The EMBER Project

The EMBER Project Reaches 1000!!!

Recently my little online outpost passed 1000 visits.  Thanks to everyone who helped me reach that milestone.  I’ve been having a great time sharing my ideas and getting feedback from readers, and it’s been amazing to get responses from Australia to Bolivia to Norway and a dozen other countries.

From the beginning the goal has been to curate a conversation about Emergency Medicine in a way that challenges traditional didactics, explores the tools we use in our daily practice from a new perspective, and puts our well-being as EPs front and center.  I hope to keep developing these ideas and posting more content for you to enjoy over the months and years to come so stay tuned.

Now also seems as good a time as any for some self promotion.  Little blogs like mine need all the help they can get, so please go to our Facebook page and LIKE  us, follow through our RSS feed, or Twitter and get the word out to friends and colleagues who you think may find this site interesting so it can grow.


Jonathan St. George MD

The Daily Cup

Thanks to my NP friend Theresa Salerno for the Daily Cup pick of the week.  For all my EM coffee geeks out there watch and learn.

By the way congratulations Theresa on getting your NP degree, between work and school I know you and coffee are good friends.

Busy Health News Day Over @NYTs

It’s been a busy news day in health over at the New York Times.  There are two good articles to read.  The first is yet another great piece on the lack of benefit found for stents and stable coronary artery disease, and the second is by Dr. Gilbert Welch about the fallacy that early disease detection is always a path to better health.

I can tell you that the mantra of early disease detection is driven into the psyche of every doctor during our training.  As a medical student I always felt a little queasy about the hunt for invisible disease.  It was one of the reasons I chose emergency medicine because I thought (somewhat mistakenly) that the only patients who come to the emergency depart are really sick (they don’t feel well, as opposed to being one of the worried well). But even in my chosen field I can’t escape the most challenging of all patients.  The one who looks fine and feels fine.

The sole reason for this is that there is a voice in the back of my head telling me that if I don’t find any disease it must mean it escaped my detection, and that I have failed my patient.  I imagine to myself that in a week, six months, or six years that patient will go to another doctor and they will find a tumor, heart problems, or a myriad of other diseases, and they and their new best friend Dr. Ifoundit, will say “if only that doctor in the ED had discovered your problem sooner you wouldn’t be in this predicament!”

But what if finding that disease in someone is simply a gateway to anxiety, fear, painful tests and procedures, and a hefty bill rather than a longer or better quality of life?  Suddenly Dr. Ifoundit is not looking so smart.

These articles are a great reminder to patients and physicians alike that the forces pushing for the detection of disease and the forces for better health are not always perfectly aligned, and that if we choose to build our health care system on the former rather than the latter we may find ourselves individually and collectively on a long and painful road.


No Extra Benefits Are Seen in Stents for Coronary Artery Disease, By NICHOLAS BAKALAR, Published: February 27, 2012

If You Feel O.K., Maybe You Are O.K., By H. GILBERT WELCH, Published: February 27, 2012

Who Are Emergency Physicians?

W Eugene Smith. Country Doctor - Life Magazine 1948

I have often tried to explain to friends and family what it is I do, since I find it hard to describe all of the aspects of my job in a concise way. To my ears, most explanations of a typical day in the life of an EP seem vague, long-winded, or self-indulgent.

I often describe emergency physicians as some combination of a modern emergency care specialist and an old-fashioned country doctor.  Sure we take care of critical trauma, strokes, heart attacks, infections etc, but we also deliver babies, set bones, suture up cuts and so on.  This recent attempt by Dr. Marlene Buckler comes across as a more accurate, no-nonsense description.  Thanks Marlene.


I See Dead People – A Journey Into Medicine’s Heart of Darkness

Bruce Willis and Haley Joe Osment in The Sixth Sense

Does anyone remember the movie, The Sixth Sense?  The twist, as everyone knows now is that Haley Joel Osment’s character is not just a disturbed little boy, but actually sees ghosts (really, you didn’t know? sorry), and the well-intentioned child psychiatrist played by Bruce Willis doesn’t know that he is, in fact, dead.

I always found this movie a compelling metaphor for one of the great terrors of life: that at any moment our world can radically change around us, and more terrifying still, it is possible that we may continue on, unaware of our fate until visions become nightmares, and our ignorance is confronted by a painful new reality.

There is a similar drama that plays itself out in medicine every day, where like Bruce Willis, we as the doctors with all of our training in finding and treating disease discover that the effect we are having on patients was quite different from the one we intended, and that we are in fact hurting and not helping.

As a doctor I have to live with the reality that some of my actions may have unintended consequences, but when the foundation that my actions are built on become unstable then those unintended consequences can become a nightmare.

The cognitive errors that lead to this phenomenon are many and varied, and recent medical history is full of them (radical mastectomy for breast cancer, hormone supplements for menopause, COX-2 inhibitors for pain, bisphosphonates for osteoporosis).

Another of these errors is recently well described by Dr. David Newman on his blog over at SMARTEM about the current state of affairs in the world of cardiology, and the literature supporting the use of stress tests and revascularization techniques to treat coronary artery disease.

Like all great medical empiricists, David has asked a simple question.  Where is the observed benefit?  In asking this question he instead unearthed a pervasive flaw in the body of evidence that cardiologists hold up daily to patients as proof that what they are doing for them is in their best interest.

The flaw, simply put is this:  that an intervention for something (opening up or bypassing a clogged artery in this case) is not the same as the the something (heart attack or death from heart attack) itself.  Successfully placing a stent in someone’s coronary artery does not mean you succeeded in preventing a heart attack in that patient, and equating the two may, by a certain sleight of hand, offer some impressive numbers to justify continuing to put stents in people, but they do little to reassure the patient who now has a stent in their heart that all they went through was worth it.  In fact, according to David’s review of the literature.

Studies and meta-analyses have proven repeatedly that except for patients actively having a heart attack, placing stents neither saves lives nor prevents future attacks. This is a discomfiting fact that even the American Heart Association has recently conceded.(1) Furthermore, the most optimistic trial data suggest that, at best, 3 to 5% of bypass surgery patients live longer because of the operation.(2) Thus at least 19 of 20 people who have bypass surgery will not experience a life-saving benefit.

No benefit for stents unless you are actively having a heart attack?  Well, at least there is some small benefit for bypass you say.  But when you add up the personal cost of having your chest sawed open (time in the hospital, pain, complications, etc) just for the one in 20 chance that you may live a few months longer, the benefit seems much more questionable. David sums up the effect this cognitive error has on the practice of medicine like this:

“The great tragedy of flawed study design in research is its legacy. Instead of stress tests being a predictor of what patients care about (having heart attacks or dying), they are a predictor of an invasive, expensive, and largely fruitless techno-bangle. Instead of modern cardiac drugs being proven effective against heart attacks and death, many are effective only at preventing bad tests and unnecessary procedures. In a twisted way this seems useful too, but it’s a dishonest and ineffective approach to preventing real heart problems.”

His plea to “untangle the legacy of past research errors and…to understand and learn from them in order to prevent them in the future” seems an obvious call to reason.  But will anybody listen?

I don’t believe on the whole that it is greed, lack of compassion or intelligence that perpetuates these types of errors, rather something much more frightening to us as doctors.  Our version of the Sixth Sense metaphor: that perhaps without realizing it, our training has led us into a world where healing becomes harm.

For 200 years modern medical training has focused on finding and treating disease in the service of our patients.  As doctors we depend on this training to see through our patients to the disease.  So why wouldn’t a cardiologist, focused on atherosclerosis as the object of his attack, see revascularization as cutting through to the problem rather than a misstep of logic.

But what happens when you are forced to admit that your current field of knowledge is inadequate, and that treating disease is, in this instance, not equivalent with helping the patient.  What happens if your realization of this fact places the body beyond the interventions you were trained to perform?

For many doctors this is an intolerable reality, made even worse by the thought that you might be hurting or even killing some of the people you intended to help.  Better to gloss over and ignore the possibility than address it.  “We’ll get to that later, I have patients to see”.

Whether we  choose to delve deeply into these issues, or skirt them like inevitable ghosts in the machine living furtively in the background, they are questions that haunt all of us as doctors. I have learned to deal with it by asking myself what is it we are about as a profession?

Is the search for disease a means to an end, or is it the end in itself?  Are we going to be technocrats inculcated in a belief system, or are we going to be philosophers and free thinkers; doctors who accept our cognitive errors and try to address them (no matter how jarring it may be to our worldview) in order to benefit our patients.

When we stray from the latter course, it is not because we don’t want health and healing, rather it is that to do so means having to let go of some of the comforts of 200 years of belief that disease always has an objective structure, one that we can “see” and therefore manipulate.  More importantly we have made the grave error in believing that the ability to manipulate a disease process and benefiting patients are always the same thing.

I decided long ago, that while I carry the tools of modern medicine into battle against disease every day in my effort to help patients, I must understand and accept the limitations of my weapons.  In doing so I hope I’m not blindly following dogma, and in turn being a better doctor to my patients.  I also hope I’m a little more prepared when a new paradigm comes along to disentangle us from our current visions and the nightmare of disease.  Sound crazy?  Well everyone thought Haley Joel Osment’s character was crazy too.

Google Doctor Graduates

Oh happy day. Google Doctor Graduates!!!  Team Google has announced a new feature of its search engine that caught my attention.  Apparently (although I tried it today without success) if you have some unexplained symptom and go to Google Doctor (but you would never do that would you?) you will get a new search algorithm working on your behalf.  Here’s what they have to say about it:

Every day, people search on Google for health information…to make the process easier, now when you search for a symptom or set of symptoms, you’ll often see a list of possibly related health conditions that you can use to refine your search (shown below).

This seems to be a very promising beginning, unfortunately the state of medical education is not what it used to be, and Google goes on to explain:

The list of health conditions you see is aggregated from what’s written on the web about the symptoms you searched. The list is not authored by doctors and of course is not advice from medical experts.

We hope this feature makes it easier and faster to research symptoms and related health conditions on Google. We’re humbled by the number of people who turn to Google with such important questions (as are we), and we are working especially hard to make our search results even more useful for health searches.

Thank you Google Doctor, I’m very happy you can come up with a differential diagnosis, now please stop sending all your patients to the ED and start doing the workup yourself.

Sincerely your friendly neighborhood ED physician.

Keeping It Together

It’s about that time of year when senior residents are accepting their first jobs and getting ready to kick ass.  I remember being shocked when I started residency by how much paperwork and administrative requirements there were as a resident.  Bad news, it actually gets worse: between keeping your state license(s), DEA license, bls/acls/pals/atls, hospital credentialing, and on and on and on.  The only way to keep from becoming a raving lunatic bent on anarchy is to become really organized so that it doesn’t dominate your life.  Okay, residents you are about to go through the process so listen up, here are a few tricks I have learned to cope with the bureaucracy.

  • First, find acceptance.  Sure I rant and rave, but it never gets me anywhere and only makes me feel worse so try not to do it (sometimes you just can’t help it, but try).
  • Get your credentials verified over at the FEDERATION CREDENTIALS VERIFICATION SERVICE (FCVS).  At some point you will want to move, or get a second state license, and this service will get all of your basic credentials verified and stored in one place and then keep them available for whomever you want to send them to.  Sure you could get each piece of your medical training history from the USMLE to your MD diploma, to your ABEM credentials over and over and over for each application, but why would you want to.
  • Scan all your credentialing documents and put them in a Google documents or Dropbox account.  By my count I have 21 separate pieces of paper that a hospital credentialing person may want at any given moment to complete my application.  I remember how the gloom would spread over my day as I contemplated having to go home, find the document, find a fax machine, find the fax number, send it, and then call the next day to see if they got it.  Now multiply that by a dozen times or so during the process, and you can get pretty frustrated.
  • Dropbox is a free and invaluable cloud storage locker.  Scan your documents once, upload them to Dropbox (keeping them safe from harm or getting lost), and now whenever someone asks for a copy of your DEA license or ATLS, you just email the link to them and your all done. Nothing is more satisfying than getting an urgent note from a credentialing person about how they don’t have a copy of your medical school diploma, tapping on your iPhone once or twice, and then getting back to your coffee and your book and forgetting about it.

Desktop image of all my credentials on Dropbox

  • Set up reminders in your calendar six months before something expires so you can make a plan to get it renewed.  You know how quickly a couple of years can go by.  Most credentials require renewal, there are a lot of them, and the list continues to grow, so stick it in your calendar and plan ahead.  You don’t want to find out that you can’t get your hospital credentials renewed unless you take that ACLS course on the only day you have off with your wife.  I promise you it will happen.
  • Plan for the expense and keep a list of all your receipts.  As a doctor there is no end to the number of people who want to get between you and your money (for your own good of course) in the credentialing world.  Doctors are easy targets.  75 dollars here, 300 dollars there, it adds up.  At least you can claim some of it as a tax deduction.  I’m not a tax expert so I won’t talk about what and how much, but just keep the receipts.

Now, I’m not the most organized person in the world ,so if you are, and you have some more advanced techniques in this area of an EM doc’s life please, please share your knowledge here in the comments or visit us on Facebook and leave your pearls of wisdom there.  Thanks.

The Daily Cup – Feeling Human Again


Coffee and doctors seem synonymous, but there is another reason it finds its way onto this blog.  The EMBER Project is about exploring all aspects of daily life for emergency physicians and how we find ways to keep doing our job.  In order to be of any use to anyone we have to take care of ourselves, and while coffee is a way to prepare for work, it’s also a ritual I perform on my days off when I need to reconnect with just being human again.

Jamie making perfect shots

One cool thing about being an emergency physician, is that unlike the 9-5vers, I can just have a regular Tuesday afternoon off.  This gives me a chance to hang out with my more bohemian neighbors at 10:45 am and pretend I’m not really a uber responsible geek who just happens to live in the east village surrounded by people more interesting than me.

A Perfect Latte In My Favorite Cups

So after a string of shifts, Abraco is one of those places where I reclaim my personal existence again. A little conversation, a little time to just sit and enjoy the morning, a chance to enjoy a perfect NYC snapshot of people living their daily lives.  Now I don’t know if the owners of one of my favorite little places know how much I appreciate what they do for my spirits (beyond making a perfect cup of coffee and a delicious slice of olive oil pound cake), but I love them for it.  Thanks.

Waiting Patiently Outside

Tools to Live By – PediStat

I can remember as a resident some of my mentors throwing up their hands in despair when I couldn’t remember the normal respiratory rate for a 3 yr old. Now, I do think there is a databank of key information that you need to be able to recall at a moment’s notice, but with the advent of the mobile peripheral brain (iPhone) I’ve begun to rethink what is actually important to keep in my brain.

Now I know there are purists out there who will be chagrined at my saying this, but not remembering is liberating.  With the purchase of my iPhone I have found I spend less time worrying about things like medication doses and how to calculate ideal body weight, and spend more time on higher order thinking (like about my patient and what’s wrong with them).  Sure, if there’s an electromagnetic pulse over the United States I’m screwed, but for now I’m going with it.

So here is my all time favorite Peds ED app in the peripheral brain category.  Like most ED docs with a sick kid, my brain goes out the window, does a couple of laps around the ED,  and then needs a good slap to calm down.  Sick kids are scary.  So in the first 30 seconds of the resuscitation I would rather have my eyes on the kid and be working on what’s wrong, than trying to figure out the dose of atropine.

Enter Pedi Stat, this lovely app needs only one little bit of information like weight, age, height, or Broselow color to give you everything you need to effectively care for your patient.  All the vital signs, medications, equipment sizes and essential algorithms for seizure, PALS, hypoglycemia and more at your fingertips.  Whew!!!  Now I can get back to the patient, and when the nurse calls out for the next medication I won’t be stressed.

Are You Ready to Have Your Mind Blown?

Education is like baking.  It’s pretty easy to measure out the ingredients, but mixing them together in just the right way to make something amazing is really, really, really hard. For me, great educational content is engaging, relevant, accessible and then adds that little bit of seasoning to make you want more.  Well look no further, sit down, grab a plate and slice yourself  big slab of this EM content from our friends over at TheNNT.

I’ve been a huge fan of this site for a while, and I have it on my short list of must go to EBM (evidence based medicine) content. I share it with residents late at night as a jumping off point for conversation, with patients, and even friends who are interested in knowing how good (or not) the therapies we offer them really are.  The group over at The NNT describe their work like this:

The NNT is an intuitive and simple way of estimating how likely it is that a treatment or medicine will help an individual person.

And they are right.  The first time I found this site, I couldn’t stop clicking through the categories, it was addictive and frankly mind-blowing.The NNT makes the numbers accessible at a glance, but for EM people with some time on their hands, I suggest taking the time to go through their tutorial about how they get the numbers.  It’s a nice refresher (particularly for a person like me, who never feels entirely comfortable with his knowledge of statistics), and then head down to the “where we get the numbers” section of each entry to see the methodology and the references. In this age of big pharma, and questionable composite end points, it is really nice to find a smart, unbiased source of very useful information where truth still rules.  Enjoy.

Example of TheNNT at work

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My favorite new iPhone app

Say hello to my little friend. I love EM podcasts, one of my favorites is SMARTEM by David Newman and Ashley Shreves. I usually listen to podcasts on my iPhone, but Apple and iTunes have really fallen flat when it comes to aggregating and organizing podcasts on your phone. Enter Instacast. This little app lets you subscribe, stream, or cache podcasts for later consumption all inside one nifty app that automatically updates itself with new content, and with Apple’s new ios5 software you get a nice little notification on your screen when a new episode is available from one of your favorite podcasters. LOVE IT!!!!

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