Många oroas över arbetsmiljön på akuten. Sköterskorna slutar. Något måste göras.
Jag håller med, men jag tror inte de konventionella lösningarna fungerar.

Akutsjukvård är till sin natur oplanerad. Vi som älskar att arbeta på akuten avskyr regelbundna arbetstider med planerade möten, rutiner och tider. När vi kommer till jobbet vill vi inte redan veta i detalj vad som kommer att hända. Vi stimuleras av de snabba tempoväxlingarna, där man kan gå från ett hjärtstopp till att hålla förvirrade farbröder i handen så att de inte smiter iväg från akuten. Våra sköterskor är experter på att övervaka svårt sjuka patienter, samtidigt som de tar emot ordinationer och för femtioelfte gånger artigt förklarar för otåliga patienter att ingen vet det är deras tur. Det är en unik kompetens som inte erkänns. I stället för att stärka den, införs trubbiga triageinstrument och tidsregler, som gör att sköterskorna inte längre tillåts prioritera sköra patienter med särskilda behov. Sådant är stressande.

Vissa dagar larmar det i ett på akuten. I slutet av passet kan en sköterska berätta hur ingen varken hann äta eller gå på toaletten, men, och här bryter det stora leendet ut: – Vilket jäkla flyt vi hade!
För det är den där känslan. När vi känner ambulanspersonalen och får en riktigt bra rapport. När alla på akutrummet vet vad de ska göra. När vi kopplar upp, tar odlingar, smärtlindrar, ringer, dokumenterar, kommunicerar med varandra och med patienten. När patienten som så behöver får gå direkt till avdelningen. När allt det fungerar och vi känner att vi gör ett riktigt bra jobb. Då trivs vi på akuten. Då kan vi ta att det finns dagar som blir alldeles för stressiga.

Det är inte de intensiva arbetspassen som sliter ut oss. Det är sirapen. När den lilla dementa damen som tjoar i korridoren inte får komma till avdelningen. När läkarna beställer undersökningar som alla vet inte är akuta. När röntgensvaret aldrig kommer. När patienten som sköterskan försökte hänvisa till vårdcentralen tjatar om att hon inte orkar vänta längre. När man mitt i allt kaos ska avbryta det man håller på med för att någon bestämt att man måste ta lunch en viss tid, eller ha ett avstämningsmöte för att säkerställa att man följer ett arbetssätt som bestämts av någon som tror att akuten är en bilfabrik.

Det går att skapa en bra arbetsmiljö för oss på akuten. Den kommer inte att passa en kontorsråtta, men vi kommer att vara nöjda. Vi kommer att se till att vi får äta, vila, skratta och gå på toaletten. Och vi kommer att göra det som är viktigast av allt för vår arbetsmiljö, att få prioritera akut sjuka patienter. Men det kräver att vi får stöd av resten av sjukvårdssystemet, såväl öppenvård som slutenvård. Kan vi få det?

Jag är arg. Jag borde nog inte skriva blogginlägg när jag är arg. Men jag kan inte låta bli. Det har varit för mycket dumheter den här veckan. Och att avsluta den med Åke Andrén-Sandbergs debattartikel på DN blev bara för mycket.

Under ett halvår har jag försökt förstå problemet med akutsjukvården i Sverige. Jag har arbetat på alltifrån sjukstugan i glesbygden till universitetssjukhusen i Stockholm och Lund. Problemen är av olika karaktär, men ingenstans finns den akutsjukvård i världsklass som Åke Andrén-Sandberg talar om. På de mindre sjukhusen saknas ofta kompetensen att ta hand om riktigt svårt sjuka patienter. Som tur är, är dessa patienter ovanliga.

På universitetssjukhusen saknas en organisation för att hantera det stora inflödet av patienter. Sjukhusen ligger centralt och det finns inte en naturlig tröskel för att söka vård, såsom i glesbygden där tanken på att tillbringa en timme i bilen enkel resa, verkar avskräckande. Eftersom det i stort sett alltid varit långa köer på akutmottagningarna har detta i sig gjort att människor drar sig för att söka vård. Det är ett synnerligen dåligt styrinstrument. Jag vet inte när Andrén-Sandberg senast satte sin fot på en akutmottagning, men de som väntar är inte alls ”de som som inte alls borde söka på mottagningen utan vända sig till en vårdcentral i stället”, utan ofta svårt sjuka människor som väntar på en ledig säng på sjukhuset.

Visst finns det gott om patienter som har godartade åkommor där den akuta bedömningen inte påverkar deras framtida hälsa. De är emellertid ofta inskickade till akuten av sjukvårdsrådgivningen eller vårdcentralen. För sjukvårdsrådgivningen kan inte avgöra på telefonen om buksmärtan skulle kunna bero på en blindtarmsinflammation. Vårdcentralen vill inte ta emot patienten, eftersom de inte tycker att de är kompetenta att utesluta detsamma. Och hur ska då patienten själv kunna göra det? Patienten ska inte behöva ställa diagnos på sig själv innan hon söker sjukhus. Vi har också ett ansvar för att inte överutreda.

När jag gjorde AT för tio år sedan klämde vi patienterna med buksmärta på magen. Om det inte verkade så farligt, fick de gå hem och komma tillbaka. Var man osäker la man in patienten, så kände kirurgen på magen igen efter sex timmar. Numera skickar sköterskorna iväg blodprover redan när patienten anländer till akuten. Om dessa är lite förhöjda, vågar ingen skicka hem patienten ens om symtomen verkar aldrig så beskedliga. I stället får de komma tillbaka för nya prover dagen efter. Om man misstänker att det är en blindtarmsinflammation, eller en inflammation i tarmfickorna, är det inte längre bara att lägga in patienten på kirurgavdelningen. Först ska det beställas en skiktröntgen. Förhoppningsvis visar den något, för är den blank, men man ändå är orolig för patienten, är det i stort sett omöjligt att lägga in denne för observation. På universitetssjukhusen behövs röntgenundersökningarna akut för att veta var patienten ska läggas in. Frågan är inte om patienten ska läggas in utan var.

Men patienterna sorteras inte alltid efter allvarlighetsgrad på akuten. Olika specialiteter har arbetat upp snabbspår för sjukdomar som de tycker är prioriterade. Det är förstås inte konstigt att stroke eller hjärtinfarkt tas om hand direkt. Problemet är att för att hitta dessa fall, blir en massa patienter med mindre akuta åkommor högprioriterade. När ambulansen larmar för en bröstsmärta är det vanligare att det inte är en hjärtinfarkt än att det är det, enligt min erfarenhet. Det tas ekg på nästan alla patienter som visar sig på akuten och sköterskorna sticker den ena efter den andra under min näsa. När jag hittade ett som visade på hjärtinfarkt och sa att patienten måste påtittas omedelbart, var det ändå ingen läkare som gick in dit. När jag gick in en halvtimme senare fick patienten hjärtstillestånd. Det akuta drunknar i bruset.

Andrén-Sandberg menar att det kan lösas genom att kirurgerna och hjärtläkarna kommer ned på akuten, men att de behövs på sjukhuset. Problemet är att dessa läkare, och i synnerhet de extremt subspecialiserade läkarna på Karolinska, inte alls har kompetens att hantera de patienter som söker till akuten. Hjärtspecialister skickar gärna patienten på en skiktröntgen av bröstet och upptäcker först efteråt att patienten har ont i magen. Att patienter dör av bristningar på kroppspulsådern efter att en ortoped har bedömt deras ryggsmärta har hänt fler än en gång i historien.

Att bedöma om det är sannolikt att en patient har en livshotande sjukdom är ganska enkelt. Att däremot helt utesluta det är extremt resurskrävande. Därför forskar man internationellt inom akutsjukvården mycket på hur man med enkla beslutsstöd kan identifiera lågrisk-patienter där vidare utredning inte är nödvändig. Eftersom vi knappt har några akutläkare i Sverige, är det också väldigt få som läser den litteraturen. Neurokirurgerna har nyligen publicerat egna riktlinjer om vilka med skalltrauma som behöver röntga hjärnan. Vissa kirurger tror att ATLS-konceptet innebär att alla som varit med om en olycka behöver en helkroppsröntgen. Kardiologerna har drivit igenom att vi ska kontrollera högkänsligt troponin T på akuten. Deras angreppsvinkel är att vi ska hitta alla som riskerar att vara sjuka. Tyvärr tar de inget ansvar för resultatet när dessa metoder appliceras på en lågrisk-population på akuten. Vi överöses av provsvar med oklar signifikans och missar uppenbara problem, som när en patient prioriterades upp av sköterskan för att troponin T var 32, men det faktum att hans natrium var rekordhöga 178 inte kommenterades.

I veckan höll jag ett föredrag på Läkaresällskapet i Stockholm om vad som är kvalitet i akutsjukvården. Det är en svår fråga som inte har något enkelt svar. Ännu svårare blir det av att akutmottagningen inte har ett tydligt definierat uppdrag. En professor i kirurgi, som inte själv arbetar på akutmottagningen, får sin debattartikel publicerad i DN. Alla har en åsikt om vad som ska göras, men till syende och sist tar man på akuten hand om de patienter som visar sig där och försöker lösa deras problem så gott man kan, eftersom det inte finns någon medicinsk ledning. Om akuten bara är till för de som har en akut sjukdom eller skada, är det förstås det vi ska bedöma och bara det vi ska utreda. Men då måste också patienterna få veta att de inte kan förvänta sig en ortopedbedömning av vad som är problemet med deras onda knä, utan en bedömning av om problemet måste utredas och behandlas akut eller inte. Den bedömningen går att göra ganska fort, men tillför å andra sidan inte något för den patient som egentligen behöver träffa en ortoped. Vilken funktion ska akutmottagningen fylla och vem kan ta ansvar för den organisation utan att förstå hela spektrumet av akuta tillstånd?

Jag vill vara med och utveckla en akutmottagning där alla patienter som tror sig lida av en akut sjukdom eller skada, får en snabb bedömning av en sköterska eller läkare med rätt kompetens. Där vi använder av oss den bästa tillgängliga evidensen för att med minsta möjliga resurser identifiera de patienter som inte behöver akutsjukvård, så att vi kan koncentrera våra insatser till de som behöver dem bäst. En sådan akutmottagning drivs av engagerad personal som utvärderar och utvecklar kvaliteten i sin verksamhet, för att hela tiden bli bättre. Jag är övertygad om att resultatet av en sådan organisation är att ingen patient tillbringar onödig tid på akuten och att så gott som alla lämnar akuten inom fyra timmar. Än så länge har jag inte hittat någon sådan akutmottagning att arbeta på i Stockholm, men om det jobbet dyker upp är jag idel öron.

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. I’ll do my best to remember that lesson.

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.

This marks the very first entry of EM Broad Spectrum, a blog designed specifically for medical students, residents, PAs, and attendings with a focus on emergency medicine. Periodically I'll be posting on an assortment of topics relevant to emergency medicine, most of which will be evidence-based--so check in!

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.

I have started to write this post several times, but I never managed to finish it. I guess I’m just afraid it will come out wrong. But I still feel I have to give it a try.When I started to practice emergency medicine in Sweden there wasn’t any structured training or good role models. I was thrilled to find all these great EM podcasts and would listen to everything I could possibly find. That also got me interested in the EM literature, which no one in Sweden seemed to follow. One could even say that this is how I was introduced to evidenced based medicine. Of course I had heard about EBM before, but it is not a term we use in our daily practice. Most doctors don’t read journals more than occasionally, unless they are into research.

Anyway, my encounter with all this information about how emergency medicine was being practiced in other countries, made me more and more convinced that we weren’t getting it right in Sweden. That impression has changed over the last year, in a way that makes me scared to go and work abroad again.
After meeting with and working with doctors who were trained in more evidenced based systems, I was disappointed. I found it to be a battle of who had read the most and the latest journals and very little of discussion about what was right for the actual patient. The doctor who could cite a publication that no one else had read, would end the discussion in victory. Any suggestion was met with a demand for evidence. As if every question had one, and only one, correct answer. And that answer was to be found in a book or a journal.

So now when I listen to Scott Weingart debate Minh Le Cong whether needle or knife is better for a cricothyrotomy, I don’t enjoy it the way I used to. Of course the debate is a great way to show the advantages and disadvantages with respective technique. But in the end, no matter what high quality studies they present, I would always trust either one of them to use the technique they feel more comfortable with. The best technique in a given situation depends on the patient, the doctor’s training and experience and all the other circumstances. The reason why things go wrong are rarely that you hadn’t read the latest publication. And reading every journal there is won’t make you a better doctor, unless you put a great deal of effort into considering how this is relevant to your practice. Before I assumed that everybody share that understanding with me, but now I’m not so sure. (I still believe that Scott and Minh do, though.)

The human body is extremely complicated, and our knowledge is limited. Evidenced base medicine is the foundation of that knowledge, but it does not represent the whole truth. There is, for example, good evidence to support the use of ACE inhibitors in congestive heart failure. But there is, on the other hand, excellent evidence to prove that an ACE inhibitor was the wrong treatment for the CHF patient who died from angioedema. This may seem obvious, but I believe it is often forgotten that just because we did the best we knew how, it doesn’t necessarily mean we did right. The question about what the evidence based treatment is, has only one correct answer. (An answer that interestingly enough changes over time.) But our main objective shouldn’t be to practice EBM. It should be to give our patients the best treatment possible. EBM is just a means and adherence to evidence based protocols is just a surrogate marker.

Focusing on one thing only, will make us lose the bigger picture. The cardiac interventionist who put in two drug eluting stents in the old man with a STEMI might have read all the latest publications. He might even be a world famous authority in his field. But since he didn’t bother to take a good history, he didn’t predict that those diverticles that had bled twice before when the patient was on aspirin, were now bleeding on aspirin and clopidogrel, with a high risk of in-stent thrombosis if this treatment were discontinued. Medicine has to make sense. Evidence based medicin is an excellent base, but it always needs a topping of good doctoring.

Emergency medicine is a new specialty in Sweden, only recognized in 2006 as a supra specialty. Basically that means you need around nine years of postgraduate training to qualify as a specialist, but still get very little emergency medicine training and exposure. The emergency departments are run by the respective departments, which can add up to eight separate sections under one roof. And I think it’s safe to say that none of the doctors working there follow the EM literature. It’s like evidenced based medicine is reserved for their patients upstairs. To get them to accept that emergency physicians take over their on call work is not a problem, but to make them realize that that will mean a change in practice is much more difficult. They are all willing to teach us their part of emergency medicine, but there are no role models to convey the integrated knowledge. Instead we have looked to international bloggers and podcasters. It has been hard to see how this could be translated to our setting, so I wanted to go somewhere where emergency medicine was an established specialty and my first choice was Australia. Unfortunately that turned out to be too complicated and expensive and I ended up in Botswana instead.

It is fair to say that my experience in Botswana fundamentally changed my perspective on emergency medicine. Talk about culture clash! I knew that Sweden was a developing country when it comes to emergency medicine, but I didn’t expect the gap to be so wide. Of couse it was tough to get used to the heavy burden of disease in this relatively wealthy country, but it was being caught in the interface between advanced, anglosaxian emergency medicine and the more improvised, basic emergency care that made me realize that I didn’t know what I was aiming for in Sweden.

I had tried to describe to the EM specialists in Botswana beforehand, how I lacked training and experience in certain areas. Like Gyn/OB, for instance. We don’t see these patients in Sweden since there is a separate ED for them. As a resident you will do a rotation there, which I hadn’t done yet, but you will be taught by gynecologists who don’t really see the point in your learning something that you won’t be dealing with once you leave their department. Another thing is trauma. I work in the largest ED in Sweden and we don’t see severe trauma cases. Of course the occasional patient wanders in after being stabbed or stomped by a mousse (actually that only happened once, to my knowledge), but it is definitely not part of our daily life. And in fact, hardly a part of our training. Of course we take ATLS and other courses, but in terms of exposure we get two weeks at the trauma center, where they see around 300 severely injured patients per year.

But it is not only the trauma cases that seem to be a lot less frequent here. I have only seen one crashing asthmatic patient. We mostly get old COPD patients with exacerbations. DKA is rare, too, in adult patients. It is hard to find another explanation than that these patients are being adequately treated in primary health care.
We have a high suicide rate in sweden, but I have never seen a serious intoxication on TCA, beta blockers or calcium channel blockers. When I was talking to the second year residents the other day, most of them had never seen a blood transfusion given in the resuscitation room.

I tried to tell this to my EM specialist colleagues in Botswana, but I don’t think they believed me. Admitting everything you don’t know is never pleasant, especially not when people are surprised that you don’t know the basic things. Like placing a chest tube. I have never seen a chest tube placed in the ED. The same goes for central lines, but maybe we just missed that train, since CVP is going out of fashion and IO is gaining ground for the really acute cases. But if one was to be placed, someone from anesthesiology would come and do it, in no time. Just like they come and intubate the patient if necessary, which is rarely done in the ED. Cardiac arrests are often intubated in the field by a nurse anesthetist. (I won’t go into whether that is optimal practice or not.) If the critically ill patient needs to be intubated, they will mostly be taken to the ICU and have the procedure performed there. An emergency medicine program director even questioned that intubation skills were necessary for emergency physicians!

My hospital only has around twenty ICU beds and it is hard to get a patient admitted there. The STEMIs go there of course, but they bypass the ED and go straight to cath lab, so we only see the not so obvious ones.

What it all comes down to is that as much as we need to increase our resuscitation skills for the really sick patients, these cases are not common enough for us to train a large number of emergency physicians. Our work is more of preventive emergency medicine and driving in the slow lane. And even though I would love to bring upstairs care downstairs, I have to ask myself if the outcomes won’t be better if we keep bringing downstair patients upstairs.

It took me several weeks to summon my thoughts, but finally I managed and was honored to have it posted on Life in the fast lane.

http://lifeinthefastlane.com/2012/01/a-personal-view-of-emergency-medicine-in-botswana/