Meditation for Physicians

When stepping into a new patient's room, I must clear my mind completely.  To make a diagnosis, it's crucial to listen with 100% attention.  If I think about the patient I saw before, or what lab result I need to look up, my focus becomes divided.  One way to be more aware of the present moment is through meditation practice.

During medical school, Jon Kabat-Zinn lectured at the U. of Rochester and led us through various awareness exercises.  One exercise was to eat a raisin very s - l - o - w - l - y, savoring the taste and texture.  I still remember how potent the single raisin tasted.

Now, I've re-discovered him on the EM Tutorials Podcast  (By Drs Chris Cresswell, Qasim Alam and Andrew Dean-Ballarat, Australia and New Zealand)
http://itunes.apple.com/nz/podcast/emergency-medicine-tutorials/id441003312

I highly recommend you download # 7 Breath Meditation and give it a try for a week.  It's also FREE.

Bottlenecks

Once you've identified the time each patient spends at a certain step, you can identify which takes the longest.

NOW, you have identified the bottleneck.

Everything is dependent upon this bottleneck.  Recall the rate limiting step (RLS) in chemistry.  This step is typically a catalyst or rare substrate.  It's the process that S - L - O - W - S  everything else down.  In the ED, this may be: time to get a lab report, a 5150 bed, or the the on-call dialysis nurse.

Use a multi-perspective approach by including RNs, Techs, ICU docs, etc. to reduce the time it takes in the slowest step.  This can be challenging, but will reap huge rewards.

Lather, rinse, & repeat.

What are the important things to measure for ED flow improvement?

There are many metrics in the ED, ranging from patient satisfaction to % of Medicaid patients.   To improve patient flow and identify bottlenecks, there are 10 steps and times that should be measured:

1. Door to Triage

2. Triage to MD (assuming MD is in triage)

3. Bed to RN

4. Bed to MD

5. MD to Decision (DC vs. ADMIT)

   6) Imaging order to read

   7) Lab order to results

   8) Recheck of patient

9) DC to actually being out of ED

10) ADMIT to floor

If you add the total time of each of these steps, this equals total Length of Stay in ED (LOS).

Based upon the review of the time needed for each of step, an ED director can determine which areas need more effort and time to reduce the time in ED.  This is crucial because patient satisfaction is linked to the overall time in ED. 

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