Ask Me Anything – Kevin Klauer, DO, EJD, FACEP

Alex, Great question. I’ll now expound on this question for the next two hours!

Wait just a minute!!! A new source of insomnia for me is the acute reduction of blood pressure in ischemic stroke to facilitate administering tPA. tPA is controversial, maybe beneficial, certainly harmful to some. However, lowering MAP decreases CPP and thus puts acute cerebral watershed areas at risk. Hypertension in ischemic stroke is cerebroprotective. There is no cause and effect between acute hypertension and ischemic stroke. BAM!!!!

OK. Alex Back to you my friend.

1. Explosion of technology good and bad
2. Regulatory aspects of care delivery have become insanely complex.
3. My hair is a lot longer!

John, really hard to narrow this down. Let’s hit some risk management (RM) basics. Three primary areas of litigation or cause of action against EPs are: Failure to Dx, Delay of definitive care and Errors in procedures.

So, in critically ill patients, we need to stabilize efficiently and safely, while being mindful of when the ED has served its purpose.

1. Talk to patients and families about their clinical condition. Let them know the risks of procedures and the potential bad outcome they may experience from their disease. I’m amazed that we don’t tell septic patients (and obtain informed consent) about the risk of pressors. We may need them to improve your blood pressure (not so sure about outcomes, another myth is surfacing), but when we do, you will likely lose a digit or extremity due to peripheral vasoconstriction. Yet, we are surprised that they sue when they experience these outcomes.
2. Consult when needed.
3. Do not exceed your capabilties

Thanks John, but really Baker Hamilton is the brain behind running this. I’m just filling in today:)

Cory,

Knock it out of the park my brother!!
Every interview question is an opportunity to tell them something vital about you. Sure, answer the question directly, but make certain you illustrate why you are “the one.” Highlight the strengths, then a weakenss, but show it as a strength by how you have or are growing in that area. You have the power of choice. If your weakness is poor impulse control and you frequently run naked through the ED, leave that one out!

Emergency Medical Abstracts are a favorite. I try to perform regular pubmed searches and it is key to search places beyond your comfort level. It is always fun and gratifying to share information that others haven’t identified yet.

“Guest,” another great question. Refusal forms aren’t worth the paper they are printed on if the informed discussion for the informed refusal is absent. Talking to the patient and getting the informed refusal is more important than a signature on a form. So, if I had to choose, I’d much rather you discuss in the EMR that the pt had the capacity for medical decision making (C,A and Ox4) and understands the risks and benefits of all treatment options and of their refusal (specifically what the risks are). Standard refusal forms have a signature and what they are refusing, but in no way indicates that they understand what could happen due to their refusal. ALWAYS INCLUDE THAT THEY CAN COME BACK ANYTIME

This must start during medical school and residency. Crazy that we expect people to disclose freely, but are taught in a punitive environment.
Step 1. Understand that most errors are multifactorial
Step 2. Most errors are blamed on the last provider to touch the patient, very rarely is that the case.
Step 3. If we freely disclose and do not blame, the world becomes a safer place.

Looking forward to the day when we are rewarded and incentivized for reporting our events that didn’t go according to plan

Wow.. I will have to google that one. New term for me
I have been enriched by you 🙂

Hmmmm. I don’t want to sound self promoting at all, but you know what you are close to. I think the ACEP ED Directors Academy is great! Harvard Business Review has great leadership articles also. Personal experience is key. Get involved. If you are already, then get involved in new ways, pushing your comfort zone

Just stick to the facts. They cannot be refuted. No emotion or frustration in the medical record.

Conflict resolution. I wanted everyone to be happy. Well, somedays, everybody isn’t happy. So, I knew if difficult conversations needed to occur, I tried to develop the skill to do this effectively, but not kindly. Effect does not = mean or insensitive

RUN!
Actually, it depends on the reporting relationships and your position, as well as your relationship with them. If you can go to them, then one on one is best. If you both report to the same person, let that person know that the behavior is interfering with your ability to do your job.

This is a frequently overlooked, but important educational component of one’s training. Many heavily academic sites are great at training academicians. However, most will take community, non academic ED positions. Teaching needs to include the why, how, regulatory requirements and the practical application of how to get it done in the real world

Used to be elderly delirium, but now the eval has become fairly routine. It was unsettling to not be able to get a history. When you accept it and go with what you can get, no more frustration.
Now, it is end of life. I tend to be pushing the envelope, I believe on behalf of my pts. If they will not survive or will have false hope, etc. I am frequently amending advanced directives to meet their needs and withdrawing care in the ED. Those not used to this, wonder why we aren’t “doing all that we can.” We should do the “best that we can” which sometimes means intentionally not doing all that
we can.

If you ask me, I’d say I’m a master at knowing the limits. But, opinions do vary. I have
been married for 22 years. My wife has her frustrations with me and what I like to do professionally. However, she and my 3 kids have no doubt I love them and they are #1. Words and actions. Either alone is not good enough

Here is a crazy thought. Why don’t we assess on the front end what people want? Certainly, there are basics that everyone needs to know about, clinically and administratively. However, if we know a career path early on, we should tailor the educational experience to the needs of the learner. One size does not fit all in EM education!!!

There have been mostly good influences. I’ll stick to those.
The most wonderful man and friend I have ever met in EM who has influenced me personally and professionally is my friend Rick Bukata. A rare combination of selflessness, intellect and kindness

1. My father: The youngest pilot ever hired by Delta airlines at 21 y/o and the youngest 4 engine captain for Delta. He’s 73 now and retired. Great communicator.
2. Mother: Always able to see what others could not in individuals, including me.
3. Wow, I’m getting weepy now. next question please 🙂

It’s interesting how we have the wonderful opportunity to look into another person’s life at a time of great vulnerability, but to later let the memories fade.

One case I recall is a guy with traumatic aortic injury and LeForte 3 who needed an awake cric. Survived and I saw him about a year later in the same ED for a minor illness.

Cory, Let me think…I recall a pediatric resuscitation in a newborn. Perhaps, the outcome was predetermined. I believe the resuscitation was carried out appropriately. However, it helped me to understand that the family is equally important as the patient. I am a fan of family witnessed resuscitation and involving them at the bedside if they want to be.

Alex,

My career began in formal academics and have continued to teach as I have pursued other opportunities. I could easily see myself in a formal academic setting in the future.

Dude! I love looking ahead. I just don’t always like what I see. We need to expand the scope of EM to be what others cannot and are not willing to be. We are the home for the homeless, the arbiters of end of life decisions at the right time, the interface for those with chronic conditions, etc. Now, we just need the resources to meet the demand. The patients have selected us. The federal and state governments need to recognize and respect that choice!

Show them something new. Also, show them the impact they can have just by their interactions. Medicine is not about expensive tests and journal articles. It is about the art of communication and understanding fears and needs of our patients, while motivating them to help themselves.

CAUTION. If any nurse feels you are unsympathetic to nurses, that can tank your reputation. If there are performance issues, use the established chain of command (e.g. ED Medical Director, ED Nurse Manager). Bring examples, not complaints

Insightful question. I would advise not doing (committing) medical malpractice. It’s messy and not a lot of fun. Just kidding of course.

This really depends on what you are after in life and what motivates you. I have to be honest here.
1. The plaintiff’s side is where the big money is.
2. However, defending your colleagues in a system that is fraught with challenges that they are often not trained or equipped to deal with, is a wonderful pursuit.
3. If you become a plaintiff’s attorney, try to make certain you are doing the right thing, as you will know the medicine and cannot claim you don’t

Alex, I’ll reflect on my previous thoughts and comments, regarding out
expanded scope of practice. If we expect to see traumas and MIs only, we are in the wrong business.

Clinically?
1. The disposition is the most golden thing ever. If you can dispo, do it.
2. No unecessary tests that cloud your mind and your judgment and slow things down.
3. Dispo
4. Dispo
5. Dispo

Establish whether or not he has medical decision making capacity (not drunk or head injured, orientated, understand everything), then you technically can’t do much. However get to the root, it is likely fear. Police, pain, being reported to family???? Then negotiate a limited work up. When in doubt treat (when reasonable) If the patient’s behavior is incredibly unreasonable, and no one would likely make the same decision, they may not have medical decision making capacity. Recent court ruling on rectal exam for head trauma pt. He was fine and oriented and said no. Court ruled in favor for defense.

I was a paramedic before going to medical school and during. So, my fate was sealed. However, in my second year at LSU, I was offered a neurosurgery spot after someone vacated the spot. I thought about it, but just couldn’t change.

All out of wisdom Alex, but I certainly hope there was some along the way. I appreciate the opportunity to participate.

Sincerely,

Kevin