Healthcare Update Satellite – 04-08-2014

See more healthcare-related news from around the web on my other blog at DrWhitecoat.com

Emergency physicians more likely to miss signs of strokes in young patients – often headaches with dizziness. Those misdisgnoses may account for 40,000 to 80,000 preventable deaths each year.
Of course, the answer to save lives is to perform MRIs/MRAs on everyone with those symptoms.
Until some beancounter tells you that the MRIs and MRAs are “unnecessary”. Then you’re a bad doctor for ordering the tests. So you don’t order as many tests.
Then you miss a stroke and the news media references a journal article about missing strokes with those same symptoms, points to your care and tells everyone what a bad doctor you are.
Then some administrator tells you that your failure to order a test that missed the uncommon presentation of a disease cost them a million dollar settlement.
Then you order more tests to keep from missing another case of a stroke.
Then the beancounters tell you that your testing is unnecessary …

Kansas City area pain clinic gets hit with $2.88 million verdict when patient commits suicide due to pain from MRSA meningitis. Clinic physicians allegedly performed spinal injections through an abscess that had formed on the patient’s back and seeded his spinal canal.

Speaking about pain, the American College of Medical Toxicology meeting had research showing that there was a 65% increase in opioid prescribing for headaches. For hydromorphone (Dilaudid), the increase was 450%. Investigators noted that “we are concerned that providers are prescribing these medications, despite guidelines recommending against their routine use” but also noted that patient satisfaction scores and regulatory requirements (pain is the fifth vital sign, right Joint Commission?) are likely driving these prescribing trends. These types of unintended consequences are exactly what happens when you have clueless people trying to regulate health care.

Physicians finding it more and more difficult to deal with online trolls. “Because the Health Insurance Portability and Accountability Act (HIPAA) of 1996 prevents doctors from discussing patients, disgruntled and anonymous individuals can pick fights over their quality of medical care with little chance of being successfully hit back, leaving physicians almost powerless to defend themselves. In some instances, aggravated patients use that advantage to mount calculated attacks with the intention of inflicting irreparable damage to careers and reputations.”
Anyone willing to donate to a Kickstarter campaign to create a HIPAA compliant web site for doctors to rate patients?

Physician describes how he prescribes more Adderall and Dexedrine to increase his satisfaction scores on Yelp. He also notes how he “hasn’t advised a single patient to exercise regularly or maintain a healthy diet since 2011, saying he learned his lesson after receiving a devastating one-star review.” Courtesy of the Onion – America’s Finest News Source.

Former nurse jailed for 20 years for killing her infant … by breastfeeding. The woman was taking morphine for chronic pain due to a car crash and prosecutors convinced a jury that there was sufficient morphine secreted in the woman’s breast milk to kill the infant. A pathologist testified that there was enough morphine in the infant’s system to kill an adult.
Yet the American Academy of Pediatrics actually recommends using morphine over other pain medications when breastfeeding.

How can you spot a psychopath? This article gives 20 psychopathic traits and also gives a good discussion of what makes a psychopath. “These people lack remorse and empathy and feel emotion only shallowly … it’s like colour-blind people trying to understand the colour red, but in this case ‘red’ is other people’s emotions.”

Breath-actuated nebulizers and traditional handheld nebulizers showed no difference in clinical effectiveness when compared in the emergency department. Guess which one is more expensive.

We’ve Been Facebooked — Part 1

4-6-2014 2-50-29 PMI’m developing an increasing dislike for certain forms of social media.

Fortunately, this first incident didn’t happen to me, but the nurses who endured the onslaught were still twitching the following day when I came into work.

The day before started out as a pleasant day, or so they said. Even pace. Good flow of patients. No holding patients in the emergency department. Waiting room nearly empty. Nurses got to take their lunch breaks. One of those days that you leave feeling refreshed. But those days are subject to change without notice.  And change, it did.

Lumbago Joe hobbled in the front door.

Lumbago Joe was a well built guy in his forties. Rough around the edges. Always walked with a limp on hospital grounds. It was almost pathetic to watch him come in the door. Chronic back pain. Surgeries didn’t help. He refused further surgeries because they only made his back worse. He had seen so many doctors who told him they couldn’t help that he kept a copy of his latest lumbar spine MRI on his iPhone. That damndable iPhone. He’d even show you pictures of his bodybuilding days many years ago. He used to be in great shape. The thing about Lumbago Joe was that when he was off hospital grounds, he was different. See him in the store and he was lifting cases of beer with no problem. In the bars he would dance the cha-cha – unless he saw someone he knew from the emergency department … and he knew EVERYONE from the emergency department. Knew their names, knew their significant others. Sometimes even knew their work schedules. So when Lumbago Joe knew he had been sighted, suddenly he’d catch himself, grab his back and put on a show, pretending he didn’t see the hospital personnel. Or sometimes he’d come up to say hello, mentioning how well his pain was in control after getting those 8mg of Dilaudid in the emergency department the other day. Yeah, Lumbago Joe was like a modern day medical Verbal Kint (by the way, if you’ve never seen the movie the Usual Suspects, don’t click the link, stop reading this right now, go rent the movie or pull it up on NetFlix, and thank me later).

So Lumbago Joe slowly limped back to his assigned room. As luck would have it, Lumbago Joe’s favorite doctor was working that day. Yes, Dr. Feelgood was in the house.

Dr. Feelgood works a few days a month at several different hospitals. He doesn’t like to spend all his time at one place and likes the “freedom” of working at several hospitals. Nice guy. Fairly good clinician. Gets great patient satisfaction scores. And boy does he write. You come in with pain, you get Dilaudid. If you even may have pain when you leave, you get Percocets for home use. Finger sprain? Dilaudid. Ankle sprain? Dilaudid. Toothache? Dilaudid. Have Narcan on standby if your back is bothering you or if you have a migraine. Yes, despite being only a part-time physician, Dr. Feelgood is at the top of the leaderboard for both Dilaudid prescriptions and for Narcan use. Little old ladies probably don’t need 4mg of Dilaudid for back pain … but they get it.

Lumbago Joe got a spring in his step … er, um … in his hobble when he caught a glimpse of Dr. Feelgood’s combover while Dr. Feelgood sat at the desk charting. The triage nurse would even recount how it initially appeared like Lumbago Joe was going to stand upright and say “Hi” to Dr. Feelgood, but caught himself and began to limp even worse.

Dr. Feelgood didn’t disappoint.
“I’ve got this,” he told the other doctor on duty.
He went into Lumbago Joe’s room and a few minutes later he came out and started pecking away at the computer.
New orders up. Start an IV line. Dilaudid 4mg IV push. Valium 10mg IV push.
To put that into perspective, 1mg of Dilaudid is the analgesic equivalent to between 6mg and 8mg of morphine.
While most people would have suffered a respiratory arrest shortly after receiving the medications, Lumbago Joe was up and walking around, back straight with perfect posture. He smiled and shook Dr. Feelgood’s hand, thanking Dr. Feelgood profusely for his kindness.
Lumbago Joe was discharged home a half hour later with a prescription for thirty Norco tablets.

To show his appreciation for the care he received, Lumbago Joe posted a Facebook update.
Apparently a Facebook “friend” of the ED secretary was also friends with Lumbago Joe. The ED secretary was therefore able to see what Lumbago Joe had posted after he left the emergency department. This makes no sense to me, but that’s because I currently do not and never will use Facebook. In fact, I call it Fecesbook. Anyway, suffice it to say that the secretary was able to see Lumbago Joe’s posts.
“Just left Metro General Hospital pain-free for the first time in several weeks. Thanks to Dr. Feelgood for his excellent care.”

About 30 minutes later, the waiting room was filling up. Sixty minutes later, it was full. Fifteen patients registered within the 90 minutes after Lumbago Joe left. Looking through the names of patients, it was like a class reunion for Ridgemont High. The complaints were overwhelmingly pain-related. Headache. Migraine. Toothache. Fell down the stairs – back pain. Low back pain. Abdominal pain. Headache. Back pain. It was a flashmob of misery.
The odd thing was that the waiting room patients in all their misery were laughing and joking … until the doors leading into the emergency department clicked then swung open. Then there was an eerie silence as the next name was called and the next patient was brought back holding a random body part in terrible pain.
The rest of the day and evening were filled with long waits and lots of opiates.

One nurse, still twitching as he recounted the afternoon, simply stated “That Lumbago Joe character facebooked us real good, he did.”

I just smiled and shook my head, being thankful that I wasn’t working that day and thinking how ironic it was that the provision of medical care would even lead to creation of such a term.

———————–

This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

Healthcare Update Satellite — 04-02-2014

See other medical news on my other blog at DrWhiteCoat.com

Liberal use of blood transfusions may increase the incidence of serious infections. I don’t have access to the entire article, but wonder if the study also looked at overall mortality. In other words, is the increased risk of developing a serious infection outweighed by preventing more deaths from severe anemia (lower oxygen carrying capacity, increased cardiac demand, etc)

Traumaman … Traumaman goes wherever a trauma can. Sprayable nanofibers may soon replace sutures and may revolutionize trauma care. I imagine it’s only a matter of time until the idea is weaponized. One splat in the face and you’re through.

I’m with Skeptical Scalpel and SurgeryWatch on this one. If patient satisfaction and doctor ratings are of such value to the medical industry, we really need to expand the concept to other industries as well. Enter Airline Pilot Ratings. One of you flyboys hits turbulence and you’re ratings are through. If my ticket price is too high, you’ll be lucky if I give you a single “fair” rating on your whole report card. And if there are any delays, I mean ANY delays … I’ll give you friggin negative numbers. You hear me? NEGATIVE! Oh, by the way, I don’t like how your voice is muffled when you talk on the speaker. You get points off for that, too.
Yep. That’s how all enterprise should work.
Next up: Patient ratings.

Can charm be taught? Meet this generation’s version of (a female) Dale Carnegie and decide. The article is long, but well-written and enjoyable, so grab a cup of coffee before clicking on the link.

Another hospital closes its doors. Hospital board votes to close North Adams Regional Hospital in Massachusetts with only three days’ notice. The hospital had previously been open for 129 years. Nearby Berkshire Medical Center is going to attempt to preserve services at the hospital, but a source for funding has yet to be identified.

Give me the girl. Judge gives permanent custody of a Connecticut girl who is hospitalized in a Massachusetts hospital to the Massachusetts Department of Children and Families. “Closed-door juvenile court hearings late last year” allegedly proved that the parents were unfit to handle their child’s complex needs. It probably didn’t help that the girls dad was being a tool, failing to work with healthcare providers, threatening the social worker assigned to the girl’s case, and calling hospital personnel “Nazis.”
But if these types of things are sufficient to take custody of a child away from the parents, then we’re a few virtual reality computer programs and a holodeck away from the real life Hunger Games.
Another story on this case in the Boston Globe.

Association for Comprehensive Energy Psychology (the “other” ACEP) tries to get Wikipedia to open up its policies to encourage more articles about topics such as Emotional Freedom Techniques, Thought Field Therapy, and the Tapas Acupressure Technique. Wikipedia co-founder responds rather thoughtfully.
“If you can get your work published in respectable scientific journals—that is to say, if you can produce evidence through replicable scientific experiments, then Wikipedia will cover it appropriately. What we won’t do is pretend that the work of lunatic charlatans is the equivalent of “true scientific discourse.” It isn’t.”
Lunatic charlatans, eh? If advancing directives without having work published in reputable scientific journals and without those directives resulting form replicable scientific experiments is what defines the term, then the Joint Commission, Press Ganey, and most of the people who created Hospital Compare fit the definition.

Right on, brother. A leading neuroscientist asserts that ADHD is not a disease, it’s a label that is used to prescribe dangerous medications to children. The medications given to ADHD patients cause long-term changes in the brain and “their rewards systems change.”
Maybe that’s why some people call Ritalin and similar medications “kiddie cocaine.”

Another interesting article about the human microbiome. Certain bacteria in a woman’s vagina may protect against HIV infection. In the study, patients with bacterial vaginosis and taking an antiviral medication had significantly reduced antiviral activity while those patients with healthy vaginal bacteria and treated with the antiviral produced significantly less HIV.

High school teacher forced to resign after taking a 20 year old student (an adult capable of consenting to the actions) to the emergency department for an undisclosed problem and then paying for the cost of the student’s medical treatment.
Huh?

Bwaaaaaaah. District Court Judge Carter Schildknecht has open and closed door meetings with hospital administrators after her husband had a heart attack in the emergency department at Medical Arts Hospital. Ellis Schildknecht apparently had a gag order imposed by his wife as he remained silent during the meeting … and because of HIPAA laws, the hospital can’t respond publicly to the Judge’s complaint, leaving District Court Judge Schildknecht’s vague question “Is this the reputation that you want our hospital to have in this community?” out there for debate.
Saving the life of a patient suffering from a heart attack? Yes. That’s the reputation we want.
Perhaps you could order that your husbands files be released to the public so everyone could review the care that you deem so deficient and worthy of contempt.

Happy Doctors’ Day

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According to the Southern Medical Association,

Doctors’ Day was first observed in 1933 as a way to honor the profession. Initially, it involved mailing cards to physicians and their wives and placing flowers on the graves of deceased physicians.
It wasn’t until 1958 that the US House of Representatives adopted a resolution commemorating Doctors’ Day.
In 1990 several Mississippi legislators drafted a bill to make March 30 National Doctors’ Day.  George Bush signed this bill into law later that year.

A red carnation has traditionally been used as the symbol of Doctors’ Day.

Give your doctor a fist bump today.

Excuses

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I recently got into a rather … shall we say “colorful” … discussion with another doctor about lawsuits. I’m involved in another one. This one is even more screwy than the one I wrote about before. But this lawsuit isn’t finished yet. I expect that it will be over with in the next few months, but I’ll have to wait and see about that.

The discussion centered around medical records, which were one of the issues in my lawsuit.

The other doctor believed that what people write in the chart plays a big part in whether a doctor is successfully sued. In other words, the doctor believed that medical providers largely have the ability to document themselves out of a lawsuit.

I, on the other hand, asserted that charting generally does more harm than good. Sure, a well documented chart may make a doctor look more thorough and conscientious, but in the end if a diagnosis is missed, experts and jurors will work backwards from the diagnosis to determine all of the things that a doctor should have done to arrive at the diagnosis. If it’s a difficult diagnosis, documentation *may* save you. But if it is a disease where a patient manifested a couple of symptoms – even if those symptoms were nonspecific – documentation won’t do much. Electronic charting also provides a LOT more information, so it gives plaintiff attorneys more opportunity to show inconsistencies within a patient’s complaints, review of systems, and physical examination. Create an inconsistency by checking the wrong box or accidentally clicking “yes” instead of “no” and you look like either a careless schlubb who couldn’t be bothered to do an accurate exam or you look like someone who’s documenting an exam you didn’t perform in order to bill more money.

Then I started thinking. You know where that leads.

Suppose that a patient came to the emergency department with chest pain. He has a couple of risk factors for heart disease. His chest pain wasn’t classic cardiac pain, but he had chest pain. His EKG didn’t show any acute changes, but sometimes they don’t when someone has angina. His blood tests were normal, but again, blood tests often are normal when someone has angina. The pain gets better, so the emergency physician sends the patient home with a diagnosis of “chest pain” and instructs the patient to follow up with his doctor. But the patient doesn’t live that long. He dies that night from a heart attack.

Of course there’s going to be a lawsuit because a patient died from a heart attack after going to the emergency department with chest pain. I’m not going to argue whether or not the physician should have been sued. I didn’t give enough information in this example for anyone to make that determination.

My question is this: Given this scenario, is there anything about the chest pain patient’s history or physical exam that the physician could write in the chart to lessen the likelihood that he would be sued? If you were jurors, what types of things would sway your opinion (if anything) and make you decide that the doctor shouldn’t be liable for missing a heart attack in a patient complaining of chest pain? If the medical professionals were acting as expert witnesses, what documentation (if any) would make it more likely for you to conclude that the doctor complied with the standard of care?

I’ll let you know my thoughts once I read some comments.

Healthcare Update Satellite — 03-25-2014

Patients gone wild. Really wild. 70 year old Brookdale Hospital nurse Evelyn Lynch gets knocked to the ground by patient Kwincii Jones and has her head stomped. She was knocked unconscious and suffered severe facial fractures. Also underwent brain surgery, so it is likely she suffered a brain bleed or has brain swelling as well.

Congratulations to the antivaccination movement for increasing the worldwide incidence of pertussis and measles. Measles and mumps are now “crushing” the UK. Patients with “religious exemptions” to receiving vaccinations were reportedly the source of one recent California pertussis outbreak.

Rise of the machines. I thought I was pretty good at spotting patients in fake pain. Turns out that most observers are only slightly better than chance at picking out fakers from the real deal. This computer program can achieve 85% accuracy in picking out patients who are truly in pain just by analyzing their facial expressions. Of course, watching the surveillance video of people skipping in the parking lot, then limping into the ED hunched over in “pain” is also a dead giveaway.

Machines are also pretty darn good at sniffing out cancer. A device called BreathLink can detect changes in a woman’s breath that suggest breast cancer and has a diagnostic power similar to mammograms. The device may also be able to test for tuberculosis.
The article also has a neat table about the odors different disease processes cause. Did you know that rubella may cause your sweat to smell like freshly plucked feathers or that schizophrenia may cause your sweat to smell like vinegar? Typhoid fever may cause your skin to smell like fresh-baked bread.

Wrapping that rascal is more and more important lately. The CDC is warning that gonorrhea may soon become untreatable. The “love dart” – otherwise known as an injection of Rocephin – has been a stalwart of treatment and now gonorrhea is showing resistance to this class of medications as well. Another article on the topic in The Verge here.
By the way, do you know what you get when you kiss a parakeet? Chirpes … fortunately that’s still tweetable.
Stop groaning. That thar’s funny and you know it.

What do you do if you’ve been diagnosed with cancer? Take a deep breath. Own it. Don’t run to consult Dr. Google. Dr. Peter Edelstein has some more suggestions here.

Utah Senate passes bill allowing doctors to prescribe Narcan to third parties to administer to patients who may be suffering from opiate overdose.
Initially, I had problems with this idea. Would people be able to inject it IM or assemble the intranasal administration assembly? How would the lay public deal with patients who are suddenly thrown into withdrawals?
Then I thought that it would be better to at least attempt to reverse an opiate overdose and deal with the consequences rather than having a patient die.
So why require a prescription? Shouldn’t Narcan just be made over the counter?

Rhode Island emergency department becomes first in nation to incorporate Google Glass into patient care.

Call of Duty – Dialysis Edition. 14-year-old Norwegian kid drinks 4 LITERS of an energy drink over 16 hours so he could stay awake playing Call of Duty. Ends up in a coma in a hospital for two weeks with “kidney failure” but is expected to respawn and live to fight another day.

Many people in New York contracting rare skin infection called Mycobacterium marinum. All of the 30 cases diagnosed were in people who were handling seafood.

Trying to change the message again. Obamacare architect Dr. Ezekiel Emanuel asserts that “you don’t need a doctor for every part of your health care.” If you like your high school sophomore with a 16 hour course in basic first aid, you can keep your high school sophomore with a 16 hour course in basic first aid.