Lessons Hard Learned: Dr Anand Swaminathan

Welcome back.

Another week and another Lesson from one of FOAMed’s finest minds.  Dr Anand Swaminathan is a leader of ED education and has been instrumental in bringing a lot of excellent resources to us over the years.  I was very privileged to be able to invite him on the podcast to share a case – it is a case of the VIP patient.

This case contains a lot of lessons about how our decision-making can become a little biased and clouded when we treat patients whom carry the VIP status or are too close to us personally.


You can also read another perspective on the VIP patient from Simon Carley on St Emlyns here.

Check out Swami’s other projects (there are a lot!): CORE EM , Keynotable,   REBEL EM, EM:RAP…..  the list goes on, and on.  Anand is also a key contributor to the Life in the Fast Lane R&R and weekly Reviews.  Apparently he does not sleep!

I would love to hear your tips and strategies when confronted by the familiar scenario we discuss this week.



  1. David Berger says

    Very engaging podcast. I am not sure this is specifically a VIP patient issue, though. This is more about the physician being able to overcome their intrinsic aversion to a particular course of action. I had an elderly patient admitted with a traumatic haemopneumothorax on a NOAC and with many comorbidities following a fall just as all the other doctors in the hospital had gone home at 11pm. There is only skeleton nursing staff on in the ED at that point and no immediate back-up.

    I managed to talk to the cardiothoracic opinion at the tertiary hospital and convince her and myself that, given the risks and given the lack of resources and his relatively stable state, that I should delay his chest tube until the morning. It was a thoroughly stupid decision which I had time to reflect on over the next three hours as I watched him deteriorate and eventually I called in the lab tech to cross match and the overnight anaesthetic doctor to have another pair of hands available and gave him some prothrombinex and put the tube in.

    No harm done in the end, but it took me a while to realise that I was making the decision solely because I didn’t want to do this somewhat risky procedure all on my own, even though I absolutely knew it needed to be done and done now. I just had this image I couldn’t get out of my head of me fiddling around in his axilla, him getting sicker in some way as I did so and then mayhem as I was all on my own with one nurse and that poisoned my decision-making process.

    Solo practice in remote areas is challenging and we don’t have it hard here at all in Broome compared to the remote areas of Australia with their single doctor hospitals at which really sick patients quite commonly rock up.

  2. Victoria Brazil says

    Hey Casey and Swami
    thanks for a great podcast – enjoyed the frank and fearless reflection.
    I agree about the VIP thing clouding clear judgement.

    That said – i think you have been a little harsh on your judgement.
    I believe (no expert opinion) that the complications and infection rates of temp wires esp in hands of generalists is quite significant…?
    Maybe just maybe you made a better call in this case than the others where you decided to do it.! Maybe the caution was well judged? We have no parallel universe to know the outcomes of alternate management in either case 🙂

    Disclaimer – I don’t consider myself skilled to insert a temporary pacing wire and would not consider doing it myself in the case you describe, and maybe that clouds my judgement. (and i’ll go out on a limb and suggest that would be the case for the majority of Australian EM doctors). I have done external pacing a handful of times with less than ideal experience as you also describe.

    Just providing a counterpoint..


    • Agree with your points Victoria. I am very far from any competence in transvenous pacing. Also very far from a Cardiologist – so would be stuck in Swamis situation.
      Australia very different to USA. We are not all skilled like Swami to do this.
      Tough case, but I think the lesson holds for many cognitive blocks in our treatment of VIPs

    • Hold that thought
      Another lesson coming up on doing unfamiliar procedures and the tiger territory you can land in!

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