Low Risk Chest Pain in the ED

I had a conversation with a few of the residents about the management of low risk chest pain in the Emergency Department. The issues which always seem to come up are:

• If the first troponin is normal, can I send them home?
• I don't think this is cardiac, let's just get one troponin and then send 'em home.
• Okay fine, let's just do two sets and then send 'em home.

The patients which are obviously cardiac and obviously not cardiac are easy, but what about those ones in which there's some question?

Interactive Medical Cases

With the advent and ongoing evolution of online medical education several excellent interactive case management simulations have been developed.  Below are two of those outstanding simulation resources:

1. NEJM Interactive Medical Cases
2. DIEM (Digital Instruction in Emergency Medicine) courtesy of CDEM

Enjoy!

VIPER: Video Instruction of Procedures in ER

The following link is to an excellent blog for Emergency Medicine named 'Academic Life in Emergency Medicine'.  Dr Michelle Lin is the author of the blog and an Associate Professor in the Department of Emergency Medicine at UCSF. Enjoy...

Click Here to visit VIPER

SBP: Understanding Malpractice 2

Just a little education on medicine and the law

There are two kinds of legal action within the law. Criminal action is when the government sues an individual for going against public interest - such as murder, rape, robbery. Physicians usually are not subject to these sorts of cases, unless they wilfully hurt their patients. Malpractice insurance won't cover you against criminal action.

Civil action is when one individual sues another. When wrongdoing (such as negligence under which malpractice falls) is involved, this is called tort. In order to be prosecuted for medical malpractice, the plaintiff needs to prove four things:

1. The physician owed the patient a duty of care. This happens whenever anyone comes into an Emergency Department. We are obliged to see this patient.
2. The physician falls below the standard of care. This means the physician didn't do what an average physician would do in the same circumstances. This is what the jury decides. If there's a recognizeable standard of care, this is what the doctor will be held up against. If there isn't, then they may call in expert witnesses.
3. The patient sustained harm. This can be morbidity or mortality suffered by the patient, but also loss of wages, pain and suffering, etc.
4. The harm is a result of not meeting standard of care, that is the negligence of the physician caused the injury. Not all bad outcomes are the result of the physician.

What do you think the cost of defensive medicine is? How can it be reduced? Given these four aspects necessary to win a verdict against a physician, pick a diagnosis and list everything that must be met in that particular case in order for damages to be awarded to the plaintiff.

SBP: Understanding malpractice

Lawsuits are one of the most dreaded possibilities facing doctors. Within Emergency Medicine, missed fractures, retained foreign bodies, MI's, and ectopic pregnancy are our most common causes of lawsuits. Whether we like to admit it or not, it does affect our practice.

Given your experience in the Emergency Department so far, how would you suggest we protect ourselves from these foils?