Crash Cart: Patient discrimination, nasal delivery, and marathon related deaths from road closures

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This week: Patient choice sometimes includes racism and sexism, ER docs issuing more “up yours”, and marathon detours cause more deaths. Join in as our editors discuss the week’s headlines.

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One study says as many as 15% of pediatric docs experienced discrimination from patients

With 1 in 4 U.S. docs being international grads, a Muslim doctor reflects on the code of silence surrounding the issue. Original Article by Medscape.

Jyoti Mahapatra, MD: About a year ago, an elderly husband left his wife’s bedside to come tell me “We were SO impressed with you.” I took it as a compliment that my bedside manner just keeps improving until he added, “Your English is absolutely PERFECT.” When a demented patient screamed “I don’t want that foreign intern coming back in here!” I was more offended that she called me an intern but I wasn’t thrilled about the other half of the insult either. I grew up in the Midwest and have practiced here for 11 years. I’m used to being the only Indian my patients have ever spoken with, other than another doctor perhaps. Add in my gender and somewhat youthful appearance, and I end up defending my medical knowledge, immigration status, and language on a daily basis. I found it incredibly insulting until I realized these patients were always elderly and more curious than skeptical. By the end of their visit, they were genuinely pleased and satisfied with our interaction. They were delighted to have met someone who clearly escaped the destitution of Slumdog Millionaire. And I was thrilled they were at least asking questions and truly wanted to know more about my background, which is more than I can say for the patients just looking to score a z-pak. Then, like Dr. Yasmin’s students, I found myself in tears the day after the presidential election. Working the AM shift, I was astonished at the number of times I had to collect myself after walking by a TV. I calmly tell people they have STEMIs and metastatic cancer for God’s sakes! I had built a shield telling myself patients “don’t know any better” and thinking I was changing the conventional image of a female, a doctor, and an Indian. But that shield was shattered by my sense that our country had responded “we do know better and we still don’t want people here that look like you.” It’s heartbreaking and infuriating that some patients only see me as someone who can barely speak English, and not a physician with decades of education for the privilege of practicing medicine. The golden rule doesn’t apply to the ED often, but we all hold ourselves to a higher standard. I couldn’t live with myself any more than the next EP if I didn’t treat patients better than they treat me. Whether they think I belong there or not, I am exactly where I am supposed to be.

William Sullivan, DO, JD: Sorry, I stopped using Medscape when it forced me to sign in any time I visit the site. Lots of other resources out there. Piggybacking onto Jyoti’s experiences, though, I also sometimes feel resentment. The fact that we are forced to endure discrimination, aggression, rudeness, or even violent acts from some patients while maintaining a smile and calm demeanor is sometimes difficult and when it happens multiple times in a shift, it often becomes downright frustrating.

E. Paul DeKoning, MD, MS: I’m going to try to avoid getting into a political debate here and simply restate what I said before in another recent Crash Cart: We all view each other through the lenses of our experiences, upbringing, preferences, and even the generation in which we were raised. But, this issue has nothing to do with who won (or didn’t win) an election. Jyoti, I’m sorry you experienced that–it’s not ok. Period. I think back and shudder at some of the things my own grandmother used to say–some were just ‘innocent’ turns of phrase–because she had been raised in an environment and generation in which those things were ok. But it’s not ok. It’s not ok for patients to treat my white female colleagues inappropriately. It’s not not ok for any staff to be physically threatened or attacked while trying to provide care. It’s also not ok for a patient to assume I’m [racist/sexist/misogynistic/bigoted/etc] because of [fill in the blank here]. Yet, these things still happen because humans are human and there are few places where ‘human-ness’ is more evident than in an Emergency Department. Every time I’m on the receiving end of a year’s worth of F-bombs, I have to remind myself that the patient is not at their best. It can (and usually does) still hurt, though.

Ryan McKennon, DO: Add in patient bias to an overall decrease civility leads to awful interactions between people seeking help and those trying to help them. This simply should not be tolerated. Other than a no tolerance policy and prompt discharge where appropriate, the how can be difficult when the patient is unstable. The worst I have had to deal with is a women who refused to see a male physician for her active labor (single coverage at night, delivered 10 minutes after arrival). This is a constant reminder to me of how bad ass my colleagues are who have to deal with all the challenges of the ED that I do, while dealing with the sexist/racist patients on top of that. It reminds me of Ginger Rogers who did everything Fred Astaire did, “but backwards and in high heels.”

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ER Docs see benefits in choosing nasal delivery for drug delivery, including kids

Pros and cons were published in Annals of Emergency Medicine recently. Original Article by NPR.

Jyoti Mahapatra, MD: I am trying to get my hands on an atomizer for our FSED, no doubt it will be practice changing. But versed for pediatric sutures to “calm them down and help with anxiety”? Unless we’re talking about extensive facial injuries or complex extremity lacerations, I wouldn’t be using a sedative anyways. Today’s pediatric versed patients are tomorrow’s adults demanding dilaudid for their ankle sprain.

William Sullivan, DO, JD: The play on words in the title takes away from the substance of the article. I can count on one hand the number of times I’ve personally used any intranasal medications in the emergency department. As the article notes, the application seems better suited to use outside the emergency department – such as Narcan administration. Hopefully people will also begin using it to administer epinephrine in lieu of using a $300 EpiPen.

E. Paul DeKoning, MD, MS: This is becoming the next best thing. We have found it useful as an adjunct or a bridge until IV is placed or X-rays are obtained, for example. I personally haven’t found it all that useful as a solo med. And, if you have to wait to get the correct concentration from pharmacy, your time save is out the window. I guess I just need to use it more. Or maybe I don’t.

Ryan McKennon, DO: I personally haven’t used this much. I can see its usefulness in kids though, at least as initial treatment prior to starting an IV.

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A NJEM study says more elderly die when roads are closed for sporting events

The study looked at Medicare reports for ten years in 11 cities and found for every 100 patients who have a heart attack or cardiac arrest, an additional three people would die within one month if the cardiac event happened on the day of a marathon. Original Article by Harvard Business Review.

William Sullivan, DO, JD: Interesting study. The only thing that makes it a little more difficult to determine the conclusions is that the study measured 30 day mortality. Do small delays in transport amount to mortality many weeks away? Harder to swallow that pill without further data. On the other hand, if an increase in transport time of 4.5 minutes really does have this much of an effect on patient mortality, think about the implications of closing rural hospitals where the transport times to the next closest facility then are delayed many times that much.

E. Paul DeKoning, MD, MS: I don’t know what to do with this. I guess this means we should outlaw marathons. While we’re at it we should probably get rid of stairs–you might slip and break your neck. Don’t even get me started about forks. Totally agree, however, with the good Dr. Sullivan with regard to the effect of rural transport times–something I live everyday.

Ryan McKennon, DO: Probably more important is the increase in transport time for those driving themselves to the hospital (23% of patients). While the increase was 4.5 minutes for an ambulance, with all the road closures, it was probably much larger for self transport. I do not envy the panning committee who has to decide what roads to close down and when as well as any alternative routing.

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