James Nelson MD
@tothebedside
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Emergency physician #Physicaldiagnosis, #bedsidemedicine, #diagnosticreasoning
San Diego, CA
Joined August 2020
Restore patient ownership of physician orders, like when they left the office with paper orders in hand. Email a secure Rx/diagnostic order usable at any pharmacy or imaging center.
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Dry LP, no fluid? Have the patient Valsalva or cough if you think you might be in the right place 1/2
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Capacity to leave AMA from ED is NOT 1) Capable of affixing signature to hospital paperwork 2) Orientation x 4... It IS: understanding one's condition, choices, anticipated consequences of each.
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Level 6 does not always apply, but with experience, is the governance level: "This problem fits a pattern we see. Here is the policy we can implement centrally that would not only solve this problem, but prevent the others like it."
I stole this idea and now use it with every single employee. It’s the best illustration I’ve seen of teaching someone to be high agency. It says there are 5 levels of work: Level 1: “There is a problem.” Level 2: “There is a problem, and I’ve found some causes.” Level 3:
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For example, the patient who presents with a fever, and buried in the past medical history is a prior encounter for an infection that speciated to a specific organism. 2/2
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One of the best things AI will eventually do for emergency/hospital medicine is take all the disparate and complex history and establish a clear prior probability for the patient's presentation 1/2
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Aside from being the right thing to do, it also works for those patients who have a bad habit of blaming others for their problems. Redirecting their energies to what they can do is the best thing for them. 2/2
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Essential bedside skill we need to teach in residency: The gentle scold. Some patients are not doing enough for their health. I empathize with how much work it is for them but tell them if they do not do the work they will go downhill (eg managing diabetes, etc). 1/2
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"The best interest of the patient is the only interest to be considered." -William Mayo, M.D. Founder, @MayoClinic
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Yes! And it makes work more fun too.
7. HEALTHCARE IS A TEAM SPORT "Thank you for this interesting consult" snark notwithstanding, a hospital thrives on multidisciplinary cooperation Respect what other services can do than you cannot Synopsize the case rapidly & phrase your questions for them precisely
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This saves time too! Go immediately to the bedside and resolve it in seconds.
5. IF NURSES ASK YOU TO SEE A PATIENT, DO SO Their (highly proximate!) clinical judgment matters too Best-case scenario? You can intervene meaningfully in the care of a patient in extremis "Worst"-case? You can reassure everyone (yourself included) & rest easier afterwards
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We didn’t train for years to answer to bureaucracy. We are trained to care for people. Let us do what we were called to do.
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Sepsis: 25% mortality. Sepsis + CHF as high as 90%?
pubmed.ncbi.nlm.nih.gov
Acute heart failure (AHF) is a common clinical challenge that a wide spectrum of physicians encounters in every practice. In many cases, AHF is due to decompensation of chronic heart failure. This...
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Medication shortage disrupting your hospital operations? Work with pharmacy to create a drug substitute protocol, so that the doctors are not stuck in convoluted EMRs, trying to write an order for something not yet in the system.
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As one grows in their interpersonal skills, the shifts become less and less effortful. Knowing people well makes it easier. 3/
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You have to be able to read other patients or other specialists, and infer what brings out their best and their worst, read that quickly, and adapt to bring out their best 2/
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In emergency medicine, when a resident is told they have to improve their interpersonal skills, they sometimes take it personally. But the reality is the negotiations required just to get through a shift are extremely high level. 1/
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As the complexity of hospital care increases, inefficiencies increase. Solving the day's top problems accumulates like compound interest and creates a better experience for patients and those who provide care.
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