Little's Law Applied to the ER

Little's Law is a fundamental equation in operations. It's like F = m*a to physics and CO=HR*SV to critical care.

Applying it in the ED, Little's law states:

Number of patients in ED = Arrival rate of patients/hr * Avg length of stay in ED/Pt

Two of these numbers are readily available. Number of pts in ED and the arrival rate.

For example, lets assume that the ED bed capacity is 50 beds and normally has 40 beds occupied at a given time. The arrival rate on an average day is 10 pts/hr. What is the average length of stay in the ED?

Avg length of stay = # of pts in ED / arrival rate

= 40 pts / (10pts/hr)

= 4 hrs

Based upon this, we can figure out average LOS in ED and work on factors to decrease total ED length of stay for patients.

* More on Little's Law (pdf)

The CPR Game for iPhones

Last night, I was hunting for new apps on my iPhone 4s and came across this gem.

I only have the Lite version, but I was entranced into playing for hours.  Its comparable to being in a tiny Tetris Sim center

In this game, your goal is to resuscitate the old, young, and very sick.  A nice touch is the option to use the cardiac and FAST ultrasound while running the code.

The complete version is $1.99, a very tolerable price.   Enjoy!

Axioms for Community Medicine

I've been a community MD for a few months and I recently came across Dr. Rob Orman's ERCast.  This is a great podcast that's supremely relevant for community ED docs. One of his recent podcasts had a discussion on academics vs. community medicine (including Drs. Scott Weingart and Rob Rogers). Dr. Orman ends the podcast with these powerful axioms:

1.  When first starting out (6-12 months) think of it as doing an EM fellowship in community medicine.

2.  Give service to the group.  Devote a chunk of time to group practice by adding value, i.e. develop U/S, clinical pathways for PE, A.fib.

3.  Remember, proximity to a CT scanner (or MRI) is not a reason to order the test.

4.  You can only see ONE patient at a time.  The patient in front of you is the only patient you have.  If you focus on the waiting room, the last patient, you might end up spinning your wheels.

5.  Be nice to the nurses.  They can help and teach you or really HURT you.

6.  Take an advanced airway course early on.  This will reap huge dividends throughout your career.

7.  You are always a student FIRST.  Keep on learning and staying current, in addition to LLSA/CME.  Be the best emergency physician you can be.

8.  Be gracious with your consultants and be congenial.  These are people you will be working with for a LONG time. “Seek first to understand, then be understood.” ~ Stephen Covey

9.  Go to the monthly meeting.  Although you may think they are optional, they are not.

10.  The silent chief complaint is anxiety. In addition to the chief complaint, alleviate the anxiety of their symptoms.

11.  Always advocate for the patient.  When in a bind, ask yourself, “Self, what's best for my patient?”

Listen to ERcast by subscribing on iTunes!

Collected Tweets from ACEP Scientific Assembly 2011

In case you missed my tweets from ACEP in San Francisco, here is a collection of some of my updates.

Go with person with possible SAH & get immediate CT angio if positive. @emcrit

Pods sign: one spot that orthopods can listen to heart, lung, abdomen and document WNL...We Never Looked. Henry

More than 2 nerves affected in posterior fossa = bleed or tumor. Check articulation, word differentiation. Henry

Dizziness questions: Did the room spin? Did you feel like you were going to faint? Is this worse at night? Henry 

What is Purpose of lecturing?  Get people to learn. Do Audience centered speaking. Mattu

Audience will forget 40% of new content by 20 mins. After one week, 90% of new content forgotten. Mattu 

Limit content to 3-4 points U want them to remember. Be explicit about these points. Mattu 

Audio and videotape your lectures to improve speaking skills. Mattu

Buy "Secrets of Successful Speakers" by Nick Morgan, Lilly Walters, ET al. Mattu 

"At the end of this lecture, I want the audience to___". Plan for this when beginning your presentation. Mattu 

Come up with take home points and conclusion FIRST. What behavior change is the goal? Mattu 

Anything more than 4 points in your lecture and they will remember ZERO! Mattu 

Customize your lecture for the specific audience: degree, training level, specialty, native language, why are they there? Mattu 

Have a dynamic title in lecture. Use words like Pitfalls, Advances, Pearls. Death, disasters, killer NOT chapter titles. Mattu 

Start strong and finish strong! Grab their attention. Memorize the intro. Start with humor or a challenging case. Mattu 

Don't take questions at the end. Its a weak finish. Final 10 seconds are the most memorable. Mattu 

Don't need as many visuals. Simple slides. Big fonts: tahoma and arial are good. You are the message! Mattu 

Approach the sleepy or texting person and they will wake right up!" Mattu 

It's not what you say, it's how you say it. Tone, speed, body language. Mattu

Have 2 jokes prepared just in case of an AV glitch. Mattu 

On Rest and Balance

I finished emergency residency on June 31, 2011.  Some of my co-residents started their jobs the next day and accordingly began earning a salary immediately.   Even with the the looming student loan payments, I needed a rest.

I chose to go to San Marcos La Laguna in Guatemala.  My initial travel plan was to go to San Marcos for medical spanish lessons, then Antigua, then Copan Ruins in Honduras, and lastly spend four days getting scuba certified in Utila, Honduras.

Once I got into the small town by Lake Atitlan via shuttle & tuk-tuk, I realized that I could not leave San Marcos quite yet.  I decided to change my entire travel plans and stay in one spot.

San Marcos is special because there is a tranquil energy vortex here.  There are also a number of healers and wise people in this spot.   They use massage, Reiki energy healing, acupuncture, hypnotherapy, cranial-sacral massage, crystals, meditation, yoga, and the Mayan Calendar.

It was definitely a change of pace from allopathic medicine.  I used this time to rejuvenate myself from the twelve years of training to be an emergency physician.  It was a pleasure to interact with people of the San Marcos community and take time to slowly enjoy each moment.  Some days, I would simply lay in a hammock and stare into the clouds or watch the hummingbirds.

I learned many things about myself, my path in life, and the importance of balance in life.  When I came back to LAX a few days ago, I was saddened about what I had left behind.  But I also realized that I can create my own balanced life by planting the seed of tranquility.  As my friend says, "Creer es crear." Thank you, San Marcos La Laguna.

An Anonymous Doctor Tweets About An Anonymous Patient

I am late to the discussion about a recent interaction between two doctors online. To summarize, the first doctor blogged about a second anonymous doctor for being unprofessional on Twitter.   This launched a massive debate about doctors' presence online.  Ultimately, the anonymous doctor deleted the Twitter account and the first doctor closed the comments section of the post.

After catching up on must-read blogposts from:

TheAngryPharmacist

AllBleedingStops

ResidencyNotes

MediaBistro

I've come to the conclusion about the importance of anonymity for some doctors online.   Even President Obama states, "I just miss — I miss being anonymous," after he won the presidential election.

Physicians are held to a high standard.  But, frequently we cannot meet that standard because we remain human. We dispense health tips and advice to patients, while failing to care for ourselves.  These societal and self-induced pressures may actually lead to higher suicide rates and drug/alcohol abuse in doctors.

In a Utweetpia, all doctors could proudly publish their names online and freely vent-rant-educate-entertain-share online.  But there is too much to lose if a post/tweet becomes viral or #trends.  As long as patients cannot be identified, I believe that anonymous doctors should be allowed their freedom of speech and appreciated for their transparency into the medical world.

BUT it is extremely difficult to be truly anonymous online.

From the BlogHerald:

"True anonymous blogging requires that you ensure there is no connection between your real identity and the site as well as no direct connection or traceable connection between your network/your computer and your blog’s server.

To be clear, there are ways to do this and many great guides have been written on this subject, including an official one by the EFF and one on TechSoup.

However, especially for someone new at using these tools, the process is intimidating and the since perfection is required to be completely safe, it’s virtually guaranteed that there will be a break in the protection."

Emergency Medicine from THE ULTIMATE GUIDE TO CHOOSING A MEDICAL SPECIALTY

On Emergency Medicine from THE ULTIMATE GUIDE TO CHOOSING A MEDICAL SPECIALTY, by B. Freeman, 2003. 

What makes a good emergency physician (EP)?

-Likes working with hands
-Adventurous, action-oriented leader, and team player
-Can make logical decisions during rapidly changing situations
-Likes the variety and unexpected
-Is capable of juggling multiple tasks at once
-Comfortable with broad knowledge base


2.8% of ALL physicans are EPs
70% are in private practice, 25% are in academics
EP's work an average of 38.7 hours per week
75% report that their salary is equal or higher than expected

2002 Match Statistics
-1,564 applicants for 1211 positions
-992 US seniors and 600 IMGs ranked at least on EM program
- 98% of all positions were filled in the Match

90 residency programs are a THREE-year program, 14 are a FOUR-year program, and 20 require three years of EM residency after a separate internship year.

EM residents also complete rotations in medicine, critical care, anesthesia, cardiology, and OB/GYN.    The bulk of their training consist of monthly rotations in adult and pediatric emergency medicine, trauma, surgery, toxicology, emergency medical services, and ultrasound. Many programs require research:)

Check out SAEM's website for detailed information about residency programs HERE.