From determining whether a burned child has been abused to using forensic medicine to decide if a death was a homicide or suicide, emergency physicians attending this year's Scientific Assembly of the American College of Emergency Physicians in Seattle can count on finding solutions for problems they face every day.
When a problem in the ED thwarts effectiveness, for example, finding a way to fix it frequently is seen as difficult, impossible, or somewhere in between. By following a four-step process, however, such solutions aren't so tough to achieve or implement, said James Augustine, MD, the director of clinical operations for the group EMP in Canton, OH, and the medical director for the Atlanta Fire Department.
Dr. Augustine's presentation, “Best Practices: From Chaos to Consensus,” will offer guidance for emergency physicians faced with trying to find the means to meet good standards of care amid a growing volume of patients and high professional expectations. The session will be held Wednesday, Oct. 10, at 9 a.m.
One of the ways in which ED operations can be improved is by following a process of four basic steps: “Plan, do, check, act,” he said. Does this sound straightforward? It is, but it's not as simple as it seems, he said.
In the “plan” phase, the task is to define the problem, usually by assembling a team of people with an interest in solving the issue at hand. He cited the time-consuming task of registration, which might be solved by completing the process at the bedside. When a change like bedside registration is implemented, leaders have to consider that some staff members will advocate it while others will resist. At that point, the leaders have to explain why the change is being recommended. The planning phase continues with the design of one or more solutions. Keep in mind, Dr. Augustine said, that “people on the team may or may not be supportive of any single solution,” but, as they help with design, “the biggest skeptic may become the best salesperson.”
“People on the team may or may not be supportive of any single solution,” but “the biggest skeptic may become the best salesperson.”
—Dr. James Augustine
“I am often asked questions like: ‘What's the worst thing you ever saw?’”
—Dr. William Hauda
“We have all had cases that weren't what they seemed,”
—Dr. Rita Cydulka
In the second phase, the “do” phase, a new process is initiated. Many ED leaders have had success in placing a new process in only one area of the department at a time or on one shift. Setting up a new system in a pilot program, again using appropriate benchmarks and metrics, may allow the process to be developed further before it is implemented in all areas of the ED and on all shifts. The “check” phase involves a careful review of the metrics designed to review the effectiveness of the process. This may involve metrics for patient satisfaction, staff satisfaction, ED finances, or quality improvement.
Finally, in the “act” portion of the process, results demonstrating change should start to pour in with the early pilot phases, such as quicker processing of patients. These can be reviewed and the process tweaked to get the desired outcome when the new process goes to a 24/365 basis. Leaders should be prepared for small problems that may continue to crop up, and small and persistent adjustments will have to be made.
Dr. Augustine noted that in one ED he knows, patient satisfaction wasn't the only improvement with bedside registration; staff morale went up, too. Why? With buy-in from the staff, coupled with good planning and a successful pilot program to work out the kinks, team spirit flourished and so did a sense of accomplishment after implementation.
The practice of emergency medicine often takes a combination of diagnostic ability, problem-solving skill, and detective-style digging. And what better venue to test that capacity than the annual meeting of the American College of Emergency Physicians? In the presentation, “Challenging Cases: How the Experts Practice Emergency Medicine,” Rita Cydulka, MD, and three panelists, will share cases that stymie but stimulate, ED “mysteries that proved solvable,” in an interactive session that has drawn heavy attendance for the past five years. The presentation is to be held Thursday, Oct. 11, at 8 a.m.
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Dr. Cydulka, an associate professor and the vice chair of emergency medicine at Case Western Reserve University School of Medicine and MetroHealth Medical Center, will be joined by James Adams, MD, a professor and the chair of emergency medicine at the Feinberg School of Medicine at Northwestern University and Northwestern Memorial Hospital in Chicago; Earl J. Reisdorff, MD, the director of medical education at Ingham Regional Medical Center in Lansing, MI; and James R. Roberts MD, the chair of emergency medicine at Mercy Health Systems and a professor of emergency medicine at the Drexel University College of Medicine in Philadelphia. Her fellow panelists, “do a great job,” she said. “They keep everyone entertained while making important teaching points.”
And teachable moments are what the panel is all about. “We have all had cases that weren't what they seemed,” Dr. Cydulka noted. “These are common problems that present in an unusual way or unusual problems that present in a common way.”
In her own case, she and other members of the emergency department staff were surprised by the etiology behind the loss of consciousness in a woman who at first glance appeared to have overdosed. She had collapsed on a doorstep with needle tracks up and down her arms, but she also bore the signs of an adrenal crisis. When her sister showed up at the hospital and wanted to know whether medicine had been given for the woman's medical condition, questions about that revealed that the woman had a pituitary insufficiency, Sheehan's syndrome, Dr. Cydulka said.
An infusion of corticoid steroids enabled the woman to regain consciousness. “We were able to quickly turn her around,” she added. Cases like this will be offered by all the panelists, who “will walk through their own thought processes in these cases,” she said. Question-and-answer portions will be included, in which those in attendance will be able to ask about the cases being presented.
In previous years, the presentations have revealed some memorable cases, she said. Dr. Adams, for example, presented a case in which a newborn infant was brought to the ED. That's not unusual, nor was the reason behind it: a sick baby. But the presumed cause, an infection, couldn't be found. With the clock ticking and the status unchanging, Dr. Adams finally found the correct diagnosis, a subtle heart abnormality. The steps he took to arrive at his finding were informative and intriguing, she recalled.
“Is it really like CSI?” That is the question William Hauda II, MD, is asked most frequently. It's so common, in fact, that he is now surprised when someone doesn't pop that question. He is, after all, an emergency physician with an unusual board certification: forensic medicine.
He is an official forensic examiner, a title bestowed by the American College of Forensic Examiners, and among the many hats he wears, the one of greatest interest to many colleagues seems to be “registered medicolegal death investigator,” he said.
“Obviously, there have been a lot of books and a lot of TV shows and movies on the subject of crime-scene investigations and medical examiner systems,” he explained. “When people find out what I do on the side, though it's not a full time job, the conversation is usually just getting started,” he said. “I am often asked questions like: ‘What's the worst thing you ever saw?’”
Emergency physicians will get a chance to ask their own questions of Dr. Hauda at a session that will cover evidence preservation and collection and other aspects of crime-related work on Monday, Oct. 8 at 10:30 a.m.
As an emergency physician board certified in both specialties, forensic medicine might seem an unlikely career turn, he acknowledged. But in Virginia, the local medical examiners are appointed to the position based upon their interest, said Dr. Hauda, an assistant professor of emergency medicine at George Washington University and at Virginia Commonwealth University, as well as an assistant professor of pediatrics at the University of Virginia.
“I had done a forensic medicine clerkship as a medical student and found it fascinating,” he explained. “The thing I like about emergency medicine is the same, trying to figure out what is going on from the clues that you can elicit,” he said. “In emergency medicine, we ask patients questions, we examine them, and we do tests.”
Dr. Hauda, also a sworn auxiliary officer of the Fairfax County Police Department in Virginia, noted a crime scene has similarities to an ED. “We interview witnesses, we examine the scene, then we do tests to determine if our assumptions were correct,” he said. It is “the same process as the ED, just a different venue. You might say my special interest in emergency medicine is the forensic part of emergency medicine.”
Dr. Hauda said there are a few general tips emergency physicians can benefit from knowing, and he will provide case illustrations of them during his presentation. In general, they comprise a list of don'ts:
- ▪ Don't move dead people. (There's information to be gleaned from how the body is positioned.)
- ▪ Don't put sheets over bodies. (Sheets aren't clean of DNA and trace evidence, will soak up blood or fluids, and could blow away trace evidence when draped over the body.)
- ▪ Don't move or unload a firearm. (The positioning of the gun, the state of the chamber and magazine, and the presence or absence of blood on a gun are all important, especially in determining if the death was a suicide or a homicide.)
- ▪ Don't give the clothes back to the family. (The clothing can have a wealth of information about how the injury occurred, and sometimes the family members are the perpetrators.)
- ▪ Don't wash the patient's hands. (Use the hands as a last resort for an IV because gunshot residue, blood spatter, trace fibers, hairs, and DNA can be present. As soon as access is obtained, place small paper bags over the hands to preserve evidence.)
- ▪ Don't cut through tears in clothing or skin. (Leave tears in clothing or skin alone. If you need to cut off clothes, use the seams. Don't use a chest wound for a chest tube.)
- ▪ Don't guess about gunshot entrance and exit wounds; leave that for the pathologist.
- ▪ Place clothing in separate paper bags. (Dumping all the clothing into one plastic bag will cross-contaminate the blood, hairs, and fibers.)
Dr. Hauda said he is aware that some people think he is “crazy for what I do,” but others “wonder how they can start doing this, too.” He is hoping some of those attend the presentation.