Memories …

Juicy FruitA sweet little lady was brought to the emergency department by her caregiver after having difficulty breathing at home. She got a few breathing treatments and some steroids and was doing much better an hour or so later.

When I went back in the room to evaluate her, several family members were present.
“Oooh. You got the good doctor. No wonder you’re doing better.”

I thanked them because … obviously they were right … but I mentioned that I didn’t recall seeing their mother in the emergency department before.
“She hasn’t been here in a long time. You took care of our father.”
“Oh. I see. How is he doing?”
“He died a little more than a year ago.”
One of the family members could obviously see the confusion in my face.
“He was dying from cancer and he came to the emergency department many times before he died. One of the last times he was here, he was having trouble swallowing and his mouth was dry. You started the IV on him and gave him some fluids. Got him feeling better. He kept saying that all he wanted was some Juicy Fruit gum. So you went to the vending machine and got him a pack of Juicy Fruit gum. That was all he talked about after that day … how his doctor in the ER went and got him some gum when his mouth was dry.”

At that point, I realized several things.
First, it showed me that patient opinions of medical care can be arbitrary. I was judged as being a “good” doctor because I did something nice for a patient, not because of the medical care I provided. This interaction just reinforces my belief that our current means of rating medical care is woefully inadequate and inappropriate.
Second, this family’s story showed me how small acts of kindness can have a tremendous ripple effect. Something I had long forgotten had made a lasting impact on the patient which in turn made a lasting impact on the family and will probably continue to be a story that is always associated with our emergency department.
Finally, this interaction reiterates a quote from Maya Angelou that I frequently paraphrase when talking to residents and even in some of my lectures: Patients may not remember your medical knowledge and they may not remember your diagnostic acumen, but they will ALWAYS remember how you made them feel.

Pretty good returns for an investment of a 35-cent pack of gum …

Healthcare Update Satellite — 05-14-2015

Morally corrupt and illegal at any other hospital, but the VA system will sweep it under the rug and absolutely nothing will happen about it. Patient in car just a few feet outside the emergency department calls emergency department for help getting out of car so that he could come in for treatment of his broken foot. Seattle VA Hospital tells him ”No, we’re not going to come get you. You’re going to have to call 911 and you’ll have to pay for that.” A fire captain and three firefighters end up coming to help him out of his care and wheel him into the emergency department.
Meanwhile, the VA changed its story about the incident several times. The best quote was the VA didn’t consider the vet’s condition an “emergency.” Because you can really differentiate emergency from non-emergency over the telephone. Idiots.
Don’t worry, though. The patient has government insurance!

Uninsured rate has decreased under Obamacare, but for some strange reason, the number of emergency department visits keeps rising. Wasn’t this expansive new legislation supposed to stop the problem of emergency department overuse?

The Unaffordable Care Act strikes again. I’ve been harping on the difference between healthcare “insurance” and healthcare “access” for years. Now people are finally starting to understand … when they have insurance and can’t afford care because of insurance copayments. In the past 5 years, copays have increased from 20 to 43%. Copays associated with Obamacare cost even more. The effect is reportedly that more people than ever are delaying treatment for serious medical conditions due to the high costs of care.
Just because you have insurance doesn’t mean that doctors are going to accept it as payment.

Unfortunately, it will probably take a patient death or a huge security breach before this problem is rectified. Patient medication infusion pumps are “the least secure IP enabled device” that one security expert has ever worked with. It is relatively easy to both control the pump and to use the pump to gain access to other devices on the network.

This is a larger problem than people realize. Five year old goes Tasmanian devil mode at school, knocking over bookcases and desks, biting, screaming, and flailing his arms. Teachers call police. Police handcuff child and put him in leg shackles, then take him to the emergency department for evaluation. Wonder what the discharge diagnosis was …
Now child’s mother is “appalled” and “sickened” by the events and she wants everyone involved in the event “investigated.”
The problem with incidents like this is that parents who have a need to blame someone often turn events like this into a no-win situation. If the kid hurts someone when he’s acting out, then the teachers are at fault for not acting quickly enough. If the teachers try to restrain the kid, then they get in trouble for corporal punishment. If the teachers call the cops when he acts out, then they are at fault for overreacting. And if some other kid acts out against little Taz, then the teachers are at fault for that, too.

Probably wouldn’t have mattered in his accident, but still kind of ironic … Georgia politician who campaigned against motorcycle helmets dies in motorcycle accident after he crashes into a car that pulled out in front of him.

Canadian patient left in waiting room of doctor’s office for 90 minutes while staff was at lunch. Gets upset and bills the hospital $112.50 for her time. One of the last lines in her letter was most relevant. How is it that we pay $300 a year or more for our “free” healthcare and yet we are billed for an OHIP covered service?
Remember the Engineer’s Triangle. Fast care, free care, quality care: Pick any two.

Ebola-infected doctor flown to Emory University for treatment and declared cured. Develops burning sensation in his eye and the color of his eye turned from blue to green. Culture of fluid within the eye tests positive for Ebola virus. Article also notes sexual transmission of Ebola six months after patient cured from active disease. Now what?

NY Times article discusses how medical bills are often filled with jargon and indecipherable numerical codes. Up to 90% of hospital bills contain errors and “there is no general law that says bills must be clear and there are no rules about which can be reported to credit agencies.” There *needs* to be a general law saying that bills must be clear. Suing for consumer fraud (which allows plaintiffs to recover attorneys’ fees) is a good way to stop this scam.

Good Morning America article also gives some information on decoding the hidden charges on hospital bills.

Healthcare Update Satellite — 04-26-2015

Both an unusual case and a great attitude. Woman with cerebral palsy for 33 years seeks care for a physician who questions the diagnosis. Considers that the patient may have rare type of dystonia and starts patient on L-dopamine. Within 2 days, the woman’s symptoms are nearly gone. She has been living a life without symptoms for the past 5 years

Food stamp use in the United States continues to rise. This article questions whether Obamacare is to blame.

Good way to save money. Veterans Affairs just keeps denying claims until the veterans die. Then they mark the files as “no action necessary” so that the surviving family members don’t get benefits, either. Records falsified, employee whistleblowers being retaliated against, management lying to Congress, oh, and a supervisor who required staff members to pay $30 for fortune telling by the supervisor’s wife. If you think things are expensive now, wait to see how much they cost when they’re free.

Another example of the Golden Rule. England’s NHS considering rationing healthcare to certain demographic groups. Obese patients may not be eligible for joint replacement surgery, breast reduction surgery, or varicose vein treatment. Smokers may not be eligible for in vitro fertilization.
He who has the gold makes the rules.

Forget treating asthma. Soon we may be able to *cure* asthma.

What’s the most unethical thing you’re seen in a medical setting? This Reddit thread has quite a few amazing storied. One which was particularly applicable to this blog read as follows:

I briefly worked at the front desk clerk for an ER at a local hospital. The rule was the anyone that came in complaining of chest pains had to be back and on a machine within 10 minutes of arrival. Once I entered their name into the system a clock started. So I was told not to enter their name until they had already been taken back to essentially make our numbers look better and make it appear as though they were receiving care within the prescribed 10 minutes.
***
“There are three kinda lies in the world; lies, damned lies, and statistics.”
MY OPINION: never trust an individual stat, they’re almost always manipulated and if you have chest pains take aspirin.

Some people just get it. Unfortunately, those who use and rely on healthcare statistics often aren’t included in those groups of people.Knuckle Cracking

Ever wondered what actually happens when you pop your knuckles? These researchers did a study using video MRI of cracking knuckles to find out what causes the noise. One of those things I always suspected, but now there’s proof. Now the bigger question is whether the childhood threats from my mother that cracking your knuckles will cause arthritis is really true.

California’s Doctors Medical Center closes its doors after 60 years. The clientèle were mostly indigent minority patients and the hospital wasn’t able to survive the financial pressures. Now nearby hospitals are feeling the pressure. One is operating above capacity since the hospital closure.
I can say without equivocation that people are going to die. It’s a guarantee people are going to die because of the closure of DMC,” … “It depends on what your emergency is going to be, and how long it takes you to get to another hospital.”

More and more patients being required to pay “deposits” before receiving non-emergent care in the emergency departments. In this Arkansas hospital, a patient with chronic back pain complained to the media after being requested to provide a $200 deposit for care. When the reporter went to the Arkansas Department of Health, a spokesperson noted that if a patient had Medicaid and the care in the emergency department was not emergent, the patient would not be reimbursed for the $200 fee.
I guarantee that “screen and street” will become a widespread practice in emergency departments in the near future as Obamacare insured patients have more and more difficulty finding primary care practitioners who are willing to take their “insurance” and come to the emergency department by default.

Healthcare Update Satellite – 04-15-2015

You’ve heard of a CAT scan? Get ready for the dog sniff. Dogs can identify bladder and prostate cancer with a 98% accuracy rate when smelling male urine samples.

Not into the whole dog sniffing thing as a screen for prostate cancer? A $1 screening test using gold nanoparticles 10,000 times smaller than a freckle is more accurate than PSA screenings and gives results in minutes. When blood is mixed with the nanoparticles, tumor biomarkers cling to the surface and cause clumping. I’m guessing the test will cost consumers several hundred dollars.

Doctors are using scorpion venom to create “tumor paint” to help surgeons find brain tumors. The tumors literally glow green when viewed with near-infrared light.

The good news is that plucking hairs in a specific pattern and density may cause an inflammatory response that will cause up to 1200 replacement hairs to grow in their places. Scientists are studying the phenomenon in mice, but touting the idea as a possible treatment for male baldness. The bad news is that if you don’t do it right, you’ll end up looking like you have mange.

In Australia, parents aren’t forced to vaccinate their children. Then again, if those parents are receiving welfare benefits, they’ll soon start losing the benefits if their children remain unvaccinated. Really like this idea as a means to encourage healthy decisions and to determine the true motives of those who think vaccinations are “bad”.

More with the microbiome. MIT scientists are studying sewer samples to determine presence of food-borne pathogens and biomarkers for certain diseases. When they can start tracing the diseases back to your toilet, that’s a problem.

Really hoping that this is an isolated incident … Woman stabs husband because he stank up the bathroom. Of course failing to wash his hands after using the toilet and then trying to help his 3 year old son go to the bathroom only made matters worse.

Small changes in your diet may have a significant impact on weight gain and body fat composition. Yogurt, seafood, chicken and nut ingestion most strongly associated with weight loss later in life. Carbs with high glycemic loads were especially bad for weight gain.

Then again, taking bodybuilding supplements may increase the chances that men will develop testicular cancer. Chances of testicular cancer rose by an average of 65% in patients who took muscle building supplements. Risk was even greater for those who used supplements at an earlier age, took multiple supplements, or used them longer. Keep in mind that the incidence of cancer increased from 3.7 cases per 100,000 men up to 5.9 cases per 100,000 men, so testicular cancer is still an uncommon disease.

Acetaminophen may be bad for your emotions. Study shows that participants who ingested Tylenol reported less intense emotions – both positive and negative – than controls who were given a placebo.

It took NY City firefighters hours to get a 700 pound man out of his sixth-floor apartment and to the hospital. They needed to use a rope, net, and pulleys and pull him from a stairwell window. Ten firefighters had to lift him into the ambulance. If he couldn’t get out of the house, then someone must be bringing him all the food to maintain his weight. Those people should be ashamed.

Are the waits in the VA system getting better? Not really — according to this video.

Our country’s veterans are in the best of hands … really. It’s bad enough that the VA is failing to provide proper medical care to some of our veterans. But when the veterans then go public with the problems and become “whistleblowers,” VA officials admit that they illegally go through the whistleblowers’ medical records in an attempt to harass and discredit them. One report in 2010 showed 14,000 privacy violations at one VA center in Pittsburgh. The VA threatened to decrease the disability rating of one whistleblower and another had superiors commenting at work about her psychiatric care.
H/T to the Drudge Report.

Thoughts from a husband whose wife was diagnosed with brain cancer. Quite sad, but you really need to read this – especially if you are caring for someone with a terminal illness. “The hardest thing for me to do … is to hold the hand of my wife.”

First it’s Progressive Insurance’s tracking device to get you “discounts” on your policy for good driving behaviors. Now health insurance John Hancock wants to track your activity to give you a 15% discount on your health insurance premiums … if you live a healthy lifestyle. One interviewee for the article uploaded data to the web alleging that the watch showed him having sex from 1:07 AM to 2:00 AM one morning. Right. And each of the five spikes in activity was an orgasm, too.
I’m not sure whether it bothers me more that companies want this data or that so many people are willing to give up so much of their privacy to provide the data.

Semantics and the $28 Million Unnecessary Test

MRI LumbarThere’s been an awful lot of Internet hullabaloo about “unnecessary testing” lately. The Choosing Wisely program keeps trying to assert that we should not perform any “unnecessary” tests. Recently, a paper was published in the Journal Academic Emergency Medicine alleging that “overordering of advanced imaging may be a systemic problem” since many emergency physicians believe that such testing is “medically unnecessary.” The paper was based on surveys that were presented to emergency physicians and the work was at least partially funded by the Veterans Administration and the National Institutes of Health — which should be considered a conflict of interest. After all, don’t the entities that pay for the testing stand to gain to gain the most from limiting “unnecessary” testing?

But now that the paper has been published, the media has been whipped up into a frenzy, stating that doctors admit they perform “unnecessary” testing and are single-handedly bankrupting our medical system.
Consultant Magazine has an article stating that “ordering unnecessary imaging tests ‘may be a systemic problem.’”
NewsMax Health states that “97% of ER docs order unneeded tests out of malpractice fears
HealthLeaders Media trumpets that “97% of ED physicians order unnecessary imaging tests
Even Time Magazine has a headline stating that “your doctor likely orders more tests than you actually need.”
However, I’d bet my white coat that if you asked any of the study authors or any of the authors of the articles in these prestigious magazines what the definition of an “unnecessary test” was and how to prospectively determine whether or not a test is “unnecessary,” they would all look at you with blank stares and shrug their shoulders.

Unfortunately, defining the term “unnecessary” is more difficult than it seems. The American Heritage Dictionary defines “unnecessary” as being “not necessary.” In turn, “necessary” is defined as being “needed or required.” “Needed” is defined as “A condition or situation in which something must be supplied in order for a certain condition to be maintained or a desired state to be achieved.” This definition gives us a little bit of help, but is still vague as it applies to medical care. When discussing advanced medical imaging, a necessary test would be that which must be performed so that a “certain condition can be maintained or a desired state can be achieved.” Ruling in or ruling out a disease process would seem to fit that definition.

Based on the paper’s abstract, it appears that almost 500 emergency physicians were given a survey and 97% of them stated that at least some of the advanced imaging studies (CT scans and MRIs) they personally ordered were “medically unnecessary.” In other words, the researchers took a politically charged statement and, using a fallacy of definition, created a statistic which is in itself both untrustworthy and sensationalistic. Rent-Purchase
The questions used in the survey aren’t available. If you want to look at them, you can “rent” the article for $6 or you can splurge and purchase the article for $38 – neither of which I’m planning to do. However, consider the questions that would be raised if the researchers asked 500 people whether they were “good parents” and then published a study saying that, based upon survey data, bad parenting did not exist in the United States. Or consider a study asking doctors if they acted in “professional manner” and then declaring that unprofessionalism does not exist in medical care because 97% of doctors answered “yes.” Those studies would get laughed out of Medline because it is easier to see the bias in asking people ambiguous questions when the terms of the questions haven’t been defined. That’s why I’m very surprised that some of these authors would put their names behind a paper with such dubious conclusions.

Shortly after the JAEM paper was published, Lenny Bernstein then published an article in the Washington Post noting that patients with low back pain who were first sent for MRIs instead of first going to physical therapy paid an average of almost $5000 more for their medical care. The reason was apparently that MRIs tended to show all kinds of “benign changes” in the patient’s backs. The article is based on a study in the Journal “Hospital Services Research.” Again, it will cost you $6 to rent or $38 to own this piece of research. It would be nice to know whether or not the authors, two of whom were physical therapists and one of whom was a researcher in “Clinical Quality and Outcomes Research”, discussed whether there were any adverse outcomes associated with proceeding directly to physical therapy as opposed to obtaining advanced imaging. It is difficult to draw any conclusions from the abstract other than physical therapists are advocating more physical therapy for low back pain.

Finally, also published right around the same time as the above two articles, there was an article in the Los Angeles times noting how Kaiser Permanente was ordered to pay a young woman more than $28 million after delaying an MRI that could have detected an aggressive cancerous tumor. According to the article, the patient was 17 years old and experiencing severe lower back pain. She and her mother repeatedly requested an MRI of her lower back, but the patient was instead told that, at 125 pounds, she had too much “belly fat” and needed to lose weight. After three months, Kaiser ordered the MRI and found a large fast-growing cancer in her pelvis. Ultimately, the patient required amputation of her right leg, removal of half her pelvis and part of her lower spine in order to remove the tumor. The patient’s lawyer argued that her leg and pelvis could have been saved had the MRI been performed and the cancer diagnosed earlier. Kaiser argued that the cancer was already so large that the patient would have lost her leg even if they had ordered the MRI sooner.

Admittedly, it is difficult to determine whether care was appropriate based upon an incomplete clinical picture, but I think we can safely assume that the patient falls into the “don’t image” guidelines that ACEP has created for the “Choosing Wisely” initiative (see guideline #8).
Note that the Choosing Wisely guidelines for acute low back pain are different than the low back pain “red flags” that are traditionally considered an indication for diagnostic imaging. This patient had at least two “red flag” symptoms.

The Kaiser case also raises an issue as to whether or not the jury award was unreasonable and based upon emotion rather than based upon the patient’s injuries. However, consider that the award must provide for lifelong care of a young adult who had to have her leg amputated, half of her pelvis removed, and part of her spine removed. She’s going to require quite a bit of care and is going to go through a lot of suffering for the rest of her life. This case took place in California where there are caps on the “suffering” or “non-economic” portion of the damages. We don’t know how much of the award was based on future medical care and punitive damages (neither of which are subject to the caps) versus noneconomic damages which would be capped at $250,000. If the patient was able to introduce evidence that Kaiser had a pattern of engaging in denial of care to increase profits as the article suggests, punitive damages would be more likely to be imposed.

The thing I found most interesting about the Kaiser case was that Kaiser did not argue that the MRI of the young patient’s lumbar spine was an “unnecessary” test. Nobody in the comment section of the article argued that the MRI was an “unnecessary” test, either. Why? Because the results of the test were positive and anyone who argues that a test is “unnecessary” when it shows gross abnormalities needing immediate therapy would be viewed as an idiot. Had the exact same MRI in the Kaiser case been normal, everyone would have rolled their eyes, shook their heads, and proclaimed what a waste of money it was to perform the test. However, because the MRI was grossly abnormal, the consensus is instead that the test was not only “necessary”, but that it should have been performed much sooner.

This concept underscores why the JAEM article is so misleading. The authors don’t adequately define the terms on the surveys that they provided and, as a result, the conclusion they base on those ill-defined terms do not pass scrutiny. When we define the utility of a test by that test’s results, we engage in medical mumbo-jumbo which neither improves the health of patients nor improves the practice of medicine.

It sure makes for some great “unnecessary” headlines, though, doesn’t it?

Healthcare Update Satellite — 03-04-2015

Homeless North Carolina VA patient comes into the ED to be evaluated for the sores on his feet. His shoes are falling apart. Nurse Chuck Maulden bandages up the patient’s feet and then gives the patient the brand new Nike sneakers off of his own feet. Chuck then works the rest of his shift in a pair of shoe covers and doesn’t say anything about it. Only way that people found out was because the patient’s family called to say thank you. We need more people like Chuck.

I’m not aware of too many uses for virtual reality in medicine, but this seems to be a good one: seeing what it’s like to suffer from schizophrenia. Imagine being cooped up in an elevator with strangers staring at you and voices telling you “you will fail”. The author of the article wore the VR headset only briefly, but noted that after he removed the headset, “the feeling of discomfort lingered.”

Long Island woman fights to keep database about NY physicians online. It is scheduled to go offline due to lack of funding. “Choosing someone because they were nice just didn’t work anymore.” Just think, you can always rely upon the accurate and reliable data from Press Ganey and Healthgrades.com. /sarcasm.

Long Island town demanding that nearby hospital construct an emergency department in its town. Hurricane Sandy destroyed the prior hospital in 2012. Commenter to the article notes “Everyone wants the luxury and availability of a hospital but fails to support it financially. Don’t be like Long Beach or your hospital will also be Long Gone.”
Spot on, ma’am. Spot on.

I suppose this explains why I never see any parents of newborn children coming to the emergency department with strokes. Sleeping more than 8 hours per night associated with almost a 50% increase in stroke risk.

Woman complains to TV station because Florida’s Gulf Coast Medical Center emergency department is close to maximum capacity, and her 87 year old father had to sleep in the hallway. News flash, lady: Emergency departments are crowded all over the country. However, Florida doesn’t have enough doctors because of the miserable environment Florida has created for its medical providers. Remember the amendment to Florida’s Constitution revoking the licenses of doctors who had three malpractice cases against them? You reap what you sow.

California hospital’s emergency department volume up 7% after Obamacare implementation. Our hospital’s ED volume is up 15%. According the article, Obamacare advocates say that ED numbers would decrease once people received insurance. Now they’re walking it back, citing studies that the decrease in emergency department use only begins to show up at 1 year after insurance enrollment. They’ll be sure to measure and report on the new numbers … just after the next election.

Patients gone wild. Louisiana’s own Patricia Munzey arrested and charged with assault and battery of emergency personnel after she threatened to “slap and kill” ED staff and then kicked a nurse in the face when she was trying to bandage the patient’s injury.

More patients gone wild. Pennsylvania patient William Whitmoyer gets brought to emergency department and threatens to come back to hospital with gun and “make hamburger meat” out of everyone in Geisinger Medical Center. Upset over administrator making $5.6 million. Because the threat of violence caused alarm and was an inconvenience to staff, he was arrested and charged with disorderly conduct and with making terroristic threats.

Quite an interesting idea circulating on Reddit: People waiting in the emergency department for a someone else to be treated should be encouraged to donate blood.

Interesting infographic on the shelf life of multiple foods. According to the comments, though, it seems to create more questions than it answers. Some people are claiming that eggs can be left out on a shelf for a year without spoiling if they aren’t washed. Not sure I’d be the first to try a year old omelette.