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ALiEM Bookclub: Bouncebacks! Emergency Department Cases: ED Returns

2016-11-11T19:45:21+00:00

bouncebacks

There are many pitfalls the practicing Emergency Medicine practitioner can encounter,  but hopefully avoid during their time in the ED. Bounceback patients, the ones who come back the next day, usually worse off than the day before, are definitely dreaded events that most would like to avoid. Of course, the ideal goal would be to never have that happen to you or your patients, but that is just not realistic. That’s why Bouncebacks! can be integral to anyone’s reading list.

The smart doctor is not one who learns from his own mistakes, but from the mistakes of others. Here’s hoping that this book is read by a lot of smart doctors. – Dr. Greg Henry

Synopsis

Bouncebacks! Emergency Department Cases: ED Returns is a collection of cautionary tales and pearls of wisdom about the return patient who plagues both the seasoned physician and resident alike. If you are not intrigued and terrified by bouncebacks before reading the book, some startling numbers at the beginning will definitely grab your attention. According to the authors, approximately 3% of all patients will bounce back. In 2005, out of 115 million ED visits, it is estimated that 34,500 patients died within 7 days of their initial ED visit, including 10,350 unexpected deaths that may have been related to a medical error. For a practitioner that works 30 hours per week, he or she will average one bounce back per shift, and over the course of a career may send home 17 patients that will die unexpectedly within 7 days.

For those truly aghast by those statistics, Weinstock provides a 2-step, simple plan of action that is detailed in the introduction of the book with suggestions of how to implement it.

  1. Identify high-risk patients being discharged
  2. Review their evaluation and management prior to discharge

The remainder of the book is dedicated to case discussions. The cases highlight many high-risk chief complaints in different patient populations; for example, “abdominal pain” is reviewed in the geriatric patient, pediatric patient, the pregnant female, and in those presenting with trauma. Some cases highlight challenging patients, such as those with language or cultural barriers, patients who lie, and patients who are looking for secondary gain.

Each case begins with the chief complaint followed by the initial visit chart. The chart is left unedited to highlight areas of inconsistencies. Following the initial visit, a commentator, Dr. Greg Henry, analyzes and provides pearls of wisdom. The cases are also graded based upon the following metrics:

  • Appropriateness of charting
  • Evaluation of the patient
  • Risk of illness being missed
  • Other risk management issues

The next section in the chapter details the subsequent visit(s) that followed and the eventual outcome, including hospital course if known. Each chapter ends with a discussion of the salient points of the case, including pearls on the approach to the particular chief complaint, lab and radiologic evaluation, differential diagnosis and management. Finally, there is a brief summary of the case and take-home teaching points.

Using BounceBacks as a learning tool

So how can medical practitioners use this book to further their education? Consider replacing some of the more traditional Morbidity and Mortality educational conferences with a BounceBack conference. A presenter could walk the audience through the initial case followed by commentary from a selected audience member who is blind to the outcome. A discussion of the subsequent visit and conclusion of the case would follow. Using each bounceback as a learning tool, learners could acquire invaluable tips on optimal charting and decision-making to help avoid medical errors.

Discussion questions

  1. How do you identify high-risk cases when working in a busy ED?
  2. What charting tips will you take from Bouncebacks?
  3. Which case in the book sticks out to you? How would you have changed your initial visit to prevent return visits?
  4. Are there any cases in your own practice where you have had a bounce back? Do you treat these cases differently or change your management on the second visit?

Google Hangout Discussion February 23, 2016

Soundcloud Podcast Version from the Google Hangout

Final thoughts

The practice of Emergency Medicine is tough. We work in a busy place, where critical decisions need to be made with imperfect, incomplete information. Bouncebacks will happen, but this book highlights ways in which we can try to prevent them and ultimately improve patient care and safety. This is a must read for all clinicians.

* Disclaimer: We have no affiliations financial or otherwise with the authors, references or hyperlinks listed, the books, or Amazon.

Zach Risler, MD

Zach Risler, MD

Emergency Medicine Chief Resident
Drexel University