Healthcare Update Satellite — 01-19-2015

Penicillin allergy? It’s associated with increased bad outcomes, but not for the reasons you think. The allergies themselves are mostly not allergies. And no, “my mother said I had a rash when I was a baby” isn’t an allergy. However, when compared with patients who don’t have penicillin “allergies”, patients with penicillin allergies have longer hospital stays and are between 14% and 30% more likely to get resistant infections while in the hospitals – possibly because the penicillin “allergic” patients are being treated with much stronger antibiotics that kill off the “good” bacteria in their systems.

Ever wonder why it seems that whenever you call a doctor for a medical problem they tell you to go to the emergency department? Here’s a good reason why: 26 week pregnant patient calls on-call obstetrician with severe abdominal pain and severe headache. On call physician attributes symptoms to a “gastric condition” and that she did not need to come to the hospital. The following day, the patient suffered a stroke. Patient and family sued and were awarded $10.9 million.

Georgia malpractice attorney Wilson Randolph Smith settles case on behalf of his clients, then forges client’s name on settlement check and keeps the money. Tells clients that the case would likely be set for trial later this year. Eventually gets caught and is now cooling his heels in the county jail.

Florida prosecuting pain clinic physician whose prescriptions were associated with three patient deaths. One patient was prescribed 3360 oxycodone pills in the year before his death.

I’m not a big fan of the AMA, but Steve Stack, an emergency physician and president-elect of the AMA is doing a good job at keeping medical issues in the media. I’ve seen multiple interviews pop up in my news feed quoting him on pertinent issues. The latest is about EMRs and “meaningful use.”

Patient writes local newspaper to thank caregivers in emergency department and hospital for providing great care to him. At first I thought this was a great thing and trust me when I say that his letter made an impact on the providers. Then I thought how sad it was that patient gestures like this are so uncommon given the 160+ million emergency department visits each year.

“Glassholes” go into mourning. Google pulling Glass version 2.0 from the market and this Forbes writer Steven Rosenbaum wonders whether Glass will be this decade’s Apple Newton. I sure hope so.

Sad story. Beautiful Ecuadorian beauty queen wins coupon for $1000 worth of liposuction as part of pageant prize. Initially refuses and tries to donate the prize to someone else, but finally talked into procedure after doctor “insists” she have the surgery. She then dies of cerebral edema during surgery. Under Ecuadorian law, doctors may be imprisoned for up to 3 years for medical malpractice.

What happens to patients when one emergency department stops taking ambulance runs? The patients don’t just disappear and the emergencies don’t just vanish. Ultimately they will seek care at other hospitals and ambulances will have to spend more time taking patients to facilities that are farther away. This is just what is occurring in California after Doctors Medical Center stopped taking ambulance runs. Ambulance runs and patient volumes at other facilities increased dramatically. Doctors Medical Center is trying to avoid closing, but is running “deficits because it serves mostly patients of MediCal and Medicare, which provide low reimbursement rates.” Now ambulances and surrounding hospitals will receive the trickle down effect of low reimbursements as the ripple effect spreads throughout the medical system.

Innovation pays off. When researchers were having difficulty culturing any new organisms in labs to try to create new antibiotics, they went au natural. Digging up dirt cultures from one researcher’s backyard, they were able to find 10,000 additional compounds to test against human pathogens. One bacteria from a grassy field in Maine was found to be more effective than vancomycin at killing MRSA and was able to do so at much lower concentrations. In addition, the bacteria so far haven’t developed a resistance to the medication. Just give it some time. Zithromax was a blockbuster antibiotic, too – until most docs started giving it out like M&Ms at a holiday party. Now bacterial resistance to Zithromax is so high in some areas that it is marginally better than a sugar pill.

Voodoo priests on the frontline of Haiti’s mental health care where there are currently about 10 psychiatrists for a population of 10 million. Yup. Pretty soon this will be about all that most patients will be able to get from their Aetna and United Health Care “Affordable Care Act” plans.

How Can You Be Sure?

“How can you be sure?”

That question stopped our discussion for a second.

During some down time, several nurses and I were talking about childhood coughs. Her 6 month old child had just started daycare 2 weeks ago and has been coughing ever since. The child was put on amoxicillin and then Zithromax by her pediatrician but … [GASP] … her cough wasn’t getting any better. The nurse thought her child had pneumonia.
“What should she be taking now?”
I was in a particularly snarky mood, so, with a smirk, I said “probably vancomycin … maybe add gentamycin just for the gram negative coverage, too.”
“I’m being serious. She’s not getting better with antibiotics.”
“BINGO! That’s because she has a virus infection and antibiotics don’t kill viruses any more than RAID kills dandelions.”
“But a virus infection isn’t going to last for two weeks.”
“Neither is bacterial pneumonia. The fact that she isn’t getting better with antibiotics should tell you that she has a chest cold. It’s a virus.”
“How can you be sure?”

Ugh.

There’s just no good response to that question. The truth is that we can’t be “sure” that there isn’t a bacterial infection present. We can’t be “sure” she didn’t aspirate a foreign body. We can’t be “sure” that she doesn’t have tracheomalacia. There is just no way that we can ever give a Flo’s Progressive Insurance 100% guarantee that a given set of symptoms is being caused by a given disease process and nothing else. The problem is that often patients expect this kind of diagnostic accuracy and get upset when there’s a misdiagnosis. Unfortunately, medicine is an inexact science at best. One of the things that I always found ironic is that many patients and even some medical experts expect doctors to “prove” their diagnoses do exist or to “rule out” other diagnoses by showing that those diagnoses couldn’t possibly exist. However, in court, when a doctor is accused of wrongdoing, an expert is required to testify to “a reasonable degree of medical certainty” which in most cases means that something is “more likely than not.” In other words, court testimony demands only 50.001% certainty while clinical practice often demands a much higher level of certainty.

Our discussion transitioned from snark to reality.
“Most of the time you can’t be ‘sure’ of a medical diagnosis – especially a diagnosis with a symptom as vague as a cough.”
“Well patients want certainty. If I bring my child to the doctor, I want to KNOW what’s wrong, not get some wastebasket diagnosis like a viral infection when my baby could have pneumonia.”

I nodded my head. Then I went to the cafeteria to get some lunch and I mulled that last statement while walking down the hall. How could I explain the concepts of pre-test probability and futility without getting too far into the weeds? The runny cottage cheese at the salad bar gave me an idea.

I got back to the ED and asked the nurse
“Have you ever given your child poisoned food?”
“Of course not.”
“But how can you be sure? How do you know that the formula doesn’t have contaminants in it – like that Chinese infant formula contamination back in 2008?”
“That’s completely different from diagnosing pneumonia.”
“True, but it’s the same concept. We assume that a healthy-appearing child with a runny nose and cough in the middle of winter has a head cold the same way we assume that the food we eat is not contaminated. If there are signs of complications with a coughing child, we may do further testing to see if there are other problems. If there are signs of food spoilage, we may choose not to eat the food.”
“Not the same thing.”
“Hear me out. We naturally eat food without examining it much because the likelihood of it being poisoned is quite small. However, if we wanted to be “sure” that the food wasn’t contaminated or poisoned, then we could do a bunch of microbiological testing before we eat every bite to make “sure” that the food wasn’t poisoned. But because the likelihood of poisoning is so small, all of the expenses of the extra testing probably would be a waste of money.”
“Not the same.”
“Even worse, if we do a bunch of testing on a well-appearing child with a runny nose and cough, there may be some complications from the testing or complications/side effects from the treatment for a disease that may not be present. People can get resistant infections or bad diarrhea from antibiotics for a “pneumonia” that was over-read on a chest x-ray.”
“I’ll say. My daughter has had diarrhea for a week.”
“Exactly my point. She’d probably be doing better with nasal saline, suction, and perhaps some … OTC cough medications” – a cringeworthy concept for most pediatricians.

I was convinced I had prevailed in our little discussion until she asked “Can children take Levaquin?”
“Only for bacterial infections.”
“But …”
“No. Just no.”

Healthcare Update Satellite — 12-16-2014

Answering the important questions … why does the flu vaccine suck this year? Keep a lookout for next month’s issue of EP Monthly which will tell you everything you need to know about influenza diagnosis and treatment.

Of course, if you had read the backboard article in EP Monthly’s November issue, you’d already be doing this … Florida fire department abandons use of backboards for most trauma patients.

4 year old boy develops carotid artery dissection and left sided hemiparesis after riding a roller coaster. Fortunately, he had made significant recovery by six months. How scary is that, though? Can you imagine calling the neurologist and vascular surgeon telling them that you have a four year old child with an acute stroke?

A patient suffering from a rare condition called ossifying fibromas had lost the structural integrity of two bones in her back. Normally, the vertebrae are removed and replaced with artificial bones, but the process is difficult because the artificial bones must be filed down during surgery to make sure that they fit. Surgeons in Zhejiang University used CT scans and a 3D printer to create a titanium implant that exactly matched the patient’s spine.

A lot of insight about emergency medicine wrapped up into a few paragraphs from a Florida Times-Union columnist who went to the emergency department with his wife.
“Most [patients] probably shouldn’t have been there, but the poor and uninsured use emergency rooms for all their illnesses, from a head cold to a sprained ankle …”
“Nearly everyone at the ER was surly because of the wait, and they took it out on the staff.”
“Emergency room patients get outrageous bills even for simple ills. Many just toss them in the trash and the rest of us pay through higher bills. American health care is a mess. I’ll be really grateful when someone finds a cure.”

Using ground coffee to stop bleeding from wounds? I never heard of this one before. After reading this letter to the editor, I did a little internet searching and found other recommendations including powdered sugar, corn starch, and cayenne pepper. Don’t know if any of these work, so don’t try them without contacting your personal physician first. Direct pressure for at least 5 minutes always worked best for me.

After miserably failing to pass Proposition 46 in California, a medical malpractice plaintiff, supported by an amicus brief from a consumer watchdog group, have now successfully petitioned the California Supreme Court to review the state’s medical malpractice caps.

Emergency department visits on the rise … again. Latest estimates from ACEP are that there will be about 140 million emergency department visits in 2014. Thirty percent of those visits were for injuries – many in patients 75 and older. Nearly 75% of hospitals continued to board patients in the emergency department, showing how hospitals are operating at or above capacity.

In medical malpractice cases, expert witnesses are usually required to practice in the same specialty as the defendant physician. A malpractice case against a prison physician in Indiana was thrown out because a plaintiff’s medical expert was not a prison physician and was therefore deemed unqualified to testify about “correctional medicine.” The Appellate Court stated otherwise, holding that the standard of care for doctors practicing in prisons is no different from the standard of care for doctors practicing in the general population. Allowing this distinction would “empower prison physicians to determine for themselves what standard of care should apply for each individual case.” The 19-page opinion is here (.pdf file) and incidentally presents a fairly in-depth discussion on management of patients who have undergone a sex change operations.

Innovative new research shows how chronic neuropathic pain can be relieved by activating a receptor in the brain by using either adenosine or a drug invented at the National Institutes of Health. Bonuses are that no tolerance develops, there is no potential for addiction, and the “protective” actions of acute physiological pain (such as pulling your hand away from a hot stove) are not affected. How long until patients develop allergies to this medication?

Healthcare Update Satellite — 12-01-2014

More health related news from around the web on my other blog at DrWhitecoat.com.

This edition begins with another installment of the Ebola Chronicles … perhaps the last in the short-lived series now that the media has stopped whipping the public into a panic.

New York City actively monitoring 357 people for symptoms of Ebola – most of whom came to the US from the three Ebola-affected countries.

Arizona man returns from Sierra Leone after being involved in “Ebola response” then decides he doesn’t feel well the following day and calls 911. Brought to Maricopa Integrated Health Systems by firefighter in hazmat gear and part of the emergency department was shut down to accommodate the patient.

Number of Ebola cases in West Africa doubling every 2-3 weeks. Among factors contributing to the increase are 60% of Ebola patients remaining undiagnosed, terrorist groups such as ISIS attempting to weaponize Ebola, and Ebola’s nonspecific symptoms. The article’s author calls Ebola a “slow-motion atomic bomb.”

Interesting insight into why half of the doctors in Liberia have died. Liberia had two civil wars between 1989 and 2003 and still has no centralized h
ealthcare system leadership.
This quote really puts things in perspective:“People are giving up their sick dying and dead family members to people wearing anonymous white space suits, in most cases never to see them again,” Moran said. “Give them the benefit of the doubt that, just like Americans, if people in your family are sick, you want to take care of them.”

Clipboards visit UC San Fransisco on their national tour to tell medical providers how to prepare for patients with Ebola.

Oh, and the Ebola nurse from Maine wants everyone to stop calling her the Ebola nurse. Did I mention that she was the Ebola nurse?

—————————–

Can EKGs predict risk of death in patients with syncope? The GESINUR study shows that 65% of syncopal patients had abnormal EKGs but that only a few findings were predictive of all-cause mortality at one year. Of 524 patients, 6.3% died within 1 year, but only one patient died from a sudden cardiovascular cause. Presence of atrial fibrillation, intraventricular conduction delays, LVH and paced rhythm were all associated with increased all-cause mortality at one year.

Woman and her husband go to emergency department after woman begins having “serious internal or abdominal pains,” thinking she may need surgery or something. Twelve hours later, doctors found the source of the patient’s problems: a 7 lb 14 oz baby boy. The patient and her husband had no idea she was pregnant.
Every time I hear about a case like this, it reminds me of this story from many years ago.

Study in the American Journal of Public Health shows that drinking sugar soda affects length of telomeres and can shorten your life. Drinking one 20 ounce bottle of sugared soda per day is estimated to shorten one’s life by 4.6 years – which approximates the effects of cigarette smoking.

Started taking NSAIDs recently for aches and pains? Your risk of dying if you have a stroke just went up an average of 42% – depending on what type of NSAID you’re using. According to this study recently published in the journal Neurology, etodolac (Lodine) (which may have been discontinued) creates the biggest risk of the medications studied.

Think hand dryers are more “sanitary” than using paper towels? Think again. Bacterial counts in the air around jet air dryers were 27 times as high as those around paper towel dispensers and stayed around for up to 15 minutes after the drying ended. Bacterial counts for warm air dryers were about 6 times as high as those around paper towel dispensers. In other words, using a public bathroom with electric hand dryers is likely causing you to inhale the bacteria on other peoples’ hands … after they have used the toilet.

Then again, if you live near this defecating dwarf, you probably don’t have to worry about airborne germs – just those on the steps.

Finally, the video of the week takes one final look at the media coverage of Ebola in the US versus that in the UK. There is some profanity, so probably NSFW. Also note that the one person being filmed discussing “Ebola ass-ness” is a comedian doing a comedy spoof. Still pretty funny, though.

Healthcare Update Satellite — 12-01-2014

More health related news from around the web on my other blog at DrWhitecoat.com.

This edition begins with another installment of the Ebola Chronicles … perhaps the last in the short-lived series now that the media has stopped whipping the public into a panic.

New York City actively monitoring 357 people for symptoms of Ebola – most of whom came to the US from the three Ebola-affected countries.

Arizona man returns from Sierra Leone after being involved in “Ebola response” then decides he doesn’t feel well the following day and calls 911. Brought to Maricopa Integrated Health Systems by firefighter in hazmat gear and part of the emergency department was shut down to accommodate the patient.

Number of Ebola cases in West Africa doubling every 2-3 weeks. Among factors contributing to the increase are 60% of Ebola patients remaining undiagnosed, terrorist groups such as ISIS attempting to weaponize Ebola, and Ebola’s nonspecific symptoms. The article’s author calls Ebola a “slow-motion atomic bomb.”

Interesting insight into why half of the doctors in Liberia have died. Liberia had two civil wars between 1989 and 2003 and still has no centralized h
ealthcare system leadership.
This quote really puts things in perspective:“People are giving up their sick dying and dead family members to people wearing anonymous white space suits, in most cases never to see them again,” Moran said. “Give them the benefit of the doubt that, just like Americans, if people in your family are sick, you want to take care of them.”

Clipboards visit UC San Fransisco on their national tour to tell medical providers how to prepare for patients with Ebola.

Oh, and the Ebola nurse from Maine wants everyone to stop calling her the Ebola nurse. Did I mention that she was the Ebola nurse?

—————————–

Can EKGs predict risk of death in patients with syncope? The GESINUR study shows that 65% of syncopal patients had abnormal EKGs but that only a few findings were predictive of all-cause mortality at one year. Of 524 patients, 6.3% died within 1 year, but only one patient died from a sudden cardiovascular cause. Presence of atrial fibrillation, intraventricular conduction delays, LVH and paced rhythm were all associated with increased all-cause mortality at one year.

Woman and her husband go to emergency department after woman begins having “serious internal or abdominal pains,” thinking she may need surgery or something. Twelve hours later, doctors found the source of the patient’s problems: a 7 lb 14 oz baby boy. The patient and her husband had no idea she was pregnant.
Every time I hear about a case like this, it reminds me of this story from many years ago.

Study in the American Journal of Public Health shows that drinking sugar soda affects length of telomeres and can shorten your life. Drinking one 20 ounce bottle of sugared soda per day is estimated to shorten one’s life by 4.6 years – which approximates the effects of cigarette smoking.

Started taking NSAIDs recently for aches and pains? Your risk of dying if you have a stroke just went up an average of 42% – depending on what type of NSAID you’re using. According to this study recently published in the journal Neurology, etodolac (Lodine) (which may have been discontinued) creates the biggest risk of the medications studied.

Think hand dryers are more “sanitary” than using paper towels? Think again. Bacterial counts in the air around jet air dryers were 27 times as high as those around paper towel dispensers and stayed around for up to 15 minutes after the drying ended. Bacterial counts for warm air dryers were about 6 times as high as those around paper towel dispensers. In other words, using a public bathroom with electric hand dryers is likely causing you to inhale the bacteria on other peoples’ hands … after they have used the toilet.

Then again, if you live near this defecating dwarf, you probably don’t have to worry about airborne germs – just those on the steps.

Finally, the video of the week takes one final look at the media coverage of Ebola in the US versus that in the UK. There is some profanity, so probably NSFW. Also note that the one person being filmed discussing “Ebola ass-ness” is a comedian doing a comedy spoof. Still pretty funny, though.

An Argument With No Clear Winner

Fingertip Amputation“You’re going to the hospital.”
“I’m NOT going to the hospital. There’s nothing they’d do and it would cost us thousands of dollars for nothing. Besides … we have to leave. We’re already late.”
A husband was attempting to attach the family’s camper onto the trailer hitch of the family’s truck when the trailer slipped. His middle finger didn’t make it out of the way and got caught between the ball of the trailer and the top of the hitch. When family members helped him pull the camper back off of the hitch, they saw a lot of blood. Then the last portion of his middle finger dropped from inside the trailer hitch onto the leaves.
“Dammit.”
The wife raised her voice. “Get in the truck. We’re going to the hospital.”
The husband wrapped his bleeding finger in a Brawny paper towel he had retrieved from inside the camper. He raised his voice louder. “YOU get in the truck. We’re going to the CABIN.”
“Paul, don’t be silly. You’re bleeding. The tip of your finger is sitting on the ground. If we get to the hospital quickly, maybe they can reattach it.”
“They’re not going to do anything except sew this up and charge us thousands of dollars to do it. I’m NOT going to the hospital. I’ll have Doc Welby call me in a prescription for antibiotics. We can pick it up on the way out of town.”

So the patient shows up in triage with a blood soaked paper towel wrapped around his finger. It was obvious that he’d rather be about anywhere else than sitting in the emergency department at that point.
The finger was amputated just past the distal interphalangeal joint – meaning that the tip of the finger, the nail, and the end of the bone were missing. Clean wound. There were some extra flaps of skin to the sides of the finger which would make it easier to repair the wound. I did a digital block to numb the finger so that we could clean it and we used a commercial tourniquet to stop the bleeding.
The wife softly asked “Is there any chance that the end of the finger could be reattached?”
I started to respond “I don’t think so …” when the patient let out a loud “HEH” and smirked at his wife.
“You were saying, doctor?” She continued.
“I was saying that I didn’t think so, but I can ask the hand surgeon. Do you have the end of the finger with you?”
“Tell him what happened to the end of your finger, Paul.”
“We couldn’t find it.”
“Tell him what really happened to the end of your finger, Paul.”
“It’s gone.”
“Paul didn’t want to come to the hospital. I told him that you may be able to reattach the end of his finger. Paul had a temper tantrum, picked up the end of his finger, and threw it into a field. Isn’t that right, honey?”
Paul folded his arms and looked at the opposite wall, maneuvering his tongue to pick an imaginary piece of food from a tooth. He pretended he didn’t hear what she had said.

OK, then.
So I called the hand surgeon. He came down, looked at the patient’s finger, and arranged to send the patient to outpatient surgery to repair the injury.
Just as the patient had predicted, he was probably charged thousands of dollars to sew up his finger. He was discharged later that day.

For the rest of the day, I kept thinking how that husband and wife dispute ended up in a draw. They were both right. The wife was right that he needed to come to the hospital for evaluation, but he was right in that the surgeon probably wasn’t going to do much except sew up the injury.

OK, I also wondered how many times during their vacation that the husband held up his hand and waved the dressing on his injured finger in front of his wife’s face … as in “see which finger I injured, honey?” … but the irony of their argument was still pretty compelling.

———————–

This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on WhiteCoat’s Call Room please e-mail me.