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Emergency Medicine: Neil Khanna
27 Plays5 years ago
Season 1, Episode 4: Dr. Neil Khanna is a fourth year emergency medicine resident in the University of Michigan's Healthcare System. Listen to Neil talk about the fast pace of emergency medicine and appropriate techniques for delivering bad news to patients' families.
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Transcript
Introduction and Guest Overview
00:00:09
Speaker
You're listening to The Wound Dresser, a podcast that uncovers the human side of healthcare. I'm your host, John Neery.
00:00:21
Speaker
Today, my guest is Dr. Neil Khanna.
Dr. Khanna's Medical Journey
00:00:23
Speaker
Dr. Khanna is a fourth year emergency medicine resident physician in the University of Michigan Medical System and a graduate of Northwestern's Feinberg School of Medicine. His research interests have varied across ultrasound imaging, palliative care, and diagnosis of pediatric concussions. Neil, welcome to the show.
00:00:42
Speaker
Hey John, thank you. I'm excited to be here. So first I just want to hear about your journey into emergency medicine and whether it was the fast-paced environment or perhaps something else that led you to that specialty.
00:00:54
Speaker
Yeah, absolutely. So as happens with most med students, I bounced around pretty much every specialty, thinking I was going to go into ortho, general surgery, internal medicine, OB, kind of bounced all over, and ultimately landed on emergency medicine, of course, for a few different reasons. I'd say the biggest one is that
00:01:19
Speaker
You don't really in medicine these days get the truly undifferentiated patient in any setting other than the emergency department. What I mean by that is medicine has become very specialty driven. So really the diagnostic
00:01:41
Speaker
mysteries and the initial workups are things that are primarily left up to the emergency department team, which is a huge driver of why I went into the field. Additionally, for me, the resuscitations that we deal with in the emergency department of the coding crashing patient was a big draw for me. I think that some of the environments under which I perform the best
00:02:09
Speaker
And I think those are kind of major reasons why I went into emergency medicine.
Thriving in High-Pressure Situations
00:02:13
Speaker
I'd say it's pretty similar across most emergency department physicians, both the ability to actually work up an undifferentiated patient and become a true diagnostician as well as an expert in resuscitation. Wow. Why would you say you work best in a resuscitation situation? Is it just the heat of the moment that makes you thrive?
00:02:37
Speaker
I think so. I think it's just the that pressure, that pressure cooker environment that just personally I think I do a lot better in as opposed to
00:02:50
Speaker
dragging my feet and having a whole day to spend on ruminating over a case or something like that. Just having a patient in front of you who really needs you and they're not doing very well and their outcome really depends on your quick decision making. Just that entire idea really appealed to me. And I like to think that that's something that I'm good at in an environment that I do well in.
00:03:18
Speaker
I imagine it could go the other way too, right? Where some people in those situations would panic and have somewhat of a meltdown. Have you seen the consequences of not being able to handle the pressure in the emergency room? Oh, absolutely. And this is not to say that I kind of walked into the emergency department and immediately felt as confident and comfortable as I am now.
Residency System in Emergency Medicine
00:03:43
Speaker
It was actually quite the opposite.
00:03:45
Speaker
where early on in training, whenever resuscitation would come in, I'd certainly get nervous and feel the heat of the moment and kind of shy away a little bit. I think it's part of why the training is so rigorous and why residency is so difficult because you're really
00:04:03
Speaker
Taking someone who is nervous and uncomfortable and doesn't want to necessarily be involved in making those calls and developing them into a team leader. So yeah, I personally absolutely felt that way when I first was starting out in my first couple years of residency where I.
00:04:24
Speaker
didn't really know and I certainly drew blanks and just kind of had that deer in the headlights look on me. And it's tough, it's a difficult thing to get comfortable with that and I don't think that anybody really can just walk into that role and immediately succeed. I think there's a lot of human emotions that go through that are inevitable and
00:04:50
Speaker
Because of that, it does take some time before you are comfortable working in an emergency department and running a resuscitation. Sure, sure. Now can you talk about how the resident system is set up in the emergency department? It seems that the emergency room would be a very peculiar place to learn because mistakes there can be fatal.
00:05:12
Speaker
Can you talk about how the hierarchy is set up with first year, second year, third year, et cetera, and how the residents work hand in hand with the emergency physicians, and ultimately how the system is set up such that learning occurs, but also there are the best outcomes for the patients?
00:05:35
Speaker
Yeah, I think it's interesting and it's a difficult environment to practice in because you do have learners and sometimes that can be a huge advantage and sometimes that can make things a little bit difficult. There are both three-year emergency medicine residencies as well as four-year. Michigan of course is a four-year residency program.
00:05:57
Speaker
how ours is structured is our intern year, our first year. You spend quite a bit of time not in the emergency department, so you're in the operating rooms with anesthesia, you're in the ICUs, and you're really learning in those environments where it's a little bit
00:06:18
Speaker
Not to say necessarily low pressure, but a little bit, you have a little bit more time to learn and to get your feet wet and to learn those procedures that you're going to need to know on the fly in the emergency department. So our intern year is well structured in that we give our interns the opportunity to kind of a.
00:06:38
Speaker
Get comfortable with patient care with the medical records with a lot of their procedures and to also get a good foundation of knowledge before they start up in the emergency department.
00:06:52
Speaker
And then that goes into our second year. And our second year is probably our trial by fire year, so to speak, where you are in the emergency department the majority of the year. You do a lot of night shifts. It's a pretty rigorous year. Tough to do that many nights and kind of maintain your life outside of the department. But I think a lot of it is learning by doing. And when you're in the emergency department and you're working those overnight shifts,
00:07:22
Speaker
There's not a whole lot of people around, so a lot of the responsibility does fall on you. So you do kind of have to learn pretty quick, and it's a steep learning curve. So our second years, they were...
00:07:35
Speaker
Pretty darn hard, and I know it's a rough year for them, having done it, and I know it's a pretty rough year. I'd say my colleagues feel similarly. Third year, you're really continuing to work more emergency department shifts, working more day shifts. And then your fourth year, you are continuing to work emergency department shifts.
00:07:57
Speaker
However, in your fourth year, you are more in a supervising role as opposed to having patients primarily yourself. You have interns or second years who are seeing the patients and then they come up and staff with you and then you then staff with the attending.
Teaching and Learning in the ER
00:08:15
Speaker
So it's an interesting education system because a lot of our junior residents learn from the senior residents and then the senior residents are learning from our attendings. And that's kind of how the system is set up. So as a resident, it's tough because once you start to feel comfortable in your practice, you all of a sudden have to turn around and start teaching the juniors.
00:08:43
Speaker
It's fun. It's fun to teach, but it certainly can be difficult because like you're alluding to, it is a
00:08:50
Speaker
high pressure environment and the stakes are certainly high in the emergency department. And it really does come down to whoever is in that supervising role to make sure that the junior residents feel comfortable and that if they don't, that they're comfortable coming up and talking to you and asking you for your help. So you really have to be pretty vigilant as a senior resident and in a teaching hospital to make sure that your department's running smooth and that your juniors know
00:09:19
Speaker
what's going on and that they're learning as you go. And when you do change things and you do change their plans in terms of how they want to manage a patient or the procedure they want to do or something like that, those are all your opportunities to teach. And I think that's a lot of where that teaching by experience comes from because you are learning and hopefully you learn something from every single case and every single patient you see. There's certainly an
00:09:48
Speaker
an age-old piece of wisdom. There is nothing you can't learn from every single patient that comes into the emergency department. And I've found that to be true. There's certain techniques and how you're interacting with patients and interacting with other people in the hospitals. There's something to learn the whole time you're there. Of course, I'm in my fourth year of residency right now.
00:10:11
Speaker
But I fully expect that the learning will continue. Those first few years out in particular, you realize that there's nobody really above you. The buck stops at you, so you have to be much more confident.
Follow-Up Care and Specialist Involvement
00:10:25
Speaker
You need to really know what it is that you want to accomplish with every single case.
00:10:34
Speaker
have to learn a lot because there's no longer somebody helping out with those slight nuances or those maybe little small things that you weren't quite aware of that were happening within the system. So everyone says those first few years out, you do learn quite a bit. And I totally expect that. And I've talked with many senior faculty who's, of course, they're also learning medicine is always changing. So I don't really think that the learning and the education that that ever ends
00:11:01
Speaker
in medicine, I think you kind of have a lot of it stacked up front in residency in those first few years of being in attending. But no, I don't think education ever stops in emergency medicine or in medicine in general.
00:11:14
Speaker
That's interesting, it sounds like you're trying to make your way up the ladder in the emergency room and then you kind of have to turn around and help somebody else up in order to create the best experience for the patient. Now I wanted to shift gears and talk a little bit about the logistics of being a patient in the emergency room.
00:11:33
Speaker
For most, I'd imagine that the emergency room isn't really a one-stop shop. Presumably most gooners receive further care from some other medical outlet. What would you say is the percentage of patients you go on to see a physician from another specialty? So that's an interesting question. I think that it's
00:11:58
Speaker
is highly variable. So in my residency program, we work at the University of Michigan, which is a large university-based health system. We also work at St. Joseph Mercy, which is also a very large health system. It's more community-based, but it certainly has all the subspecialties. We also work at Hurley Medical Center up in Flint, and that also is a very large center with many subspecialists. But
00:12:23
Speaker
The culture among the hospitals is different and I also moonlighted a much smaller community hospital that really does not have any extra resources or very many of the specialists that we have the luxury of at the large centers like Michigan.
00:12:38
Speaker
In each of those centers, it's very different. Somewhere like Michigan, you do involve specialists very early and very often. You do consult them because you have them available and that's a lot of times you're getting patients who need them and they do need to hear from those consultants in the emergency department. We're certainly spoiled and I think we
00:13:02
Speaker
often talk about it ourselves that maybe we consult too much and we bring in the specialists too often at the emergency department of Michigan. But again, that's the practice environment. That's what it is. We have those specialists available. It's tough to have a patient who needs to see a gastroenterologist, for example, and have that specialty available to you.
00:13:30
Speaker
Not provide that service to them. There's really, it's tough to say that you're not going to do that when you have all of the specialists available. Now, say that you're working at a very small center that doesn't have a lot of these specialists in house.
00:13:45
Speaker
In those cases, you do have to discuss with the patient how you're going to go forward. And that is a conversation that you have with the patient and see what their comfort level is. There's many options. There's setting them up with somebody to see as an outpatient where they'll see them the next day or the next week. There's admitting them to the hospital so they can see a specialist in the morning. You can also try to make a phone call and see if you can get somebody on the phone. And it really does
00:14:14
Speaker
depend on that patient and that's where emergency medicine gets difficult. It gets difficult to practice in an environment where you don't have your specialists available because all of a sudden you have to make that decision of does this patient need to see a specialist tonight right now or can they wait a week or can I just get the specialist on the phone and talk with them. So it really does open you up to needing a lot
00:14:42
Speaker
but needing to know a lot more about all of these different conditions. You do have to be much more comfortable with sending people home because
00:14:51
Speaker
a specialist 100% of the time. So it's definitely an interesting variation in practice. A lot of people like to work in the community setting because they do like to use the knowledge that they have about all of these various medical conditions and try to manage them in conjunction with a specialist as opposed to other centers where it's very easy to make a quick phone call and have a specialist come down and see the patient right away.
00:15:18
Speaker
It's an interesting question. I think it just opens up the discussion of what kind of care you'll receive at these different hospitals, which is a little bit tough.
Ultrasound in Emergency Medicine
00:15:29
Speaker
I think each of these hospitals, they serve a purpose. You know, the community hospitals, they serve their purpose. The university centers, they serve a purpose of those extremely ill patients that need BC specialists early. So they have different
00:15:46
Speaker
purposes, but it shows you how variable the practice of emergency medicine is and how different the job is at different hospitals. Very interesting. Now I wanted to talk about one of your areas of expertise, which is ultrasound imaging. Traditionally, we associate ultrasound with pregnancy, but I wanted to hear more about the other applications in the emergency room and how they compare to other imaging techniques. Yeah, absolutely. I think ultrasound is
00:16:17
Speaker
Pretty interesting, of course. It's one of my areas of interest.
00:16:26
Speaker
Just to kind of go over it pretty quickly, you can these days either have ultra basic ultrasound training within an emergency medicine residency, or in some residencies like in Michigan, you can go down a specialized track where you get more in-depth exposure to ultrasound and teaching with different ultrasound modalities.
00:16:51
Speaker
You also can do a fellowship in ultrasound when we're kind of going to what the benefits of that are. Eventually, the fellowship is going to be accredited by the ACGME, which means that it's going to be a little bit more regulated by the folks who are in charge of graduate medical education.
00:17:13
Speaker
Right now it's not an accredited fellowship, which means it's something that's run and supervised by individual hospitals. And the pay structure is not as regulated. It's a small difference, but the recognition from ECGME and having it transform into an accredited subspecialty will be great for us.
00:17:38
Speaker
You're right though, most people do think of ultrasound as babies and getting to see a little baby. In the emergency department, we have found a great use for ultrasound. It's become increasingly portable and the cost of the machines has come down as well, which is why it's pretty easy for us to use. But there's actually quite a few different applications for ultrasound, one of which is
00:18:01
Speaker
the entire field of procedures that we do. Many years ago procedures such as placing certain lines in vessels were done essentially blind. You would use landmarks and you would have to basically decide where you thought these vessels were and then you'd go for it.
00:18:19
Speaker
These days with ultrasound, we can watch exactly where a needle tip is when it goes under the skin and we can watch it go into each blood vessel. And it's become standard of care to use ultrasound for many different procedures such as central lines. We can use it for arterial lines and IVs as well. It's made a huge impact for our procedures and to increase the safety with which we do these procedures for our patients.
00:18:45
Speaker
Additionally, with those very sick patients, ultrasound can be used to take a very rapid look at the heart, see how well the heart is pumping to see if there's an issue with the heart that's causing the patient's distress. Whereas many years ago, that's not even a question. You could not look at the heart, you just had to
00:19:06
Speaker
take your best gas based on the information that you did have available. So we, again, are pretty spoiled with having an ultrasound for that. There is also multiple different diagnoses, such as a collapsed lung that we can diagnose immediately with a bedside ultrasound, as opposed to waiting to get a chest x-ray or other more
00:19:28
Speaker
time-intensive or expensive machines such as CT scans or x-rays, we can get our answers much more quickly with an ultrasound. Additionally, there's some other diagnoses such as an abdominal aortic aneurysm, which is
00:19:47
Speaker
essentially an abnormality of the big blood vessel that runs down the center of the abdomen and feeds most of your body. And all of those things really provide a lot more safety to our patients. They also increase our ability to
00:20:03
Speaker
help speed up how quickly we're seeing our patients and how quickly we're getting to the bottom of what it is that's going on.
Integration of Palliative Care
00:20:11
Speaker
You can certainly save a lot of lives with ultrasound and it's a great tool, something that emergency medicine has adopted and we kind of expect it to be a core part of everyone's education in our residency as well as emergency medicine residencies across the country.
00:20:31
Speaker
you know, getting there and having the people who are trained to do that education is important. It's something that I hope to be a part of. You've also done extensive work in palliative care, which correct me if I'm wrong, is related to the management of symptoms due to a chronic disease. Yeah, I think that's quite a bit of palliative care is a lot of symptom management. It also deals with
00:20:58
Speaker
general care of patients who are nearing end of life and making sure that what we do as medical professionals is in line with what a patient would want. With our aging population and our advances with many different
00:21:19
Speaker
medications, procedures, surgeries. We have really gotten to a new point in modern medicine where we need to take a hard look at what it is that we're doing when a patient comes into the emergency department. In the emergency department, we are resuscitation experts. We like to take care of sick patients and help them and resuscitate them and bring them back, so to speak.
00:21:47
Speaker
A lot of times though, that's not necessarily what a patient would want. They would not necessarily desire the quality of life that certain procedures and certain interventions that we would perform would give them. A lot of times these are patients who unfortunately do have multiple chronic medical conditions and with their quality of life, they don't want to go home with a tube in their neck. They don't want to go home with a feeding tube.
00:22:17
Speaker
they much rather would prefer to be comfortable at the end of life and to enjoy the remaining days that they had at home as opposed to being in a hospital. So there's a lot of little nuances to it, but in the emergency department, I think we have a remarkable opportunity to intervene. And what I mean by that is we have the opportunity to guide where a patient goes. A lot of times,
00:22:43
Speaker
sitting down with the family, sitting down with the patient and asking them, what is it that you value in life? And what is it that I can do to make sure that your values are maintained? A lot of times that will lead down a much different path than having somebody undergo multiple different procedures, multiple different scans, weeks in the hospital, admitted to an ICU, going to a nursing facility afterwards.
00:23:12
Speaker
And I think that's a lot of where palliative care has the opportunity to make a huge impact in emergency medicine. And that's where my particular interest in palliative care is stemmed from.
00:23:25
Speaker
that and finding a way to make sure that they are taken care of in the way that they would want and not necessarily just applying a cookie cutter approach to every single patient. That is intensive resuscitation, multiple procedures, and bringing them into the hospital. That's just not something that a lot of people would want, and we need to make sure that we're giving people that option.
00:23:49
Speaker
So a couple things off that. Originally, I didn't associate palliative care with emergency medicine because it seems a lot of the chronic illnesses and diseases would not be relevant in a time-sensitive atmosphere like the emergency room. However, from what you're saying, palliative care is related to emergency medicine because of the resuscitations. So are resuscitations the only link between emergency medicine and palliative care?
00:24:16
Speaker
Oh, no, I'm purely speaking of palliative care from the perspective of an emergency department physician. Palliative care is a much, much, much more broad field and they do many great things. They have inpatient hospice beds. They have hospice facilities. They assist with symptom management. They help with family planning. It's a long list of what a palliative care specialist can do.
00:24:43
Speaker
And that is its own medical specialty that you can enter through emergency medicine. I believe through internal and family medicine as well. But they do much, much, much more than that beyond what I'm familiar with. I'm merely commenting on from my experience, why it is that I found it so valuable and why it is that it's something that I personally would like to develop skills in and maintain skills in. Because I think that setting in
00:25:14
Speaker
patients is important to emergency department physicians. We need to take a step back sometimes and have those discussions. And that's where my particular interest comes from.
00:25:27
Speaker
So speaking of end of life care, can you talk to the experience of holding someone's hand at the end of the road and ultimately having to communicate that loss of a loved one to their family? You know, it's pretty difficult. I don't think that there is ever a case where you are dealing with a patient at end of life where it doesn't
00:25:54
Speaker
affect you. I think in medicine I know personally and I know a lot of my colleagues early on it was to the point of affecting you personally which is difficult because that's the human side of you that death and end of life is of course a very depressing and sad experience and we feel for our patients and we feel for their families
00:26:23
Speaker
It's tough because after that happens, you do have to get up and go back to work, unfortunately.
00:26:32
Speaker
Early on in training, I think it's something that we all have to reconcile with ourselves of how it is that we are going to deal with that and how it is that we're going to respond and to learn a way that we can encounter something like this in the hospital and still move on and still perform our job to take care of that next patient who's waiting for us. I can say it never is an easy experience.
00:27:02
Speaker
you kind of learn ways to cope, but it never is something that just sits with you completely fine. And there are times where you connect with patients or their families to a much greater degree and where that rapport kind of hits. And in those cases, it's particularly difficult and
00:27:30
Speaker
It's just tough to get through, I would say. But that's just part of, unfortunately, what we need to learn, which is how to take something like that and not internalize it and not let it take over us and to learn that we need to find a way to separate that from everything else that's happening, or at least
00:27:55
Speaker
To table it until we get out of the department or get out of the hospital for the day and then let ourselves feel the emotions that we're going to feel. But I think.
00:28:05
Speaker
anybody who thinks that doctors or advanced practice providers or nurses or anything like that are just kind of strolling through and moving on to the next case, do not have a very good understanding of how it is. It is a difficult experience and it's a difficult process and it's very hard to conceptualize that you are the last person that may talk to somebody on this earth, that you're possibly the last person
00:28:35
Speaker
whose hand they shake, that you're their last source of contact, and it's kind of a difficult concept to do that. And it's also, I think, one of the hardest things is to inform the family and the friends and people who are left behind of what has happened.
Delivering Bad News Sensitively
00:28:53
Speaker
personally find that to be the most difficult because that's when you really are exposed to those emotions and you can't really separate yourself in those situations. You can't fully. So I personally find it the most difficult to talk to families and friends and you do take a minute. You do kind of say, all right, I need a moment and you sit there and you kind of
00:29:20
Speaker
Brace yourself and go through the words that you're going to use and think about what you're going to say and how you're going to say it. And then take a deep breath and then you go and deliver that news. But it does weigh on you. It does weigh on you. I don't think anybody in this world wants to
00:29:37
Speaker
see another human being sad or suffer or upset. And when you deliver that news, that's what happens. Understanding that is how people feel and it's difficult to see those emotions and to know that you're a part of that. There's another perspective that I like to take and that I personally have used to kind of make this a little bit more palatable. And that is that
00:30:04
Speaker
There's a lot of ways to make these encounters, I don't know, the word's not better, but to make these encounters easier for families and for patients. And that's a lot of what I found helpful in palliative care. Because these are moments that patients, their families, their friends, they will never forget. They will never, ever forget how you said it, when you said it, the words you used, the look
00:30:36
Speaker
and learning how to make that encounter something that they can look back on with less difficulty is I think something that is rewarding. I do like the idea that I can do this in a way that may make you
00:30:57
Speaker
a little bit more at peace with all that's happened and to give you that comfort in a very difficult time to be there to comfort patients and their families. And palliative does teach you that is to palliative care and palliative medicine and that entire discipline does teach you that and how to make this experience something that you know there's a huge spectrum of how people are going to experience these emotions and we're trying to find a way to make it
00:31:26
Speaker
less difficult for people, but it's never easy. You definitely bring up some interesting points about the sheer emotional weight of these experiences. I'm sure a lot of physicians can relate to just feeling overwhelmed when you're there at a patient's bedside during their last days.
00:31:47
Speaker
Also interesting what you're saying about a sort of silver lining though, you have the opportunity to comfort a patient and their family during some tragic and confusing times. Going off of this, I know you've lectured on giving bad news in the emergency department. Can you talk to the strategies and points you try and hit home for the residents who are trying to learn how to give bad news?
00:32:14
Speaker
Yeah, I think that we are very good about teaching our residents about the kind of the steps that go into a procedure. And we teach them all that preparation is key, that for every procedure that you have, you need to prepare. You need to
00:32:38
Speaker
get yourself ready, get your equipment, get your supplies ready, get your team ready, everything like that. And I think we, you know, in my lecture, I talked about how we need to approach the delivery of bad news as a procedure as well. And I think that it is something that needs to be approached as such, because there's a right way to do it and there's a wrong way to do it.
00:33:10
Speaker
And if we take the approach of that, this is another procedure. We'll take it more. We'll take a more.
00:33:20
Speaker
rigorous approach to teaching this and to executing this. So there's multiple different actually protocols, I guess is the word out there, in terms of how you can deliver bad news in the emergency department. And all of them focus on
00:33:41
Speaker
going in and making sure that you go through this in a very systematic way and a systematic approach and thinking about it before. The last thing you want to do is just say, oh, I got to do this and then just walk in and then just say it. That would go terribly. But to know exactly the words that you're going to say and to pick whichever of these protocols that you want to use.
00:34:03
Speaker
they called the grieving protocol, where each letter kind of stands for one step in the process. So G gather, which is gathering the family, get them in a quiet place, optimizing that environment, making sure that there's enough chairs for everybody, making eye contact with everyone. R would be resources, so calling for a chaplain, social workers,
00:34:30
Speaker
whatever else that you may have available at your institution, I identify yourself and identify the name of the patient as well as everybody in the room. Um, and then unfortunately E educate them about what the, um, state of events were, um, and make sure that they're aware, um, of what has transpired in the department. Um, and then V.
00:34:56
Speaker
verify that they understand what you're saying. A lot of times you'll say something like, uh, you know, the, um, so-and-so has moved on, um, or has passed away. And you know, death is a difficult thing. People's minds, they'll protect themselves and they will think, Oh, he means that they moved to a different room or they moved to a different part of the hospital and it's happened. So you really need to make sure that they understand what's going on here and what has exactly happened.
00:35:24
Speaker
And then you give them space and you let them process it. Everybody will process it differently. Everybody's going to have a different approach to it. No approach is right or wrong, but everybody's just going to respond differently. And then I, you inquire, ask them if they have any questions about what's happened and if there's anything you can do to help. And then N is the, unfortunately with death, there are a lot of nuts and bolts, such as setting up a funeral home, an autopsy and, um,
00:35:54
Speaker
things of that nature. And then G is to give them your information to make sure that they can always reach out to you. And I think that if people take this approach, that they can make this a much better experience for both themselves as well as patients and their families. It sounds a little bit bizarre that we have a protocol on a way to go about this and that there's kind of a
00:36:22
Speaker
regimented way to do this, but it works and it avoids a lot of the issues that we run into when people aren't prepared for these procedures and they aren't in the right mindset to be delivering this kind of news. And it grounds you, especially when something very traumatic happens, like any death in the department and you kind of forget and lose your words, you remember something quick like, oh, grieving, I remember that. All right, what's the first thing I need to do? What's the next thing I need to do?
00:36:53
Speaker
And it works, you'd be surprised.
Holistic Practices and Opioid Crisis
00:36:57
Speaker
It does make a big difference. So I wanted to shift gears a little bit and talk about medicine as a holistic practice.
00:37:05
Speaker
Allopathic medicine as a whole is increasingly starting to embrace the viewing the body as a whole, as opposed to a sum of parts. And I could see how, especially in end of life care, that would be really relevant in terms of a more holistic healing process. How do you try and view the body as a whole in your own practice?
00:37:35
Speaker
An interesting question. It's a tough one because I do think that there are many things we're learning in medicine that are beneficial to our patients and helpful that maybe previously were discounted. The issue that I frequently run across is that unfortunately in this kind of capitalist society, a lot of people are taking advantage of that and they're taking advantage of these things with
00:38:05
Speaker
claims of things like essential oils and certain diets to cure cancer and things like that. And there's absolutely a value in a lot of these things. We know that things like
00:38:21
Speaker
yoga and meditation and all of those will help with your blood pressure and help with stress and they make big impacts. And a change in your diet certainly will help decrease incidence of cardiovascular disease and can help with diabetes. We embrace our nutritionists and ask for their assistance frequently. And these certain diets will be helpful in our trauma burn patients. We know these things and we accept them. And the problem is that when people start to
00:38:52
Speaker
take advantage of the system and our patients and it's very difficult. The big thing that I see as a result of all of this is, I'm sure everyone listening and you're aware of is this whole anti-vaccination movement. And, you know, a lot of that's done from the same idea that we need to move into a more natural,
00:39:21
Speaker
treatment course and away from medicine and things of that nature. And I certainly will not discount a lot of these thoughts, but things that have been researched medically numerous times that save lives. It's very difficult as a provider to watch people ignoring things that we have spent decades and millions of dollars investing in to save lives and just
00:39:49
Speaker
tossing them to the side for alternate approaches. So I did a little digging here, and I found that you also have a DEA licensure. I'll do my best Walter White impression here. Could you tell us what that's for? So that's for pretty much every provider. I believe everyone has to have one for prescribing controlled substances.
00:40:17
Speaker
So narcotics and benzodiazepines and things like that. The license itself, not unique by any means, but I do think that in the emergency department, we do have a unique role in this opioid crisis that's come about. And it's difficult, again, to try to figure out
00:40:44
Speaker
what the best approach is. And we're starting to find a lot of different therapies and interventions. A lot of things are coming about in the community to help with our patients who unfortunately are suffering in this opioid crisis. But it's a difficult practice environment where people are used to coming into the emergency department and getting their pills. And all of a sudden now you're just saying, nope, I'm not giving out narcotics or benzodiazepines for this or that.
00:41:13
Speaker
It's unfortunate that you are given a lot of, you're faced with a lot of hostility and aggression from patients when you're not writing them pills for narcotics or benzodiazepines and complaints go in and they're screaming at you and it makes the practice environment pretty difficult. Especially when all you're trying to do is what's best for the patient and the community.
00:41:39
Speaker
Now, so I obviously want to stay within HIPAA here, but can you give us one of the weirdest cases you've seen in the emergency room?
Light-hearted Stories and Personal Insights
00:41:46
Speaker
Oh boy. That's a, that's a tough one. Weirdest case. Let's see here. Oh man. You want, what do you, what kind of weird are you looking for? Weird as in I have to go home and tell my buddies this cause this is just so goofy. Oh man. I mean,
00:42:09
Speaker
I think one of the more weird ones that we've seen was a gentleman who had inserted a light bulb into his rectum.
00:42:27
Speaker
But really emergency medicine is just full of foreign bodies and orifices. So you type in the emergency department provider and you're going to be getting a laundry list of different items that have been placed in various orifices. But the light bulb was an interesting one.
00:42:46
Speaker
Was it lit? I was not there to pull it out and we left that up to our surgical friends. I also heard through the grapevine that you were a Best Buy customer service specialist in your previous life. Can you talk about that groundbreaking experience? Oh boy. What year are we talking? Oh man, this had to have been, oh five maybe? I think sometime in high school, sophomore year of high school, I think.
00:43:16
Speaker
So is that pre-geek squad, or were you part of the geek squad? Oh, that was when geek squad was nice and popular. I was working right next to geek squad. I was the guy you go to to yell at because something broke. So I just kind of stood there and got yelled at all day. It's very similar to emergency medicine. So one more fun one for you. I know you live in Ann Arbor. So what's your favorite place to eat an A2?
00:43:46
Speaker
So it's actually in Ypsilani, but Ann Arbor and Ypsi are touching. But it's a place called Malu's Hot Fried Chicken. It is incredible. I've been to Nashville, have the hot chicken. Vindaloo, they'll have the chicken. But this place, this is incredible. Do yourself a favor and get out there.
00:44:09
Speaker
Yeah, I didn't really get a chance to venture into Ypsilanti too much. We used to go to Dom's Donuts, though. That was a good place. Oh, yeah, I've been over there. I love Ypsilanti. It's a fun place. There's a lot of cool restaurants, a lot of fun bars. It's a fun place. We go out there to shift quite a bit. Well, Dr. Neil Kuna, thanks for joining the show. Absolutely. It was fun. Thanks for having me.
00:44:45
Speaker
Thanks for listening to The Wound Dresser. Until next time, I'm your host John Neery. Be well.