More HealthCare Updates from around the web are at my new digs at http://drwhitecoat.com.

“Dear ER staff. Our friend is drunk. Fix him.” Unconscious Arizona college student who was “turning blue” left in hospital lobby with Post-It note stuck to his body after losing “drinking contest” at frat house. Nice friends.
If you decide to follow the link, turn down the volume on your computer. Gannett’s KSKD.com has an auto-start video ad that will blow your ears out.

Irish emergency department so crowded and busy that it has to pull an ambulance up to the front door to act as an extra resuscitation room for a patient. To be fair, there were five patients all needing resuscitation at the same time. I actually think that the doctors were pretty resourceful in coming up with the idea.

Nice article on how University of Michigan is decreasing medical malpractice expenses by disclosing errors and compensating patients before lawsuits are filed. Open claims have declined to 63 from 262. Lawsuits have declined to 0.75 per 100,000 patients per month from 2.13. Claim resolution time also has declined to 0.95 years from 1.36, costs to defend lawsuits have dropped to less than $1 million per year in 2009 from $2.2 million in 2001, and the amount needed for reserves has fallen to less than $16 million in 2009 from $72 million in 2001.
They seem to be on to something.

Nice article in the Atlantic about the decline of emergency care. Emergency department visits have increased by 44% while emergency departments have closed at a rate of 11%. In addition, 339 trauma centers have closed. A 10% increase in the number of African Americans treated correlated with a 41% increased risk of the emergency department closing.

If you’ve got nothing to do for a few hours, you can read the 4951+ comments on Reddit that were posted after an emergency physician offered to answer any questions that the readers might have.

The UnAffordable Care Act may leave cancer patients requiring “specialty drugs” with a hefty bill. Some states will require patients to pay up to 30% of the cost of their medications – which could total thousands of dollars each month.

Wisconsin hospital offers machine that dispenses prescription medications. Bad news is that patients need a credit or debit card to pay for the medications … no cash allowed. In addition, you have to visit the hospital’s own ED or acute care clinic – no other prescriptions work in the machine.

Interesting social experiment in New Zealand proves the obvious. Patients don’t use the the emergency department because they can’t afford to see a primary care physician – they use the emergency department because it is convenient. Patients were eligible to receive vouchers to obtain free appointments with primary care physicians for non-urgent complaints. Not one voucher has been handed out this year.
There was a wide belief that people used the emergency department because it was free, but the “clinical head” of the ED stated “that’s probably not as strong as a driver as you might think.”
Bullhokey. Institute a $20 co-pay for each emergency department visit and see how quickly ED patient volumes decrease.

More HealthCare Updates from around the web are at my new digs at www.drwhitecoat.com.

Annals study shows clinical signs that necessitate admission in patients with ALTE (when newborns appear to stop breathing): “obvious need for hospitalization (they used persistent hypoxia as one example of this), significant medical history, and more than one ALTE in 24 hours.

Dual energy CT scan can diagnose knee ligament tears more effectively in the emergency department.
Is it necessary to definitively diagnose ligament tears in the emergency department, though?
And how long will it take until government officials blast doctors for ordering these tests?

You know all of those hospitals that advertise their emergency department wait times? Now those ads may end up biting hospitals in the rear. Nevada patient chooses hospital based upon advertised average wait time of 17 minutes, then waits five and a half hours before getting treatment. Newspapers publish statements suggesting that the signs may be “false advertising.”
Will consumer fraud cases against hospitals based on these advertisements be too far behind.

Florida House tries to improve medical malpractice environment by passing bill that would require experts to be in the same specialty as the physicians about whom they are testifying and that would allow ex parte communications between lawyers and a patient’s treating physician.
I still wouldn’t practice medicine in Florida.

Conditions at California’s Contra Costa Regional Medical Center are endangering patients according to the emergency department staff. Examining patients in the lobby and behind screens in the hallways are alleged as the emergency department is seeing twice as many patients as it was designed to accommodate.
So what do hospital administrators do in response? They hire a consultant to tell them the same things that the staff is already telling them.
What? Did you expect rational thinking?

Hospitals finding that they can cut costs by catering to emergency department “superusers”. For example, homeless patient Dennis Manners was treated in the emergency department 337 times in less than two years, amassing charges of more than $626,000. The hospital found him an apartment, assigned him a primary care doctor, and enrolled him in a drug treatment program.
I think that what the hospitals are doing is great, but why should this financial burden fall on the backs of private enterprises when government should be providing the services for its citizens?

Social media strikes again. Picture from Cumberland Infirmary in England shows that the hospital isn’t meeting the government targets for patient throughput.

For those of you who don’t know what alarm fatigue is, think of a car alarm. The first time you hear it going off, you run to your window to see who’s breaking into a car. Maybe you run to the window the second time and the third time, too. By the tenth time the alarm goes off, you’re thinking that the alarm is broken and someone needs to get that fixed. After about thirty false alarms, you’re feeling like going out there and busting up the car yourself – especially if the car alarm wakes you when you’re asleep.

So alarms can be good, but if there are too many “false positives” – in other words if they go off too much when nothing is wrong – people tend to become tired of listening to them and eventually ignore the alarms.  On the other hand, if there are too many “false negatives” – meaning that they don’t go off when something is wrong – then the alarms aren’t fulfilling their purpose.

The same problem holds true for multiple types of alarms. Think about virus alerts on your computer. If they are set to alert you about everything, the first few times you freak out, then, after investigating, you dismiss them. If they alerts keep occurring too often, eventually you figure out a way to disable them. If the alarms don’t alert you when a virus is trying to hack into your computer … then what good is it to have the software?

With electronic medical records, medical providers are often alerted to multiple types of medical problems with each patient. No recent tetanus shot. Haven’t asked whether the patient is abused at home. No allergy information available yet. Time that patient was first evaluated not entered. Did you review vital signs? The list seems endless sometimes. Some of these alerts are useful. Most just serve to document some government mandated question that we must answer in order to receive payment for billing or to look like we provide better care on some database that only hospital administrators and reporters ever look at.

It was busy as heck during a shift and I kept getting knocked off task by alarms which are supposed to be helping us. A patient is having an acute heart attack. I try to put in orders for basic treatments and labs. Once I get logged into the patient’s chart, that takes a minute or so. Then, before the system will accept the orders, I get the alerts.
“No medical allergy information had been entered for this patient. Medication orders will be canceled.” The only button to hit is “OK” on that screen. Well, he’s a new patient. So I have to spend another few minutes clicking through a dozen or so screens to tell the computer that the patient has an allergy to sulfa drugs (causing him to have an upset stomach) and to iodine (which gave him a “warm” feeling when he received dye for a CT scan once).

Phew. Close call.

Then I spend another few minutes re-entering all of the medications I want the patient to receive. I have to enter all the medications by hand now instead of clicking on the boxes since the computer system won’t let me enter the same “order set” twice on the same patient.

First, let’s give the patient some aspirin. Everyone knows that’s an important treatment for patients having a heart attack.

Whoops.

Alarm. Now I have to go through a few more screens and enter my password to confirm that I dare to give aspirin to a patient who gets an upset stomach when he takes sulfa medications. Where the connection is … GOK.

Well, I’ve dodged that bullet. Now let’s start an IV so that we can give him some IV fluids and have access to give him other medications if he needs them.

Whoops.

Alarm. Now I have to go through more screens and enter my password to confirm that I dare to give salt water to a patient who felt warm after receiving CT scan dye. Where the connection is … GOK. Salt water contains three things: sodium, chloride, and water.

Now that I’ve averted that disaster … oh yeah, the patient has a history of GI bleeds and was pretty anemic last time he was admitted to the hospital. Let’s get a type and screen on him too, just in case he needs blood.

“Reflex order: Blood transfusion.
“How many units of blood will patient receive?” Um … zero. We’re just doing the preliminary stuff if he should need blood.
“Should patient receive Lasix with blood?” Um … no. We’re not transfusing him yet.
Nevermind. Cancel the blood. Cancel. Cancel. Cancel. Yes, I’m sure I want to do that. Confirm.

OK, now let’s … wait a minute. Where was I? Oh yeah. Trying to take care of the patient having a HEART ATTACK.

In creating a “safe” environment for patients, the medical records have delayed me from providing necessary and time-sensitive care to a patient.
Now imagine going through the same or similar scenario multiple times each shift. Every shift.

Ready to go bust up someone’s car yet?

More HealthCare Updates from around the web are at my new digs at www.drwhitecoat.com.

Diagnostic errors account for most paid claims in medical malpractice cases. Errors in diagnosis were the most common type of claim and also amounted to the highest proportion of total payments. The total inflation-adjusted amount of diagnosis-related payouts was $38.8 billion over 25 years.
Remember, these statistics represent just the payouts. On average, two of three medical malpractice lawsuits end in no payment to the plaintiff.
And we still wonder why doctors do so many “unnecessary” diagnostic tests?

Missing bamblance. University of Virginia is on the lookout for a stolen ambulance after the driver left the ambulance unlocked with the engine running.

Another missing bamblance. This one was from University of Alabama Birmingham ED ramp. The ambulance company executive said that it “wasn’t clear how or why someone took the vehicle.”
How – The driver obviously left the keys in it.
I agree with him on the “why” part.

Ex-boyfriend kidnaps patient from hospital room. Waited until she was called back to the treatment area from the waiting room, then stuck a gun in her ribs and made her leave.
I can’t make this stuff up.

Another application of federal EMTALA law. Everyone coming to the emergency department must be evaluated and treated – even if they just bombed the Boston Marathon.
Cases like this come up every once in a while and it is very difficult for the emergency department staff to set aside their feelings.
Another story on the topic here

Surgical complications good for a hospital’s bottom line. With insured patients, hospitals made an extra $39,000 per patient who had post-surgical complications. Medicare patients with post surgical complications earned the hospital about $1750 more. Hospitals lost money on Medicaid and private pay patients with post-op complications.
Don’t believe people who try to draw the conclusion that “errors” and “complications” are the same thing – they aren’t.

Interesting issue brought to my attention by a reader in South Carolina.

One of the hospitals in South Carolina wanted to post a sign in its emergency department waiting room stating the following:

Prescribing Pain Medication in the Emergency Department

Our Emergency Department staff understands that pain relief is important when one is hurt or needs emergency care. However, providing pain relief is often a complex issue, especially when pain is a chronic or recurrent process. Mistakes or misuses of pain medication can cause serious health problems and even death. Our Emergency Department will only provide pain relief options that are safe and appropriate.
• The primary role of the Emergency Medicine provider is to look for and treat an emergency medical condition. We will use our best medical judgment when treating pain, following all legal and ethical guidelines.
• You may be asked about a history of pain medication use, misuse, or substance abuse before prescribing any pain medication.
• We may ask you to show a photo ID, such as a driver’s license, when you check into the Emergency Department or receive a prescription for pain medications. We may also research the statewide prescription data base regarding your prescription drug use.
• We may only provide enough pain medication to last until you can contact your doctor. We will prescribe pain medications with a lower risk of addiction and/or overdose when possible.

 For your safety, we do not:
– Give pain medication shots for sudden increases in chronic pain, or aggravation of chronic pain syndromes.
– Refill lost or stolen prescriptions for medications. You must obtain refill prescriptions from your primary care provider or pain clinician.
– Prescribe missed methadone doses, or provide prescription refills for chronic pain management.
– Prescribe long-acting pain medications, such as OxyContin, MSContin, fentanyl patches, or methadone for chronic, non-cancer pain.
– Prescribe pain medications if you already receive pain medication from another doctor or emergency department.

The Centers for Medicare and Medicaid Services (CMS) had a different take.

EMTALA requires that every patient seeking care in the emergency department receive a “screening exam” and then receive “stabilizing treatment” of any emergency medical condition. In other words, if you are having a heart attack, the emergency department is required to stabilize you regardless of your ability to pay. If you have a runny nose or other non-emergency condition, the emergency department still has to examine you, but then doesn’t have to treat you. In either case, the hospital isn’t allowed to discourage you from seeking care.

CMS therefore wrote a letter to the South Carolina Hospital Association [.pdf flie] and advised it that hospitals displaying such a sign would likely “unduly coerce[ patients with legitimate medical needs] to leave the ED before receiving an appropriate medical screening exam.” Therefore, CMS considered such signs as potentially constituting an EMTALA violation.

I disagree with a lot of things about EMTALA. It is an unfunded mandate. Its reach has progressed far beyond the initial intent of the statute. But unless and until we repeal it, we are stuck with it.

I’m interested in your opinion, though.

Should a sign like the one above be considered an EMTALA violation?
Is it any different than hospitals that advertise their wait times? After all, a patient with an emergency medical condition may see the advertised wait time as being too long and might not go to a hospital because of it.

Vote below and leave a comment.

See more HealthCare Updates from around the web at my new digs at www.drwhitecoat.com.

More of a free market approach to medical care. Australian private hospitals noting a large uptick in emergency department patients as patients opt to pay for emergency services rather than wait for care at the public hospitals. Some emergency departments are recruiting highly regarded specialists to further increase patient demand for services.

Another article about Australian medical care. Patient goes to hospital complaining of the “worst headache of his life.” In many cases, that translates into doctor speak for “order a head CT scan to rule out bleeding”. The patient had a head CT nine days before going to the emergency department which showed the presence of an aneurysm. He was discharged from the emergency department and died the next day.

More arrests for oxycodone prescriptions. In this case, a physician wrote prescriptions for more than 500,000 pills over 2 years. The prescriptions were filled in New Jersey – even though they were written in New York. Other allegations surfaced as well.
The investigation was sparked by an overdose death where a prescription bottle bearing the doctor’s name was found at the scene.

More Unaffordable Care Act follies. Smoking is considered a “pre-existing condition” under the Act and smokers therefore can’t be charged higher rates than non-smokers for insurance. Which means that non-smokers will be charged even more to cover the cost of treating smokers.
I’m getting the impression that the government wants the insurance industry to fail.
Get your healthcare now while you still have insurance, folks.

“Sounds good my man, seeya soon, ill tw …” The University of Northern Colorado student sending this text message never got to finish it. He was driving while texting, drifted into oncoming traffic, jerked the steering wheel, and rolled his car. He died from the resulting injuries.
His parents published pictures of his phone with the message hoping that they can keep others from texting and driving. I hope that every parent prints this article and discusses it with their children.

So much to rant about today.

The girls are doing a dance competition this weekend. I’m trapped in my own little version of Dance Moms. Aaaaauuuuuggghhh. Somebody help me. One daughter complains because she’s in the back of one dance the whole time. Another daughter is upset because people are mad at her because she’s in front during one of her dances. Glitter is all over our fricking kitchen and it doesn’t come up with wet wipes, either. We have to purchase hair extensions with curls for $25 for the girls, and we have to make SURE to purchase the color that most closely matches the girl’s hair. We can’t just curl the girls’ hair because judges can apparently tell the difference between real curled hair and fake curled hair and that makes a difference on how they grade the performance. Sounds like a Joint Commission inspection.
I just keep thinking that they couldn’t pay me enough to participate in a reality show based on this crap.

Junior WhiteCoat is ramping up lacrosse season. He’s loving it. Playing in a huge tournament at Notre Dame next weekend. Junior was also one of the main characters in a movie that won first place and multiple other awards at an indie film festival last week. He’s now getting requests for auditions with some bigger movies. Hear that, Adam Sandler? Pick him and your movie could grace the pages of WhiteCoat’s Call Room.

On the doggie chew list for the past week include a Jenga block, a decorative pillow from the couch, a garbage can in the office, the leg from a “Monster High” doll (since when did it become cool for young girls to go from modeling themselves after Barbies to modeling themselves after zombie high school kids, anyway?), and the middle of her doggie bed. The last one is most interesting. You see, she’s chewed half of the inside out of her own bed and now she no longer wants to sleep on the bed. So when it gets dark out, she runs upstairs to the bedroom and lays on the other dog’s bed before he gets there. That means that the innocent dog is stuck sleeping on a disaster of a dog bed that he had no part in creating. After the first couple of times that happened, I started moving the doggie garbage disposal off the good bed and letting our other dog lay on his bed. By the morning, though, there was more foam filling sitting on the floor, Chewmeister was laying on the good bed, and our other dog was laying on the floor. I’m getting to the point that I’m going to start making little Chewy sleep in a cage … on her own frigged up bed.
Then I thought to myself … those beds are a lot like, say California and Texas right about now.

Speaking about cages. I’m in the closet getting my clothes for the day and I hear some little animal running in the wall. My back has been bad lately, so I haven’t been able to climb in there and see whatever the hell it is that is running around in there. But now I’m in pain, but at least I can move. So I pull off the piece of plasterboard covering the wall, shine my flashlight in there, and a damn squirrel stops, gets on his hind legs, and gives me a “what are YOU doing in here” look. So I did what every normal homeowner would do under the circumstances. I barked at him at the top of my lungs like a dog. He jumped up in the air and then scurried into some other hole he had chewed in the wall. Now at least I know what the varmint is.
So I went to Home Depot and found the varmint killing aisle. There were surprisingly few choices for varminticide. There was the humane live animal cage trap and then there was the not-so-humane sticky board for large animals. I got both.
So I set up the cage trap. I put some almonds and strawberries on it because that is what the trap directions say that squirrels like. I set the trap up at 11 o’clock at night. About 6:00 the following morning, I am woken by the trap snapping shut and I hear some additional banging around. Well. That was easy. I put on a sweatshirt and looked inside the wall. The little squirrel had knocked over the trap and taken all of the almonds. Okay. I balanced it over two of the ceiling studs, so that was probably my fault. One point for the squirrel.
Then I got a piece of old floorboard and put it inside the area, and I set the trap on top of that. Nice and sturdy. Added another handful of almonds and set the trap. Then I left for work. I checked the trap after work and it was knocked off of the floor board. Again, the almonds were gone. Score: WhiteCoat love, squirrel 30.
Okay Mr. Smarty Squirrel, this time you are getting the sticky board. So I put a bunch of almonds right against the wall and it put the sticky board right in front of the almonds. That way, when he stepped on the board to get the almonds, his foot would become stuck to the board. Gotcha this time. When I went back to check on the second trap, both the board and the almonds are gone. WhiteCoat love, squirrel 40. Little bastard.
What I have learned from this experience so far is that squirrels like almonds and that I don’t like squirrels.
So I’m trying to figure whether I go try to purchase some cyanide on the black market so I can poison the almonds or if I just pull an Elmer Fudd and wait in the attic until he comes back and then blast him to smithereens with a shotgun. Feel like Bill Murray in Caddyshack right about now.
The chess match continues.
Oh, and if you happen to see a squirrel sitting up in a tree with a rectangular board stuck to his foot, whack him with an assault rock for me, will ya?

The new web site has been a colossal exercise in frustration. I had everything almost ready to go except for a few formatting tweaks. Needed to add a couple of spaces to put ads to help pay for a new doggie bed and some gruel for my kids. Wanted to change the formatting for Healthcare Updates so that I could make a lot of daily updates without making 15 new posts that bury all of the more substantive posts. Then I got advice from someone who will heretofore and henceforth remain nameless. Said nameless advisor recommended multiple changes to the web site. I could help more patients with tips and tricks. I could get higher search engine rankings when I rant against Press Ganey. Oooh, and I could automate! E-mail summaries of the posts of the week for the readers. Maybe even a member’s only section.
Really? Hmmmm. So I listened. I had meetings. We optimized.
And now the site is still sitting like the old rusted-out clunker car in the backyard of the house next door to my brother.

But then there are the good things in life.
Over the holiday we had friends over, cracked open a couple of bottles of wine, and just talked … and laughed. Wish we could do that more often.
Mrs. WhiteCoat and I rented a movie and curled up on the couch to watch it. We’ve been running so much lately that we both fell asleep within 10 minutes. When I woke up, I had to smile and think about how luck I was to be able to curl up on the couch and relax with my honey.
My brother came out to visit for the holiday. Not sure what it is that makes certain grown adults act like teenage kids when they’re around each other, but I need more of it. I haven’t laughed that much in a while. More about that in another post.
Came home from work one day and found a note sitting on my chair. It was a picture of me with a big head and really long legs holding hands with my daughter who had flowing blonde locks and was in a dress and wearing a crown. The sun was shining and there was a single colorful flower growing out of the barren dirt around us. The caption said “You’re the best dad ever. You relly are.” That made a half-sucky day into a really good day.

Despite the stress, the freeloading squirrel, and the web site, life is good.

Then again, I’m typing this before sitting through 7 hours of dance competition.
I may have to post an update.

A young lady comes to the emergency department and wants to be evaluated for a … somewhat nonurgent … problem.

Chief complaint: “I’ve lost 50 lbs in the past month.” She felt a little weak as well, but she had just lost too much weight. No other symptoms.

The patient weighed 132 pounds. Her skin wasn’t sagging. Her jeans didn’t appear to be new and they seemed to fit pretty well. Nothing about her seemed abnormal on exam. But she insisted that she weighed 180 pounds just a month earlier.
No old records in the computer.
I asked her if she could show me a recent picture of herself on her iPhone. She briefly stopped texting to check, but she couldn’t find any.
I asked her to show me her drivers license. Nope. Didn’t have that, either.
I was quickly developing an opinion that this was a snipe hunt.

Snipe hunts like this are an example of another conundrum that many physicians face.

We are often expected to prove a negative.

Clinically, I can say that the patient did not appear to have lost 50 lbs in the past month. I can even say that it is unlikely [although not impossible - don't comment with all your weight loss feats] that any patient could lose 50 pounds in a month.

But what if …?

What if the patient had cancer that caused some type of weight loss and I didn’t evaluate her for it? What if the patient had a bad outcome from a metabolic problem that I didn’t screen for?
What if, as a result of weight loss, the patient had developed an severe electrolyte abnormality or other blood abnormalities?

Retrospectively, if the patient suffered a bad outcome, it would be easy to allege that weight loss is an obvious symptom of [insert bad outcome here] and that Dr. WhiteCoat was careless because he didn’t evaluate the patient for this problem.

I suppose that the same issue holds true for a febrile child. If a three year old with a runny nose had a fever of 102 at home, but looks fine and is afebrile in the emergency department, he’ll probably get a pass on the workup. But if an afebrile 27 day old infant reportedly had a fever of 102 at home, get the lumbar puncture tray ready.

A physician must have a certain degree of risk tolerance in choosing whether or not to do testing to evaluate an odd complaint, but where should we draw the line between “necessary” and “unnecessary” workups?

And in case you were wondering, yes, I did labs and a chest x-ray on the incredible shrinking woman. She was anemic. Her hemoglobin was 10.5. Not enough to hospitalize her, but enough to recommend that she follow up with the on-call physician for a more thorough weight loss/anemia evaluation.

I’m going to be eating my words if she comes back next month weighing 80 pounds.

Second time in a week.

The first episode, the patient from the assisted living facility came in with sharp anterior chest pain. She said that she was sleeping and woke up with sudden onset of pain. When she opened her eyes, her roommate was standing over her with a crazed look in her eye. Sticking out of her right breast was a ball point pen. Fortunately, the injury was to adipose tissue only and didn’t require any surgical intervention.

On her most recent visit, the same patient returned after waking to her roommate’s friend beating her with a cane. She tried to fend off her attacker and fell to the floor where the friend repeatedly pounded her in the stomach with said cane. She had a lip laceration and multiple bruises to her abdomen.

I feel so bad for this patient because she’s doing nothing wrong and getting beaten in her sleep. It’s not like a loan shark is trying to collect on a debt or anything like that.

Definitely time to find a new roommate.

Or a new facility.

———————–

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.

Columbus, OH paper compares hospital wait times from 15 different hospitals throughout central Ohio. Metrics include minutes until diagnostic evaluation, minutes until pain medication, minutes until admission decision, and minutes from admission to room placement. I just wonder how accurate the metrics are. It isn’t like self-reported data like this can’t be manipulated.

Evanston Northwestern Hospital in Chicago suburbs also making news because of its wait times – nearly twice the national average.

The problem with providing patients with insurance: When the insurer cuts payments, what happens if providers won’t take your insurance? Government cuts payments to providers so that it costs more for cancer clinics to provide chemotherapy to some Medicare patients than the government reimburses. To stay afloat, some cancer clinics have now begun turning away Medicare patients needing cancer infusions. Now patients go to hospitals where the charges for cancer treatment are higher and the waits for treatment will likely be longer.
But we’re going to be insured! And we can keep our doctors, too!

Patients gone wild. Two brothers in Lebanon “attack” an emergency department, smashing windows and insulting the doctors and nurses on duty. In other words … a normal day in a typical American emergency department. And their Press Ganey scores probably stink for that day, too.

What a great story. Six year old Long Island kid treated in emergency department raises $275 with a fundraiser and uses the money to buy coloring books for other emergency department children.

Remember how CMS promised to give incentive payments for “meaningful use” of electronic medical records? Not so fast. Rules changing. Now it is doing random audits of 5-10% of all applicants to see whether they should actually get their bonus payments. Self-reporting isn’t good enough any more.
Wouldn’t it be interesting to see what would happen if all providers went back to paper records?

Canadian paramedics visiting patients with “non-urgent” issues to keep them out of emergency departments. The only question I have is who determines whether the issues are “non-urgent”?

A second interesting Medical Economics article. What are the tech trends that will affect how doctors practice medicine in the future? Interesting to consider. Remote patient monitoring. Personal health records with biometric security. Cool stuff.

More than 25% of Oklahoma patients enrolled in Medicaid. Of those, about a quarter used the emergency department a total of 528,000 times at a cost of $170 million. Oklahoma is now trying to determine how to deal with the high utilizers – those who use the ED more than 15 times every 3 months.

Speaking about Oklahoma … Oklahoma Dentistry Board officials are deciding whether to pursue criminal charges against a dentist. Officials found rusty instruments, “potentially contaminated drug vials” and “improper use of a machine designed to sterilize tools” in the dentist’s office.
The Oklahoma Dentistry Board accused the dentist of re-inserting needles in drug vials after their initial use and using the same drug vials on multiple patients. This happens often in medicine. The dentistry board also stated that a sterilization machine hadn’t undergone monthly testing in six years. Concerning, but when the Board officials tested the machine was it not properly sterilizing equipment? They did test the machine, right? Were the rusty instruments used on patients? Where was the rust located – on the handles or on the surfaces that come into contact with patients?
In addition, the dentist allegedly allowed dental assistants to administer IV sedation when only dentists are allowed to perform such acts.
For each charge, the dentist could face up to four years in prison and a $10,000 fine.
Are the alleged actions above worth throwing someone in jail for 8 years over?

Rhode Island emergency department reportedly one of few in country to have an MRI available in the department. Wonder how MRI use at this hospital compares to national averages.

Remember … fast care, quality care, free care – pick any two. Patient upset because she was treated quickly in a freestanding emergency department, but her bill was too high and included a $1,500 “facility fee” typically used by hospitals. Some of those costs to go complying with governmental regulations.

One British Columbia hospital emergency department is in a “state of emergency” due to understaffing and high patient volumes.

Emergency department personnel don’t routinely ask suicidal patients about availability of firearms in the home. Will patients admit to having guns and if so, will intervention make any difference in suicide rates?

Woman with double uterus told not to have any more children due to possibility of dying from complications. Goes for abortion and learns several days later that the abortion was unsuccessful. Instead of going for repeat procedure, keeps pregnancy. Now, after delivering healthy 6 pound girl, woman sues abortion clinic for the pain, suffering, and emotional distress of having undergone an improperly performed abortion.

A patient was sent to the emergency department to have an ultrasound of her uterus performed.

She had been having abnormal bleeding which coincided with about the time her period was due – only it was a little heavier and lasted a little longer than usual. She decided the best course of action would be to make an emergency appointment with the gynecologist. She was seen the day before she was sent to the ED and the gynecologist performed an ultrasound in his office … which was normal.

The patient called the gynecologist the following day and said that the bleeding was still there, so the gynecologist told her to go to the emergency department for another ultrasound and some blood testing.

The patient arrived stating “I’m here for my ultrasound. Dr. Speculum sent me.” Since patients need orders for testing to be performed, the patient was given the choice of waiting to be seen in the ED or of getting a prescription from her doctor for the exam. She chose the former.

After examining her, we performed a pregnancy test which was negative and a CBC which was normal. So I told the patient she was likely just having a heavy period and that she could follow up with her gynecologist as an outpatient.
The patient demanded an ultrasound. After all, Dr. Speculum sent her to the ED specifically to have an ultrasound done.

So I called Dr. Speculum.

“Hey, it’s WhiteCoat here. Your patient is here with metrorrhagia and I’m trying to discharge her, but she insists that you want her pelvic ultrasound repeated.”
“Yeah. Can you do it?”
“Well what are we doing it to look for?”
“Fibroids”
“OK, well if she does have fibroids, are you going to admit her? Her hemoglobin is fine.”
“Noooooo. Discharge her after the ultrasound.”
“So then why … nevermind. If all you’re looking for is fibroids, weren’t you able to see that she didn’t have any fibroids on the ultrasound you did on her in the office yesterday?”
He must have really wanted that ultrasound by his response.
“Naaaaaaah. The ultrasounds I do in my office aren’t accurate.”
Allrightey, then.

The repeat ultrasound was still normal. I guess he was more accurate than he gave himself credit for.

Wonder if she’ll be referred back to the ED tomorrow for repeat pregnancy testing.

———————–

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.

By an Anonymous Emergency Physician

Hi. I’m Anon. I’m a 44 year old emergency physician. And I’m an addict.

My addiction came to light when my Press Ganey scores plummeted after I started to stand up to the chronic pain and frequent ER patients.
The fact that I have an addiction was reaffirmed when I went to my state’s Prescription Drug Abuse Summit. When I saw so many professionals from varying fields (medicine, law enforcement, pharmacy, education, etc…) assembled, I realized my problem: I’m addicted to prescribing pain medications.
As with any addiction, the first step in treatment requires acknowledgement of the problem.

I thought back to how my addiction began.
Coming out of medical school, there is a certain power that comes on the first day of residency. You suddenly have the power of the pen. You can write prescriptions for low blood pressure, high blood pressure, low blood sugar, high blood sugar, too many bowel movements, not enough bowel movements.  The list goes on and on. But one of the largest ways in which we can help patients is by treating their pain. Controlled substances. Yes, the new physician quickly learns that the pen wields an awesome power and an awesome responsibility. This feeling fades quickly in the face of an 80+ hour work week.

Fast forward 5-10 years. You are seeing 10-12 patients at the same time, all the chest trauma goes across town, and you have a waiting room that is 20 patients deep, and you already know the medical history of ten patients waiting to be seen on the tracking board. Hospital administrators pressure you to make sure that all nonemergent patients are treated and released within 90 minutes. All admits must be up to the floors within 240 minutes … if only the medicine consultant would get down and actually see the patient.
It’s not uncommon to see 40 or more patients in a shift. I make it a point to look up the prescription/controlled substance database our state has. This has been an absolute lifesaver to me and to several patients I have confronted.
The problem is that it takes time:
- 2 minutes to look up the patient and print off the list
- Another minute to count up the number of prescriptions (it does take time to count to 50 or even 72 – my personal best record for one year)
- Another 3-5 minutes to go to the room and confront a patient who has an issue
- Then a few more minutes to sit down and document the conversation.

So I have 10 minutes to evaluate a patient, create notes in an arcane electronic medical record, and discharge the patient. Yet all of that time can be taken up by doing what is right with drug seeking patients. I cherish the ability to “catch” someone who is diverting drugs, to be able to sit down with them and have that “aha” moment. I have even had a few patients come back and thank me for confronting them. But my worth is partially measured by the number of patients I see per hour. My worth is also partially measured by my patient satisfaction scores. It’s not all possible.

Why do I and so many other physicians have this addiction? NOT providing the prescription is very hard. It takes time to do the research on the patient. Confronting the patient with a problem is emotionally draining. Doing it 5-10 times in one shift is not only a reality, it is downright crippling. It sucks out last bit of energy out of your soul. Rather than confronting patients and arguing, it’s far easier to write a prescription for narcotics and move on to the next patient. This is the mindset of thousands of physicians. Healthcare is different than it was 5-10 years ago.

As soon as I started saying “no” to drug-seeking patients, it was as if I had been liberated. I still have lapses and give out prescriptions to a patient against my better judgement. And I occasionally get burned. I am human and some days I just don’t have the energy to argue and fight with drug seeking patients. As time passes, however, saying “no” gets easier.

Physicians need to start saying “no” once in a while. Take the time to review a patient’s medication history. Don’t be the doctor who prescribes the patient’s 300th Norco tablet of the week. Saying “no” just once a day can be liberating. Try it just once a day for a month. Then twice a day. It gets easier. At first, I actually felt guilty when I wrote for Ultram instead of Vicodin. It has become easier with time.

Physicians can’t fight this addiction alone, though. We need the backing of hospital administrators. Hospital administrators must listen to physicians and see how much of a toll the prescription drug abuse epidemic is taking on patients, the healthcare system, physicians, and the bottom line. How many $500 ER visits will a hospital be willing to write off when they learn the patient just wants 20 Vicodin? Hospitals must stand behind and support physicians who are willing to stand up to drug-seeking patients. Perhaps patient satisfaction scores will take a hit. So be it. Administrators need to take a step back and see the big picture on this one.

Maybe administrators need to be held legally liable for patient overdose deaths when they haven’t created a policy for dealing with medication prescriptions. Sometimes getting sued is the only thing that makes administrators wake up.

So, I’m out of the closet. I am a recovering “controlled substance prescribing addict.”

It feels good to be free of that burden.

Well … most of the time at least.

A nursing home patient is brought by ambulance with a cough. Nursing home staff believe the patient may have aspirated lunch 30 minutes ago. The patient’s workup is normal except for his EKG which is shown below (you can click on it for a much larger/printable version).

What’s the diagnosis? What needs to be done with the patient? Does it make any difference whether this was a new finding or an old finding?

I’ll provide the answer in the comments section in a couple of days.

This case report is entirely bizarre. Patient gets awarded more than $800,000 after visit to doctor resulted in incorrect diagnosis of cancer when the patient really had pneumonia and caused patient to have amputation of her foot. A trial was held on the case four years ago with a verdict in favor of the doctor, but the judge declared a mistrial because Washington State jurors were referring to the plaintiff’s Japanese attorney as “Mr. Miyagi” and were making other racist comments against him.
Then, the article notes that the doctor had been disciplined by state regulators for making “erroneous diagnoses” and for prescribing methadone to drug-addicted patients. So now Washington State physicians’ licenses can be on the line for failing to perfectly diagnose patient symptoms and for prescribing medication for one of its intended uses.
I admit we don’t have all the information behind the license actions, but the article makes the Washington State Medical Board sound a little overeager to discipline physicians.

Congratulations! You delivered a healthy 6 month old! 15 lb 7 oz baby delivered vaginally in UK. More than 20 doctors reportedly assisted in the delivery.

Curing patients gone wild? Australian hospital emergency department guards petitioning to carry guns at work. Medical workers claim that it will make emergency departments more dangerous.

Australian patient held four days in emergency department waiting for psychiatric bed to open up. Shortage of beds creates high demand. Patient’s mother alleges that his condition worsened because of the long wait.
Not that anything like this could happen in the US. Oh wait. What a coincidence. LSU is closing their mental health emergency department, resulting in other hospital emergency departments having to care for “an additional 2,000 people who are a danger to themselves or others, who are desperately in need of stabilization and potential further hospitalization.”
When medical services are curtailed, the patients needing those services don’t just disappear.

Kevin Pho’s latest USA Today article advocates expanding New York-style limitations on opioid prescriptions to hospitals all over the country.
If we do implement strict opioid policies all over the country — just like when hospitals close their emergency departments — patients aren’t just going to disappear. If patients can’t get the medications they need at one facility, they’ll go to another facility where they can get the medications. Or they’ll visit the same facility multiple times to get the same number of medications which will increase costs to the hospitals when government “insurance” doesn’t pay its bills for the patient care.
Some will argue that the guidelines are voluntary [wink wink]. No uninformed journalists would write scathing articles about doctors who prescribed more than the limits suggested in the guidelines if a bad outcome occurred – especially if the bad outcome occurred in NY City, right? And no administrator would threaten a physician’s job for failing to strictly adhere to the “voluntary” guidelines, right?
One of the biggest problems that I have with this and so many other policies that are created for our own good is that they haven’t been vetted to see if they are effective. We wouldn’t start treating cancer with antibiotics just because some sphincter mayor thought it sounded like a good idea. We’d create studies and control populations then study the results to see if the proposed treatment achieved its desired benefit before implementing the treatment on a widespread basis.
We’ll have to see how things turn out in New York … if anyone is even going to look at the “before and after” effects.
Right now, I think this is an idea with good intentions that will have many unwanted unintended consequences.

Resident work hour limitations cause MORE errors – 15-20% more. In addition, shorter shifts have not improved young doctors’ mental health or the amount of sleep they get.
Study author cites “unintended consequences” of policies to decrease work hours because there “wasn’t good data to support them.”
Where have I heard that before?

Trenton, New Jersey’s emergency departments are “clogged” with patients who have no health insurance. One patient who has diabetes and kidney failure and who often left his dialysis sessions early ended up costing the system more than $1 million in one year.
Do people think that things will change for the better with “insurance” under the UnAffordable Care Act?

Cancer patient advocates for closing insurance loophole. Intravenous cancer medications are covered by a flat co-pay, oral cancer medications are covered on a percentage basis – leaving patients with huge medical costs that are allegedly based on the route of medication administration.

Making an appointment to have your emergency treated. More and more emergency departments are allowing advance online registration for emergency patients. According to this article, the only people who weren’t happy with the patient using the service “were those in the lobby watching as she walked right by them to be seen.”
Advance registration of emergency patients is such a big EMTALA violation it isn’t even funny.

Valley Fever is increasingly prevalent in Southwestern States. No, it doesn’t cause you to dress up in Spandex and repeatedly say “Oh my Gawd!” You’ll get a cough and some flu-like symptoms that don’t go away. It is caused by a soil fungus called Coccidioides and is most commonly seen in Arizona and California.

Man awarded $2.1 million after radiologist failed to report “destructive lesion” noted in patient’s spine. Surgery to repair the lesion was delayed by two weeks resulting in a compression to the patient’s spinal cord.

My gosh. I actually get angst when I haven’t posted for a few days.
Actually, I have angst for other reasons, but not posting just adds to the angst.

So what’s been happening lately?

First, the poor WhiteCoat children are having trying times in their love lives.
Oldest daughter WhiteCoat found out from a member of her track team that her boyfriend of 6 months was cheating on her. Another member of her track team was apparently going around and telling everyone that she had a “secret boyfriend” and was also telling everyone the sordid details of the interactions she was having with her “secret boyfriend.” So daughter WhiteCoat dumped Mr. Two-Timer. Mrs. WhiteCoat called his parents to let them know what was up. Papa Two Time said that he didn’t know what we were so upset about because the other woman “pushed herself” on Daughter WhiteCoat’s ex and that the other woman was a “two bit whore” anyway. I’m kind of thinking that this breakup was a good thing.
The next day, Junior WhiteCoat’s girlfriend texts him and says she “wants to be single.” The text gets posted to Instagram. Then about 60 comments later, there are accusations flying back and forth that she’s been dating someone else and that he deserves better. When I was 12 years old, I was climbing up trees with a bag of tomatoes and tossing them at cars. Now my kid is 12 and he’s in need of relationship counseling.

Health hasn’t been great lately. Pretty much every person in the family has had vomicking and/or diarrhea in the past week. Zofran is our friend. But it gets a little frustrating when you’re working in the ED and patients who puked once or who have had a couple of loose stools want work notes to be off for the rest of the week.
Got kind of a kick out of one patient walking into the emergency department as I was leaving work. He was heading toward his car in the parking lot and I saw him suddenly turn around and head back toward the hospital. He was walking like he had a load in his pants. He gets closer to me and he starts shaking his head.
“Ya try to do the right thing and what happens? It bites you in the ass. I’m holding in my gas in the ER and I waited until I get outside to pass it … then I crapped my drawers.”
He did have a load in his pants.
Although if he passed gas in the ED, it probably would have been just as embarrassing.

Grandma and Grandpa WhiteCoat have been having issues. Their health has deteriorated to the point that they were unable to stay independent, so they moved in with my brother. The only problem is that Grandma WhiteCoat has a few cats … like 10 … and that Grandpa WhiteCoat has a book collection … like about 30,000 … all in boxes. He also has a good thousand or so small plastic boxes of pictures that he has taken through the years. All categorized, but none of them ever seen by anyone but the person at the photo lab who initially developed them. And if you want to look at one of them, you can’t take it out of the house because you may copy it and the pictures are copyrighted. Fortunately, he converted to digital pictures about 7-8 years ago, so now it’s just a matter of storage on his computer drive and no additional plastic boxes. But then he sends pictures to you and the pictures have copyright marks all over them.
Well things came to a head when the grandparents wanted to move their things into my brother’s house. My brother had a bad experience with a cat and a muzzle loader once and doesn’t really want any cats near his house. There was a lot of arguing and hand wringing. Finally, Grandma WhiteCoat talked a friend of hers into keeping the cats in her basement. Grandpa WhiteCoat is upset because he has to rent out a storage facility to keep his prized book collection and all of his pictures.
I get caught in the middle with all of the phone calls. Brother WhiteCoat is at his wit’s end. Grandma WhiteCoat says that the cats are the only thing in her life that keeps her happy and that Brother WhiteCoat is just trying to keep her from being happy. Grandpa WhiteCoat just walks around the house in his tighty whities (which are reportedly still white but not quite as tight in certain places) complaining about how these schlubbs at the storage facility better not ruin his book collection.
If you ever wondered whether your family was dysfunctional, it isn’t. Trust me.

The biggest source of my angst lately is a change for me. I’m changing my blog site. I registered a new site at DrWhiteCoat.com and have been working to get it up and running for months. Over the past week, I put a lot of my non-ED time into trying to finish it and it’s almost there. But that was at the expense of posting. As a result, I have a stack of notes on my desk about all the things I want to write about. Literally. There are 11 pieces of paper. Several of them have more than one topic on them. So I’ve got a lot of writing to do.
I’m not leaving EP Monthly, but I’m planning to expand this blog beyond just emergency medicine and I don’t want to keep straying from EP Monthly’s mission, so I’m going to split my time between the sites.
I want to try to do a more regular posting of Healthcare Updates perhaps 3-4 days a week rather than doing them once a week. I don’t like pushing out stale news.
Also planning to do a hospital administrator/hospital rating page within the site – a health care worker satisfaction page. Still need to come up with some cash for that project, but it is already planned out and I obtained a list of all the hospitals in the US to populate the site.
Planning to write some more articles with information to help patients.
Also planning to reincarnate Grand Rounds. Creating a separate page just to promote other medical blog posts.
And I’ve got a few guests who are going to help me with the blogging.
Hoping that it will be a win-win-win for readers, EP Monthly, and me. One way or another the site will be up this week. If you want to be notified when it is up and running, click over to the site and enter your e-mail – you’ll get a notification when there’s new material.

The past couple of days have been spent hanging out with family. Lots of the Rock kind of things. After the kids got sugared up on Peeps and jelly beans, we went out to the park and flew kites. Then we came back, had a great dinner and laughed. Mrs. WhiteCoat opened a bottle of wine, and we are getting ready to watch a movie.

Now I’ve at least gotten my blogging fix and am not in need of intravenous benzodiazepines.

Time to go have a glass of wine and relax.

Back to blogging as usual in the morning.

Another medical issue with overweight patients: Intramuscular injections. An Epi-Pen may not work in patients who are obese since the distance through the subcutaneous fat to the muscle is greater than the length of the needle. This study showed that in more than 4 of 5 obese children, the subcutaneous fat layer was too thick for an IM injection one quarter of the way down the thigh. In nearly 1 of 5 obese children, the subcutaneous fat layer was too thick three quarters of the way down the thigh. In those patients, the study suggested injecting the calf.
I suppose the manufacturer could be forced to make autoinjectors with longer needles, but then non-obese patients would theoretically risk getting a bone marrow injection of epinephrine.

How good are emergency physicians at dispositioning psychiatric patients when compared to psychiatrists? Not horrible, not great.
95% of patients assessed as “definitely admit” were admitted by the psychiatrist. For other emergency department psychiatric patients, there was an 87-90% concordance rate.

Sugary drinks may kill 25,000 people each year. That’s nothing. SALT [allegedly] causes one out of 10 deaths in this country each year and more than 2.3 million deaths worldwide in 2010.
Wonder what that sphincter Michael Bloomberg is going to do with this information. Salt tax? Force NY City hospitals to draw serum sodium levels on all patients? Outlaw salt shakers in restaurants? Or maybe he could just go after the salt shakers with the larger holes and call them “asSALT” weapons.
Bwaaaaaahahaha. Sometimes I crack myself up.

Another nice article by Alicia Gallegos at AM News. Liability involving patients who overdose on medications is increasing. Families of suicidal patients who overdose on medications are blaming physicians who prescribe the medications … and winning.
According to the article, physicians are having also disciplinary actions taken against them if they prescribe medications to a “doctor shopper”.
This is getting ridiculous.
When pain patients complain that they are treated like “drug seekers,” this is part of the problem why.
Maybe the next step should be forcing all patients to sign a statement requiring them to list any doctors that have prescribed them medications, any medication that they have at home or have access to at home, and any medications or street drugs they are using or have used in the past 12 months.

Lawsuits involving robotic surgeries increasing after patients suffer bad outcomes related to the machines. Intuitive Surgical’s da Vinci machines are common targets. This news in the wake of the ACOG recommendation against using robotic surgeries for certain gynecologic procedures.  “[T]here is no good data proving that robotic hysterectomy is even as good as—let alone better—than existing, and far less costly, minimally invasive alternatives.”
Yet hospitals spend $1.5 million on these machines and a lot more in advertising them to the public.
Where are our patient safety advocates the Joint Commission amid all of these patient safety issues? [crickets] But they’ll sure cite you and make you come up with an action plan if holiday peel off stickers are on the windows of trauma bay rooms, though.
Would you pay several thousand dollars more for your surgeon to use a robot on you?

US Supreme Court nixes North Carolina state law declaring that one third of a Medicaid beneficiary’s medical malpractice lawsuit recovery is attributable to medical expenses and therefore may be taken by the state. Justices called the law too arbitrary.

New lethal strain of meningitis concerning New York City health officials. Thus far it seems to be largely confined to men who have sex with other men. The NYC Health Department released a warning that men “who regularly have intimate contact with other men through a Web site, digital application or at a bar or party” should be vaccinated for meningitis. Men who have intimate contact with other men through a digital application can get meningitis? Wow. Talk about a computer “virus”.

Scary video of how a lifeless child was resuscitated by a shopper in an Australian grocery store. Not unlike a pediatric code in an emergency department – just with less medical equipment. Notice the tension during the event and how the rescuer keeps his cool. Outstanding job, mate!

Sixty percent of patients in the UK wait more than 48 hours to see a primary care physician. Patients who need cataract surgery, hip replacements and knee replacements are facing “rationing” of resources as the government tries to cut costs. Coming to a health care system near you?

More on why ObamaCare should be renamed the UnAffordable Care Act.
Cost explosions and several other facts we have learned about ObamaCare since it was signed into law three years ago.
Insurance rates for individual policies could more than double while those for small businesses could rise by 50%
Another article about insurance premiums doubling.
Also, a funny quote I read on Twitter (but I can’t find the tweet to credit the source). How is the Affordable Care Act like stool? You have to pass them to see what’s in them and neither one smells very good.
Want some advice? If you still have insurance and are considering having an elective procedure performed, get it done now. 2014 is going to be ugly.

Influenza killed 105 children this year … and most of those children had not been vaccinated against the flu. But … the flu vaccine didn’t protect much against the circulating strains of flu this year. So were the childrens’ deaths preventable?

Legislators from both sides of the aisle are in favor of repealing a medical device tax that was implemented with ObamaCare.

CVS creates a “better mouse/better mousetrap” conundrum. If ObamaCare forces employers to offer employees insurance, employees are going to have to jump through a lot more hoops to get it — such as revealing a lot of personal health information. Want to keep your information private? You’ll have to pay a $600 annual penalty. Or you can always go and get health care somewhere else …
Now will legislators have add a few hundred more pages to Obamacare to prevent requiring such disclosures?

New EM blog up – from an emergency nurse. I overlook the name of the blog because the content is good. Hope he can keep up his pace.

I happened to catch on Twitter a web site where people could search up their Twitter names and get their tweets translated into gangsta talk. Probably not something you should read at work or in church, tho … yo.

So I tried it with some other sites. I can’t decide which is more amusing.

A newspaper story about a crime?

A court opinion?

A medical article?

Press Ganey’s web site? Note at the bottom of the page the type of “Regionizzle Symposium” they have in 2013.

Or a WhiteCoat post?

Wanna be an instant YouTube sensation? Have someone video you doing a grand rounds translated by Gizoogle.

I made a chronic back pain patient who was out of his pain medications cry in my emergency department today.

Actually, he was already crying when he came in. The nurse said that he hobbled in from the waiting room bent over like an old man and using his wife’s shoulder for support. He couldn’t stand upright because of his severe pain.

I was finishing up with the patient in the room next to his when I heard him get put into the room. He was moaning and moaning. As I discussed the discharge instructions with the current patient, the moans sometimes overshadowed what I was saying.

Before going to see the patient, I looked up his old records on the computer.

He was 41 years old. According to his old chart, he had wrenched his back while fixing the tire on his car more than a month ago. Ever since then, he had been having pain in his lower back. His primary care physician gave him a couple of weeks of Percocets and some Valium. Those medications helped him somewhat, but he still had pain. When he ran out of the meds, he got one week’s refill and was referred to physical therapy. He went to physical therapy twice and it caused the pain to get so bad that he stopped going. He called his doctor back and his doctor ordered MRI of his back. I pulled the MRI report which showed multiple minor disk bulges but no other problems – definitely nothing that would cause his back pain. So his doctor set him up with a pain clinic. No appointments were available for more than a week and his doctor had cut him off from narcotic pain medications after the relatively normal MRI. This was his third ED visit in the week.

When I walked in the room, he was in a fetal position on the bed and he was crying.

“I’m Doctor WhiteCoat. How can I help you today?”
“My back, doc. It’s killing me.”

He described the whole story. I already knew most of it from notes in the computer. I also saw the several doctors from whom he had received pain medications.

He wouldn’t lay flat on the bed because he said it made his back worse. His position of comfort was laying in a fetal position or laying on his back with his knees flexed.

Back in medical school, I worked part time in a back pain clinic for a year or so (long story). After a normal neurologic exam, I thought he probably had a psoas muscle spasm. Pretty common cause of non-traumatic back pain.

So I gave him some Toradol and Valium. I told him that I thought I knew what was causing his pain and that if he trusted me, I could probably make him feel better. Fortunately, the ED wasn’t too busy that day, so I could spend a little extra time with him.

I got him to lay on his back with his legs flat. I went to see another patient.
I came back and had him roll on his stomach. I went to see another patient.
I came back and used the stretcher to extend his back a little. I went to see another patient.
I came back and used the stretcher to extend his back a little more. He moaned in pain. I went to see another patient.
After the third incremental extension, I let the bed back down. I showed him how to get out of a bed without putting a strain on his back. Then he stood upright.

No pain.

A win!

I showed him a few stretching exercises he could do to hopefully help keep the pain from developing again.

I left the room to finish discharge instructions, printed out some examples of stretches he could do and came back to hand the printouts to him. When I came in the room, he was crying again.

“I thought that your pain was gone,” I said hesitantly.
“It is. I was just telling my wife that you’re the first doctor through this ordeal that has actually sat down and listened to me and who tried to fix my pain without pumping me full of drugs. I don’t even think I’ll need the pain prescription. My back feels that good right now.”

I smiled. He reached out and gave me a firm handshake. Then he pulled me in and gave me a hug.

A little surprised by that whole man hug thing, but I was glad that I was able to help him.

I was working in the charting room (which is out of the patient’s view) when I heard him walk up to the desk and say “Tell Dr. WhiteCoat thank you again. He is an excellent doctor. And thank you for all your help.”

After he left, I had to rub it in. I walked out and said to the nurse “I heard you have a message for me?”
“What?”
“A message for me from a patient?”
“Nooo.”
“Something about being an excellent doctor. Come on now. You can say it. Ehhhhhhxellent … Ehhhhhhxcellent.”
Then the secretary chimed in.
“I heard him say that you were a dork. Dorrrrrrk. Dorrrrrrk.”

The insubordination that all of us excellent physicians have to put up with some times …

———————–

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.

Another factoid about the UnAffordable Care Act sparked by an e-mail link from DefendUSA (thanks!).

Number of pages in the document that formed the basis for creating our nation: FOUR. Well, five if you include the Bill of Rights

Number of pages in the document that purports to provide affordable “care” for everyone by requiring that people have “insurance” (which likely won’t be accepted by many medical personnel providing care), increasing the costs to purchase said insurance, encouraging companies to reduce their workforces so they don’t have to provide such insurance, and imposing taxes on people if they don’t purchase said insurance from third parties: 20,000 and counting according to Senator Mitch McConnell

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You’ll probably consider this post non-medical, but I consider it a discussion of anatomy which IS medical.

A New York newspaper article caught my eye. Two New York City miscreants were arrested for drug trafficking. Big deal, right?

The thing that caught my eye was how police found the drugs, the amount of drugs, and where the drugs were located.

First, Ebony Howard and William Waters need to choose their friends better because someone narcked on them.

OK stop there. English majors … what is the proper spelling of “narcked”? “Traffic” adds a “k” to make it “trafficking” (see above). Does “narc” add a “k” to make it “narcked”? Doesn’t look right. Should it be “narced”? That doesn’t look right, either. Or should I just change it to “tattled”? The American Heritage Dictionary doesn’t help much. It only contains the definition of a “narc” being a law enforcement officer who deals with narcotics violations. Now I am getting off track.

So Ebony and William travel to the quaint little Upstate New York town of Waterville to see the sights. But police arrested the couple as they filled up at a Waterville gas station based on a tip that the couple would be traveling to the town to deal drugs.

When police searched the couple, they found 645 oxycodone pills with a street value of $20,000 … packed in to Ms. Howard’s body cavities.

I thought about this. I have a bottle of 500 Tylenol pills that is pretty full and it measures 3 inches in diameter and 5 inches in height. Think of two tennis balls next to each other. I’m having trouble imagining how it would be comfortable taking a several hour car trip and then walking around a gas station with more than two tennis balls worth of contraband in one’s body cavities.

Then there’s the value of the pills. One can get 30mg oxycodone pills (I’m presuming that was the strength of the pills found in Ms. Howard’s cavities) at a pharmacy for about $6 each. According to police reports, the street value of the pills is more than $30 each. Even if someone faking pain in the ED only received 20 Oxys from the visit and then sells the pills, that’s a $500 profit in a few hours — a lot more than most doctors make.

Finally, there’s the manner in which the drugs were found. I need some help from police officers here. If one’s friend is found with a small amount of marijuana and another unknown substance (assumed to be ecstasy) on his person, does that give police sufficient cause to perform a pelvic exam and rectal exam on everyone in the same vehicle?

I’m not condoning what these people did, but just thinking that if police can do body cavity searches based upon an anonymous tip and some drugs found on a traveling companion, “SWATTING” is soon going to take a back seat to “NARCKING” … or “NARCING” – however the hell you spell it.

The Veteran’s Administration intentionally changed and hid data to avoid providing costly yet critical medical care to soldiers from the Gulf War? A head VA epidemiologist alleges that more than two thousand veterans responding to a study felt like they would be “better off dead”. In 95% of those cases, the VA did nothing to assist those veterans with follow up care. In a subsequent study when the same epidemiologist attempted to ensure follow up care for potentially suicidal veterans, he allegedly had disciplinary actions instituted against him. If that’s true, I wonder how everyone else will be treated once they have medical insurance under the UnAffordable Care Act.

American College of Obstetricians and Gynecologists advises against using the da Vinci robots for hysterectomies. Robotic surgery adds about $2000 to the cost of surgery and “there is no good data proving that robotic hysterectomy is even as good as, let alone better than, existing and far less costly minimally invasive alternatives.”
I hope that other specialty societies have the integrity to make similar inquiries.
All those hospitals that spent millions of dollars on these machines to keep up with the Joneses may just be in for a big surprise.

Insurance companies expect health insurance premiums to rise 20% to 100% once the UnAffordable Care Act is implemented next year. Department of Health and Human Services responds that it is misleading to look at the one provision of the UnAffordable Care Act because “taken together, the law will reduce costs.” Well, gee, that broad unsubstantiated assertion sure convinced me.

You know all those things your hospital does to stop the spread of clostridium difficile infections? Yeah. They don’t work (.pdf file). 42% of hospitals implementing such policies noted decrease in c. difficile rates while 43% of facilities noted an increase in c.difficile rates.
Can’t wait to see the spin that the Joint Commission puts on this one.

States that participate in Medicaid managed care plans on the hook for $15 billion in extra annual fees (or are they “taxes”?) imposed under the UnAffordable Care Act.

Several interesting studies recently cited in MedScape …
BMC Neurology study shows that propofol is an effective treatment for patients suffering from migraine headaches. Too bad that many doctors are hesitant to give it and many hospitals restrict its use. Wouldn’t want to be thrown in jail if there’s a bad outcome…
Intravenous lidocaine works better than morphine in controlling pain from kidney stones. Unfortunately, administering lidocaine rather than morphine will undoubtedly result in a statistically significant decrease in your Press Ganey scores. Are we going to be seeing more lidocaine allergies on the horizon?
Would you rather have thin bones or die? Calcium can KILL you! Patients who ingested more than 1400mg/day of calcium were 49% more likely to die from cardiovascular disease and 40% more likely to die overall than those who did not take calcium. Patients who took more than 1400mg/day of calcium tablets were more than 250% more likely to die than those who ingested 600-999mg/day.

ZeePacks can KILL you, too! It only took 17 years, but through its diligent and exhaustive research, the FDA has finally come out with a warning to strike fear into the hearts of all those patients who take Zithromax. You could die from a heart arrhythmia just by taking Zithromax (or any other macrolide or many quinolone antibiotics).
I’m not sure what worries me more … the side effects from Zithromax or the fact that it took the FDA 17 years to figure this out.

Giving seniors money to come and receive Medicare screenings. In the past, the Department of Health and Human Services has fined entities that tried bribing patients to get more medical care. Providing monetary incentives to patients who have federal insurance is a violation of anti-kickback laws. Now the feds are condoning the same behavior.
Can you say “unintended consequences”?

And that’s why they call it “dope”. New Jersey woman goes to emergency department where staff discovers a big stash of heroin and a couple of hypodermic needles. Instead of getting a high, she gets a court date.

US Justice Department probes drugmaker Sanofi over disclosures about Plavix. When you make the #2 drug in the world based on revenue and pull in $9 billion/year from that drug, you’ve got some seriously deep pockets to pick at.

Should there be federal intervention to improve medical malpractice problems? This author argues that there could be many unintended consequences to doing so.

One reason why your asthma may not be controlled. Nearly half of asthma patients don’t use their inhalers correctly. That incorrect use results in poor asthma control and more frequent ED visits. The easiest way to remedy this problem is to purchase a spacer device – or make one yourself if you can’t afford one.

Remember the Obama claim that policies are working because there are fewer hospital admissions? Senator Chuck Schumer notes a concomitant “huge uptick in elderly patients under observation status.” New York hospital observation hospital stays increased by 32% in the past 6 years.
Observation status – as opposed to a full admission – means that seniors have to pay out of pocket for some services like rehab or nursing home care that is rendered after a hospitalization.

Lots of people still texting and driving in the US. I suppose that’s a good thing for hospitals that will take care of your paralyzed family members after your car accident.
Is the text message really THAT important? Put the phone away when you’re driving already.

Hospitals charging “facility fees” in addition to all of the other charges for medical care provided to patients. Should such fees be outlawed?
Goes back to free market principles. If hospitals are going to charge the fees, the fees should be clearly disclosed prior to the time that treatment is rendered. Then patients can decide whether the care they receive is worth the cost.
One hospital has the right idea – it advertises that it chooses “not to take advantage of its patients” by charging such a fee.

What is it with some people and rashes?

The patient waits 3 hours to be seen. When I enter the room, the patient says “I had a rash on the back of my leg 2 months ago. Can you tell me what it was?”
Out of the 4 or 5 things running through my mind at that point, the least pressing one of them wasn’t about calling up the feds to get satellite video feeds of the patient’s house two months ago so I could zoom in through the window shots and hopefully identify the cause of the mysterious rash.

“The rash isn’t there now?”
“No.”
“Well, sir, I honestly don’t know what caused the rash because I can’t see it any more. As long as it isn’t there any more, I don’t think it’s going to be a problem.”
“Was it scabies?”
“I doubt it because it wouldn’t have just gotten better.”
“Well what does scabies look like?”

At this point, I should have stopped the conversation and discharged the patient. Unfortunately, my foresight gene had gone offline for a few moments.
“Scabies is usually little itchy spots or pus-filled blisters. Most commonly the spots are between the fingers or the toes. Sometimes there will be little red lines where they burrow under your skin.”
“Wait. You mean scabies are bugs?”
“They are mites.”
“Oh my God. That’s what the rash looked like. I’ve got bugs burrowing in my skin.”
“No. You don’t. The rash is gone.”
“What if they’re just sleeping? Couldn’t they still be in my house?”
“I’ll tell you what. If the rash comes back and you think it is scabies, there’s cream called elimite that you can buy over the counter to kill the mites. Until then, I wouldn’t worry too much about it.”

An hour after he was discharged, we start getting the phone calls.
“My son said you told him my house was infested with bugs. What’s THAT all about?”
“How long should he stay home from school for?”
“Can these bugs be sexually transmitted?”
“Should I be going to work? I work in a nursing home.”

[facepalm]

My shift couldn’t end soon enough.

———————–

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.

A patient calls his family doctor and gives a history of having chest pain on and off for the past few days. Pain worse with activity. Not having any now. Of course, you know that the family doc is going to send the patient to the Emergency Department. You just know it.

So the patient gets to the emergency department and of course the EKG is normal … and the labs are normal … and the chest x-ray is normal.

Because the patient has no history of chest pain workups, of course you know we have to recommend that the patient stay overnight and have a stress test in the morning.

“You’re kidding. I really have to stay? Everything is normal. Can’t I just go home and do it later? ”
“Well … no … not really. We can’t force you to stay in the hospital, but we really think that it would be a good idea.”

Then you start to second guess yourself. This guy’s in good health. He’s not having pain now. Of course the insurance company is going to call this an unnecessary admit.

Fortunately for everyone, you found a reason to justify the admission.

About 15 minutes later, the alarm goes off.

Holy sh**! Torsades! Get the paddles!

It seemed like several minutes, but it ended up being more like 35 seconds until this happened.

“What happened?”
“Um. You nearly died.”

Had the patient not called his doctor, had the doctor not sent the patient to the hospital, had the patient not been brought right back and place on a monitor, or had the patient decided to leave AMA, he probably wouldn’t be here right now.

Triple vessel disease with a CABG.

Every once in a while those useless workups end up saving a life.

———————–

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.

Courtesy of mednificentcomics.com

Not quite a case medical student’s disease, but close. Have to love it.
The thing is that when I was a medical student, there wasn’t an internet and there definitely wasn’t a Dr. Google. So we were a lot more stressed out because we had to rely on the advice of our professors – who weren’t always that well versed in the diseases.

Doctor treats child born to HIV positive mother with full three-drug regimen of HIV drugs one day after birth instead of one or two drug regimen typically used until an HIV infection can be confirmed. Treatment continued for 18 months, then the patient’s mother stopped bringing the patient to appointments.
The child is now 30 months old, has been off HIV medications for a year, and has no HIV infection according to ultrasensitive testing performed at Johns Hopkins.
Now the doctor’s colleagues are planning a celebration.
Of course, if the child did poorly or had a bad reaction to the medications, the doctor would likely have been arrested, lost her license, and sued for millions.

More warnings about superbugs. MRSA is bad enough, but what happens when the organisms living in all of our intestines become resistant to antibiotics?

Patients gone wild returns. Minnesota goof screams profanities and disrupts medical care. Tied down in four point restraints until police arrive. Will likely be charged with disorderly conduct. Wow. If every patient that did this kind of thing was charged with disorderly conduct and whisked off to jail, our ED volumes would drop by a good percentage.

Electronic medical records are supposed to improve care, right? In this study, alert fatigue caused 30% of VA doctors to miss important alerts. 87% of doctors said that the number of alerts they received was excessive and more than half blamed the design of the EMR for the problem.

Quite possibly better than the lollipop story. Police find loaded gun in woman’s hoo hah during search. Also had crystal meth in her butt crack. And THAT, dear readers, is why they call it “dope.”

You think your wait in the emergency department is long? Try going to LA County Medical Center where the wait averages 12 hours at some points.
In the past, certain people have equated high wait times to a poorly run hospital, but we won’t go there.

Spider bites may be a common complaint when coming to the emergency department, but the complaint often turns out to be a MRSA infection. As the Milwaukee Brewers General Manager discovered, bites from other arachnids may also require an emergency department visit when you try to squish them up in a tissue.

British Columbia emergency physicians describe horror stories in their emergency departments allegedly due to funding issues and overcrowding. Performing CPR on the waiting room floor? Even I haven’t heard of that one before.

Nurse in New York caught stealing medications from nursing home patients.

Not sure how to take the wording in this article. Polish man walks into emergency department with screwdriver sticking two inches into his forehead, article reports that there was no damage to the patient’s brain.

South Carolina inmate grabs an officer’s gun during emergency department visit. Second officer “fires shot to subdue him” – inside the emergency department. Inmate then gets taken back to jail. What happened to the gunshot wound?

Did medical malpractice kill Bruce Springsteen’s saxophonist? Clarence Clemons’ brother, an attorney, pursues malpractice litigation against doctors for Clemons’ stroke.

Could medical malpractice climate in Florida be changing? Bill working its way through Florida House would increase burden of proof on medical malpractice claimants and would limit who can serve as an expert witness. Also protects hospitals from liability for actions of their contracted health providers.
Florida Medical Association attorney notes that Florida’s current malpractice laws are “doing a disservice to our state and are a driving force in a physician’s decision to leave critical-need specialities, retire prematurely and even leave to practice in another state.”

We’re watching you …California wants $10 million in funding to create a prescription-tracking database so that it can find doctors who overprescribe narcotics. Once the system was up and running, doctors and pharmacists would be REQUIRED to check it to look for signs of narcotic abuse. Of course, the definition of “signs of narcotic” abuse is purposely not included. That way the state could just attack at will any physicians who prescribe any narcotics. The database would be paid, in part, by raising physician licensing fees.

Interesting statistic. Top 25% of Medicare beneficiaries account for 85% of total Medicare spending. Prime targets for “death panels,” huh?
Seriously, though the article has several good points about how to improve the medical system, even though it is written by someone with no apparent experience in the medical system.
One point in which I disagree with the author is that “guidelines” should be used both as a shield and as a sword. We all saw what happened when NY Times reporter Jim Dwyer misused guidelines. In general, guidelines are situation specific and failure to follow them to the letter shouldn’t be considered malpractice.

Obese patients eligible for special seating at the 2014 World Cup in Brazil. Just need a medical certificate stating that your body mass index is 30 or more, which apparently qualifies people as being disabled under Brazilian law.

Doctor threatens to call police on patient if she does not consent to immediate Caesarian section.

The mother was a high-risk pregnancy (due to VBAC), was post-dates and had gestational diabetes. The fetus wasn’t in a good position to facilitate vaginal delivery, and an ultrasound showed the fetus in possible distress.

The patient was sent to Tampa General hospital for immediate C-section, but refused to have the surgery done that day. She wanted the baby delivered on Friday, not Tuesday. So the obstetrician sent her an e-mail which stated, in part

I am deeply concerned that you are contributing to a very high probability that your fetus will die or your child will incur brain damage if born alive. At this time, you must come in for delivery.
I would hate to move to the most extreme option, which is having law enforcement pick you up at your home and bring you in, but you are leaving the providers of USF/TGH no choice

The doctor was promptly contacted by the National Advocates for Pregnant Women, whose New York attorneys advised him (apparently applying their vast knowledge of Florida law to the case) that he was making “legally and ethically unjustifiable” threats and demanded he cease taking further action against the patient. The NAPW even put up a post about the incident on their web site. Hopefully, the attorneys at NAPW have licenses in Florida, otherwise some might consider them to be practicing law in Florida without a license – which I think might be illegal.

Now the patient is having her baby delivered on Friday as she wanted.

When I initially read this article, I was upset with the doctor.

The more I thought about it, though, the fetus has as many rights as the mother does. If the mother was doing things to endanger the life of the fetus the day after it was born, a call to the police would be expected, not ridiculed. States mandate reporting of suspected child abuse and impose liability on providers if suspected abuse is not reported.

In this case, it is questionable whether a failure to deliver a child that is possibly in distress would be considered “child abuse,” but usually if there is a suspicion, a report is mandated.

I side with the doctor on this one. And I probably would have called the state child welfare agency on the woman just to cover myself.

This case will get ugly real quick if there are complications during the pregnancy or if the child isn’t born healthy.

If the baby is stillborn, should the mother be charged with a crime?

Nevada Senator Tick Segerblom proposes bill that would allow patients addicted to prescription drugs to sue doctors for prescribing the addictive medications and manufacturers for creating the medications.

Patients can already sue doctors for prescribing medications if they can prove that writing the prescriptions violated the standard of care and that they have suffered damages as a result. But Tick wants to take the concept a step further. If the patient sues a doctor and wins, the patient should receive payment for rehabilitation, possible punitive damages, and attorney’s fees.

It doesn’t matter that “addiction” can be either physical or psychologic and that there is no reliable way to determine when addiction occurs. Tick’s bill doesn’t define addiction. It also doesn’t matter that people can get addicted to pretty much anything … alcohol, illegal drugs, porn, gambling, even collecting Cabbage Patch Kids. Tick’s bill only cares about those evil doctors. Beware internet service providers, you could be next on the list if your subscribers get addicted to the internet.

But Tick has good reasons for proposing his bill. Since people lived without drugs before, Pharmacologist Tick doesn’t believe that drugs are the only way to treat pain now. That’s true. Patients in cancer pain could always try incantations and faith healing instead of popping pills. Or patients in pain could bust out some whiskey and a bunch of bullets to bite on … after they take anger management classes so they can purchase the bullets. Oops. That’s Florida. Sorry. Wrong state. Double oops. Alcohol could be addictive. Bad example.
Besides, since children are allegedly taught from an early age to do whatever the doctor says, Neuropsychologist Tick says no one has the free choice whether or not to take addictive pain medicines.

It’s not so much that, at least according to his Twitter feed, Tick seems just all giddy about seeing his proposal published in newspapers. The scary thing is that people like Tick Segerblom are elected to public office and may be able to regulate our lives.

More comments at Overlawyered.com

I’m in shock about the case where a nurse refused to give CPR to 87 year old Lorraine Bayless in a California senior living facility – a housing setup akin to an apartment complex.

Ms. Bayless fell unconscious in the dining room of a senior living facility. Facility members called 911. Ms. Bayless wasn’t breathing and the 911 operator recommended that the facility member perform CPR. The person at the facility would not perform CPR.

It took EMTs about 7 minutes to arrive on scene. Ms. Bayless later died from a “massive stroke.”

The 7 minute call can be heard HERE in its entirety.

A couple of other things made known in the case were that the senior living community did not have any trained medical staff. Remember – the facility was similar to an apartment house. In addition, Ms. Bayless had made known her intentions to “die naturally…without any kind of life-prolonging intervention.” According to the family, Ms. Bayless knew that there were no medical staff when she decided to live at the facility.

So why am I in shock?

Look at all the whacked out opinions that are being generated from this case.

Some people demand criminal charges be filed against the people who wouldn’t help.
One person recommends “Depraved Indifference Homicide”
Another person notes that if a law says that “you cannot deliberately withhold medical care from a dying person” then ignorance of the law is no excuse for failing to act – applying that hypothetical to this case, of course.
Bakersfield California police are looking into whether there was anything criminal and the county Aging and Adult Services Department is determining whether “elder abuse” may have taken place because of the incident.
The thing is that if criminal charges were appropriate, then everyone in the dining room of the senior living facility who saw Ms. Bayless collapse would have to be thrown in jail. No one helped her. Let’s just charge everybody with a crime.
California can’t pay its bills as it is, so it is unlikely that they will criminally charge a group of elderly patients requiring nursing care and then be required to provide continuing medical care to them. Maybe they’ll all get electronic monitoring bracelets and weekly visits via the wheelchair van to a parole officer, instead.

Then the “experts” across the news stations pile on.
Virginia Commonwealth professor of geriatrics Dr. Peter Boling stated that without advance directives, patients “wind up sometimes in a very painful and trying situation.” This quote seems to acknowledge that patients may receive unwanted CPR if  there is any question about a patient’s wishes.
CBS legal analyst Jack Ford calls the actions “morally reprehensible” but also notes that our society has become much too litigious.
Ah, but what about California’s Good Samaritan statute? It exempts people who provide emergency care from liability for civil damages, but it also contains exceptions. Providers have to act in “good faith”. It doesn’t apply to those who are grossly negligent. And it doesn’t apply if the provider is being compensated. Employees of the senior living facility are, by definition, being compensated. So a plaintiff’s attorney may have the ability to circumvent the protections afforded in the Good Samaritan statute just through the “compensation” angle.
Other people argued that the 911 operator took all liability for the actions of the nurse. How does such a promise, which is essentially a verbal contract, absolve the nurse from liability when the nurse is the one performing the actions? If a lawsuit was filed, the nurse would still be named regardless of the 911 operator’s promises.

Then there’s the question of a DNR order. According to the Bakersfield Fire Department there wasn’t such an order on hand when paramedics arrived. Not that people carry DNR orders around with them in their pockets or anything. After all, this was a dining room in an apartment complex, not an ICU bed. But even if that was the case, does there have to be a readily producible advance directive available to prevent unwanted care?

A sweet old lady entered a senior living facility knowing that there were no trained medical staff and not wanting any life-prolonging treatment.

Now a firestorm has come down on the living facility for abiding by the patient’s wishes and pundits all over the internet are basically demanding that we perform medical procedures on patients who don’t want them. Don’t agree? It’s off to jail with you. You’re a criminal.

Ms. Bayless’ family issued a statement saying in part

We regret that this private and most personal time has been escalated by the media. Caregivers, nurses and other medical professionals have very difficult waters to tread in the legal and medical landscape of our country today.

About the only thing potentially criminal about this case was the unauthorized dissemination of Ms. Bayless’ private health information to the media.

Are state and local authorities investigating that?

Daughter WhiteCoat doesn’t have the stomach for her science class.

They were dissecting a sheep heart in her class not too long ago and she was becoming increasingly queasy. Apparently the sheep had been recently slaughtered because she said that there was still blood in the heart. She was more skeeved because the science teacher was manipulating and dissecting the muscle without using gloves.

She went up to the table where the dissection was taking place, but had to leave the class at one point because she thought she was going to throw up. Mrs. WhiteCoat and I? We can watch surgery while eating a plate of spaghetti and meatballs. Or eggs and sausage.

After the class, several “concerned” classmates came up to my daughter. Instead of consoling her, they said “Eeeeewwww. You have heart juice on your sleeve” or “Gross. There’s heart juice on your notebook.”

Heart juice?

Heart juice?

What the hell is heart juice? It’s called “blood” people. You all fricking fail.

I gave her a bottle of disappearing ink and told her to squirt it on those people’s notebooks, saying that they had crab heart juice on their notebooks (yes, horseshoe crab blood is blue and it contributes to modern medicine), but she wouldn’t do it.

Can’t wait for them to start discussing reproductive system. I’m going to have to send the teacher some smelling salts for use on my daughter.

Drunks caught on security camera beating each other in a Turkish emergency department waiting room. Best part of the video is when one dope pulls off his belt to start hitting people and his pants fall down. Then he waddles about swinging his belt like a little kid with a load in his diapers.

Another bamblance theft from the emergency department. If you don’t know why it’s called a bamblance, you need to listen to the video below (strong language alert). This latest ambulance theft occurred at University of Michigan. Many of the commenters to the article suggested that the patient was going to a different emergency department due to the wait times.

http://www.youtube.com/watch?v=bBa0blUoE8U

FDA stifling pharmaceutical innovation through excess regulation. You don’t say. Scary that the average time and cost involved in developing a single drug approved by the FDA is 12 years and $1.2 billion.

How much will you be charged for your emergency department visit. This study in PLOS-ONE gives you a good idea of what you should be charged. Keep in mind, though, that the numbers are “median” values, meaning half of patients got charged more than those numbers and half of patients were charged less than those numbers. The range of charges was ridiculous. For a UTI, the lowest charge was $50 while the highest charge was $73,002. That doesn’t mean some poor patients actually paid $73,000 for a Bactrim prescription, only that insurance was billed that much (which is still a crime).

Yet another way for government to cut healthcare costs: Pay for services, then go back years later and allege that those services were provided inappropriately. Demand reimbursement and penalties. Publish news articles about how horrible the providers were and how patient’s lives were in jeopardy. Then show how federal agency intervention is the only means to help patients.
In this article, nursing homes had patients on two whole anti-psychotic drugs and one depression medication and didn’t even have tons of paperwork to show how the drugs were being monitored! Gasp! Another patient had paperwork for the government, but the paperwork showed that he kept getting physical and occupational therapy even though all the therapy goals had been met. What “poor nursing home care.”
Too bad we can’t compare private hospital performance to VA hospital performance on the HospitalCompare web site. Data for government institutions is blocked. Wonder why that is?
One of the biggest impediments to the government providing health care to the general public is that it would be crushed under the weight of its own paperwork and regulations.

Obama administration creates statistics showing that its policies have decreased the hospital readmission rates by a little more than one percentage point. A CMS official says that the news is “exciting” and that we are seeing “a fundamental, structural change.” Penalties work!
Read into the article a little further and you’ll see that the penalties amount to a whopping $1 per Medicare patient for one hospital. You’ll also see that the government is penalizing 2,217 hospitals which is a little less than half of all the non-federal government hospitals in the United States. In other words, whether or not hospitals will receive penalties pretty much becomes a coin-flip.
I’d like to see how many of those non-readmissions were classified that way simply because the hospitals admitted the patients as “observation” stays – meaning that more of the costs were shifted to the patients and that the number crunchers still met their goals. Doubt you’ll hear that sound byte from the administration, though.

Interesting findings. When admitted patients receive “clot-buster” thrombolytics for acute strokes, they had more complications and higher death rates than patients who came to the hospital and received thrombolytics on arrival. Even when the study was adjusted for age and baseline clinical characteristics, in-hospital patients still had worse outcomes and more complications.

What will some of the other effects of the UnAffordable Care Act be? Silent exodus of physicians from the workforce. More employed physicians that punch clocks and work 9-5. Hospitals monopolizing medical care in certain regions. Some patients maintaining insurance, though … for now.

When Greek pharmacies stopped paying for their shipments, eventually the pharmaceutical companies stopped sending the medications. Greece owes pharmaceutical companies almost $2 billion Euros. In addition, due to the low price of medications in Greece, some of the wholesalers are selling medications to other countries to make a profit.
Now there is panic among the population because many medications are in short supply.
But I’m pretty sure that the Greeks have national healthcare insurance, right?

A little late, but worth repeating. Medscape publishes warning about physicians being liable for any bills sent to the government in the physician’s name. Note that the original federal OIG Alert regarding this issue was posted in February 2012.

Would you trust your own hospital for medical care? More than one third of 101,000 doctors, nurses, and paramedics surveyed in Great Britain wouldn’t recommend their own hospital to family or friends. In addition, one third of survey respondents had witnessed medical blunders or near misses at least once in the previous month.
Notice how contempt in the comments is directed toward the government? By providing “insurance” instead of health care to patients, the government in this country is able to redirect that contempt.

EPIC – one of the many electronic health record software companies – goes to hospital administrators and demands that they force a physician blogger to remove pictures of EPIC’s user interface from a snarky post about the software. Dickweeds.
First of all, anyone with half a brain can do a search for EPIC EMR screenshots and come up with dozens of pictures of your bloated EMR. Trust me, your EMR isn’t that good and it takes way too much time away from me being able to provide care to my patients. Oh, and talk about alarm fatigue.
Looks like I’ll have to prepare an educational article about EPIC now — including screen shots. Maybe I’ll call it EPIC FAIL. And I have no problem filing a SLAPP suit for inappropriate letters from attorneys.