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Wednesday, September 19, 2018

​Fluoroquinolone Side Effects Just Got Scarier

BY JAMES R. ROBERTS, MD

Fluoroquinolones were rather remarkable antibiotics when first introduced to our clinical armamentarium. They had a broad spectrum and relatively few known side effects, and they quickly became the drug of choice for some common conditions. But fluoroquinolones, as with many antibiotics, have been overused. Serious side effects have been associated with them over the years, and numerous cautions from the FDA limit their use. A number of label changes have been mandated, and some fluoroquinolones even have black box warnings. Google "fluoroquinolones" if you want to be flabbergasted about patient issues and lawsuits.

Fluoroquinolone Antibiotics: FDA Requires Labeling Changes Due to Low Blood Sugar Levels and Mental Health Side Effects
FDA Drug Safety Communications
July 10, 2018; http://bit.ly/2OQvFmh 

Clinicians were recently warned of additional adverse side effects of fluoroquinolones, further limiting their use. Many emergency clinicians have not seen some of the particular problems with these drugs because they don't see patients on a continuing basis and don't follow them in the hospital. And the side effects are so peculiar you wouldn't have automatically made the connection between some of them and fluoroquinolones, such as tendon rupture and peripheral neuropathies. Now the FDA has identified two additional side effects associated with fluoroquinolones: low blood sugar and mental health conditions.

We have been warned about these complications in the past, but the FDA thought it was necessary to strengthen the current warnings. Broad-spectrum antibiotics have been used for more than 30 years, have been quite effective, and have been frequently prescribed, but their use has waned due to drug complications, changes in antibiotic resistance, and the development of new antibiotics.


Infocus 1.gif
The FDA has issued strong cautions about multiple adverse effects from all fluoroquinolone antibiotics. The most recent are hypo/hyperglycemia and mental health effects. It has been advised that this class of antibiotic not be used for sinusitis, bronchitis, or cystitis if other options are available. Unfortunately, it is impossible to predict who will suffer adverse events, and some of those, such as neurologic effects, can occur after only minimal use. Neuropathies can last for months or be permanent. The vast majority of Achilles tendon injuries are not associated with fluoroquinolones, though this patient suffered that injury. Note the characteristic hemorrhage, loss of plantar flexion with calf squeeze, and indentation where Achilles tendon should be felt. (Photo: Lippincott, 2013.)

Their drug labels warn that changes in blood sugar can be high or low depending on the fluoroquinolone class. High or low blood sugar is easily recognized and proven, but the mental health side effects may be more subtle. They include conditions from simple insomnia, a very common reaction to fluoroquinolones, to disturbance in attention, disorientation, agitation, nervousness, memory impairment, seizures, and full-blown delirium. Diabetic patients have been warned to check their blood sugar more frequently when on fluoroquinolones because of possible changes in glucose levels. Many of the complications with fluoroquinolones are self-limited, and may even go unnoticed by family and clinicians, but some can be permanent.

Achilles tendon rupture is a classic complication that requires surgery. The side effects of fluoroquinolones can occur quickly, with only one or two pills or injections creating a problem, though side effects are generally related to the duration of therapy.

Comment: Five fluoroquinolone antibiotics are currently available for use in the United States, and five others have been withdrawn from the market since the late 1990s. Fluoroquinolones are the only class of antibiotics in clinical use that are direct inhibitors of bacterial DNA synthesis. Ultimately, the effect on DNA damages the bacterial cell, making it incapable of surviving. Fluoroquinolones have a true bactericidal effect, but it's a mystery why halting bacterial DNA would cause such unusual systemic effects.

Reports have shown that Staphylococcus aureus exposed to fluoroquinolones for only five days is associated with significant drug resistance. Resistance has also developed in Klebsiella pneumoniae, Escherichia coli, and Enterobacter. These organisms apparently have a mechanism that will protect bacterial DNA enzyme from fluoroquinolone action. U.S. fluoroquinolone resistance has been more common with methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa. Fluoroquinolones are no longer recommended for treating gonorrhea in the United States because of the emergence of resistance by Neisseria gonorrhoeae. Fluoroquinolone resistance has emerged over time for a variety of organisms, but the percentage of susceptible strains varies among institutions and localities, requiring clinicians to know local sensitivity.

The most frequent adverse effects occur in the GI tract (3-15% of patients) as anorexia, nausea, vomiting, and abdominal discomfort. Mild diarrhea is usually not significant, but fluoroquinolones can cause Clostridium difficile-associated diarrhea.

The next most frequent adverse effects involve the central nervous system, unusual for an antibiotic but seen in 10 percent of patients. That's a rather high incidence. Many patients have mild symptoms, such as headache, dizziness, and insomnia. Nonspecific alterations in mood are quite common. Frank hallucinations, delirium, and seizures can occur. Patients treated with fluoroquinolones are at higher risk for developing clinical neuropathies that include pain, burning, tingling, weakness, and a change in the sensations of light touch or sense of body positioning. Peripheral neuropathy can occur at any time during treatment, can last for years, and is quite problematic for some patients. Clinical neuropathy can occur within a few days of use, and no specific treatment exists.

Fluoroquinolones have neuromuscular blocking activity and can exacerbate muscle weakness in patients with myasthenia gravis. They have also been associated with pseudotumor cerebri, though the incidence is low, and they decrease the protection afforded by sunscreens.

Arthropathy, with cartilage erosions and effusions, has been seen in animals given fluoroquinolones, and it was initially a concern in children, but it is probably uncommon and has little clinical presence. Arthropathy appears to be reversible.

The fluoroquinolone complications that have garnered these drugs a block box warning are tendinopathy and tendon rupture. Most cases involve the Achilles tendon, but they can occur in other tendons, such as the shoulder or hand. Patients should be warned to stop fluoroquinolones at the first sign of tendon pain or inflammation because Achilles tendon rupture can occur rather early in the course. Tendon rupture can develop without associated symptoms of tendonitis, and minimal trauma can cause complete tendon rupture.


infocus 2.jpg
Position the patient prone at the end of the table and squeeze the calf muscles. This normally causes plantar flexion of the foot as shown on the right. The left foot does not plantar flex, indicating a complete rupture of the left Achilles tendon. Also note the lack of definition of tendon on the ruptured left side compared with the right side, with soft tissue swelling. (Photo: 
Lippincott, 2016.​)

​Some fluoroquinolones have been associated with QT prolongation and arrhythmias (torsades de pointes). The QT prolongation from torsades de pointes can be life-threatening. The two fluoroquinolones most likely to cause QT prolongation have been removed from the market, but experts recommend avoiding moxifloxacin and levofloxacin in patients with known QT interval prolongation, hypokalemia, and hypomagnesemia. The use of class 1 antiarrhythmics (quinidine, procainamide, amiodarone, and sotalol) may also put a patient at risk.

All these complications led the FDA to issue warnings that the serious adverse effects associated with fluoroquinolones generally outweigh the benefits in patients with acute sinusitis, acute bronchitis, or uncomplicated urinary tract infections, and they should not be prescribed when other treatments are available. Many of these cases are viral rather than bacterial infections, but it was once common for clinicians to prescribe a quinolone for acute bronchitis, UTI, or acute sinusitis. Note that ciprofloxacin is no longer considered a first-line drug for uncomplicated urinary tract infection. Antibiotic choices for patients hospitalized with acute community-acquired pneumonia still include levofloxacin and moxifloxacin or a combination of the beta lactam and a macrolide. Many clinicians are eschewing fluoroquinolones in favor of a beta lactam and a macrolide.

Dr. Roberts is a professor of emergency medicine and toxicology at the Drexel University College of Medicine in Philadelphia. Read the Procedural Pause, a blog by Dr. Roberts and his daughter, Martha Roberts, ACNP, PNP, at http://bit.ly/EMN-ProceduralPause, and read his past columns at http://bit.ly/EMN-InFocus.

 

FDA Advises Restricting Fluoroquinolone Antibiotic Use for Certain Uncomplicated Infections; Warns about Disabling Side Effects that Can Occur Together

"5-12-2016: The U.S. Food and Drug Administration is advising that the serious side effects associated with fluoroquinolone antibacterial drugs generally outweigh the benefits for patients with acute sinusitis, acute bronchitis, and uncomplicated urinary tract infections.

An FDA safety review has shown that fluoroquinolones, when used systemically (i.e., tablets, capsules, and injectable) are associated with disabling and potentially permanent serious side effects that can occur together. These side effects can involve the tendons, muscles, joints, nerves, and central nervous system."


Fluoroquinolones Available for Systemic Use in the United States
Ciprofloxacin
Levofloxacin
Moxifloxacin
Ofloxacin
Delafloxacin

​Fluoroquinolones Removed from the U.S. Market
Grepafloxacin: Adverse cardiac effect
Sparfloxacin: Lack of sales
T
rovafloxacin: Hepatic toxicity
Gatifloxacin: Hypo/hyperglycemia
Norfloxacin
Gemifloxacin

Wednesday, September 12, 2018

From Boom to Bust: Freestanding EDs
in Texas Closing One after Another

BY GINA SHAW

Since the Texas legislature passed a law in 2009 allowing freestanding emergency departments to operate in the state, a virtual tidal wave of FSEDs swept across the landscape.

FSED.jpg
Neighbors Health System, based in the Houston area, closed one of its two freestanding ED in El Paso, reported El Paso, Inc. (Photo by Jorge Salgado.)

Fewer than 20 operated in 2010, but that number grew to more than 220 by July 2018, according to Kelli Weldon, a press officer at the Texas Health & Human Services Commission. That growth, however, may have been too much, too fast, however, and the resulting glut now appears to be leading to the closure of multiple FSEDs and the bankruptcy of others.

Mercer ER, a freestanding emergency department (FSED) in Victoria about halfway between San Antonio and Houston, went under this May. FSED giant Adeptus Health, which operated more than 90 FSEDs in five states—including 31 in north Texas—declared bankruptcy in April 2017, citing chronic underpayment by insurance companies. It was later acquired by Deerfield Management.

And as this issue went to press, Neighbors Health, which operates 22 FSEDs across Texas, filed for Chapter 11 bankruptcy on the heels of closing one of its two El Paso locations in April 2017, just as it was opening a new site in Amarillo, which already had four FSEDs. The Amarillo location shut its doors in September 2017. The company has already lined up a buyer for its Houston-area emergency centers, and an auction was set for August 27 for the others.

FSEDs Operating in Texas
Date                     Number
7/1/2018                 221
1/1/2016                 200
1/1/2015                 139
1/1/2014                  88
1/1/2013                  51
1/1/2012                  27
8/31/2011                25
8/31/2010               19

The boon was perhaps the reason for these FSEDs' demise—too many FSEDs oversaturated the market. A couple of big players built facilities quickly and often geographically close to each other. Some of the big companies also had problems with the revenue cycle, said Carrie de Moor, MD, who launched Frisco-based Code 3 Emergency Partners in 2015 with one FSED and six emergency physicians. Her company has since grown to six FSEDs and eight urgent care centers staffed by 120 physicians. "Honestly, people were building on every corner. To this day I get calls from corporate real estate agents: 'Don't you want to put an ER on this corner?' They see that it can make a relatively low income-producing real estate property get more rent," she said.

What this all means for emergency physicians in Texas remains unclear. Anecdotal reports to Emergency Medicine News suggested that EPs have lost jobs when FSEDs closed, have seen salaries plummet, and have had difficulty finding new positions, but we were unable to verify these claims. "As far as emergency physicians looking for work, we are seeing more coming to us from the big, publicly-traded groups in hospitals than those who lost positions in other FSEDs," said Dr. de Moor. "There still aren't enough of us to fill the void of how much we're needed in emergency medicine."

But Cedric Dark, MD, MPH, an assistant professor of emergency medicine at Baylor College of Medicine in Houston and an expert on FSEDs, had a different take. "It looks like the bubble is bursting," he said, noting that Houston-area physicians had difficulty finding jobs in the area this year because the market has condensed as a result of post-Harvey hospital closures. "We are going to reach the saturation point" for emergency physicians, he said.

EP Ownership
FSEDs hold wide appeal for emergency physicians. Dr. de Moor said she believes their success is due to its emergency physician ownership structure; all of the 65 invested partners in Code 3 are board-certified emergency physicians.

Like Code 3, ER Now has two locations in Amarillo and seven board-certified emergency physician owners, said co-founder Gerad Troutman, MD. He said he decided to launch them because of the lack of control he felt in a hospital-based ED. "I felt like a hamster on a wheel," he said. "You try to make things better, and they get bogged down in administration. When I saw the opportunity to be part of an ED that physicians could control, that was exciting."

FSEDs have been criticized as costly, however, with patients complaining about surprise out-of-pocket and out-of-network charges. One study by Dr. Dark and colleagues found the average price per visit of a hospital-based ED and freestanding ED were similar at about $2,200 in 2015, while the price for urgent care centers was $168. (Ann Emerg Med 2017;70[6]:846; http://bit.ly/2NOSPYF.) Between 2012 and 2015, the average price per visit at freestanding EDs increased 54 percent, from $1,431 to $2,199. The average price per visit at hospital-based EDs during this period increased 23 percent, from $1,842 to $2,259 while prices at urgent care centers increased only two percent (from $164 to $168) between 2012 and 2015.

Those patient complaints about costs are largely a result of patient confusion about the differences among FSEDs, hospital EDs, and urgent care. Patients have been quite vocal in complaining about high FSED facility fees, perceiving them as urgent care offices instead of thinking of them as similar to hospital EDs that just happen to be freestanding. Texas recently passed legislation requiring FSEDs to post information clarifying the differences. (See photo of sign.) Others have said that FSEDs provide misleading information about their fees and how insurance covers services, but FSEDs that accept Medicare and Medicaid are governed by EMTALA and cannot discuss fees with patients before they are stabilized. Whether this leads to patient backlash and leads to FSED closures remains to be seen.

Dr. de Moor said EPs face a bigger threat from the corporate practice of medicine and being replaced by lower-cost practitioners, such as nurse practitioners and physician assistants, than from FSED closures. "That's what we're seeing more of," she said. "I've had a number of friends move to the freestanding industry because of fear of bigger groups coming in and taking their contracts."

She predicted that the market in Texas will continue to consolidate. "But if you look at the success of the smaller, locally-owned groups with emergency physicians in charge, I think that type of model could spread throughout a number of states," Dr. de Moor said.

P.S. If you liked this post, we think you'd enjoy the EMN enews, which delivers breaking news and online exclusives right to your inbox.


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Wednesday, September 5, 2018

Why I Quit Emergency Medicine

BY ALEX MOHSENI, MD

​Walking up to the waiting room door, I knew what lay behind it. The gnawing torment started the day before, sometimes two. Three parts nausea, two parts dread, and a dash of anxiety — the recipe was always the same. Just add an organic grass-fed physician, and the health care system has a nice little snack to chew up and unceremoniously spit out.

This is my story: a successful emergency physician by external parameters, but strained by internal ones. What came out of residency — a supremely confident physician ready to take on the world — would never recognize himself 11 years later. My experiences in our health care system transformed me, and my story is not unique. A sickness seeps into clinicians, and it is as easy to catch as influenza and as hard to treat.

quit EM.JPG

"Health care system" is a phrase I find difficult to write because it is an inaccurate representation of what it intends to describe. If we take the words "health care" to mean the mishmash of hospitals, physicians, insurance companies, and vendors that profit from our physical and mental maladies, then perhaps we would be more accurate calling it "sickness billing."

It is truly sickness that we try to solve in our current model, not health, and it is billing with which we spend the better portion of our time, not care. The word "system," which means an organized set of things working together for a common goal, would be better replaced with "ataxia" given the uncoordinated manner in which this mishmash operates, but "ataxia" is too exotic, so I'll use the term "industrial complex" with the coded chart as our industry's widgets.

The sickness-billing industrial complex (SBIC) is an uncoordinated amalgam of special interests profiting from a series of unintended consequences of poorly designed policies. How did we get here? What happened in the past 20-30 years? Here is my version of the story:

Government policies, such as subsidizing corn and promoting sugar and carbohydrate-rich foods as low-fat alternatives, and societal changes in expectations of portion size and taste, resulted in a massive increase in calorie-dense, nutrient poor, and highly processed "foods" in our diet (corn syrup, refined wheat). These dietary changes led to dramatic increases in obesity, diabetes, heart disease, cancer, and autoimmune disorder rates (Curr Allergy Asthma Rep 2014;14[1]:404; http://bit.ly/2yw0yZd), swelling costs borne by Medicare and insurance companies within a strained system unprepared to handle the increasing need for preventive care. CMS responded by creating obstacles to physician reimbursement, believing this strategy could help reduce its expenditures. These obstacles started as documentation-focused rules, requiring physicians to record a certain number of data points for each medical visit; otherwise, reimbursement would be reduced. (Medicare Learning Network, Evaluation and Management Services, 2016; https://go.cms.gov/2K0wut3.) This is why some physicians ask patients seeking care for an ankle sprain about constipation, vaginal bleeding, and tinnitus.

​Barriers to Payment
These obstacles started as documentation-focused rules, requiring physicians to record a certain number of data points for each medical visit; otherwise, reimbursement would be reduced. (Medicare Learning Network, Evaluation and Management Services, 2016; https://go.cms.gov/2K0wut3.) This is why we ask patients who sought care for an ankle sprain about constipation, vaginal bleeding, and tinnitus.

Physicians, often slow but never dumb, adapted to the new rules, learned how to document their charts to recover lost revenue, and spent extra time asking and documenting endless nonsense. Medicare responded to the physician adaptation with yet more barriers—the Core Measures. (CMS.gov, July 28, 2017; https://go.cms.gov/2t5Z0zM.) Of course, Medicare couldn't admit these were barriers to paying physicians and hospitals, so it called them a switch to value-based care. The problem was that most of the parameters on which it based value were questionable or had little basis in the scientific literature, so most physicians saw the parameters for what they were: ways for CMS to pay us less.

One ED where I worked decided that all patients with the remotest possibility of pneumonia in triage were to be given a dose of antibiotics by mouth immediately because Medicare had decided that antibiotics within six hours of arrival was a measure of quality. Some patients received antibiotics they did not need; others needed IV antibiotics but received oral instead. We were practicing bad medicine to meet our "quality" goal.

Medicare created more games, represented by a never-ending litany of acronyms that read like a Sesame Street song, PQRS, MIPS, and MACRA. These new programs were so complex that many physicians faced three stark choices: spend hundreds of hours of their own time to learn and adapt to the new rules, sell their practice to a hospital or group with the resources to hire a consultant to figure out how to play the game, or accept significantly lower payment.

Sadly, many physicians opted to sell their practices and give up their autonomy to a corporate entity. This is a major loss to our communities because independent practices are the last refuge against the corporate practice of medicine. Just as sad are those physicians who try to stay afloat in the sea of acronyms, barely staying above water, seeing patients more hastily with less face-to-face time, more stress, more rushing, more mistakes, and more frustration,  all of which may lead to decreasing empathy, a dangerous state for a physician.

None of these new Medicare programs will solve the problems in our sickness-billing industrial complex because we are not dealing with the core fundamental issues. We treat sickness instead of fostering health, we focus on billing instead of care, and we are completely uncoordinated. We have an unhealthy population gorging themselves on sugar-rich foods, developing preventable diseases like type II diabetes with expensive complications (kidney failure, heart attack, stroke, blindness, etc.), and holding false expectations that physicians and medicines can work miracles to reverse years of horrendous nutrition. Meanwhile, physicians are coerced into spending a majority of their time figuring out how to play documentation games instead of engaging patients in real health-oriented change.

​A Lawsuit
The transformation of our system from volume to value is a much needed one, but it is missing one key element of success (which generates my cynicism), and this element is well explained by the Stanford behavior scientist, B.J. Fogg: For a new behavior to succeed, you must make the desired behavior easier.

Raise your hand if you think MIPS and MACRA are easy to understand, let alone implement. Which of you believe the EMRs have done everything possible to help us succeed with all these new measures? In fact, most of us earn $20 per hour less than we should to subsidize the cost of a scribe, a resource now required to finish your shift with your sanity intact.

Into this sickness-billing industrial complex in 2006 came a fresh, young, eager, new emergency physician. I truly loved learning about and practicing emergency medicine when I began my career. It was exhilarating — the tight-knit teams dealing with the chaos of endless streams of patients, time pressure, challenging problem-solving, and quick decision-making. Great teamwork, amazing saves, and warm appreciation from patients were the norm.

Then, in my second year, came my first lawsuit as an attending. It was a case I remember with photographic precision because it was one of my most intense. He wasn't even my patient. He had been seen by several other physicians and admitted for a complaint with an atypical presentation. The patient crashed during my shift, and my team and I did our best to save him. I remember having a heartfelt, warm, and sad moment with his family at his bedside before we sent him via helicopter for an emergency surgery that we could not perform at our hospital. That night, I was saddened by this gentleman's death but proud of my team's effort.

I recounted the scene in court, including how the blood bank coordinator, an older woman we rarely saw, ran her fastest into the ED with several units of O-negative blood, knowing that every second counted. Every single person was doing everything possible to save this man's life.

I felt like a leader of heroes. Yet, we were sued and treated like criminals. To be sued when you've done something egregiously wrong is understandable, but it is demoralizing and discombobulating to an unimaginable degree to be sued when you're proud of your effort, skill, and decision-making and when you cannot see what you could have done better. To be sued when you remember standing by the patient's bedside, your eyes welling up with tears because you are a human being who feels the suffering of those around you—nauseating.

I did my best, what I thought was right. Every medical decision and intervention I made was correct, but somebody thinks I did everything wrong, so much so that they want to ruin my life and end my career. Somebody thinks I am evil. Such was the narrative in my mind for the two years this case was active. Sleepless nights. Stressful shifts. Two years of self-doubt chipping away at my confidence and pride.

Self-doubt taking hold in an emergency physician is poison. The hallmark of a great emergency physician is the confidence to make quick decisions with limited time, information, and resources. No amount of training or knowledge can supplant low confidence, and patients can sense it immediately.

​Losing Confidence
I remember as a young attending that I could sense decreasing confidence in some of the older attendings. They shied away from some of the more complicated cases, and we younger attendings happily took these on. I remember thinking quietly to myself back then, "I hope I never lose my confidence," and now I was starting to feel it.

My colleagues and bosses thought my performance was great. I was seeing patients quickly, providing great medical care, and achieving high patient satisfaction results. I posted among the best numbers in my practice for quite a few years, but I felt increasingly unsure of myself. One of my older colleagues joked to me privately that emergency medicine is the only profession in which you can feel more unsure the longer you practice it. Not only does emergency medicine rank among the highest lawsuit rates of all specialties, but we also deal with the unintended complications from every other specialty. This means that the more an emergency physician practices, the more acutely he experiences the tragic ways the sickness-billing industrial complex can fail. We learn quickly, from seeing tens of thousands of cases of our own and our colleagues, that no matter how good of a physician you are, you are going to miss certain things, you are going to make mistakes, and certain things are going to happen to your patients that nobody could predict or prevent.

We also learn, unfortunately, that society is not OK with that. Society wants somebody to blame. Family members want somebody to blame. Hospitals want somebody to blame. Society expects perfection. Physicians aren't human; they don't make mistakes. I told my colleagues that being a physician is like being a wildebeest crossing the Mara River: The crocodile is going to eat one of us. And then he'll get another and another, whenever he chooses, each and every time a devastating shock to the wildebeest and those around him.

I saw some of my colleagues get taken down by crocodile lawsuits in the ensuing few years while I continued to deal with my own. Meanwhile, Medicare ramped up its value-based programs, increasing the documentation burden on physicians and hospitals. The first and second generations of electronic medical records were deployed in hospitals. EMRs were intended to streamline medical documentation, but they dramatically reduced physician productivity. The chief reason was that EMR companies got away with designing software with horrendous user interfaces and workflows.

How? Unlike most consumer software, the purchase decision-makers in the SBIC world are not the end-users. EMRs sold the C-suite on integration, and nobody paid attention to usability. The Mayo Clinic just announced in May that they were paying $1.5 billion to switch to the Epic EMR system. (Healthcare IT News, May 1, 2018; http://bit.ly/2M4kyUj.)

Pause for a moment: How could software cost $1.5 billion? When your user interface is so unintuitive that you have to hire and deploy an army of consultants and trainers to hold each user's hand for two weeks, it can lead to truly "epic" implementation costs. As if this were not bad enough, the internet buzzed with stories of Epic bullying anybody who criticized its software, and this happened to me as well. (KevinMD.com, Sept. 29, 2015; http://bit.ly/2K1DHc9.)

Can you imagine the backlash if Microsoft or Google instituted gag orders to prevent criticism of its software? Yet this is the world of the sickness-billing industrial complex. The negative effects of poorly designed EMRs on physician morale and productivity are well documented. (Harvard Business Review, March 30, 2018; http://bit.ly/2yjIW2g.)

Don't Make Mistakes
With reimbursement declining because of Medicare's new rules and physicians becoming less productive because of EMRs, physician practices were forced to make their physicians work faster and leaner than ever before. Hospitals increasingly expected higher and higher patient satisfaction results from physicians (some of whose unintended consequences we are seeing in today's opioid epidemic). Practices expected the physicians to work leaner and faster. Patients and families expected perfection in care—no complications or unexpected events allowed. Insurance companies expected perfectly documented charts or else no payment. EMR vendors expected you to use their dreadful software and keep your mouth shut.

Work faster, make everybody happier, document more, and, oh, yeah, don't ever make a mistake.

The feeling for me before an ED shift flipped from being one of excitement, eagerness, and energetic anticipation to one of nausea and dread. One of my residency colleagues developed a trepidation of ED shifts even before graduating from residency, and promptly quit emergency medicine the day he graduated. Only later did I truly appreciate what he must have felt.

All physicians and nurses, especially those in our nation's EDs, make personal sacrifices to enter and practice a profession that provides the opportunity and the honor to heal, comfort, and advise their fellow human beings at all hours of the day or night ,  working weekends, overnights, and holidays while most people are sleeping or spending quality time with friends and family. When the constituent forces in the SBIC repeatedly insult, trample, and interfere with the humanity and virtue of medical physicians, they do great damage to the physician's ability to empathize.

Damage to a physician's ability to empathize is the sickness within our providers to which I referred in the beginning of this essay. Every condition needs a name, so I shall coin the term "empathitis." Empathy, in my personal perspective of its application to the medical profession, is the ability to preserve your sense that you are treating another human being, not just "Room 12" or "the hypertensive stroke patient" but rather a human being with a name, a story, family, friends, hopes, and fears,  a human being who deserves your full attention, your touch, and your diligent and meticulous thoughtfulness.

Empathitis: an acute or chronic reduction in a person's ability to empathize, often affecting his work and life performance. (Purely fabricated word and definition).

​Saying Goodbye
When the forces surrounding me made it difficult for me to be the type of physician I wanted to be and had trained to be, when those forces repeatedly directed my attention to documentation, billing, EMRs, and moving patients as fast as possible, and when those forces continually chipped away at my mountain of empathy, reducing it to scarcely a handful, I knew the time had come to say goodbye to the ED. My last ED shift was last summer.

Luckily, my departure from the physical world of hospital EDs did not signal the end of my medical career. I was fortunate during my career to work for a medical practice that gave me the opportunity to develop skills and experience in health care technology, data analytics, business development, and telemedicine, and now I have the great pleasure of practicing telemedicine with CirrusMD, an innovative group of amazing human beings transforming how health care is delivered.

Now when I see patients from my computer screen, I can chat with them as long as I want. They share stories with me, and sometimes we laugh. I advise them the same as I would advise my own family. We don't rush anything. More often than not, they just need reassurance and a little bit of guidance. I am no longer placing central lines and doing intubations, but I feel more like a true physician than ever before. I spend time talking to patients about health, not just sickness.

In addition to dealing with whatever the patient's acute medical condition might be, we talk about food choices, exercise regimens, sleeping habits, behavior modifications, and stress reduction techniques and how these things may be connected to the patient's acute condition. Sometimes we discuss fears and anxieties; I've even coached patients through full-blown panic attacks online. Now I can truly focus on health and care, not just sickness and billing. Now I operate in a system that I actually like to use and that supports me and my mission.

I feel blessed, but I know that many of my former colleagues and friends in the world of emergency medicine continue to endure and suffer. Less than half of my residency class is still practicing traditional emergency medicine. In an era of physician shortages and long wait times in EDs, I felt this story was important to share, so we can finally talk about what lies behind the waiting room door.

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Dr. Mohseni is an emergency physician, telemedicine provider with CirrusMD, and the author of his own ​blog, http://CreativeHealthLabs.com. Follow him on Twitter @amohseni, and read his past EMN columns at http://bit.ly/EMN-DocAPProvED. This article was originally published on Medium: http://bit.ly/2s1KlFb.

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Monday, August 27, 2018

Ultrasound's Immediate Answers for Diagnosing Endocarditis

BY CHRISTINE BUTTS, MD

Making the diagnosis of endocarditis in the ED can be extremely difficult. Many cases present with vague symptoms (malaise, body aches, fever) and can seem like a benign viral syndrome. Certainly the Duke criteria (http://bit.ly/2nAphmA) are not very helpful for emergency physicians because blood culture results take days.

The initial presentation in a lot of our high-risk patients, specifically those with a history of intravenous drug use, is our best opportunity to catch this condition. I often cannot reach patients after discharge when I receive notification of positive blood culture results, which I suspect is not uncommon for other EPs. Ultrasound of the heart and lungs can add concrete evidence to our clinical suspicion and help to convince our hospitalist colleagues that endocarditis is a likely cause of the patient's vague symptoms.

Knowledge of basic views of the heart allows an assessment of most valves. The standard parasternal long axis view demonstrates the mitral and aortic valves (two of the three 3 cusps). Mobile vegetations are often visible from this approach. (Image 1..)

sound 1.png
Image 1. Parasternal long axis view demonstrating mitral regurgitation (blue jet in left atrium).


From this view, tilting the transducer slightly so that its base (where the cord comes out) rises toward the patient's head will reveal the right ventricular inflow view. (Image 2.) 

sound 2.png
Image 2. Right ventricular inflow view. Left ventricle (LV) seen to left with right atrium (RA), ventricle (RV), and tricuspid valve on the right.

sound 3.png 

Area of consolidation seen adjacent to the pleural border. Note the liver like appearance (H) compared with the surrounding normal lung tissue (L) and the adjacent "B lines" (arrow).

This view allows assessment of the tricuspid valve, which is often tough to see unless a quality apical view can be obtained, and that's not always easy, even in a cooperative patient! If a heart murmur is detected, the addition of color flow can demonstrate regurgitation, best seen in the apical four-chamber view. Small, nonmobile vegetations also may be tough to see with transthoracic echo, and regurgitation may be an important clue.

After assessing the valves of the heart, consider taking a look at the lungs. Septic emboli, particularly when small or early in the course, are often difficult to identify on plain films, but can easily be seen with ultrasound. Using the low-frequency transducer (the cardiac transducer works well), each side of the chest should be examined superiorly and inferiorly. Breaking these sections down further into the anterior, axillary, and posterior aspects will help assess the entirety of both fields. Emboli appear similar to the consolidation seen in pneumonia with "hepatization," in which the normally hazy gray appearance of the lung is replaced by dense, liver-like tissue. An irregular border is common and signs of interstitial edema, such as "B lines," may be seen at the periphery. If a patient has back, flank, or chest pain, consider that ground zero for looking for these signs.

We are likely only seeing the beginning of an increase in the cases of endocarditis related to the intravenous drug use. Putting our antennae higher by combining our clinical judgment with ultrasound can help catch these patients earlier in the course of their disease.

Dr. Butts is the director of the division of emergency ultrasound and a clinical assistant professor of emergency medicine at Louisiana State University at New Orleans. Follow her on Twitter @EMNSpeedofSound, and read her past columns at http://bit.ly/EMN-SpeedofSound.

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Tuesday, August 21, 2018

​Preventing Physician Suicide Starts with Radical Honesty

BY JANAE SHARP

Last night I had a dream about the funeral. My elder son was 5 at the time, and he was following the casket, crying about opening it so that he could see his dad.

Of course, they didn't open the casket.

Some days I still wake up hearing the screams of my son, when he couldn't see the face of his father one last time. John died by suicide in 2015 before starting a residency in pathology.

suicide janae sharp.jpg
 Janae Sharp and her children. (Courtesy of Janae Sharp.)

John was still writing music while he was in medical school. He still loved to go to the park with his kids. But he was exhibiting signs of stress. He tutored for the MCAT on the side and frequently told me that he was doing more than other medical students. He started acting differently. He was angry. I asked about it. People said all doctors were angry. People said school was the problem. That I was the problem. That this was normal.

Based on what people told me while John was in school, a lot of people thought most doctors are grouchy jerks who are terrible parents and partners. They said that is part of the "culture." (KevinMD.com, Nov. 23, 2011; http://bit.ly/2LnrGPN.) But it was more than that; it can also be a warning sign for depression and increased risk of suicide, and family support is crucial.

I noticed John's classmates talking about ways to kill themselves; the references became particularly macabre when they started taking anatomy. Sometimes I earnestly couldn't tell whether they were playing memory games, committing difficult anatomical terms to memory, or making particularly dark jokes. I forgot the amount of propofol you need to kill someone, but I've heard it multiple times.

Were they just under a lot of pressure to remember things for pharmacology and too steeped in medical school to realize these jokes were not funny? Did they even stop to think what it might sound like to other people, non-physicians, even patients, to hear these jokes? Some doctors I spoke to had a daily ritual of thinking of ways they could die. Some find these conversations harmless, but they aren't.

​Problems with the Culture
I also noticed how much a toll the job itself took on them. I noticed when the students would visit clinics in high-poverty areas, seeing such high need without much access to care. Between visiting rural Pennsylvania, where a physician asked parents how often they gave their infant whisky to induce sleep, to inner-city Philadelphia EDs to practice trauma surgery on gunshot victims, there were a lot of people they could not help. That feeling coupled with some shock about what life was really like for patients and how to survive that reality as a physician with your same sense of purpose intact wasn't a class in the curriculum.

There were other things wrong with the culture too. The jokes about dying and using Adderall to perform well were things that I noticed during medical school, but I think I grew up more sheltered than some. Was it that unusual to use a lot of drugs? Physicians have more substance abuse issues than the general population, but when they explain that they are maximizing their potential, it seems like taking an antidepressant—perfectly normal and actually good for your health.

One of John's classmates, an emergency physician, expressed it perfectly: "You would think that a lot of what doctors do is important to improving health. You would be wrong." The realization that their dream or their job is different from the reality can be discouraging.

It was for John. He had issues with mental health and attempted to end his life more than once. He stopped talking to his kids; his brother tried to help him. It wasn't enough, and he passed in May 2015. The combination of stress and other factors was too much for him.

And it is not only John.

Forty-two percent of physicians reported burnout in the 2018 Medscape survey. (http://wb.md/2E58ouW.) Female physicians are 2.3 times more likely to die by suicide. (Am J Psychiatry 2004;161[12]:2295; http://bit.ly/2LNOjsQ.) And many depressed physicians do not seek help because medical licensing forms ask about mental health in many states. (The DO, Oct. 25, 2017; http://bit.ly/2NJcYiY .) Physicians do not make great patients. Because your mental health history is part of your medical license in many areas, some physicians don't report mental health issues. No one wants to be the "crazy" doctor.

The reality of physician suicide and burnout is that patients are getting worse care. Physicians are quitting medicine. People aren't really sure how to help or when they should be worried. Mental health care in general doesn't have enough physicians to meet the need. This extends to personal care too. We aren't giving physicians in training the resources they need to meet expectations. Medical students and residents report being unprepared for how hard training can be. (Scientific American, April 2, 2018; http://bit.ly/2LHaNyS.) I wasn't sure how hard it would be, and I also didn't know where the line was of protecting myself and my children and what was normal.

​The Sickness is the Disconnect
I did not understand the changes and the anger and the frustration John had in medical school. Humans tend to name a problem and try to understand what caused it. There are so many names for the problems physicians in training and in practice have. Compassion fatigue. Burnout. Depersonalization. Depression. Stanford Medicine recently published research about how physician burnout may contribute to large numbers of medical errors. (July 8, 2018; https://stan.md/2mJnrzA.) If you can't focus on your work, you don't do good work. If you can't connect with patients in the present, you miss important signs of future problems.

Much of the problem has to do with physicians obscuring their own symptoms from loved ones and from the medical establishment. A physician might hear a patient talk about wanting to die, and follow up on it. He might also hear a fellow physician joke about it the same day and pass it off or not know if it is real.

​Hiding from the Problem
Most current physician wellness plans may help with physicians who need an inspirational speech and a yoga class to get themselves back on track after a stressful day's work. This might not be possible in a system where working unhealthy hours is the norm. Coping skills are helpful, but a major study found that the higher a doctor's level of burnout, the less likely he was to seek help. (J Am Coll Surg 2016;222[6]:1230.) Some recovery programs place more burden on an already-overwhelmed system. They want to change as little as possible about the existing power structure and schedules. But if physicians work so hard they never sleep, they will have significant problems.

Pointing fingers of fault is difficult, but there is a lot of room for improvement for physician mental health. With the growing narratives about electronic medical records being components of or at fault for burnout, and technology vendors subsequently using the threat of burnout to sell new software, I wonder how much more medicine will turn into an echo chamber of academic papers and self-important peer-evaluated studies rather than actually solving any of the problems. (Harvard Business Review, March 30, 2018; http://bit.ly/2yjIW2g.) The current health care education and delivery system is failing to solve the problem of burnout. Our narratives aren't working, just like the narrative that "these things are normal" didn't work.

The way academic medicine evaluates for burnout and addresses the problem with "thought leadership" and academic inquiry is identical to the depersonalization we see from burnout. It desperately tries to separate itself from the real mental health issues by hiding behind a series of clicks.

​We Can Have Hope
I never want other parents to raise a child with no father. We started the nonprofit Sharp Index to help reduce suicide attempts and get more support to physicians. (https://sharpindex.org.) We also work with health care systems and communities so people can identify the warning signs. We need less pushback from people about what is "normal" in medicine and what is "necessary" to give great care. The less we hide, the easier it is to help. This means radical honesty and looking outside ourselves.

I have a profound hope that things will get better and that help is out there. I know because when John died, suicide-loss survivors helped me understand what was going on. We can help with tools for support. We can help with changing the work environment. We can help by telling family and friends where the line is between stress and suicide so we don't lose any more physicians to suicide, so no mother has to wake up from the nightmare of her child chasing a casket.

Ms. Sharp is the founder and CEO of the Sharp Index, a nonprofit organization dedicated to better physician mental health. (https://sharpindex.org.) Her work involves health care data and analytics marketing to improve health care outcomes for the underserved. She has learned to code in python and enjoys making communication easier in tech production, but her true passion is in matchmaking companies to create elegant health IT systems to improve health. She has worked with interoperability and social determinants of health, and is an expert on patient and physician engagement. Follow her on Twitter @CoherenceMed, and follow the Sharp Index @sharpindex. Watch Zubin Damania, MD (@ZDoggMD), interview Ms. Sharp at http://bit.ly/2LmByJP.

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​Raising Awareness about Physician Suicide

Sept. 17 is National Physician Suicide Awareness Day, and the Resilience Committee of the Council of Emergency Medicine Residency Directors (CORD-EM) is leading the way with the support of AAEM, AAEM/RSA, ACEP, ACOEP, ACOEP-RSO, EMRA, and SAEM in improving the wellness and resilience of residents and emergency physicians.

The committee, led by Chair Ramin Tabatabai, MD, and Vice Chair Loice Swisher, MD, is developing recommendations, programming, and curricula to address the ACGME well-being common program requirement and providing resources on a wide range of resilience and wellness subjects.

Estimates say that up to 400 physicians take their lives each year, according to CORD, with the relative risk for suicide being 2.27 times greater among women and 1.41 times higher among men than the general population. CORD's Vision Zero calls on individuals, residency programs, health care organizations, and national groups to commit to breaking down stigmas, increasing awareness, opening the conversation, decreasing the fear of consequences, reaching out to colleagues, recognizing warning signs, and learning to approach colleagues who may be at risk. (http://bit.ly/2LUzbKc.)

Current projects by the CORD Resilience Committee include 100 five-minute wellness activities, a resilience mini-fellowship, and a second victim toolbox. More information is listed at http://bit.ly/2mLOpWY.

 

Suicide Prevention & Postvention Resources

Need someone to talk to?
  • National Suicide Prevention Lifeline: 800-273-8255
  • Crisis text line: Text HELP to 741741

After a Suicide

Time to Talk about It: Physician Depression and Suicide

NPSA Day

​More resources for suicide prevention can be found in a presentation created by Dr. Swisher and Christopher Doty, MD, at http://bit.ly/2AcD0sP, and on the CORD website at http://bit.ly/2mJnnja.


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