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Emergency Medicine

Emergency Medicine, Health and Fitness, Mental Health

Stanford’s “time banking” program helps emergency room physicians avoid burnout

Stanford's "time banking" program helps emergency room physicians avoid burnout

saving_timeFor emergency room doctors, few things are more important than time. They’re trained to work quickly and efficiently to gain the moments, minutes and hours that can be the difference between life or death for a patient. Yet, few ER doctors have the luxury of time in their personal lives.

According to a 2012 study, physicians’ work weeks are roughly ten to 20 hours longer than that of other professionals. This means that it would take the average professional about a year and a half to accomplish what a hard-working physician does in a single year. With a schedule like this, it’s no wonder that burnout is an issue for many physicians.

So, Stanford’s Department of Emergency Medicine adopted a “time banking” program that allows doctors to log the time they spend doing often under-valued activities, such as mentoring and covering colleagues’ shifts, to earn credits for the work and home-related services that would normally gobble up their free time.

Recently, the Washington Post highlighted this time-saving initiative in a story featuring emergency physician Gregory Gilbert, MD. “This gives me more bandwidth at work,” Gilbert said. “And because I can hang out with my kids and not be exhausted all the time, I’m able to be the kind of parent I’d always hoped to be.” From the Washington Post story:

Stanford’s time bank, part of a two-year, $250,000 pilot funded largely by the Sloan Foundation, showed big increases in job satisfaction, work-life balance and collegiality, in addition to a greater number of research grants applied for and a higher approval rate than Stanford faculty not in the pilot.

And for the first time, this year there are no openings for new fellows in the Department of Emergency Medicine. “All our spots have been retained,” Gilbert said. “There’s been no turnover.”

Previously: Surgeon offers his perspective on balancing life and workProgram for residents reflects “massive change” in surgeon mentalityLess burnout, better safety culture in hospitals with hands-on executives new study shows and Using mindfulness interventions to help reduce physician burnout
Photo by: mbgrigby

Behavioral Science, Emergency Medicine, Health Disparities, Pain, Patient Care, Pediatrics, Research

Blacks, Hispanics and low-income kids with stomach aches treated differently in ERs

Blacks, Hispanics and low-income kids with stomach aches treated differently in ERs

crying-613389_1280When a child arrives in the emergency room complaining of a stomach pain, appendicitis is the last thing you want to miss, says KT Park, MD, assistant professor of pediatrics.

“The question is, ‘Does this patient have appendicitis – yes or no?,” he said. It is the most common immediate emergency that could bring a child into the emergency room with abdominal pain. If not treated in a timely manner, the appendix can burst, leading to infection or a host of other serious complications.

But kids arrive in the emergency room complaining of stomach aches all the time; most with perfectly healthy appendices. And what if you’re a doctor who has seen seven kids with more minor stomach problems one day? It might be tricky to spot that first case of appendicitis.

Unfortunately, misdiagnosis happens more often when the pediatric patient is black, Hispanic or low-income, according to a study published today in PLOS ONE led by Park and Stanford medical student Louise Wang.

“Our goal in this study is getting the word out about abdominal pain and appendicitis and the importance of the decisions made in the emergency room,” Wang said.

The researchers analyzed national data from 2 million pediatric visits to emergency rooms between 2004 and 2011 complaining primarily of abdominal pain. They found that blacks, Hispanics and low-income children were less likely to receive imaging that could help their physicians diagnose serious conditions like appendicitis. These patients were also less likely to be admitted to the hospital, but more likely to suffer perforated appendicitis, a clue that perhaps they didn’t receive adequate treatment in time, Park said. For example, low-income blacks were 65 percent more likely to have a perforated appendix compared to other children.

The study was not able to precisely determine why these disparities exist, Wang said. “What is the driving influence of these outcomes? Are these kids being mismanaged in the emergency department, or are they presenting at a later time in a more serious condition?,” she asked.

She and Park have a few ideas, based on other findings and their personal experience. Minorities and low-income families are more likely to use the emergency room as a first-stop for more minor conditions, rather than visiting their primary care doctor or pediatrician.

“This is a very delicate topic,” Park said. “Physicians are humans and there is potentially some intuitive thinking that goes on about the probabilities of various diagnoses more common in certain patient groups, potentially leading to differences in how clinicians perceive the acuity of a patient’s status.”

Appendicitis can be tricky to diagnose, a task made even harder when patients are young and unable to clearly describe their pain, Park said.

“The psychology of physicians is an area needing further evaluation,” Park said. “We have internal biases that we often are not even aware of. We want to be objective, but it’s never a black-and-white decision making tree.”

Previously: A young child, a falling cabinet, and a Life Flight rescue, New test could lead to increase of women diagnosed with heart attack and Exploring how the Affordable Care Act has affected number of young adults visiting the ER
Photo by amandacatherine

Addiction, Emergency Medicine, Health Costs, Patient Care, Research

Questionnaire bests blood test at identifying patients with risky drinking behaviors

Questionnaire bests blood test at identifying patients with risky drinking behaviors

3144132736_9de39a590d_zAs many as half of the patients who visit the emergency room with traumatic injuries have alcohol in their bloodstream, and roughly 10 percent of these patients will return to the ER within a year. Today, many emergency rooms use blood alcohol tests to screen for patients with risky drinking behaviors. Yet a new study by researchers from Loyola University Medical Center suggests that a questionnaire may be a better way to identify at-risk patients.

In the study, researchers reviewed 222 records from patients 18 years of age and older that were admitted to Loyola University Medical Center’s level I trauma center between May 2013 and June 2014. Each of the patients in the study had a blood alcohol test and had answered the World Health Organization‘s 10-point questionnaire, called the Alcohol Use Disorders Identification Test (AUDIT). The research team compared the results of the blood test to that of the AUDIT test and found that the questionnaire was 20 percent more effective at identifying at-risk patients with dangerous drinking habits than the blood test.

As the researchers explain in their study, blood alcohol tests only provide “a snapshot of the patient’s recent drinking behaviors” by measuring of the amount of alcohol in the patient’s system at the instant the test is taken. In contrast, the questionnaire assesses the patient’s overall drinking behaviors by asking questions such as, how often they drink, how much they drink per day and if they have feelings of guilt or remorse after drinking.

These findings are significant because blood alcohol tests are often the only tool used to assess at-risk drinking behavior in ER patients. Their findings call this common practice into question and suggest that the AUDIT questionnaire may be a better way to identify, and ultimately prevent, potentially dangerous drinking behaviors.

Previously: Alcohol-use disorder can be inherited: But why?Could better alcohol screening during doctor visits reduce underage drinking? and How to make alcoholics in recovery feel welcome this holiday season
Via: Business Wire
Photo by: Julie °_°

Emergency Medicine, Ethics, Global Health, Medicine and Society, Patient Care

After Haiyan: Stanford med student makes film about post-typhoon Philippines

After Haiyan: Stanford med student makes film about post-typhoon Philippines

Multi-talented Stanford Medicine student Michael Nedelman has been featured on Scope before for his filmmaking and storytelling abilities. His new film, “After Haiyan: Health narratives in the aftermath of the typhoon,” is a series of vignettes about the November 2013 disaster in the Philippines. The film, which will be released soon, connects socioeconomic and structural issues of access to health in times of crisis.

It was filmed primarily in Tacloban, Leyte, in July and August of 2014, and Nedelman made a follow-up visit in November and December to premiere and promote the project. Despite his busy end-of-school-year schedule, Nedelman answered some questions for me about his work in a recent email exchange.

What was it like filming in the wake of a tragedy? 

Phil Delrosario said it best. He’s the cinematographer and editor I met here at Stanford. Knowing when to turn on the camera was a “huge balancing act” between our drive to document the truth, and our obligation to be compassionate storytellers. We couldn’t ignore the emotional weight of Typhoon Haiyan, and we couldn’t ignore the fact that we weren’t part of the communities we were documenting. So we sought out people who not only wanted to share their stories with us, but who could also provide some insight as to how they wanted those stories to be seen… For one of the videos, Deaf advocates like Noemi Pamintuan-Jara reached out to us first, not the other way around… That was really special for us, to be able to work alongside a community that has been promoting Deaf accessibility and culture long before we ever arrived on the scene. And we had these new partners who could give meaningful feedback on our filmmaking decisions.

Filming in the wake of a tragedy doesn’t mean everything is tragic. The shadow of Haiyan is still there, but there’s also a sense of living in the moment and moving forward. All over the city, you’ll see posters and graffiti that say, “Tindog Tacloban!” (“Rise Tacloban!”) That’s something that really resonated with our team and the ethos of our project. You can’t tell the full story of Tacloban without optimism and resilience.

How does this film link storytelling and health, and what is special about that for you?

When I was first discussing the project with one of the producers, Roxanne Paredes, we asked ourselves a similar question: How would our project add to or nuance the coverage of the typhoon? Right after the storm, Haiyan was all over the news. Tacloban was in survival mode. But months later, after many of those cameras had left, there was a different set of long-term challenges and a focus on recovery. Those were the issues we wanted to explore, which tend to be less covered by the media but still have profound implications for community health and future disaster preparedness. In short, just because the cameras stopped rolling doesn’t mean there weren’t more stories to tell. That really broadened the way in which I think of health stories.

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Emergency Medicine, Medical Education

“We are a team”: Advice for new residents from chief residents, in their own words

"We are a team": Advice for new residents from chief residents, in their own words

1024px-Flickr_-_Official_U.S._Navy_Imagery_-_U.S._Naval_Academy_plebes_carry_a_log_as_part_of_teamwork_training_during_Sea_Trials.There are many things chief residents want new residents to know right out the gate, but much of that goes unsaid. So the blog Academic Life in Emergency Medicine recently put together a list titled “Dear Residents: 10 Things Your New Chiefs Want You to Know.” Each one was written by a different chief resident, as part of the blog’s Chief Resident Incubator project.

It’s a thoughtful collection of reflections that offers an interesting mix of poignant comments and practical advice. The full list is worth a read, but a few stand out:


…Know that every one of your attendings and senior residents continue to go through these same trials. When you find yourself on the ropes and feeling utterly alone, call us. We might not be able to make that Surgical ICU rotation any less painful, but we’ll at least buy you a beer and share some stories from our own days working the surgery salt mine.

(Rory Stuart, Chief Resident, Wright State University, Dayton, OH)


…Our learning should not only take place during scheduled conference time; we can all learn from each other. Share your successes and failures. Teach us all what you know, and what you wish you would have known. When we get out on our own, we all represent this residency program. Together we can make each other and this program better.

(Valerie Cohen, Chief Resident, Christiana Care Health System, Newark, DE)


…Your week long string of night shifts was not borne of malice or vendetta. We try to make decisions that are in the best interest of the program and we ALWAYS consider your requests.

Your faculty, chiefs, and colleagues are paying attention to how you react to these perceived slights. When you take that extra shift in stride, we’ll notice. When you take on a task that nobody else stepped up for, we’ll notice. When you swap into a weekend night shift so a co-resident can celebrate an anniversary or birthday, we’ll notice.

(Jimmy Lindsey, Chief Resident, University of Chicago, Chicago, IL)

Previously: Soon-to-be medicine resident reflects on what makes a good teacher, Keeping an even keel: Stanford surgery residents learn to balance work and life and A call to action to improve balance and reduce stress in the lives of resident physicians
Via Wing of Zock
Photo by U.S. Navy

Emergency Medicine, Nutrition, Pediatrics, Rural Health

Study finds arm circumference is accurate measure of malnutrition in children with diarrheal illnesses

Study finds arm circumference is accurate measure of malnutrition in children with diarrheal illnesses

Malnutrition is a leading cause of mortality in children under the age of five, contributing to approximately 3.5 million child deaths worldwide each year. Currently, the World Health Organization and Doctors Without Borders recommend using calculations based on the patient’s body weight or arm circumference to assess their nutritional status. But, it’s not known if they are reliable measures of malnutrition in children that suffer from diarrhea and dehydration — two symptoms that can affect body weight and are common in undernourished kids.

Now, a study (subscription required) published this month in the Journal of Nutrition shows that mid-upper arm circumference can accurately assess malnutrition in children with diarrhea and dehydration and it’s better at assessing malnutrition than weight-based measures.

In the study, Rhode Island Hospital emergency medicine physician Adam Levine, MD, and his team analyzed 721 records of children (under the age of five) who were examined at an urban hospital in Dhaka, Bangladesh for acute diarrhea. They found that measurements based on a child’s mid-upper arm circumference accurately diagnosed malnutrition, but measurements based on weight were unreliable and misdiagnosed about 12-14 percent of the cases when the patient had diarrhea and dehydration.

“Because dehydration lowers a child’s weight, using weight-based assessments in children presenting with diarrhea may be misleading,” Levine said in a press release. “When children are rehydrated and returned to a stable, pre-illness weight, they may still suffer from severe acute malnutrition.”

Since poor nutrition is a common problem in areas where medical resources are limited, the best tools to diagnose malnutrition are effective and inexpensive. Tape measures are cheaper and are often easier to come by than scales, so the results of this study are especially encouraging for people who want the best and most affordable way to measure malnutrition in children. “Based on our results, clinicians and community health workers can confidently use the mid-upper arm measurement to guide nutritional supplementation for children with diarrhea,” said Levine.

Previously: Stanford physician Sanjay Basu on using data to prevent chronic disease in the developing worldMalnourished children have young guts and Seeking solutions to childhood anemia in China
Photo by European Commission DG ECHO

Emergency Medicine, Global Health, Haiti, Stanford News

A tale of two earthquakes: Stanford doctor discusses responses to the Nepal and Haiti disasters

A tale of two earthquakes: Stanford doctor discusses responses to the Nepal and Haiti disasters

boy in Nepal - 560

Nepal’s 7.8 earthquake in late April killed 8,000 people and displaced thousands more. Paul Auerbach, MD, a professor of emergency medicine at Stanford, spent about a week caring for the people of Kathmandu and recently sat down for a Q&A session with Shana Lynch of Stanford’s Graduate School of Business, where Auerbach earned a master’s degree in 1989.

Auerbach was also part of the medical response team in Haiti after the 2010 earthquake there killed hundreds of thousands. While talking with Lynch, he compares the two earthquakes and the very different medical responses they needed:

When you come in, you need to find the victims. You need to treat them. You need medical supplies. You need adequate personnel in order to manage the life- and limb-threatening injuries in the first few days. From the moment of the earthquake and forward, there’s a need for water and food. In Haiti, the supplies initially weren’t there. Everything needed to be carried in. In Kathmandu, for the most part, the supplies were available. Of course, they needed supplementation, and that happened and will continue to happen. In Kathmandu, they never were in a situation where they had nothing, which was unfortunately the situation in Port-au-Prince.

He also discusses some of the challenges of coordinating an appropriate disaster response plan:

There comes a point when you have enough people and enough supplies. At that point, you need to start storing things and sending people home.

The responses are never perfect because you discover that you need more of something and less of something else. The same holds true for people. For example, the changing nature of medical conditions following an earthquake causes you to need emergency medicine specialists early on, but then orthopedic surgeons and reconstructive surgeons later during the response.

Lynch and Auerbach’s conversation also touches on why community leaders need to plan for disasters, regardless of where they are. It’s an interesting inside look into how medical teams think about and respond to natural disasters.

Previously: “Still many unknowns”: Stanford physician reflects on post-earthquake Nepal, Day 6: Heading for home after treating Nepal earthquake victims, Day 4: Reaching beyond Kathmandu in treating Nepal earthquake victims, Day 2: “We have heard tales of miraculous survival” following Nepal earthquake, Day 1: Arriving in Nepal to aid earthquake victims and Reports from Stanford medical team in Haiti
Photo courtesy of Paul Auerbach

Big data, Emergency Medicine, Genetics, Infectious Disease, Research, Stanford News

Study means an early, accurate, life-saving sepsis diagnosis could be coming soon

Study means an early, accurate, life-saving sepsis diagnosis could be coming soon

image.img.320.highA blood test for quickly and accurately detecting sepsis, a deadly immune-system panic attack set off when our body wildly overreacts to the presence of infectious pathogens, may soon be at hand.

Sepsis is the leading cause of hospital deaths in the United States and is tied to the early deaths of at least 750,000 Americans each year. Usually caused by bacterial rather than viral infections, this intense, dangerous and rapidly progressing whole-body inflammatory syndrome is best treated with antibiotics.

The trouble is, sepsis is exceedingly difficult to distinguish from its non-infectious doppelganger: an outwardly similar but pathogen-free systemic syndrome called sterile inflammation, which can arise in response to traumatic injuries, surgery, blood clots or other noninfectious causes.

In a recent news release, I wrote:

[H]ospital clinicians are pressured to treat anybody showing signs of systemic inflammation with antibiotics. That can encourage bacterial drug resistance and, by killing off harmless bacteria in the gut, lead to colonization by pathogenic bacteria, such as Clostridium difficile.

Not ideal. When a patient has a sterile inflammation, antibiotics not only don’t help but are counterproductive. However, the occasion for my news release was the identification, by Stanford biomedical informatics wizard Purvesh Khatri, PhD, and his colleagues, of a tiny set of genes that act differently under the onslaught of sepsis from they way they behave when a patient is undergoing sterile inflammation instead.

In a study published in Science Translational Medicine, Khatri’s team pulled a needle out of a haystack – activity levels of more than 80 percent of all of a person’s genes change markedly, and in a chaotically fluctuating manner over time, in response to both sepsis and sterile inflammation. To cut through the chaos, the investigators applied some clever analytical logic to a “big data” search of gene-activity results on more than 2,900 blood samples from nearly 1,600 patients in 27 different data sets containing medical information on diverse patient groups: men and women, young and old, some suffering from sterile inflammation and other experiencing sepsis,  and (as a control) healthy people.

The needle that emerged from that 20,000-gene-strong haystack of haywire fluctuations in gene activity consisted of an 11-gene “signature” that, Khatri thinks, could serve up a speedy, sensitive, and specific diagnosis of sepsis in the form of a simple blood test.

The 11-gene blood test still has to be validated by independent researchers, licensed to manufacturers, and approved by the FDA. Let’s hope for smooth sailing. Every hour saved in figuring out a possible sepsis sufferer’s actual condition represents, potentially, thousands of lives saved annually in the United States alone, not to mention billions of dollars in savings to the U.S. health-care system.

Previously: Extracting signal from noise to combat organ rejection and Can battling sepsis in a game improve the odds for material world wins?
Photo by Lightspring/Shutterstock

Emergency Medicine, Global Health, Stanford News

“Still many unknowns”: Stanford physician reflects on post-earthquake Nepal

"Still many unknowns": Stanford physician reflects on post-earthquake Nepal

Paul Auerbach recently traveled to Nepal to aid victims of the April 25 earthquake; he wrote this post over the weekend.

17313678335_5f5d15dc04_zI’m on my way back to the U.S. now and getting information from people who are still in Nepal. Because I’m inundated with requests to provide information from people who have read my previous posts, I’ll keep writing, but only if there’s something useful to report. Please let me emphasize that this is no longer firsthand, but rather, based on communications from persons in Nepal whom I very much trust. They are working really hard, so it is “above and beyond” (and very much appreciated) that they find time to keep us all informed.

Surrounding Kathmandu and seen from the air, there are many remote villages that have been devastated, with all or nearly all dwellings demolished by the earthquake. These buildings had mostly been constructed of bricks mortared with mud. They crumbled during the shaking and may have been struck by rock slides. Anyone caught within the buildings could have been mortally wounded or severely injured.

Many villages are situated one or more days’ walk from the nearest vehicle (4-wheel drive truck or SUV)-accessible roadway, so rapid access will need to be by helicopter if there is a suitable landing site or the ability to carry out long-line rescues (this requires the appropriate equipment and operators with technical expertise, both on the ground and in the helicopter). Helicopters are in short supply relative to the need, so that is a rate-limiting part of the operation. The helicopters will be needed both to get teams in and to get patients out. The first step will be to provide on-site triage in order to prioritize where to deploy medical and other resources. Patients will be assessed in order to determine whom to transport and in what order. Treatment will be initiated when possible. The possibility of trekking into villages will be dictated by the condition of the paths normally used for foot travel. The paths are often narrow, rocky, and steep. It is likely that there have been rock-and-dirt slides that will render traversing some of these paths extremely difficult or impossible. If the paths are passable, that may be how some of these villages will eventually be reached, and people and supplies delivered. The delays will be overcome by cooperation and perseverance.

Medical teams from around the globe have come into Kathmandu and are assisting or prepared to assist. They will be responsive to the Nepal government, global-health agencies such as the World Health Organization, and non-governmental organizations such as International Medical Corps. The search and rescue (SAR) component intended to find victims trapped in rubble will expect from this point forward to find only a few miraculous survivors of the initial event, so the role of SAR to extricate buried people will diminish. From this point forward, it will be about getting to the injured and sustaining them until they can be extracted to a higher level of medical care, if this is what they need. Reaching all the affected villages and injured persons may take weeks. To assist displaced (e.g., no longer have a home) persons, there is need to provide food, sheltering materials, and water disinfection supplies.

The public-health mission, in particular trying to prevent the spread of potentially epidemic infectious disease (particularly diarrheal disease) is hugely important. This is essential now and particularly as the monsoon season approaches. This includes human-waste management, providing safe drinking water, possibly providing immunizations, and surveillance that promotes early detection of disease.

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Emergency Medicine, Global Health, Stanford News

Day 6: Heading for home after treating Nepal earthquake victims

Day 6: Heading for home after treating Nepal earthquake victims

Paul Auerbach has been in Nepal to aid victims of the recent earthquake; he wrote this account over the weekend.

Nepal earthquake2 - smallThe last few days have been action-packed, and my work in Nepal is coming to a close. As an emergency physician, my skills will soon be much less needed than those of orthopedic and plastic surgeons, and primary care and infectious disease specialists. Because of the incredible outpouring of active interest from people who are friends of Nepal, many health-care professionals have arrived, and more are on the way. The government of Nepal has recommended that all persons, particularly those in large groups or teams, wishing to help by coming to Nepal do so under the auspices of a government-approved organization. This is important to maintain an effective response and deploy resources where they are most needed.

It has been a bit unnerving to experience three significant aftershocks over the past few days. Each was accompanied by a jolt or shaking of the ground or building and rumbling noise, followed by silence, followed by the sounds of commotion as people fled their dwellings. Fortunately, none of the aftershocks was prolonged or destructive, but they serve as a reminder of what happened, and what will undoubtedly happen again sometime in the future. The cycle for a major earthquake in this country in modern times is approximately every 75 years.

Today we traveled to Hatia, a community close to Dhading, in order to assess need and provide care. We were greeted by approximately 100 residents with earthquake-related situations, illnesses, and injuries. Nearly all of them are now displaced from their homes. With the monsoon on the horizon beginning the end of this month or early in June, combined with the number of persons requiring new shelter, the timetable is set for an aggressive attempt to provide adequate housing, essential public health education, and water-sanitation-hygiene (WASH) programs. More victims of the earthquake will undoubtedly be found as helicopters are deployed to approach very difficult-to-reach areas, so there will continue to be an immediate medical response as long as the public health efforts.

I have witnessed many acts of selflessness and heard tales of amazing bravery, including what transpired at Everest Base Camp. The details of everything that has happened in this country related to the earthquake will be best told by those who experienced it first-hand. From a personal perspective, I’m impressed by the number of participants in the events and response that has come from the wilderness medicine community. These are some of my dearest friends and colleagues, and my admiration for them has grown by leaps and bounds. Working with my lifelong friend Luanne Freer, MD, has been a privilege. Her knowledge of Nepal and love for the country permeated everything she did this past week. There are many people like her who have come to help, and behind every person here there are dozens at home supporting their efforts.

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