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?

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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 — 07-2-2014

Ve have vays of keeping you qviet. Halt den mund! Government-contracted security force who actually call themselves the “Brown Shirts” … threatens to arrest medical providers if they leak any information to media about all of the medical illnesses that are being seen at an illegal alien refugee camp in Lackland Air Force Base.
By the way, this story is from FoxNews, so everyone should just ignore it until you or your family members sit next to one of them on a bus or in a movie theater. Combine these kids on playgrounds with anti-vax kids? What could go wrong?
Nothing to worry about. Nothing at all.

New York City urologist and surgeon father/son team up to serve the needs of the city’s hungover partiers. For a mere $250, they will send a nurse to your home or office, insert an IV, and give you IV Zofran, IV Pepcid, and IV Toradol. It’s called a “revive” package.
When people start spending more on the morning after recovery than they do on the night out, they have serious issues.
Oh, and don’t mind that you can get the same or similar medications and a bottle of Perrier for about $10.

60 year old Alaska emergency department patient gets arrested after trying to walk out with bed sheets, latex gloves and a bloody syringe, oxygen tubing, medical wrap, a pulse oximeter
Items reportedly worth $300. Patient goes to Greybar Motel where bail is set at $2500. What was he going to do with oxygen tubing and a pulse oximeter? Guess there’s always eBay.

Nice article in Annals of Emergency Medicine about how to Effectively Use Online Resources in Emergency Medicine. Article gives lots of resources with links. Included in the recommendations are: 1. Use an RSS reader. I posted about RSS readers on DrWhiteCoat.com after Feedly temporarily tried to steal bloggers’ content. Theoldreader.com and taptu.com were a couple of the favorites other than Feedly.
2. Use a PodCast Application. I don’t listen to podcasts. Popular with anyone else?
3. Find compilations of content (also suggested that residency directors post lists of compilations)
4. Use social networking to connect with content producers and peers.
5. Use custom search engines for material (such as GoogleFOAM.com – which happened to be a dead link at the time I wrote this post)

$5.2 million verdict in lawsuit filed against Maryland’s St. Agnes Healthcare, EMCARE, emergency physician, and physician assistant. Patient injured knee in a gate at loading dock. PA who evaluated patient noted paresthesias, difficulty moving his foot, and pain in the leg then diagnoses patient with knee sprain. Physician overseeing PA reportedly performed an exam, but did not write a note in the chart and did not co-sign the chart until 10 days later. Patient returned two days after initial visit and found to have torn all ligaments and tendons in his knee and suffered injury to popliteal artery. Because of the initial misdiagnosis, the patient required an above-knee amputation.
The article doesn’t say whether there was a judgment against the emergency physician, but recall that insurance policies may not cover physicians for claims involving failure to properly supervise other medical practitioners. Make sure that your contracts include coverage for such claims.
Copy of the original complaint can be downloaded here.

Arizona Supreme Court rules that “vulnerable or incapacitated adults” are able to sue for all the attorney’s fees and expert witness fees under Arizona’s Adult Protective Services Act. I couldn’t find the fee-shifting portion of the statute, but am worried about the unintended consequences.
What happens when hospitals know that there is potential for increased liability when caring for “vulnerable or incapacitated adults”?
What will lawyers do when they know that they’ll get paid more for filing such claims?

WhiteHouse pressuring states to join Obamascare’s Medicaid conglomerate, claiming that if they don’t, the states will deprive 5.7 million Americans of health coverage in 2016. The report is “based primarily on careful analysis of the effects of past policy decisions” which also brought you such conclusions as “if you like your doctor you can keep your doctor” and implied that emergency department use will decrease under the Affordable Care Act, so take the conclusions for what they’re worth.

Pennsylvania state medical board suspends license of anesthesiologist for sending nearly 250 text messages with sexual innuendos while overseeing surgeries. During a stomach surgery, he sent 45 text messages alone. Not good. Hopefully none of the patients were injured.

Now that we’re discovering about 2.2 million Obamacare enrollees may lose coverage due to unresolved discrepancies in their data and that 6 million Obamacare enrollees ended up enrolling in their new Obamacare plans because they were kicked off of their previous plans, the department of Health and Human Services has stopped providing updates in enrollment data. A net negative number of enrollments probably wouldn’t fare well for the law’s future.
Megan McArdle asks “Where Did the Obamacare Data Go?”

Patient goes to emergency department with a cough. Doctor ordered x-ray to rule out pneumonia. Radiologist read chest x-ray as normal. More than a year later, patient returns to emergency department with worsening cough. CT is performed and shows metastatic lung cancer. When lawyers go back and look at prior chest x-ray, a 1.5 centimeter nodule was reportedly missed. The patient later died. Her daughter filed a lawsuit and the jury just awarded her $16.7 million dollars.
Wonder why radiology reports are sometimes so “comprehensive”?
To wit: Master Radiologist able to hedge on every possible medical condition. Report of 7 pages and 10,000 words contained interpretation gems such as “The intestine is mildly dilated and collapsed with thick or thin walls and most organs have areas of abnormal or normal enhancement, so small bowel obstruction and organ pathology must be considered. And tuberculosis. Also, cancer. Could be cancer.”

One Way to Cure a Drug Seeker’s Back Pain

Back StatueA gentleman in his 40s limped into the emergency department for evaluation of severe back pain.

He had a chronic history of back pain, but had decided to forgo recommended surgeries because he was told that there was a chance his pain could worsen. He reportedly had multiple MRIs in the past … all of which showed “severely” bulging discs. He also just moved to the area the evening prior to his visit. In all of the excitement and heavy lifting, he strained his back, he couldn’t find his pain medications, AND he lost his wallet. That meant he had no ID and he couldn’t remember his address because, of course, he just moved into his apartment last night.

He was in excruciating pain and couldn’t move without pain shooting to his legs. Oh, and his heart stopped after taking aspirin a long time ago and he was specifically told NEVER to take NSAIDs because they could kill him.

His exam didn’t show too much except that he was in a lot of pain. So we ordered a muscle relaxant and a couple of Tylenol with codeine tablets.
After about 15 minutes, he stated that the Tylenol #3 “took the edge off.”

He got a shot of Decadron and we prepared to discharge him. He requested a couple of days of Norco pills until he could find his other prescription amongst all of the moving stuff.
I gave him the benefit of the doubt and wrote him a prescription for a couple of days worth of Norco and Robaxin. However, I wrote on the prescription “DO NOT fill prescription without verifying photo ID. Please fax copy of patient’s photo ID to Metro General Hospital emergency department at 888-555-1212.”

The patient flipped out.
“What … am I some kind of criminal?”
“Sir, you’ve given us no way of verifying your identity for purposes of creating a medical record of or providing you with a bill for the services you’ve received. We need to do this for all our patients.”
Shaking the prescription at me over the desk, he said “Yeah, well I bet you don’t write crap like THIS on the prescriptions for ‘all of your patients.’”
“That’s true. But very few of our patients come into the emergency department with no identification and not knowing their address, either. You received medications to help with your symptoms. We just need to verify your identity. If you’d like, we can call the police to have them verify your identification. In fact, Mary, can you call the police and ask them to send an officer down here?”
“You’re the biggest asshole I’ve ever met in my LIFE!”
And with that, he crumpled up the prescription, threw it on the floor, and stomped out the door with nary a hint of antalgia in his gait.

Just goes to show …
Those steroids really do help back pain.

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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.

Hemoptysis Pearls

There was a nice article over at Consultant360.com by Drs. Laren Tan and Samuel Louie on hemoptysis pearls. Learned quite a few things.

200 mls of blood (about a cupful) is enough to fill the dead space in the lungs and is therefore generally considered the minimum amount of blood to make the diagnosis of “massive” hemoptysis.

Hemoptysis with chest pain – think pneumonia/pleurisy, PE with pleurisy, pulmonary edema from an MI, or lung cancer

Hemoptysis with dyspnea – think either exacerbation of patient’s underlying medical problem or a precursor to respiratory failure

Hemoptysis with fever – think infection, autoimmune disease, vasculitis, or even PE with lung infarction

Chest xray, CBC, and coags are the initial diagnostic tests. CT scan is indicated for suspected masses, recurrent hemoptysis, or high suspicion of cancer. Although not mentioned in the article, PE evaluation would also be an indication, depending on symptoms and pre-test probability scoring. CT alone has a diagnostic yield of about 67%.

For a differential diagnosis of hemoptysis, remember the mnemonic “BATTLECAMP”

B – Bronchitis
A – Abscess
T – Tumor
T – Tuberculosis
L – Lupus
E – Embolism
C – Coagulopathy
A – Autoimmune (eg, Goodpasture syndrome, systemic lupus erythematosus)
M – Mitral Stenosis
P – Pneumonia

Healthcare Update Satellite — 06-23-2014

The right to carry a concealed weapon only exists if your doctor says so. Many states are requiring that physicians certify whether patients are competent to carry a concealed weapon. Some states require mandatory reporting of those deemed not competent to carry a concealed weapon. Of course, the natural extension of such laws is that if the doctors make an inappropriate determination, then the doctors can be held liable if the certifiee does something inappropriate with the weapon.
This New England Journal of Medicine article shows that many doctors aren’t comfortable making that determination.
Then again, I’ve heard colleagues threaten that if they’re required to report people, they’re just going to make anonymous certifications that every police officer they see is not capable of carrying a concealed weapon, then forward them to the state using USPS Delivery Confirmation to prove that the reports were received.
We really shouldn’t stop at physician certifications of competency for gun ownership. We should expand the physician certification to encompass other areas in which people could be potentially harmed. For example, physician determination of competency should be required for positions such as judges, CEOs, prosecutors, and anyone who comes into contact with a child. Dammit, we need to protect the children.

We’ll have to re-publish this study again around November, but for now, keep in mind that using hypertonic saline nebulizers to treat bronchiolitis causes less improvement than just using regular saline.

Many people reportedly complaining of headaches after using Google Glass. Harvard optometrist notes that they aren’t really headaches but a “discomfort in the eye muscles” from looking in strange directions.
Wait. That optometrist said nothing of the sort. Those quotes were taken out of context. Only a few people feel the pain. There are no health risks. Now retract your story or we’ll bury you in the search rankings.
Also see my other post discussing problems using Google Glass for medical applications.

Listen up you administrators and hospital board members … plaintiff lawyers are wising up. Children’s Hospital in New Orleans sued for institutional negligence when deadly fungus spreads through NICU on bed linens and kills five children.
By alleging institutional negligence, the lawyers avoid the $500,000 malpractice cap and also extend the statute of limitations.
No medical providers were named in the lawsuit, either.

This is amazing. Drug trial for arthritis causes interesting side effect. Person with alopecia receiving tofacitinib (Xeljanz) in a clinical trial grows full head of hair.
hair
Our government’s failure to control our borders is now having significant repercussions for the health of our nation’s residents. Deadly diseases such as tuberculosis, dengue fever, and Chagas disease coming into country along with all of the illegal immigrants.
Author of the article describes how President Obama is implementing the Cloward Piven strategy to overwhelm the public health system in order to replace it with a national welfare system to end poverty.
Worked well in Venezuela, didn’t it?

57% of all Italians fear being harmed by physicians. 44% disapprove of their national health care system. The European Commission notes that “Much still remains to be done in terms of patients’ rights, safety, and empowerment to report medical malpractice”within the European Union.

Patient taken to Houston’s St. Joseph Medical Center for an “anxiety attack.” Two hours later, the patient was reportedly discharged. The patient didn’t come home for several days. Finally, the patient was found on the hospital’s fourth floor stairwell. Now the patient’s daughter is “convinced someone from the hospital should pay.”
Hat tip to Scott for the link. Thanks!

When an attorney sued a hospital after mother and twin neonates all die from tuberculosis, he held a news conference stating that “There may have been a motivation to find a cause for her condition other than tuberculosis … If the cause was some other infection, they wouldn’t need the state government in there to investigate … a tuberculosis diagnosis invites oversight and opens up a can of worms.”
Now the hospital is suing the attorney for defamation, alleging that the attorney is implying that the hospital engaged in a cover up.
Paging Barbara Streisand …

Why are we providing better healthcare to those who killed thousands of Americans than we do to the veterans who put their lives on the line to protect us?
“The ratio of patients to doctors in Guantanamo prison is 1.5 to 1. For America’s 9 million veterans receiving VA health care and 267,930 VA employees, the ratio is 35 patients to 1 doctor. Additionally, in late 2008, when Obama was president-elect, he and his staff were warned not to trust the wait times reported by VA health care facilities. But instead of fixing the problem, their focus was closing Guantanamo and improving the comfort of detainees. Even though they already lived under some of the best prison conditions ever seen.”

Another fascinating case. Usually necrotizing fasciitis (a.k.a. “flesh eating bacteria”) causes massive tissue damage, often resulting in death or amputation of limbs. In this case, doctors cured necrotizing fasciitis using a wound vac, antibiotics and irrigation of the wound with an ingredient in household cleaners.

Patient’s pseudoseizure causes doctor to have pseudoseizure when asked to give Ativan and Morphine to treat the pseudoseizure. And I just giggle to myself thinking what would happen if a doctor really did develop a pseudoseizure when a patient went into his or her pseudoseizure.

VA tries to hunt down anonymous whistleblowers, demanding that a watchdog group turn over all records it received pertaining to “wait times, access to care, and/or patient scheduling issues” at VA facilities in Phoenix or elsewhere.
First I’d start by “losing” the requests a few times. Then I’d make them fill out all requests in triplicate. Oh wait, did you fax that? I never received it. You’ll have to re-send it. I’ll put you on a waiting list and you’ll get the information as soon as possible.
Oops. Sorry. The hard drive crashed and we lost the e-mails. No back ups, either. Darn.