up, the answers on the board are compared to the ones on the card. Now the group’s collective knowledge has been brought out, and this is when the actual teaching takes place. I highlight and elaborate on some of the answers and also address the wrong ones. It is brief and intense, and nobody dozes off.
The first time we tried this everyone was extremely positive and when it wasn’t included in the next session, they were disappointed. So now I have decided to make it a part of every session. With three teams they can do two questions each in one hour. Normally, a board game gets boring when you use old questions, because you already know the answers, but here that is exactly the point. The old cards can be used over and over, and new ones can be included. My plan is to add at least two new cards after every session, to repeat what has been taught that day. I am also considering adding bonus cards with more specific questions like ”How to calculate the osmolar gap” or ”Branches of the celiac trunk”, for teams that score a certain point.
Unfortunately, I won’t be able to develop this any further, since I am leaving my position. I will keep the cards, though, and maybe challenge some of the other EM nerds over a beer sometime.
In July Emergency Medicine was recognized as a primary specialty in Sweden. There has been some resistance among my fellow doctors to the recognition of emergency medicine, but I am not sure what their objections really are, since they cover almost every aspect from work environment to patient care. I got tired of listening to them. Or, to be honest, I don’t think I ever really listened to them. Instead I turned to other emergency physicians in Sweden or abroad, who would confirm my conviction that emergency departments should be staffed and run by emergency medicine specialists and even reassure me that this criticism has been part of the process everywhere.
I think this notion exists in every medical specialty, that other specialists just don’t understand their particular field of medicine. It creates a sense of common understanding and builds identity. This identity has been so important to me that I have been introducing myself as a resident in emergency medicine, concealing the fact that I am a specialist in internal medicine. For three years I have spent a large part of my spare time on the establishment of this new specialty in Sweden. We are part of a global movement and ACEP even has an international section. It is presented in the following way on their website:
As the trend towards globalization continues so does the need to support, promote and develop the specialty of emergency medicine. If you enjoy learning about other cultures and traveling to distant places then this is the section for you. By joining this section, you can make a global impact by sharing your knowledge and experiences with others. Together, we can serve as a resource to other countries in their development of emergency medicine and promote international interchange, understanding and cooperation among physicians practicing emergency medicine. With more than 1000 members the Section on International Medicine is one of the college’s largest and most active sections.
The international emergency physicians are going around the world to support, share and serve as a resource for less developed medical systems. That thought hadn’t crossed my mind when I went to Africa. I didn’t go there to teach, I went there to learn. After having lived abroad a couple of times before, I knew these experiences can bring fundamental changes to how you see yourself and others and there are always lessons to be learned. I find this ACEP text provocative and it seems ironical that my stay in Botswana made me reconsider my support for the specialty of emergency medicine in general and international emergency medicine in particular.
When I arrived in Botswana I was surprised to find my name in the specialist column on the roster. I had never seen anyone with AIDS or a seriously injured trauma patient and I had only done one pelvic exam since medical school. But it wasn’t just the unfamiliar case presentations that I didn’t know how to manage. Patients I would feel very comfortable about treating in Sweden made me confused in Botswana. What was the correct workup for a thunderclap headache? The single-detector CT scanner wouldn’t be sensitive enough to pick up a minor bleed, even if it happened to be working. The risks for infection from the lumbar puncture were probably higher than under the more sterile conditions we can offer in Sweden. I also believe the results from the lab were far more unreliable than at home. And if we did diagnose a bleed, the patient would need to be transferred to South Africa for a neurosurgical intervention. I have no idea what the numbers needed to treat would be in this setting. How can I teach the residents and local medical officers what to do? And even if I could estimate the benefit of this workup, it wasn’t really up to me to decide whether or not it should be done. A publicly funded system needs to manage its resources wisely, individual doctors can’t be allowed to order investigations based on neither international guidelines nor personal preferences.
I was going through a few charts for some reason, when I saw that a patient treated by one of the EM specialists had died. The patient had come in with a tachycardia of 160 and had had a CT scan of the head, which didn’t show any pathology as far as I can remember. He died later that night in the ward. Since it was hard to follow up on patients I thought I’d tell the doctor what happened. He told me that patient had only been boarded due to lack of transport back to the referring hospital. I objected. – But the patient had a pulse of 160, he was critically ill. Why did he need a CT scan?
He responded something along the line that the patient had end-stage AIDS and was too sick to be saved. It just made it more confusing to me. Why waste resourses on a dying patient? The only explanation I got was that the patient had been referred for a scan and that is what he got, since it was hard to defy the referring doctor. Scarce resources were wasted, the patient didn’t get optimal treatment and, maybe worst of all, had to die in a hospital far away from his family. Somehow the doctors involved didn’t seem to mind.
My impression from Botswana, and also from talking to doctors from other parts of the developing worlds, is that one of the main obstacles in the development of a better health care, is the autocratic leadership structure. The individual employees are expected to do their job, without being delegated the means and power needed to take responsibility for doing so. Residents and medicine students can even be obliged not to discuss hospital matters with other people. Bringing up complaints to your superiors can cost you your job. Mistakes are swept under the carpet and structural problems are never addressed. Every improvement is a struggle and choosing what battles to fight is the most difficult task. Change doesn’t come easy. Our much-awaited blood gas machine soon ran out of the necessary reagents, or broke down because the air conditioner wasn’t working. No one in the ED had the mandate to fix the problem, so the issue had to be brought further up the hierarchy. Patients in pain didn’t get proper analgesia, because the nurses didn’t find it necessary, even though there was a protocol and the medicines were available. The solutions didn’t work, because the problems were not adequately analyzed.
In an environment where patients died because equipment was assembled the wrong way, where staff, and most probably patients too, were infected with tuberculosis from unisolated patients and where bensodiazepines could run out completely, I was supposed to help train a chosen few to become specialists in emergency medicine. I did my best to prepare lectures about the vasculitides, but could not explain why the residents should even consider Wegener’s granulomatosis in a black patient with a low grade fever, hemoptysis and weight loss. I don’t think anyone thought they should, actually, but knowledge about vasculitides was part of the curriculum and something the residents needed to know for the exam.
I could not accept that a few of the doctors were getting educated about things they would never see, when the daily work was so full of errors and harmful events. Why not just get all doctors and nurses together and discuss how we could work together to improve care, setting up short- and longterm goals? Why not fix the easy things first? The foreign emergency physicians agreed with me that teaching was difficult. One of them even agreed with me that we would save more lives if we started washing our hands and sorted out all the minor problems. But, I was shocked to hear the following comment and it has kept ringing in my head. -We are not here to save lives. We are here to train emergency medicine specialists.
That statement effectively killed the discussion. Unfortunately, it also killed a lot of my interest in emergency medicine. I’ve been struggling to regain it for half a year now, but it is just slipping further away. I had to turn off a podcast where they were laughing about how they never calculated osmolality in their clinical practice, but needed to know it for the board exam. It makes me wonder, why am I doing this and what purpose does it serve? In everything I do, whether it is seeing a patient or deciding to change jobs, I like to define the problem, the short- and longterm goals and the means to achieve those goals. It might sound easy, but often isn’t. Finding out the problem can be tricky, but the hardest part is to avoid confusing the means and the goals. I realize now that I made having the specialty and specialists of emergency medicine a goal, when it is really a means.
I always enjoyed spending time in the emergency department as a medical student, so when emergency medicine started to emerge as a separate field of medicine in Sweden, I was immediately interested. Ever since medical school I have assumed that my interest stemmed from the ED environment; the action and the unpredictability. But through the years of internship and internal medicine residency in a university hospital I came to realize that the ED was the only place where the patient’s care depended fully on me. In the cardiology department a consultant told me that they only did workups for cardiogenic syncope, which of course meant that if there was another cause of the patients loss of consciousness, it wasn’t his problem. I found this attitude common in most departments, the focus was on a particular organ, not on the patient. Many doctors were busy with their research and didn’t spend too much time on their patients at all. A lot of the subspecialized internists were no longer doing shifts in the emergency department and could not provide emergency care for their patients when their conditions deteriorated in the wards.
I am convinced that the primary assessment in the emergency department needs to focus on life- and limb threatening conditions. Doctors making these assessment need to understand the whole spectrum of acute disease. My hospital still has separate sections where internists and cardiology see ”their” patients directly, which means that patients can be turfed around in the emergency department, having a part of their body worked-up thoroughly at every stop. Definitive treatment is delayed and some patients die because of this. The introduction of emergency physicians in our ED has changed the focus and improved emergency care. But the old system had some advantages. Since everyone knew that the ED couldn’t offer advanced care, specialists were fast to come down when they were called. Anesthesia still comes running within a couple of minutes, but if the patients are not unstable, they feel comfortable leaving the patient in our care, even though we don’t have the necessary resources to monitor them properly without increasing the risk for our other patients. Unstable patients are still taken to the ICU, though. We don’t put patients on vasopressors in the ED. But if we start learning how to care for these patients, maybe they’ll be stuck in the emergency department.
We still have the right to admit patients to the medical, surgical and orthopedic wards, after informing the consultant on call. If they object, they have to see the patient themselves and work out another plan. But the yet undiagnosed patients, or the ones with multiple complaints, that I as an internist could admit to medicine, are no longer as easily admitted. And the undifferentiated abdominal pain surgery would earlier gladly accept, now often stays in the ED to wait for a CT scan. The demand for a correct diagnosis before admission has increased. Lately we have started to admit patients to our recently opened observation unit. The ED that was before an extension of the department, is becoming a separate unit. Before the surgeon on call could schedule the patient for a non-acute operation or set up an out-patient appointment. We can’t do that, but have to refer the patient, primarily to primary care so they can refer the patient to a specialist outside the hospital.
But the introduction of Emergency medicine as a specialty has also brought some other changes. When I did my internship in 2003 the drunken young men who had passed out on the street stayed in the ED until they had sobered up. Now they have a CT scan of their brain before they go home, since they never remember the circumstances under which they fell and no clinical decision aid is applicable in the intoxicated patient. Chest pain patients are evaluated for dissection. If radiology allows it. One radiologist refused to scan a patient saying that ”you emergency physicians order too many scans”.
The study Abdominal pain in the ED – a 35 year retrospective (Am J Emerg Med. 2011 Sep;29(7):711-6) found that between 1972 and 1992 the admission rate for abdominal pain decreased from 27% to 18% and diagnostic accuracy increased. The authors of the article published in 1995 assumed that this was attributable to the development of emergency medicine with specialists present in the ED combined with new technology. But when the study was repeated in 2007, admission rates had gone up to 25%. At the same time CT scanning had increased dramatically from 0 in 1972 to 0,8% in 1992 and 25,6% in 2007.
Specialists like to be thorough about their diseases. My father, a master of silly jokes, likes to tell the story about the doctor who told the young man that his mother died. The young man looked troubled and answered: Oh, I hope she didn’t die of anything serious!
The modern doctor seems to reason in similar terms, going to great lengths to make sure that the patient doesn’t suffer or die from one of the diseases on their curriculum, but seeing harm caused by conditions outside of their field of expertise as extenuating circumstances.
During my rotation in nephrology I was surprised to hear how very significant the nephrologists found these 1+ urine dipsticks I had so often ignored in the ED. But surely how serious and urgent a problem proteinuria, hypertension or abdominal pain is must depend on the patient, not on what kind of doctor they see?
In emergency medicine we like to focus on life and limb-threatening conditions. Somehow that has evolved into the perception that every patient presenting to the emergency department has a life-threatening condition until proven otherwise. To prove that a healthy looking patient isn’t about to drop dead within the next 24 hours is costly and the workup definitely has some serious side effects. When I see a nice old lady who has tripped and fallen in her kitchen, I start considering a lot of potential serious causes and consequences of her fall. But when she tells me that all she really wants is someone to help her with her crosswords, which her poor vision doesn’t allow her to solve anymore, I realize that the extensive workups and admissions patients like her get are consuming the resources that could be used for the kind of home care service she is asking for.
When the 90 year-old nursing home patient with Alzeimer’s dementia is brought in, vomiting blood and in shock, I feel confident administering blood transfusions, desmopressin and iv PPIs knowing our protocol and the limited evidence behind it. But I don’t know what to do with the nasogastric tube since the patient doesn’t want it. When I leave the room for a while, the anesthesiologist puts it in and the patient is taken to the operating room. They leave saying I did a good job, but I’m not so sure. Is saving this patient’s life a good deed? Is this what he wanted? The fact that his GI bleed was probably caused by the aspirin he was on, makes it even more difficult. Surely we have to do our best to reverse the harm our medicines have caused?
A Swedish study found that the prevalence of dementia in patients over 85 years of age, had increased 40% in five years. (Increasing prevalence of dementia i very old people. Age Ageing (2011) 40 (2): 243-249.) It is getting very hard to die in our society. Saving money on rehabilitation is so much easier than restricting people’s access to emergency care, but in the end I believe the former is a better way to make people live longer and happier.
When you only have a hammer, everything looks like a nail. When you only have the tools for acute workups, everything looks acute. But most of our patients are not acutely ill. Our society is good at prevention. The traffic related death rate per 100 000 inhabitants is 33,2 in South Africa, 12,3 in the US, 5,7 in Australia and 2,9 in Sweden. (Wikipedia) I assure you that this is not due to our excellent trauma care.
Emergency care has been a neglected field for many years. Other specialists have been promoting there respective specialty. I assumed that if we had emergency medicine specialists, they would look after the interests of the patients in the emergency department. Our curriculum is based on the European one, and I have defended it, claiming that we need to know acute ophtalmology and gynecology to be real emergency physcians, even though the patients in my hospital go straight to the ophtalmologist and we never do pelvic exams. I still think we need to learn airway management to be able to give our patients safe analgesia and sedation, but for the acute intubation we have anesthesiology consultants who show up in a few minutes. Considering that patients are not often intubated in the emergency department, I doubt we could learn to do a better job. It is hard to train emergency medicine residents in this environment and we have been arguing that our ED has to be reorganized to suit our educational needs.
I rarely safe a life or a limb during a shift. My role is mainly to supervise the junior doctors, but it is difficult when I have this growing feeling of meaninglessness. We are chasing DVTs in low-risk patients. At the same time we have patients who get sent home with obvious signs of pulmonary embolism and return in cardiac arrest, chest pain patients where aortic dissection is not even considered by the cardiologist who sees them and lots and lots of patients who are not seen fast enough to keeps risks and complications at the lowest level possible. Critically ill patients are not monitored properly in the emergency department. We are ignoring the obvious risks and problems, looking for atypical presentations but still missing classical ones.
I realize I have accepted a ready made solution without carefully assessing the problem. Instead of discussing with my colleagues from other specialties I have been debating them, losing focus on what matters to our patients. But I know now that my goal is to improve emergency care, not really caring about whether this care is given at the primary care clinic, in the ED or in the wards of the hospital. Nor does it matter to me if this care is provided by an internist, a surgeon, an emergency physcian or any other kind of doctor. I actually prefer a team of different competencies working together, rather than having emergency physcians only. We need to make sure that we keep sharing a common language. To save the limbs and lives of our patients all nurses and doctors have to be better at emergency care. But, it hits me with painful clarity, my goal hasn’t been to save lives and limbs. It has been to establish the new specialty of emergency medicine.