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.

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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.

Healthcare Update Satellite — 11-04-2014

Ebola PictureBack with more of the Ebola Chronicles …

Ebola fears causing discrimination problems all over the US. Thomas Duncan died from Ebola. Now his fiancee is having difficulty finding a place to live as landlords are refusing to rent to her. People of African descent are facing discrimination just because they are from Africa. Mothers of some school children told one African cafeteria worker to leave the school because she “might have Ebola.”

In Liberia, bleeding patients are often refused medical care due to Ebola fears. The picture at the link shows a picture of a woman who was bleeding heavily from a miscarriage and who was unable to find treatment at multiple clinics.

Hospitals developing policies on what care may not be provided to Ebola patients. Invasive procedures, hemodialysis, endotracheal intubation, and CPR are all being reviewed to determine whether the risk to health care workers is worth the benefit to patients. For example, if an Ebola patient suffers a cardiac arrest and it takes a half hour to don protective gear, will doing so benefit the patient?

The CDC says it is unlikely (.pdf file), but other infectious disease experts assert that Ebola can already spread by aerosols and droplets. Even vomiting creates an aerosol which can transmit gastrointestinal viruses.

Tori Spelling's Ebola Nervous Breakdown Picture Of The Week

But at least Tori Spelling is OK. She was hospitalized with “symptoms of Ebola” which ended up being a nervous breakdown caused by her husband cheating on her. Took selfies of herself in her hospital bed with Twitter hashtags written on a facemask she was wearing. We need to have a 21 day media blackout on any celebrities that pull this crap. Make that a 21 week media blackout.

And some other select news …

Support for California’s Proposition 46 drops almost in half once voters actually learn about the ballot language.

Patients gone wild. Former police officer gets drunk, gets brought to emergency department, assaults nurse, then tries to take Taser from the police who responded to the scene. He got a smackdown by police officers before being arrested for disorderly conduct and attempting to disarm a police officer.

Alabama jury awards family of patient $4 million for missed MI resulting in patient’s death. 40-year-old man went to the emergency department complaining of abdominal and chest pain after eating breakfast two days prior. He was diagnosed with gastrointestinal problem, was sent home, and died of an MI two days later. Plaintiff attorney argued that full cardiac workup should have been performed and hopes that the large verdict “sends a message to doctors, particularly emergency room physicians.”

Remember, marijuana is a harmless drug. Adolescents who use cannabis were 63% less likely to complete high school, 62% less likely to earn a college degree, eighteen times more likely to develop cannabis dependence, eight times more likely to use other illicit drugs, and seven times more likely to attempt suicide.

Science journalist describes how she suffered a broken heart … literally. She was diagnosed with Takotsubo cardiomyopathy

British woman has cosmetic procedure performed during medical tourism trip to Thailand. She was unhappy with the results, so she returned to the clinic for corrective surgery and died under anesthesia.

Healthcare Update Satellite — 10-21-2014

More medical news from around the web on my other blog over at DrWhitecoat.com

Study from University of Maryland proves that emergency physicians are idiots … at least when treating pediatric extremity injuries. Splints were placed improperly in 93% of suspected pediatric fractures treated in emergency departments. “The researchers found that the most common reason for improper placement of a splint was putting an elastic bandage directly on the skin, which occurred in 77% of the cases. In 59% of the cases, the joints were not immobilized correctly, and in 52%, the splint was not the appropriate length. Skin and soft-tissue complications were observed in 40% of the patients.”
Of course, I’m sure that the orthopedists evaluated the patients immediately after the splints were placed to make sure that the patients had not readjusted the splints prior to their orthopedic follow up. That almost never happens.
This study makes a good case for requiring orthopedic evaluation in the emergency department for every pediatric patient suffering from any type of bone or joint injury – regardless of the time of day or night.

What no one is telling you about Ebola … from a Hazmat Trained Hospital Worker. The gear used to protect providers from Ebola is difficult to put on, difficult to remove, and can usually only be worn for 30 minutes at a time. The medical providers in Dallas who contracted Ebola had no protocols in place and this author believes that the “system failed them.”

Patients apparently believe that being in the same hospital as an Ebola patient is bad for their health. Patients at Texas Health Presbyterian Hospital are canceling outpatient procedures, no one is walking in the hallways, and the ED wait times have dropped from an average of 52 minutes to … zero.
“It feels like a ghost town,” said one vendor who recently visited the hospital.

Ketamine has almost immediate positive effect on anhedonia and depression associated with bipolar patients who are resistant to other treatments. The more remarkable thing is that the effects can also be seen on PET scans and effects from a single dose of medication last for over two weeks.

Another example of why doctors should be wary of treating VIP patients. Former NFL running back sues orthopedic surgeon after alleging that his Achilles tendon tore during Baltimore Ravens tryout. Alleges that the surgeon misrepresented the fact that the Achilles tendon had fully healed after his prior Achilles surgery.

Ambulances line up outside North Wales hospital waiting to drop off emergency patients. At one point the line was 13 ambulances long and the wait was hours just to get into the emergency department. One of the government administrators recommended that patients go to NHS Direct or pharmacies for speedy health advice.
At least the patients are covered by insurance, though — just like many of the patients in the US now.
Australian nurses want penalties to be imposed on hospitals if patients aren’t seen within four hours in emergency departments.

If this penalty materializes, a few things will happen. First, nurses will be penalized by hospitals for not effectively moving patients through the emergency department. Second, there will be massive fudging of statistics during busy times. Third, patients who have exceeded the four hour threshold wait will be passed over so that patients who have been waiting less than four hours can be evaluated within the threshold.
When you pay for a statistic, you get the statistic … not necessarily the intended benefits behind the statistic.

From comments at Overlawyered.com
Employee of a surgicenter goes to facility for a colonoscopy. When he wakes up, he was wearing pink underwear. As a result, he suffered extreme emotional distress, humiliation, loss of wages and loss of earning capacity. He is now suing.
While I probably would have laughed off a prank like this, I can understand why some people would have been upset. But suffering a loss of earning capacity from being dressed in pink panties as a prank? I’d like to see how that happened.

Healthcare Update Satellite — 10-13-2014

More medical news from around the web on my other blog over at DrWhitecoat.com

So what are medical providers supposed to do if they are faced with a potential or actual Ebola victim? Who knows?

Here’s a case you don’t see every day … Patient transferred to University of Alabama Medical Center after having what was thought to be a hand grenade embedded in his thigh. He wasn’t allowed in the emergency department, but was instead treated in an ambulance in the parking lot for more than six hours as a military consultant advised medical personnel how to remove it. Eventually was determined to be the 40 mm ammunition for a smoke grenade that reportedly was embedded in his leg when the smoke grenade went off.
I’m not sure I would have been treating him in an ambulance in the parking lot, though. Gasoline tends to make explosions worse, not better.

Medicare enrollment can be so difficult that even a journalist who has been writing about Medicare for almost 40 years needs help from an insurance expert to understand the process. Open enrollment starts soon, so get those appointments for experts now.

Patients gone wild. Arizona schmuck steals an ambulance parked outside a hospital, takes it on a joy ride, refuses to pull over for police … and then parks the ambulance outside his home. I can just see him saying “it wasn’t me” to the police as they arrested him.

You think you’re good at multitasking? You aren’t. In fact, you’re probably worse at multitasking than people who don’t multitask. Interesting study showing how multitasking significantly affects performance. Unfortunately, Forbes’ contributor must have been multitasking while writing the article. His story was based on a study that was published five years ago.

Emergency nurses want to become board certified. Article doesn’t say what board is doing the certifying, but all of the extra training is sure to save lives … and enrich the certifying organization.

Hospitals in Louisiana are charging rape victims for emergency medical care. The National Organization for Women alleges that when private hospitals charge patients for medical care related to sexual assault, it becomes “a form of political extortion to discourage the pursuit of prosecution of crimes of sexual assault.” While Louisiana has a victim compensation fund, it doesn’t provide compensation to all crime victims and under state law, victims who do not file a police report “are to be treated as regular ‘emergency room’ patients.”
Rape is a horrible crime, but is it fair for NOW to demand that companies and medical personnel provide their services for free because those companies and personnel try to help crime victims? Once we start down that slippery slope, where do we stop? Shouldn’t all crime victims receive things for free? And if they’re receiving free medical care, shouldn’t they also receive other things for free as well? Free replacement clothing from any clothing store? Free food from any restaurant if they are hungry? Free child care while attending court hearings or while meeting with police? Free travel back and forth to appointments?
If states want to provide compensation for crime victims (and many already do), then that’s the state’s prerogative. Demanding that private businesses and private citizens provide services for free solely because someone was a crime victim is rather Draconian. NOW‘s position just doesn’t make a lot of sense.

Indigent patients still using emergency departments for their dental problems. Now Minnesota is licensing dental therapists – midlevel providers of dental care than can clean teeth, fill cavities, and care for other dental problems. Other states considering doing the same.

One in ten Canadian seniors who are admitted to a hospital is kept in an emergency department for more than 31 hours before being transferred to a medical floor. “They have no privacy, no toileting facilities. Their basic human needs are unmet, largely because emerg staff are trained to deal with the constant flow of sick people.” But at least the patients all have insurance – just like us.

Healthcare Update Satellite — 09-30-2014

Pittsburgh police taser a reverend who was praying over his dead stepson in the emergency department. His stepson had been shot and was dead. The hospital stated that the reverend was interfering with attempts to revive the patient, but the video shows no such attempts taking place. Now the reverend has filed a lawsuit against the police.

Waits of two days to receive treatment in the emergency department. Frequent misdiagnosis. Lack of resources to treat simple problems like asthma. Hospitals that run out of medications regularly, forcing patients to purchase the medications at private pharmacies. 20% the amount of emergency physicians needed to provide services to patients.
Welcome to health care at King Faisal Specialist Hospital & Research Centre in Saudi Arabia.
Is this the kind of care that we can look forward to with our new “insurance”? We’re already seeing “narrow networks” where insurance companies fail to have sufficient primary care and specialty physicians to care for their patient populations.

Need an MRI and have insurance? That’s great. You still have to pay up front for your testing. With deductibles from $2000 to $5000 on the most common Obamacare plans, hospitals may have difficulty getting deductible payments after procedures have been performed. More hospitals are therefore requiring that patients pay for testing before it is performed.
The good news is that in order to require payment up front, the hospitals have to disclose their charges, which will lead to greater transparency – and hopefully downward market pressure when prices are compared. Up front pricing will also begin demonstrating to many people that medical care comes with a cost that’s more than just a $20 copay.
The bad news is that patients who can’t afford testing may not get necessary health care unless they … go to the emergency department where, by law, hospitals can’t require up front payments.

Thought provoking article on the decline of mental health care in America. The author, a psychiatrist, doesn’t cite his sources, but note that the number of psychiatric beds in the US has shrunk from 340 psychiatric beds per 100,000 population to 11 beds per 100,000 population – a net loss of 1 million psychiatric beds. As a result, 3.5 million severely mentally ill patients remain untreated. Many are arrested and housed in prisons and jails. Others use public libraries as “day care programs.” Cook County Sheriff Thomas Dart noted that with the systematic shut down of so many mental health facilities, his jails have “become the de facto mental health hospital.”

Michigan oncologist pleads guilty to administering unnecessary cancer treatments to patients who were either in remission or who had terminal disease. Government also alleged that he would deliberately misdiagnose patients with cancer in order to justify cancer treatments and would fabricate diagnoses of fatigue and anemia in order to justify unnecessary hematology treatments. He submitted $109 million in Medicare claims between 2007 and 2013.

Your data is safe, really. Healthcare.gov web site reportedly hacked twice earlier this year, but CMS didn’t tell anyone until this month. And the GAO warned that the system still remains fulnerable to unauthorized access, disclosure of confidential data, and data manipulation. Check your credit reports and your medical histories from the MIB. It’s getting to be an every man for himself atmosphere out there.

One member of Parliament when Canada’s health care system was adopted in 1966 ends up waiting in the emergency department on a stretcher for 48 hours before hospital bed opens up. Later dies in the hospital.
One commenter to the article noted that “at least he got to experience the health care system he helped create for us.”

Nice special report in the Seattle Times about the operations in Harborview Medical Center’s emergency department. Some of the pictures are quite thought-provoking.

This article mocks some of the entries in the government’s new ICD-10 coding scheme. For example, “Bizarre personal appearance” is actually a codeable diagnosis. Estimates are that the costs for a doctor’s practice to change to the new coding system will average from $56,000 to $226,000. And sure, being required to differentiate between Orca bites and piranha bites or between first and subsequent run-ins with a lamp post may seem idiotic to most people, but if the coding isn’t accurate, it gives the government the ability to allege that there was false billing and to levy huge fines or even imprisonment. That’s no laughing matter.

How To Discourage A Doctor

Doctor

This post should be required reading for every physician in this country.

A physician finds a document on a chair in his hospital executive’s waiting room and reads through it, then realizes it is a manifesto on how to disempower physicians and put hospital administrators in control of patient care. The document’s title: How to Discourage A Doctor

While the physician implies that he transcribed the information from memory, the formatting breaks and text errors in the document make it appear as if the document was scanned and then the text pasted.

Transform physicians from decision makers to decision implementers. Convince them that their professional judgment regarding particular patients no longer constitutes a reliable compass. Hiring, firing, promotion, and all rewards should be based on conformity to hospital-mandated policies and procedures”
Increase physicians’ responsibility while decreasing their authority. For example, hold physicians responsible for patient satisfaction scores, but ensure that such scores are influenced by a variety of factors over which physicians have little or no control, such as information technology, hospitality of staff members, and parking. The goal of such measures is to induce a state that psychologists refer to as “learned helplessness”.
“Above all, introduce barriers between physicians and their patients. The more directly physicians and patients feel connected to one another, the greater the threat to the hospital’s control.”

Whether the entire backstory of the article is true or more of a parable, the concepts described are being implemented … and they are a serious threat to the health care in this country.

Look at some recent medical research.

This survey showed that hospital ownership of private physician practices has increased dramatically in the past 6 years. In 2008, 62% of physicians owned private practices. This year, only 35% of physicians maintain independent private practices. Only 9% of physicians “mostly agreed” that hospital employment of physicians would increase quality of care and decrease costs. 81% of physicians described themselves as “overextended” or at full capacity.

This survey showed that government regulations regarding electronic medical records are being implemented but that 75% of physicians believe that the electronic medical records increase costs and do not save time. 68% of physicians do not believe that the regulations improve productivity and 48% do not belive that the regulations support coordination of medical care.

This study showed that time lost in dealing with electronic medical records was “large and pervasive”, costing physicians an average of 48 extra minutes a day – during which they could have been performing other tasks such as patient care.

I’m sure that hospitals, their administrators, and their attorneys will all deny that they are trying to discourage physicians or to drive a wedge between physicians and their patients. Draw your own conclusions.

However, as more physicians move to hospital based practices and exhibit less autonomy, think about who stands to gain and who stands to lose from such transitions.