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A preventable death is always unnecessary

januari 16, 2013 Lämna en kommentar

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.

Playing the game of emergency medicine

september 17, 2012 2 kommentarer

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.