- Email: [email protected]
“I Think” Is Cheap; “I Am Sure” May Cost You
Correspondence 1. Hunt GR, Crealey G, Murthy BV, et al. The consequences of early discharge after hip arthroplasty for patient outcomes and health care costs: comparison of three centres with differing durations of stay. Clin Rehabil. 2009;23:1067-1077. 2. Chalfin DB, Trzeciak S, Likourezos A, et al. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med. 2007;35:1477-1483. 3. Srivastava R, Stone BL, Patel R, et al. Delays in discharge in a tertiary care pediatric hospital. J Hosp Med. 2009;4:481-485. 4. Wong H, Wu RC, Tomlinson G, et al. How much do operational processes affect hospital inpatient discharge rates? J Public Health (Oxf). 2009;31:546-553. 5. Fonarow GC, Abraham WT, Albert NM, et al. Day of admission and clinical outcomes for patients hospitalized for heart failure: findings from the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE-HF). Circ Heart Fail. 2008;1:50-57.
“I Think” Is Cheap; “I Am Sure” May Cost You To the Editor: With great interest I read Dr. Coulehan’s original essay in Health Affairs (where I too publish narratives) and the News and Perspective piece by Eric Berger reporting it in February 2010.1 Dr. Coulehan recounts visiting the emergency department (ED), complaining of isolated severe unilateral facial pain. Although he reports diagnosing shingles “over a hundred times” in his long and accomplished career, Dr. Coulehan himself was unconvinced this diagnosis explained his pain. Yet after his ED workup turned out negative and the classic rash appeared over time, Dr. Coulehan blamed the emergency physician for inexperience and an unnecessarily complex workup costing $9,000. I wish to ask Dr. Coulehan if his life and vision are worth the money. As an academic emergency physician, I must object to the label of “excessive testing” applied to this case. Emergency physicians are experts in treating patients whose symptoms are so severe they are unwilling to wait for primary care appointments. Our workups reflect this expertise. Dr. Coulehan did not have an obvious case of shingles, but a subtle one (facial pain without a rash) and in a location (around his eye) where pathology that threatens life and function frequently presents. A differential diagnosis including ocular, neurologic, and vascular pathology is mandatory for an emergency physician worth the weight of his stethoscope.2 Physicians experienced with the slit-lamp and with ocular zoster know that corneal pathology can be subtle at an early stage or absent when the disease presents with scleritis, uveitis, or optic neuritis.3 Hence, an examination by a readily available ophthalmologist in a patient whose vision is essential to his quality of life is a reasonable consultation request. Furthermore, the consulting neurologist’s pickup of subtle ptosis may have been an essential clue to an impending neurovascular catastrophe. Dr. Coulehan’s understandable frustration from having to repeat inconclusive imaging does not make that imaging any less necessary to rule out severe pathology before it is too late to salvage the patient. 204 Annals of Emergency Medicine
There are several alternate and very plausible endings to Dr. Coulehan’s eloquent essay. Instead of simply facial zoster, he could have had zoster ophthalmicus discovered by the ophthalmologist, or a cavernous sinus thrombosis on the magnetic resonance imaging requested by the neurologist. Either pathology would have been appropriately treated, saving his vision or his life. Then Dr. Coulehan would be celebrating the well-trained and caring emergency physician, whose VIP patient in denial and the complexity of the necessary workup did not deter him from providing the high-quality care necessary to ensure a good outcome. Patients fortunate to have nothing seriously wrong in the end often love to say that the ED “made a big fuss over nothing.” Emergency physicians playing “chess with God”4 for the lives and limbs of their patients with early and subtle clinical pathology are not so quick to judge. Boris D. Veysman, MD Department of Emergency Medicine, UMDNJ/Robert Wood Johnson Medical School New Brunswick, NJ doi:10.1016/j.annemergmed.2010.02.021
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The author has stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. 1. Berger E. A $9,000 bill to diagnose shingles? Ann Emerg Med. 2010;55:A15-A17. 2. Duong DK, Leo MM, Mitchell EL. Neuro-ophthalmology. Emerg Med Clin North Am. 2008;26:137-180, vii. 3. Opstelten W, Zaal MJW. Managing ophthalmic herpes zoster in primary care. BMJ. 2005;331:147-151. 4. Veysman BD. Chess with God. Ann Emerg Med. 2010;55:123-124.
Improving Handoffs in the Emergency Department To the Editor: I read with some enthusiasm the article by Cheung et al and the accompanying editorial in the February issue of Annals,1,2 focusing on handoffs that regularly occur between emergency physicians. At our Level I suburban teaching emergency department (ED) with 58,000 annual visits, we have made significant improvements in our handoffs, utilizing several other tactics that were not mentioned in the original article. Sensing episodic dissatisfaction between providers, we made the decision that our emergency physician culture would be defined by the assumption that the new, fresher physician assuming care from the physician at the end of his or her shift Volume , . : August
“I Think” Is Cheap; “I Am Sure” May Cost You To the Editor: With great interest I read Dr. Coulehan’s original essay in Health Affairs (where I too publish narratives) and the News and Perspective piece by Eric Berger reporting it in February 2010.1 Dr. Coulehan recounts visiting the emergency department (ED), complaining of isolated severe unilateral facial pain. Although he reports diagnosing shingles “over a hundred times” in his long and accomplished career, Dr. Coulehan himself was unconvinced this diagnosis explained his pain. Yet after his ED workup turned out negative and the classic rash appeared over time, Dr. Coulehan blamed the emergency physician for inexperience and an unnecessarily complex workup costing $9,000. I wish to ask Dr. Coulehan if his life and vision are worth the money. As an academic emergency physician, I must object to the label of “excessive testing” applied to this case. Emergency physicians are experts in treating patients whose symptoms are so severe they are unwilling to wait for primary care appointments. Our workups reflect this expertise. Dr. Coulehan did not have an obvious case of shingles, but a subtle one (facial pain without a rash) and in a location (around his eye) where pathology that threatens life and function frequently presents. A differential diagnosis including ocular, neurologic, and vascular pathology is mandatory for an emergency physician worth the weight of his stethoscope.2 Physicians experienced with the slit-lamp and with ocular zoster know that corneal pathology can be subtle at an early stage or absent when the disease presents with scleritis, uveitis, or optic neuritis.3 Hence, an examination by a readily available ophthalmologist in a patient whose vision is essential to his quality of life is a reasonable consultation request. Furthermore, the consulting neurologist’s pickup of subtle ptosis may have been an essential clue to an impending neurovascular catastrophe. Dr. Coulehan’s understandable frustration from having to repeat inconclusive imaging does not make that imaging any less necessary to rule out severe pathology before it is too late to salvage the patient. 204 Annals of Emergency Medicine
There are several alternate and very plausible endings to Dr. Coulehan’s eloquent essay. Instead of simply facial zoster, he could have had zoster ophthalmicus discovered by the ophthalmologist, or a cavernous sinus thrombosis on the magnetic resonance imaging requested by the neurologist. Either pathology would have been appropriately treated, saving his vision or his life. Then Dr. Coulehan would be celebrating the well-trained and caring emergency physician, whose VIP patient in denial and the complexity of the necessary workup did not deter him from providing the high-quality care necessary to ensure a good outcome. Patients fortunate to have nothing seriously wrong in the end often love to say that the ED “made a big fuss over nothing.” Emergency physicians playing “chess with God”4 for the lives and limbs of their patients with early and subtle clinical pathology are not so quick to judge. Boris D. Veysman, MD Department of Emergency Medicine, UMDNJ/Robert Wood Johnson Medical School New Brunswick, NJ doi:10.1016/j.annemergmed.2010.02.021
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The author has stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. 1. Berger E. A $9,000 bill to diagnose shingles? Ann Emerg Med. 2010;55:A15-A17. 2. Duong DK, Leo MM, Mitchell EL. Neuro-ophthalmology. Emerg Med Clin North Am. 2008;26:137-180, vii. 3. Opstelten W, Zaal MJW. Managing ophthalmic herpes zoster in primary care. BMJ. 2005;331:147-151. 4. Veysman BD. Chess with God. Ann Emerg Med. 2010;55:123-124.
Improving Handoffs in the Emergency Department To the Editor: I read with some enthusiasm the article by Cheung et al and the accompanying editorial in the February issue of Annals,1,2 focusing on handoffs that regularly occur between emergency physicians. At our Level I suburban teaching emergency department (ED) with 58,000 annual visits, we have made significant improvements in our handoffs, utilizing several other tactics that were not mentioned in the original article. Sensing episodic dissatisfaction between providers, we made the decision that our emergency physician culture would be defined by the assumption that the new, fresher physician assuming care from the physician at the end of his or her shift Volume , . : August