February 8th, 2010
When you’re driving down the field in opposing territory in the fourth quarter with more than three minutes left, why would you ever throw a pass?
Keep to the ground game and run down the clock so they can’t get the ball back and have time to drive down the field and score again.
If Manning hadn’t thrown that horrible pass that got picked off by Tracy Porter and returned for a touchdown, the Colts would have undoubtedly won the Super Bowl. The whole Indianapolis Colts football team and their fans were irreparably damaged by Manning’s negligent actions.
Sound crazy?
This Monday morning quarterbacking is the same thing a lot of doctors go through when they make a judgment call and are sued for malpractice due to a bad outcome.
I wonder … can fans who lose money on bets on a pro football team sue the professional football players for their negligent decisions? I bet those multimillion dollar salaries could pay for a lot of damages.
VN:F [1.6.3_896] Rating: 10.0/10 (3 votes cast)
Posted in Medical-Legal | 2 Comments »
February 8th, 2010
Several times in the past few days we have gotten ambulance runs from the nursing homes in the middle of the night to evaluate elderly nursing home patients for “unresponsiveness”. When the “unresponsive” patients arrive, they are at their baseline mental status and, after the obligatory workup to rule out the bad causes of “unresponsiveness,” nothing is wrong with them.
Is “unresponsive state – rule out REM sleep” a legitimate discharge diagnosis?
Then, last night we got an 82 year old COPD patient by ambulance from a nursing home who was having “severe shortness of breath” and “hypoxia”. Her oxygen saturation was in the 70s in the nursing home (normal is in the 90s) and she was “dusky,” prompting the ambulance call.
When she arrived by ambulance, with her usual oxygen settings on the nasal cannula, her saturation was a respectable 92% – an acceptable value for a COPD patient. Was her shortness of breath and hypoxia due to some acute underlying medical disaster?
Fortunately, I like to talk to the EMTs when they bring in the patients. In this case, the patient’s nurse told them that the patient took off her oxygen to go outside and smoke a cigarette in the cold. She enjoyed the first cigarette so much that she had a second – while her oxygen canister waited longingly for her inside the nursing home. She may have gone for a third and turned into a smokesicle, but her nurse noted the lonely oxygen canister in the hall and investigated, finding the patient standing out in the cold.
Now of course none of this was written in the transfer papers and we had to call the nursing home to verify the story. The patient’s nurse had left for the evening and the nurse that was there had no idea about the patient, so we had to call the previous nurse on her cell phone at 11:30 at night. She didn’t answer her cell, so we had to call her house. Oh, and don’t forget the obligatory emergency department testing just so that we can prove that the patient really is at her baseline before sending her back – just in case she wakes up dead the next morning.
All this because granny wanted a couple drags from a Marlboro.
Kind of ridiculous, huh?
Although I get frustrated by what some people perceive as “bullshit nursing home transfers,” I also find myself bowing to the same pressures that nursing homes have when I see the patients in the emergency department.
How often does any emergency physician look at a frail elderly nursing home patient who complained of shortness of breath and not order any testing? I’ve done minimal workups on some patients (including Granny Marlboro above) and have had people tell me that I am lugging a couple of coconuts around in my scrub bottoms for not doing a million dollar workup on all the nursing home patients … and even for sending the patients back to the nursing home when they come in with vague complaints.
If a patient complains of shortness of breath in the nursing home and the nurses don’t send the patient for evaluation, the nurse and the nursing home will be investigated by all the clipboard brigades and would likely be sued if the patient suffered a bad outcome.
Similarly, if I don’t do a thorough emergency department workup on a nursing home patient with a vague complaint of shortness of breath or weakness or fleeting chest pain and the patient has a bad outcome after their emergency department visit, all the people who wouldn’t have the gonads to make a prospective decision about what care to provide to the patient would have no problem retrospectively questioning whether my care was adequate and appropriate. They might even make up retrospective assertions about why much of the negative testing I performed was “unnecessary”.
What’s the bottom line in megaworkups for minor complaints? Fear of liability. Some of us have less fear than others, but that fear still drives a whole lot of medical spending.
Just another reason health care reform will not never go anywhere without liability reform.
VN:F [1.6.3_896] Rating: 10.0/10 (1 vote cast)
Posted in Defensive Medicine, Medical-Legal | 3 Comments »
February 6th, 2010
A guy in his mid-60’s came in thinking that he had a stroke. He “felt funny” but wasn’t having any other symptoms. The initial part of his exam was normal, so I started doing a neuro exam.
I break a cotton swab in half and use it to lightly poke his arms and legs to test his sensation from side to side.
“Ow, Goddammit! Cut that out!”
I thought he was kidding at first, but when I looked up at him, he furled his brow at me.
“I’m just checking your sensory nerves, sir.”
Then I tell him I’m going to use a reflex hammer to test his reflexes. [Tap tap] I hit his patellar tendon.
“Stop hitting me with that damn thing.”
“OK, fine, but it’s going to be hard for me to see whether you’ve had a stroke if I can’t test to see how your nerves are functioning.”
I hesitated for a few seconds, still half expecting him to crack a smile. All I got was a scowl.
“I need to check to see if you have any muscle weakness. Can you pull up with your arm?”
He pulled up with his left arm but it didn’t go anywhere against my resistance. Good strength.
“Good. Now try it with your other arm.”
He began pulling against my resistance again, then he suddenly grabbed my arm with his free hand and said
“Listen, you better quit f**king with me or I’m going to kick your ass, and if I can’t do it, I have two sons who look like King Kong.”
What I was thinking: “OK, whackball. You don’t have a stroke, it’s just that the lone synapse in your skull is being overworked. And if you don’t let go of my arm in the next 10 milliseconds, people are going to read about you twice on my blog – once to hear me tell the story and a second time when I link to the newspaper article about how some crazed emergency physician slapped the snot out of one of his patients.”
What I said: “Well, sir, it doesn’t appear that you have any signs of a stroke. Be sure to follow up with your doctor tomorrow for a re-check. Have a nice day.”
I didn’t have any bananas for him to take home to his sons, so I’m sure this is just going to be another one of those bad Press Ganey days.
And dang it, I only get one post out of the incident, too.
VN:F [1.6.3_896] Rating: 8.9/10 (8 votes cast)
Posted in Patient Encounters | 12 Comments »
February 5th, 2010
Hey, its ERP from ER stories doing a guest rant post.
OK, I have blogged about this before, but nearly every shift, I have cases which emphasize the need to repeat myself.
When the hell with doctors learn to stop obsessing about hypertension? I don’t mean to say that we should not treat it – of course we should. I am talking about blaming every symptom a patient is having on it. I am talking about aggressive lowering of the BP in the acute setting. It is just stupid.
If I had a nickle for every time a patient’s headache or dizziness is attributed to hypertension I would be a millionaire. The sad truth is that it almost never is! The BP is a REACTION to the symptoms not the cause. This is obviously true in people who are chronically hypertensive – it took years for them to develop it so why do we think we need it lowered in 5 minutes? Of course their pressure will go up to 200 when they have pain. And guess what, lowering it fast will probably make new problems - like syncope and rebound hypertension caused by crappy old drugs like Clonidine.
This is different than when a young person has hypertensive encephalopathy or when someone has a big head bleed (where you want to lower the pressure only a small amount) or an aortic dissection. They people do need IV treatment but almost no one else does!
I just had a patient who was admitted to three days in England (where he was visiting I assume) for “hypertensive emergency” because he was having a room spinning sensation and a systolic pressure of over 200. Guess what, they lowered his pressure and gave him new drugs to go home with but he still had dizziness! Why? He had obvious benign positional vertigo! I gave him antivert (an antihistamine that works well for it) and it went away! And as a bonus, his pressure came down on its own!
So, patients do not check your BP when you feel pain or dizziness (unless you are on the verge of passing out – in which case you are looking to see if your BP is LOW), check it when you feel normal and have been chilling out for 10-15 minutes. Do that over several weeks and show the numbers to your doctors and let him or her decide treatment.
Doctors, do not attribute every headache, vertiginous episode, or other discomfort referable to the head to hypertension. Do not agressively lower it in the ER or your office and then discharge the patient. Do not give someone labatelol because the have a nose bleed. Do not fail to examine someone and miss benign positional vertigo. Don’t just treat the number to make yourself feel better! Treat hypertension for the long term!
VN:F [1.6.3_896] Rating: 10.0/10 (10 votes cast)
Tags: ERP
Posted in Uncategorized | 24 Comments »
February 4th, 2010
Today, the Illinois Supreme Court agreed with an earlier trial court’s decision to abolish caps on medical malpractice judgments in Illinois, calling the legislation “facially invalid” due to a separation of powers issue with the Illinois Constitution. Apparently only the judicial branch of Illinois government has the ability to reduce verdicts.
Because of an inseverability clause contained in the legislation, the entire medical malpractice reform statute was declared invalid.
When presented with the number of other states that have enacted noneconomic damage caps and the number of states that have rejected the separation of powers argument under the same circumstances, the Illinois Supreme Court justified its decision by stating “That ‘everybody is doing it’ is hardly a litmus test for the constitutionality of the statute.”
The Supreme Court’s opinion is here.
Also read an article about the legislation in the Chicago Tribune.
Hear all those papers rustling? That’s all the doctors in Illinois flipping through medical journals and newspapers looking for jobs in other states. It will be interesting to see the effect that this decision has upon Illinois citizens’ access to medical care in the coming years.
UPDATE
Some good insights and additional links to the story from Walter Olson at Point of Law. Interesting to imagine how the Court would back out of its corner if hospitals and doctors required that patients agreed to a limit for damages as a requisite for medical care – contracting around the statute as potential medical malpractice plaintiffs are often requested to do with attorney fee limits in Florida.
Also … a picture of young Abigaile Lebron, the child whose birth negligence case sparked the Supreme Court’s decision.
VN:F [1.6.3_896] Rating: 10.0/10 (2 votes cast)
Posted in Medical-Legal | 41 Comments »
February 3rd, 2010
 A patient came in for evaluation of head congestion. As the nurse was getting his vital signs in the room, he asked her who the emergency physician was.
“Dr. WhiteCoat,” she replied.
He turned his head to the side and asked his wife over his shoulder “Is that the one?”
His wife answered “Yup.”
The nurse asked him if he had a problem with me in the past.
“Not unless you call some guy shoving his fist up your ass a problem.”
The nurse looked shocked.
“I came in here with abdominal pain and I threw up blood. This guy tells me he needs to ‘check my rectum for blood.’ Then he buries his arm in my ass up to the elbow. I could have told him there wasn’t any blood up there. He ain’t coming nowhere near me with a pair of gloves from now on.”
When the nurse relayed this story to me, I looked his old records up on the computer before going into the room. Four years ago he came in with abdominal pain and complained of pus in his stool. He ended up having a GI bleed, but no pus was ever found. So the rectal examination has scarred him for the past 4 years.
The nurse and I laughed for a minute about whether I should walk into the room with a gown, mask, gloves and a tube of KY Jelly.
Then I started thinking.
Not too long ago, another patient whom I evaluated for abdominal pain complained to our hospital administration that he was having “post traumatic stress” from the rectal examination I performed. He was afraid of interacting with men bigger than he was and could no longer stand in lines because he was afraid of what the people standing in line behind him might do.
It’s not like I have gorilla fingers. My finger is about 3 inches long and about 1.5 inches in circumference at its widest. Most formed stool is much longer and much wider than my finger, but I don’t know any adults who have developed post traumatic stress disorder from taking a dump. Reactions like this are why I routinely bring a chaperone with me when I do these exams – just to make sure that I don’t lose my wristwatch doing the exam, you know.
It’s not like doctors enjoy doing rectal exams. I can’t go home and say “Hey kids! I didn’t save anyone’s life, but guess what I did at work today!”
Oh, and clenching your butt cheeks together then arching your back in a seizure position doesn’t make things any easier. If you don’t want the exam, refuse it.
If you go to the emergency department to be evaluated for abdominal pain, vomiting blood, constipation, diarrhea, or abnormal stools, it’s nothing personal, but you’re going to need a rectal examination. It’s part of the job I do.
Expect it.
If you don’t complain about it, neither will I … well … at least not that much.
VN:F [1.6.3_896] Rating: 9.2/10 (9 votes cast)
Posted in Patient Encounters | 29 Comments »
February 2nd, 2010
I wasn’t aware, but EP Monthly has been publishing Dr. Plaster’s reports from Haiti in real-time.
Here’s a link to all his posts. Definitely some things that you don’t read about in the newspapers.
He’s coming home now as larger organizations step up their efforts to assist those in need of care.
VN:F [1.6.3_896] Rating: 10.0/10 (2 votes cast)
Posted in Haiti Mission | 1 Comment »
February 2nd, 2010
See more news stories from around the web over at ER Stories in the Satellite Edition of this week’s Healthcare Update.
When it’s dead and you don’t know what to do with it, send it to pathology. When it’s alive and you don’t know what to do with it, send it to the emergency department — and don’t take it back. Wesley Healthcare Center in Auburn, IN sent a patient to the Angola Hospital emergency department and then wouldn’t take him back after he was cleared for release. Demonstrating an efficient use of resources, Gregory George was forced to stay in the emergency department for a week with around-the-clock care.
One former employee of the nursing home stated that the “patient dump” had been planned because the nursing home staff was fed up with the patient’s “excessive complaints” to the State about the nursing home.
In other news, the Joint Commission has declared that this incident shows how nursing homes may be a danger to patient safety. All nursing homes must close. Immediately.
Here’s a good way to help clear up California’s budget deficit. Start fining hospitals for mistakes.
If this takes off, soon they’ll be fining housing contractors for using the wrong pipes, police stations for arresting the wrong people, schools for failing to use the right curriculum, law firms for filing the wrong motions, and legislators for drafting crappy legislation. Instant riches!
Ooooh ooooh, I know! Maybe they can fine citizens when they move out of the state. Then California would have a budget surplus in no time.
Can’t take the heat? Get out of the kitchen. California city mayor has been to the emergency department five times in past six years suffering from chest pains after getting into arguments at city council meetings. Maybe it’s time for a career in horticulture?
Difficult decisionmaking. An elderly patient with multiple organ systems failing goes to the emergency department for an exacerbation of heart failure and decides he wants “everything done”. He is put on a ventilator, goes on dialysis, requires a feeding tube, and dies after six months in the hospital. The patient’s daughter questions whether her father’s decision was the correct one.
Attorney wins $3.8 million verdict for client in bad faith medical malpractice insurance claim, then takes $1.7 million in attorneys’ fees. When costs of the suit are paid, the attorneys will likely make more money from the case than their injured clients. Now the attorneys are suing each other about how the attorneys’ fees should split. Ironic how the attorney with the money is now referring to the ones suing him as “bank robbers.”
“Now craziness has a name … it’s called CYA.” This editorial in the Chicago Flame about health care reform and defensive medicine is spot on.
Interesting paper about defensive medicine and “disappearing doctors.” This 2005 study finds that increasing malpractice premiums generally don’t affect the numbers of physicians practicing in each state, but that increasing premiums do affect the willingness of some specialists to remain in practice – such as rural surgeons who tended to just retire. This study showed that “direct tort reform increases physician supply in the short run by 2.4 percent” and reduces growth of expenditures between 5 and 9 percent. Note that the paper was published shortly after tort reform was enacted in Texas and that there have been significant and sustained increases in physician supply in Texas since tort reform was enacted.
A graph in the paper notes that between 1993 and 2001, malpractice insurance premiums for internists in Texas increased by nearly 150%. After tort reform was enacted in Texas, medical malpractice premiums dropped by more than 40%.
What else do physicians do when faced with increasing malpractice payouts? Order tests. Significant increases in cardiac catheterizations and CT scans were noted with increased malpractice payouts.
Don’t worry, though. According to the trial lawyers, defensive medicine doesn’t exist.
Hat tip to Ezra Klein
What’s with the bizarre viral infections coming out of Africa? AIDS, ebola virus, now the chikungunya virus. Get bit by a mosquito carrying the disease and you could come down with high fevers, a rash, and severe arthritis for several years. Yes, you can sign me up for the vaccine, thank you. More about the virus from Wikipedia and from the CDC.
Minnesota is the 34th state to begin monitoring the prescription of narcotics. According to this article, 117,000 Minnesota adults abuse prescription drugs each year. Next month, prescription records for patients will be available in a centralized database. The comments section to the article has many anecdotes about people who fear they won’t get needed pain medications and about how people currently abuse the system. One post wonders whether everyone will just begin using aliases and fake addresses. That may work until you have to show a copy of your ID when picking up a prescription. No ID? No Vicodin.
VN:F [1.6.3_896] Rating: 9.0/10 (2 votes cast)
Posted in Healthcare Update | 46 Comments »
February 1st, 2010
As a special thanks for inciting the wrath of everyone favoring tort reform who reads this blog, I present to you a money-saving link. Seriously.
http://scholar.google.com/
Back in November, Google Scholar started making case law searches available for free.
Now you can type in a case citation or a search topic and can get cases mentioning the topic as well as citations to the cases and links to other related topics. See the screen grab below when I clicked on the first link from a search using the term “tort reform.” Going to the Advanced Search allows you to limit your search to specific jurisdictions.
Maybe now you can drop those subscriptions to WestLaw and Lexis. The yacht payments are coming due soon, you know.
By the way, the site isn’t just for attorneys. Anyone can use the site to find case law information that has been unavailable or difficult to obtain up until this point.
And … the site also does a great job at searching scientific papers as well.
VN:F [1.6.3_896] Rating: 10.0/10 (4 votes cast)
Posted in Medical-Legal | 6 Comments »
February 1st, 2010
January 27: We’re seeing a stabilization, but what about follow-up?
We are right down town in Port-au-Prince today; pretty much every building around us is destroyed. The only thing still standing near us is a church, which is currently housing a local boy scout troop.
The effort is starting to see a logical transition right now. At the clinics you’ll get 10 to 20 people walking in with soft tissue injuries – big gaping wounds that are infected – but fewer and fewer people are needing amputations and surgery. I did get a call from a guy in an outlying area who needed a hand surgeon, which we arranged. Other than that, we’re seeing a stabilization. We’re running a clinic today and it’s a typical third-world situation. You announce that you’re available and everybody who has had a backache or a stomach ache for the last five years shows up. As soon as we arrived today, about 200 people queued up. They were very calm and controlled, lots of kids with dehydration and plenty of vague complaints. We’ve got eight treatment stations, 2 or 3 wound treatment stations, a diarrhea station, an upper respiratory station and then whatever else walks up. It’s typical emergency medicine, really. You have to sort through the masses to find the people who are really sick. Haitians can be hypochondriacs just like Americans. They never get to see doctors, so when one shows up who is free, everybody lines up. Generally speaking we’ll run into about a dozen seriously-injured people in a day, but we’ve got to sort through 400 people to find them. We’re going to another place this afternoon where there are supposed to be some very, very sick people.
 USNS Comfort on diversion?
I got my first look at the USNS Comfort, which is off shore a couple miles. We’re next to a landing zone where helicopters are flying in and out, but right now there is no one waiting to go out. The word going around is that the Comfort is basically full and they are now trying to figure out how to bring people back on shore. The army was talking about setting up a 250-bed post-op rehab facility for all of the people coming off of the comfort. They have some tremendous injuries out there, spinal cord injuries and ICU patients, that will really require follow-up care. It’s going to create a problem on the backside. We’ve heard that the Obama administration has set a timetable for pulling forces out of Haiti – which makes sense – but there is going to be a lot of long-term care that they’ll need to plan for. There are a lot of sick and injured folks here.
Heavy on medical supplies, light on water
We’ve got medical supplies coming out our ears, but they told us when we left the camp this morning that we had no more water. They said they were going to go try to find water for us. I’ve got a bottle on my back and one in my pack, but that’s the end of my personal stores. I’m assuming we’ll find more – we’ve got a logistics expert tracking it down – but we’re getting a little hungry. I had nothing for breakfast and I have yet to eat my Powerbar for lunch. I’m hoping that I’ll get something for dinner.
Surgery Transfers
I’ve been taking patients who need surgery to Sacre Coeur (Sacred Heart), where they can receive treatment, since I know the doctors there. I put them in the back of a truck and take them there personally. When you walk into the hospital, you immediately hit an interior courtyard which is set up as a triage emergency area. It’s a big giant mess. A doctor sits out in the middle of the courtyard with hundreds of people around him, sorting through to find the ones that need to go in for surgery. I was able to bypass this, discuss the patient with the doctor, and take them straight inside. Yesterday I ordered my own X-rays, read them and handed them to the surgeon. It made for a very efficient system.
VN:F [1.6.3_896] Rating: 10.0/10 (2 votes cast)
Posted in Haiti Mission | No Comments »
|
