Crash Cart: Occult Ingested Foreign Body

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REAL PHYSICIANS DISCUSS RECENT HEALTHCARE HEADLINES

Below is an excerpt from the full conversation, which is available on epmonthly.com. Have a story you want discussed? Sound off @epmonthly or email editor@epmonthly.com

Fitness watches generate useful information, raises patient anxiety


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https://www.science.ku.dk/english/press/news/2020/fitness-watches-generate-useful-information-but-increase-patient-anxiety/

Like anything in life…too much information can be a bad thing…it’s a signal to noise ratio thing.  Too much noise creates anxiety, but some information that is useful can be quite beneficial.  I myself own one of these fitness watches and find that I get buried in my computer.  It’s nice to have a reminder to get up and stretch my legs from time to time.  Not too much, not too little, just enough to be useful.

— Salim R. Rezaie, MD


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I wore a Fitbit for years until it got in the way of the adult watch I bought myself when I turned 50. And then a patient showed me her heart tracing that her watch captured.  I had the source of her palpitations and ordered a fitness watch the next day. These watches produce a ton of information and hopefully patients appropriately filter what’s important and what’s not.  But when I see a patient who tells me they had palpitations that resolved as they came into the ED, but they have a rhythm strip to show me, I think they’re worth the purchase.  And as a former runner, and now walker, having my pace readily available can push me a bit so I’m exercising and not strolling.

—Mike Silverman, MD

These give us and our patients a lot of information, the concern being we are giving information to people who may add “Dr Google” to try and interpret (see previous crash cart) which could lead to increased anxiety, health care utilization, etc. But, I love that I can track my activity, exercise and my sleep all from something I can wear on my wrist.

—Andy Little, MD


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Was this article written about me?  In all seriousness, fitness watches are incredible devices.  I religiously use a GPS watch and fitness app. Initially it was just to log my runs and bike rides, but has become much more consuming.  I legitimately use it to track my fitness, keep track if I am overtraining or undertraining, and overall improving my fitness and VO2 Max.  But wait, there is more… how long and how well I am sleeping, something I am becoming increasingly obsessed with, how much “stress” I have in a day based on non-active HR (my ED shifts are shockingly more stressful than non-clinical days) how many calories I burn in a day and maybe most important for my health, my resting HR (low 50s).

If you want to freak yourself out about being sick, watch your resting HR go up for a few days and talk yourself into unexplained aches, headache, etc. So yeah, I can see how fitness watches are a good and bad thing and I haven’t even started talking about patients coming into the ED because of them.

—Andrew Kalnow, DO

My first reaction was information overload!  But the more I thought about it, information does just need interpretation.  I couldn’t agree more.  This is an opportunity to combine with AI to provide collaborative care.  I’m an old dog and this is kind of a new trick.  But with a little tinkering, even I might utilize it.

—Mark Plaster, MD, JD

 

Occult Ingested Foreign Body

https://www.sciencedirect.com/science/article/abs/pii/S0736467920305850

I’ve seen some crazy foreign body ingestions, but didn’t see this diagnosis coming. Finally, a reason justifying why I get an ECG and chest x-ray on all of my chest pain patients.  There are a handful of things we need to rule out on every chest pain patient.  I’ll now put “pin in the heart” on my list.

—Mike Silverman, MD

Chest pain is an all too common complaint in the ED.  Most patients just want to know if they are having a heart attack.  My job is to make sure that the chest pain is most likely from a benign etiology.  This is why a CXR, EKG, and often times bedside echo can be useful.  The number of times I thought a patient had nothing and found a significant finding with the use of these three diagnostic modalities is too numerous to count.

– Salim R. Rezaie, MD

This reminds me of an episode of House. Crazy to think something that you swallowed would end up in your heart. Kudos to the clinicians for turning over every stone to find this once in a lifetime, lifesaving diagnosis.

—Andy Little, MD

 

Discipline Against Bad Doctors Plummets amid COVID-19

https://www.southcoasttoday.com/news/20200909/discipline-against-bad-doctors-plummets-amid-covid-19—and-more-medical-errors-may-slip-through-cracks

Like everything else in life, it’s not a surprise that the COVID era slowed down state sanctions against physicians and maybe not even surprising that complaints decreased too. After all, healthcare providers have been lauded as “heroes.”  While some leeway in delivery of care during emergency operations is necessary, much like other professions, healthcare providers need oversight and the ability to sanction those who are not providing quality care.  This seems to echo other societal concerns for oversight.

—Andrew Kalnow, DO

I wish I could say that all physicians were good people, who never did anything wrong. Unfortunately, this is one of the key reasons why state medical boards exist, and with COVID shutting down many of their day to day operations it is not surprising that this fell through the cracks. I wonder if some of the other factors related to COVID may play a role in the decrease in complaints; family being restricted to see or be with patients (less patient advocates at the bedside), some areas of medicine seeing a decrease in utilization of this time (Elective Outpatient surgeries, urgent cares, ED visits, etc.). Only time and a further analysis will let us know to what extent these and other factors may have played.

—Andy Little, MD

That was just a function of fewer in person visits.  If we stay locked down, the complaints will sky rocket.  I’ve seen numerous problems where the telemedicine doctor did a lousy exam and then sent the patient to the ER only to find something much different.  Some of the problems were serious.  You always get a pass on the first mistake.  But keep it up and there will be a flood of complaints.

—Mark Plaster, MD, JD

Oversight boards are clearly a necessity, but keep in mind that ER volumes declined 50%, outpatient surgery disappeared for a while, doctors offices closed or went virtual, and almost every organization needed to find a new way of doing business during the pandemic. These explain some of the decrease in discipline rates. The question will be whether we see a resurgence in complaints, investigations and actions now that organizations are back open, volume has increased and hospitals are back to business with caseloads and visitors.

—Mike Silverman, MD

It’s really a matter of simple math.  Less visits equals less opportunity for errors and therefore less complaints.  Numbers of visits to the ED have dropped dramatically over the past few months.  This has been a worldwide phenomenon.  In addition, with the fewer visits came higher acuity with many patients at death’s doorstep.  Many doctors’ offices were closed, patients couldn’t get prescriptions filled and many waited due to fear of acquiring COVID-19 at the hospital.  My experience has been most patients are just thankful they can see a physician who is trying to help them.

— Salim R. Rezaie, MD

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