Healthcare Update Satellite — 08-28-2014

Good news is that the number of medical malpractice cases in Pennsylvania is decreasing. Bad news is that if you practice medicine in the Philadelphia area, you’ve got a big target painted on your back. Philadelphia accounts for only 12 percent of the state’s population yet in 2013, 40 percent of medical malpractice trials resulting in verdicts took place in the city. Philadelphia medical malpractice plaintiffs won 45% of trials, more than any other jurisdiction and significantly higher rate than the national average.
Looks like we’ve found another place to avoid when looking for your next place to practice medicine.

Regulating a longstanding practice out of existence. Remember going to your doctor’s office and seeing those walls full of pictures of babies that the doctor delivered? Yeah, that’s illegal. Violates HIPAA.

Travelers from Liberia still being transferred via commercial flights to Delhi and Mumbai. A few with fevers were quarantined … after they arrived … while the others were required to be tracked daily by local authorities for the following month.
Meanwhile, most major airlines are suspending service to the “crisis zones.”

With the ebola hysteria comes hysterical actions. Woman on a Delta Airlines flight in Florida was kicked off the airplane because she “looked tired and drowsy.” Staff stated that if she did not get off the flight, they would call the authorities. Delta gave her a $20 voucher for tea and soup, then let her on the next flight. Because tea, soup, and an hour wait in the lovely airport atmosphere are more than enough to kill any potential communicable diseases that cause people to look tired and drowsy.

Study in Journal for Healthcare Quality shows that diagnostic errors double the odds of malpractice payout totaling $1 million or more. There were 6,130 such “catastrophic payouts” between 2004 and 2010 and those payments amounted to .05% of the total health care expenditures each year. Years of practice and number of prior paid claims had no bearing on the odds of a catastrophic payout.
However, failure to order diagnostic testing absolutely contributes to diagnostic errors. Kind of flies in the face of the whole “lets cut back on testing” mantra, doesn’t it?

Obamacare mandates having an effect even on Major League Baseball. Cubs grounds crew hours cut to keep them under 130 hours per month so that they don’t meet “full time worker” criteria and get insurance coverage under Obamacare. During rain delay at a recent Cubs game, the understaffed grounds crew wasn’t able to get the tarp properly positioned on the infield – leading the umpires to call the game off due to poor infield conditions.

Neat idea in Singapore to curb non-urgent emergency department care. Hospital and local primary care physicians teamed together to create a “GP First” scheme. If a patient goes to their primary care physician for a problem and then has to be referred to the emergency department, they get $50 off of the $108 emergency department bill. So far, the hospital has seen a decrease in non-urgent cases by 10-12%. The resulting decrease in patient volume also caused about a 20% decrease in emergency department wait times.
Now why wouldn’t such a plan work in the US?

Flying drone delays medical helicopter’s landing at Ohio’s Miami Valley Hospital. What are we going to ban after this incident?
Once we had a guy taking pictures/video with his phone who wouldn’t get away from the helipad in the hospital parking lot while the chopper was landing. Security literally had to tackle him and drag him away.

Louisiana pays extra $18 million to keep Baton Rouge General’s emergency department open. The hospital emergency department is seeing an additional 400 uninsured patients per month with numbers of uninsured psychiatric visits up 60% and number of uninsured surgery patients up 70%. After Louisiana State closed its Earl K Long Medical center in an attempt to privatize charity hospital care, the patients had to find other care. Now Baton Rouge General is losing $1 million per month. Another story on the topic here.
I’ve been saying this for years. When hospitals close, the patients going to those hospitals don’t just disappear. They seek care elsewhere. The costs of providing uncompensated and poorly compensated (Medicaid and “Obamacare”) care at the remaining open hospitals then compounds on itself until the next hospital closes under the weight uncompensated care. Every hospital that closes causes a decrease in access and decrease in available medical care.
Wait. Wasn’t that what the “Affordable” CARE Act was created to solve?
Louisiana better write at least double that $18 million into its yearly budget. It’s trying to cure a hemorrhage by using a Bandaid and we all know how well that will work out.

Another hospital shooting near Philadelphia. Man pulls gun in hospital room then kills wife and shoots himself. Fourth hospital shooting in the Philadelphia area this year. Wait. Isn’t this the same place that has such the high rate of successful malpractice cases? Another reason to consider whether you really want to practice medicine in the Philadelphia area.

Joan Rivers goes into cardiac arrest during throat surgery and is brought to the Mt. Siani emergency department. Reportedly stable. Good job, team!
I can’t wait to hear all of the jokes about this incident.

Driving With A Foot Out The Window

Driving With Foot Out Window

I saw this while driving down the road recently. A person just tooling down a major road with their foot hanging out the window.

What possesses people do drive with their feet out the window? I see it every once in a while from both drivers and passengers. This time my daughter just happened to be in the car with me so she could catch this picture.

I did a quick search of the internet and of the medical literature and wasn’t able to find any specific literature on the potential downsides from driving like this.

I was, however, able to find other pictures/posts/comments …
calling a driver doing this a “jackass,”
noting that the practice was awkward and potentially dangerous,
stating that a person driving in this manner is “white trash skank,”
stating that driving this way is illegal in Delaware,
noting that a driver in Australia who was pictured with both feet out a window had been charged with “reckless conduct endangering life, failure to have proper control of a vehicle, careless driving, and limbs protruding from a vehicle,” and
a comment noting that the practice was something worthy of circus people.

So if driving with your feet out the window doesn’t hurt anyone and it feels nice to have a breeze blowing on your bare feet while traveling at 50 MPH, then why shouldn’t we do it?
Here are some of my thoughts.

First, you look like a freak when you drive with your foot out the window. It isn’t cool. It isn’t funny. It looks low class and smarmy. Yes I’m old and out of touch with the younger generation. You still look like a smarmy whippersnapper when you drive with your foot out the window.

Next, when you drive with your foot out the window, your foot and/or leg is blocking your view of the driver’s mirror. That makes you less able to see your surroundings and more prone to getting into an accident.

With your leg in that position, you are probably less able to shift your body to turn and look in your blind spot when changing lanes or making a turn. That makes you more likely to hit a vehicle approaching you on your driver’s side.

Finally, pretend for a moment that you get into an accident with your foot hanging out the window. Think of what will happen to your body …

If you rear-end someone and your air bag deploys, momentum will carry your body forward while the airbag forces your hanging leg into flexion and external rotation. Ever popped a chicken leg off a cooked chicken?
Your knee will probably hyperextend as well, so you’ll be in a position where you’ll potentially have no knee ligaments and no hip joint.
The anterior force on your driving leg combined with the posterior force on your leg out the window will cause a shearing force on your pelvis which may be enough to snap your pelvis like a pretzel. Pelvis fractures are potentially life threatening, tough to rehab, and carry multiple serious complications.

If you’re involved in a rollover accident, it’s even worse. You won’t have time to pull your foot back in the vehicle and the edge of the window will hold your foot in place as the several tons of car rolls on top of it, mangling your foot if you’re lucky and just ripping it from your leg if you’re not so lucky. If the roof collapses from the rollover impact, then your knee and lower leg will get caught up in the mangled metal – which may prevent you from getting out of the car.

Look at the bright side, though. If you survive a serious accident with your leg hanging out the window, at least they have a lot of advanced leg prosthetics you can choose from.

Anyone got any stories about trauma from drivers or passengers with their feet out the windows?

Healthcare Update Satellite — 08-12-2014

** CLEAR! **
Not dead yet. Having withdrawal symptoms from lack of blogging and actually violating a cardinal rule of blogging by posting from work. Now that travel is done and life is getting back to normal, will hopefully have more time to write.

Sabrina Kropp had damaged the cartilage in her nose from all of her cocaine use. She went to a plastic surgeon who repaired her nose and who then published anonymous before and after pictures of her nose on his web site. Ms. Kropp then sued the doctor for violating her privacy. The pictures pretty much isolate the patient’s nose, so it appears unlikely that anyone would be able to identify the patient just based upon the pictures. Now that she’s filed a lawsuit, everyone can identify her both as a plastic surgery patient and as a cocaine abuser.
Paging Barbara Streisand

Patient in Maryland’s Calvert Memorial Hospital emergency department steals $4600 in medical equipment from room, is discharged and then goes to a local car dealership and tries to sell the equipment to customers shopping for a car.

Genetic therapy may revolutionize treatment of heart failure. Study in London involves infusion of genetically engineered virus to increase production of SERCA2a protein that in turn increases contractility of heart muscle. Studies show good improvement in animal models and in laboratory human heart models. Human studies beginning soon.

Medical apps worrying doctors? Not me. If people are dumb enough to think that some app on an iPhone can accurately measure their blood pressure or blood oxygen levels without any additional sensors, then they deserve to lose their money. Of course they’re probably related to the same people who think satisfaction survey statistics are valid.
Paging PT Barnum

New services such as Pager and Medicast allow patients to summon physicians for house calls. No insurance, though. You’ll have to pay a minimum of $199 in cash for the convenience — more if you request the service at night, on weekends or on holidays.

Nice story about an emergency physician leaving the comfort of the emergency department to help patients in Haiti and then Tanzania before hopefully joining Doctors Without Borders. Good on you Dr. Benzoni

Number of emergency department visits related to synthetic marijuana in NYC has more than doubled in past year. Can this be related to the “safety” of marijuana?

Staten Island physician found dead in hospital bed. When article notes that the doctor specialized in pain management, commenters to the article jump to the conclusion that he must have overdosed on something.

Conflict of interests? Singapore hospital begins a palliative care service in the hospital emergency department.

Welcome to the Abercrombie and Fitch Emergency Department. Ohio U builds new 43,000 square foot emergency department, increases beds from 50 to 70 then to 100, initiates bedside registration and adds doors to rooms instead of curtains. Believes that these measures will decrease crowding and improve wait times.
Talk to me in a year and see how well that works. If you build it, they will come.

Healthcare Update — 07-24-2014

Busier may be better* … at least for for patients with life-threatening medical emergencies. When comparing very high volume emergency departments with very low volume emergency departments, a study in Annals of Emergency Medicine shows that patients with medical emergencies were about 0.4% less likely to die when they were treated at the nation’s busiest emergency departments. These statistics reportedly translate into about 24,000 lives saved each year if patients received the kind of care that was provided in the nation’s busiest emergency departments.
* A small disclaimer is in order, though. The study was performed by University of Michigan medical school. University of Michigan Hospital’s ED has more than 80,000 visits per year and is considered high volume.
I think a good idea for a similar study would be to compare mortalities in communities before and after the closure of emergency departments in the areas. This study might suggest that mega-hospital care is better, but is immediate care in small volume emergency departments better than delays in care during travel to a mega-hospital … or no care at all because patients can’t get there?

This may explain why doctors are so good at practicing defensive medicine. During their careers, doctors spend more time in the courtroom than in the classroom.
The headline is misleading since during a lawsuit, doctors aren’t in the courtroom 40 hours per week as they are during medical school. The point is that for 11% of their careers, an average physician has a lawsuit hanging over his or her head.

Johns Hopkins gynecologist admits to secretly recording patients during gyne exams. Police search home and find computer servers with naked pictures and videos of up to 8000 patients. Doctor then commits suicide.
Johns Hopkins has just agreed to a $190 million settlement with the involved patients.
If the lawyers get 30% of the settlement, they’ll net $63 million. If the remaining funds are divided equally among the affected patients, they’ll each receive about $16,000.

Kourtney Kardashian’s boyfriend can’t handle his liquor and has to go to the emergency department for alcohol poisoning. Not sure why this is news, but now you can click the link and gouge your eyes out, too.

There may be some truth to the statement from patients with chronic back pain who say “that sh*t doesn’t work with me.” Study published in the Lancet shows that there is no difference in time to resolution of symptoms between patients using Tylenol and patients using sugar pill placebos. There was also no difference between the groups in pain, disability, symptom changes or quality of life. And the strange thing is that 75% of patients were happy with their treatment regardless of whether they took Tylenol or a sugar pill placebo.

Oakland police repeatedly beat Occupy protester and Army Ranger Veteran with a nightstick, then throw him in a cell and ignore his complaints for help. When he begins vomiting, one officer told him to stop using heroin. Another officer videotaped him. Friends finally bail him out and bring him to the hospital … where he underwent surgery for a lacerated spleen.
Why does it seem like the names of public citizens accused of crimes are published in newspapers but the names of law enforcement officials who commit crimes against the public are kept hidden?

Understaffing in British Columbia hospitals frustrates patients who had to wait 4.5 hours in emergency department before they could get treatment for their infant son’s severed finger. Waiting room was packed with dozens of patients and only two doctors were on duty. Called several other hospitals that also had long waits in their emergency departments.
But at least the care is free.

9 year old patient with history of congenital heart defect and prior endocarditis goes to emergency department for a fever and “seeming sick.” Doctors give him motrin and discharge him without performing testing after he appears better. Returns two days later and diagnosed with endocarditis. Develops complications during surgery and ends up paralyzed on the left side of his body, blind in the left eye, and with garbled speech. Jury awards patient $17 million.

Laparoscopic hysterectomy begins uneventfully, then bleeding from the uterine artery is noted and the procedure is immediately converted to an open procedure. Towels packed into the abdomen to stop the bleeding and the patient’s life was saved. A month later, the patient has fever, discharge, and abdominal pain. Repeat operation showed that one of the towels had been left inside the patient. Patient required several additional surgeries and later sued. Jurors award $7.2 million. Important point in the case is that the defendants began pointing fingers at each other. The surgical techs blamed the surgeon and the surgeon blamed the surgical techs. As the author of the article noted, “once jurors see “dueling defendants” they most often assume the worst happened and find blame all around”

Jury finds that Alabama doctor and nurse midwife were not liable for birth injuries to an infant who was born a quadriplegic. Case gets overturned after attorneys discover that, when questioned about a potential deadlock, the judge sent jurors a note to “please keep deliberating” — without informing the attorneys or parties.

For a completely non-medical link that had me both appalled and laughing at the same time, check out this model citizen who became upset because McDonalds didn’t serve chicken nuggets in the morning.
Even though this video was posted last year, according to TSG, the event occurred in 2010.
A little more searching showed that the original video had no audio and that the audio was dubbed in later for amusement purposes.
And I just kept thinking that this is the type of patient whose low Press Ganey satisfaction survey scores would be the source of a monthly meeting because the emergency department staff isn’t meeting all of its patients’ needs.

Healthcare Update Satellite — 07-14-2014

Practicing telemedicine may just get a whole lot easier. Federation of State Medical Boards creating an interstate “compact” that would reduce barriers by providing an “expedited license” to physicians who wish to practice medicine in multiple states. The physician has to establish a state of “principal license” and then may apply to the “Interstate Commission” to receive a license in another state after the “applicable fees” have been paid. The hundreds of dollars per year paid to each state to maintain licensure don’t appear to be one of the barriers that is being reduced.
Most recent draft of the compact can be found at this link (.pdf)

Remember the infant who was “cured” of HIV after receiving high doses of antiretroviral drugs shortly after birth? She was taken off her medications and didn’t have any evidence of HIV in her bloodstream for several years.
Unfortunately, doctors recently announced that the child is now showing signs of HIV infection.
And the hunt for an elusive cure to HIV continues.

Milwaukee woman goes to emergency department with abdominal pain, rapid heart rate and fever. Spent nine hours in the emergency department and was discharged around midnight with instructions to follow up in the morning with her gynecologist for fibroids in her uterus. Later collapses at home and treated for septic shock which caused her to lose both arms and both legs. Sues hospital and plaintiff attorney argues that none of this would have happened if she just got a “$25 antibiotic.” Jury awards $25.3 million, saying that physician assistant and emergency physician who treated her should have provided her with a complete differential diagnosis of her symptoms prior to her discharge.
Attorneys expect that this case will get to Supreme Court as more than $16 million of that judgment would be subject to Wisconsin’s $750,000 medical malpractice cap.

Do you have any Kleenex? I need to blow my … back. Paralyzed woman has stem cells taken from her nose and undergoes stem cell transplant to try to cure her paralysis. Eight years later, she has pain at the surgical site. Undergoes exploratory surgery and doctors find a 3 cm growth of nasal tissue that was secreting mucous which was pressing on the woman’s spine.
Surgeons note that this type of complication is uncommon, occurring in less than 1% of patients.
Case report in the Journal of Neurosurgery is here.

Patients gone wild. Australian police are “investigating” after patient attacks five nurses, a security guard, a paramedic, and an elderly patient. One nurse required hospitalization. No one notified the hospital staff that the patient had previously attacked a nurse.

What are the conversations like in a rural emergency department waiting room with “country folks”? Pretty darn funny column about it by Lauretta Hannon in a suburban Atlanta newspaper. How *did* Aunt Carrie get hooked on them Oxycondoms, anyway?

Kaiser Health reports on newly implemented Dignity Health network policy where emergency department patients can “pay to go to the front of the line.” Hey – Southwest Airlines does it and so many people think that emergency departments should be more like other businesses, right?
But when hospitals start providing preferential treatment to those with money and internet connections, they’re running afoul of EMTALA laws.

Venezuela’s University Hospital of Caracas closes its emergency department in protest for 72 hours after gunmen break into an operating room and kill a patient during a surgery to extract a different bullet. The gunmen also killed the patient’s brother who was waiting in the hospital.

Improving access to health care won’t save money. Nice article in the NY Times about how increased access to medical care increases costs. My favorite quote is a variation of my “Pick Any Two” post:

One of the most important facts about health care overhaul, and one that is often overlooked, is that all changes to the health care system involve trade-offs among access, quality and cost. You can improve one of these – maybe two – but it will almost always result in some other aspect getting worse. You can make the health care system achieve better outcomes. But that will usually cost more or require some change in access. You can make it cheaper, but access or quality may take a hit. And you can expand access, but that will increase cost or result in some change in quality.

And one point on which I differ with the author is his assertion that “The A.C.A. was primarily about access: making it easier for people to get insurance and the care it allows.” The Affordable Care Act was never about access. It was all about insurance. And few if any doctors are willing to accept the miniscule payments offered by government insurance. Health care insurance doesn’t guarantee you health care access any more than auto insurance provides you access to a car.

Occupy Wall Street protester jailed in Rikers Island accuses prison of medical negligence. One inmate with Hepatitis C was reportedly coughing up chunks of her liver before she died in prison.

 

Quick Visit

Lips

A mother brought her son to the emergency department with a rather non-emergent complaint … chapped lips.

The registration clerk started taking the registration information.

“Can I get the patient’s name and date of birth please?”
“Yes, it’s Johnny …”
The clerk got distracted by the patient who first licked his lips, then smacked his lips, then rubbed his finger back and forth over his lips.
“You know, you shouldn’t do that. That’s probably why your lips are so irritated.”
Back to the mother.
“His name is Johnny Smith. His date of birth …”
The kid licked his lips, made a smacking sound, and rubbed his finger over his lips again.
“Maybe you could get some Chap Stick from your mom. You really shouldn’t rub your lips like that.”
Back to the mother.
“Sorry. What was his date of birth again?”
“December 17, 2008.”
The registration clerk started typing and all of a sudden, the registration clerk slams her hand on the desk and yells “STOP THAT!”

The kid looked at her in horror.
She started to apologize.
“I’m so sorry …”
This time the mother interrupted.
“That’s EXACTLY what he needed! He don’t listen to me. You gonna listen to HER now? Huh? You gonna listen to HER when she tells you not to do that?”
The kid kept his eyes fixed on the registration clerk and slowly nodded his head.
Then the mom thanked the registration clerk, gathered her belongings, and left.

And the biggest discussion afterward was what to call the diagnosis.

Surrogate discipline training?
Rule out tardive dyskinesia?
Left without being licked?

———————–

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.