Reporter on Obamacare describes how personally being in “coverage gap” affects her. According to a Kaiser Family Foundation graphic in the article, patients who earn between $11,490 and $45,960 are eligible for a marketplace subsidy. Patients who earn less than $5400 per year are covered by Medicaid. Patients who earn between $5,400 and $11,490 have no coverage. So what incentive does the law create for patients in the coverage gap who need medical care?
Interesting statistics about medical malpractice cases in Tennessee. In fiscal year 2013, there were 385 medical malpractice cases filed in Tennessee which was only 0.18% of all trial court filings (one in 555 cases). Despite this, Tennessee trial judges spent nearly 4% of their time on medical malpractice cases — 70% more than first degree murder cases which was the second most time-intensive type of court case.
University of Massachusetts settles malpractice suit for $4.25 million when child born with brain damage after obstetrician mishandled the mother’s labor and did not immediately agree to a mother’s demand for a Caesarian section. Of course, if the doctor had agreed to the mother’s demand for a C-section and there was a bad outcome, the doctor would have been sued for that, too.
When I first saw this article in Live Science about the strangest holiday ED complaints, I was interested in what other doctors’ perceptions were, but I first sat back and thought about what types of complaints I usually see more often on Thanksgiving than during other times of the year. I’ve given up on trying to time “strange” complaints. They occur so often that I lose track of any temporal aspect to them.
Because Thanksgiving obviously occurs on a Thursday and because many doctors offices usually aren’t open the Friday after Thanksgiving, the holiday often presents patients with difficulty in obtaining medical care. Office schedules are booked in the days leading up to Thanksgiving, few offices are open during the holiday or weekend, and the schedules are again packed the following Monday and Tuesday with patients needing care. So patient volumes in the EDs usually increase, and I typically see more patients with routine problems than I do during “normal” weeks.
Thanksgiving is also one of the times where families get together – many times when they haven’t seen each other since the last holiday season. When busy adults haven’t seen the steady decline in the health of their elderly family members over the prior year, they will sometimes bring in their family members for an evaluation of what they perceive is a sudden change in their family member’s health. Then, instead of spending time enjoying the company of their families during the holidays, many elderly patients are admitted to the hospital to rule out old age.
Thanksgiving is also a time of food and drink intake. The excesses of alcohol often result in reduced inhibitions and oversedation. So there are always the injuries from fights over such things as whose football team is better and who got to eat the turkey neck. Later in the evening, it isn’t uncommon for families to bring in family members whose excessive alcohol intake has made them difficult to arouse.
Getting back to the Live Science article … the strangest complaints for visits to the ED include burns from turkey preparation, lacerations from carving accidents, food contamination, overindulgement in alcohol and food, sports injuries, anxiety, and performance pressures. I wasn’t even close.
Lacerations and stab wounds, sports injuries and hurt feelings, heart attack and heartburn, anxiety and isolation – we’re there to take care of everyone so that hopefully families can reconnect next month to enjoy more of each others company. If you happen to be in the ED today, remember that the person taking care of you or your family member is probably giving up time with their family so that they can be there for you.
Safe and happy holiday wishes to everyone and their families.
And go visit a family member or friend you haven’t seen in a while. Bring a picture and a card. It will be worth a lot more to that person than will a “Doorbuster” you got by standing in line in the freezing cold waiting for a store to open up on Black Friday.
Why one California emergency physician weeps for the future. The patient scenarios that you read about at the link will probably frustrate you as well. Included are patients who come to the ED because they don’t want to wait for referrals or for doctor’s appointments for routine matters and several patients who won’t fill prior prescriptions because someone else isn’t paying for their cost.
When Prince Edward Island’s Western Hospital staffed its emergency department with nurses and paramedics at night instead of closing the doors … hardly any patients showed up. The emergency department has been seeing less than two patients a night over the two weeks since the change was implemented. What conclusions can be drawn from the lack of patients? One commenter stated that patients are just deciding to drive to the next closest hospital in order to see a physician rather than being triaged and transferred to the other hospital anyway.
Would be interesting to see whether the patient volumes and demographics at the other hospital bear out that theory.
Flamin’ Hot Cheetos sending many kids to emergency department for a couple of reasons. First, the spicy seasonings are giving kids stomach aches. Also, when kids eat enough of them, the dye causes their stools to become red, making the parents think that the kids have blood in their stool.
Of course I was going to make a snarky remark that we should just ban Flamin’ Hot Cheetos to protect the children … then I read that several schools in New Mexico, California, and Illinois have already done so.
Yet another reason to weep for the future.
Finally, an Unaffordable Insurance Act quote for the week. A Twitter discussion about how often that Patriots fumbled the football morphs into a new term for fumbling: “Obamacared.” As in “The Patriots just Obamacared on the five yard line.”
The best comment to the thread: “If you like your new verb you can keep your new verb. Period.”
A 26-year old female seeks your care for a bee sting to her thumb that occurred just prior to her arrival.
She states that she reached into her purse looking for her car keys and felt a sting to the pad of her thumb. She came directly to the emergency department after the incident because she is allergic to bees … and she always carries an EpiPen with her (shown below).
She’s currently having moderate pain in her thumb, but no other symptoms.
What’s your diagnosis and how would you treat this patient?
And take a guess how much it will cost the patient to refill her EpiPen.
Scroll below the pictures for the answer.
UPDATE NOVEMBER 28, 2013
The answer was more obvious than the treatment. This was obviously an epinephrine autoinjector injury and not a bee sting. After making the diagnosis, the question was what to do to treat the injury.
Many options exist, but in most cases no treatment is needed.
A 2002 review of 28 autoinjector injuries showed that minimal treatment usually resulted in relief. Soaking the affected area in warm water resulted in symptomatic relief in most patients. This review also noted that injection of phentolamine is not without risk. Injecting phentolamine into an already closed space may increase the pressure and diminish blood flow to the affected digit. When administered parentally, phentolamine can cause hypotension and tachycardia.
A 2009 review of reported epinephrine autoinjector injuries showed that despite our best efforts, patients get better. Out of 69 reported cases, various treatments including observation, warming of the affected area, nitroglycerin paste application, phentolamine injection, and other unidentified treatments resulted in the same outcomes: No permanent sequelae were reported.
A 2007 review in the journal Hand reviewed all literature from 1900 to 2005 and found no instances of finger necrosis, but a few cases of neuropraxia and reperfusion pain. This study was interesting in that one of the study authors actually injected three of his own fingers with varying concentrations of epinephrine so that he could document the outcomes. The description of the symptoms was interesting, and the author had significant reperfusion pain in one of his fingers and developed neuropraxia lasting 10 weeks in the finger injected with 1:1000 epinephrine.
In this patient, we used an infant heel warmer to warm the finger and observed the patient for symptoms. Her pain resolved after about an hour and she was discharged with a new prescription for an EpiPen.
How much did that prescription cost?
One online pharmaceutical sales company lists the wholesale price for two epinephrine autoinjectors (0.6 mg total) and a trainer as $426.
A syringe of 1:10,000 epinephrine (1 mg) costs $7.69.
How do patients choose their physicians? New survey by the American Osteopathic Association shows that 65% use word of mouth. 50% use their insurance provider directories. 10% use hospital web sites. 9% use consumer review websites such as Yelp. Then 19% who want to gamble with their lives use physician rating sites such as Healthgrades.com. The most important factor in choosing a physician is whether that physician accepts the patient’s insurance plan.
Another example of the difference between “insurance” and “health care.” UnitedHealth cuts thousands of doctors from its networks. You can have the most expensive insurance in the country, but if few doctors accept it as payment or if the company doesn’t have sufficient providers on its network to care for its patients, “health care” will inevitably suffer. One doctor noted that ”Fewer practitioners mean longer waits, longer drives, less convenience.” Another oncologist stated that ”Patients battling cancer should be focused on their treatment, not on finding another doctor.”
Should the government be prosecuted for creating Healthcare.gov? Andrew Stiles believes so. After all, a commercial venture that is likely mislead consumers violates the Federal Trade Commission Act. The whole premise that people “can keep their healthcare plan” and the “dramatic underestimate[s]” of pricing on the site are just a couple of ways in which consumers have been misled on the site.
Mental health care is in a crisis in Colorado. This report says that mental health patients make up almost half of the emergency department patients at Denver Health every weekend. When you cut funding for psychiatric care by 20% and cut the number of psychiatric beds by 30%, the patients with psychiatric problems don’t just disappear. When they can’t get help, they end up in the emergency department, in jail, or even worse. Could the Columbine or Aurora shootings have been prevented by expanding psychiatric care? Probably not. But one emergency department physician noted that for every “high-profile event that everybody knows about, there’s a hundred that were either near misses … or resulted in violence.”
An example of the downside to government-run health care. Patients in Venezuela can’t get proper medical care. 300 cancer patients were just sent home when supply shortages and “overtaxed equipment” made it “impossible … to perform non-emergency surgeries.” 70% of the radiation therapy machines are inoperable. Basic supplies such as needles, syringes, medications, operating room equipment, X-ray film, and blood needed for transfusions are all in short supply. There is no anesthesia for elective surgery. Patients can no longer get organ donations or organ transplants.
The most important point in the article is that Venezuela’s constitution guarantees free universal health care to its citizens. They don’t just get government-mandated health “insurance,” they get free health care … and look what happens.
We need to be very careful about what type of health care system we ask for in this country. The government that has the power to give everything to you also has the power to take everything away from you.
A pair of settlements paid by Iowa State underscore two important points. First, lumbar punctures are not complication-free. One 69 year old patient received $1.75 million after a lumbar puncture left him paralyzed in his lower extremities. In another non-medical case, a patient was awarded $125,000 for a retaliatory discharge from her job after she filed a workplace violence complaint. If hospital administrators take action against ED staff members for complaining about patient violence, there can be liability for doing so.
Dragon’s speech recognition is good in that it saves a lot of time and costs in transcribing medical records, especially in complicated patients where it would take a long time to type out the patient’s history and the patient’s course.
The problem with Dragon NaturallySpeaking is that it isn’t perfect. Sometimes the difference between a doctor’s dictation of “no murmur present” and the Dragon transcription of “murmur present” can make a big difference in a patient’s workup. Other times, Dragon will misinterpret a dictated phrase for a similar-sounding but inappropriate phrase.
I’ve tweeted about a few of them.
For example, in the patient with GERD who was having repeated exacerbations, I dictated “bland diet” in the discharge instructions. Dragon apparently didn’t like the patient too much because it transcribed “plan to die” onto the chart. It’s fortunate that I didn’t miss that error while I was multitasking. Imagine those discharge instructions showing up in a patient complaint to an administrator.
Another patient was recently looking for a prescription for oral contraceptives. The Catholic hospital in which I work doesn’t allow prescription of contraceptives from the ED, so I have to recommend that patients follow up at Planned Parenthood. Dragon translated my instructions as “Follow up plan paranoid.”
And then there’s the colleague who dictated his findings that “examination of the patient’s breasts with a chaperone showed no lumps, masses ….” Dragon transcribed “semination of patient’s breasts with a chaperone showed no lumps, masses ….” Dr. Grumpy regularly documents the foibles he has with his Dragon software as well.
Then I thought to myself … Self, you haven’t had a contest in a while.
So we’re having a contest for the best “Dragonisms.” What have you seen or read in a medical record that was misconstrued by voice recognition software? Add it to the comments section. Best Dragonism wins a free copy of Mark Plaster’s critically acclaimed “Night Shift” book (affiliate link). We’ll also try to find some EP Monthly swag for runner up prizes. I think I have an old coffee mug somewhere in my closet. Or perhaps a couple of Amazon gift vouchers.
Contest ends at 12AM on November 15.
Let’s see what shoe grout you’ve got.
UPDATE NOVEMBER 21, 2013
It was very tough to pick a winner from all of these great entries. We smiled at almost all of them and laughed out loud at a few. The winner is … #6 Ashley for the metaphorically true mistranscription about a referring facility transferring a patient because it had no testicles.
Ashley will receive a free copy of Mark Plaster’s new book “Night Shift.”
We also chose a couple of runner up winners who will each receive EP Monthly coffee mugs. #14 Mati whose discussion about an advance directive turned into a discussion about an advanced rectum
and #1 ndenunz whose patient’s warm feet turned into warm other body part
If the winners e-mail me at whitecoat-at-epmonthly-dot-com, I’ll get your swag to you. Thanks to everyone for their comments. Hope that the entries at least brightened your day a little.
One of the ideas behind providing more patients with “insurance” (not with “health care,” mind you) is that the insured patients will be less likely to use the emergency department. Untrue. When few doctors take the patients’ insurance, often the patients’ only option is to go to the emergency department. In addition, the emergency department is free for Medicaid patients. The Cato Institute’s Michael Cannon was quoted in the article. I’ve argued with Michael Cannon about his opinions in the past, but this time he is right on the mark when he says “Nobody spends (other people’s) money as carefully as they do their own.” In other words, with no skin in the game, patients have no incentive to limit spending.
The policymakers in Washington have no idea about the economics and incentives of this perverse system they are creating.
Our national health care plan sucks so much that doctors are refusing to accept patients with government “insurance.” That, dear readers, is the difference between health “care” and health “insurance”: Health insurance is a false promise of obtaining health care. Virginia Democrat Kathleen Murphy has a solution to the problem, though: Force doctors to accept Medicare and Medicaid patients.
Our government is getting awful comfortable “forcing” the private sector to engage in activities that go against acceptable business practices. Obamacare forces insurance companies to provide policy coverage that makes policies too expensive and that provides services many people neither want nor need. Then Obamacare forces insurance companies to offer policies to people regardless of their pre-existing conditions. But insurance means nothing without being able to provide the health care and that’s a business the government doesn’t want to be involved in. So now politicians are floating trial balloons about forcingdoctors to treat patients. Hopefully, this idea gets shot down quickly and forcefully.
Too many nursing home patients being sent to emergency departments? A research letter to the editor of JAMA Internal Medicine shows that the number of visits for preventable causes increased 21% between and that the number of visits for non preventable causes increased 23% from 2001 to 2010. More than half of the “preventable” visits were due to either pneumonia or UTIs.
If you haven’t been threatened by a patient, you haven’t been working in an emergency department very long. It’s a common occurrence that shouldn’t be so common. You can read about “patients gone wild” on this blog almost every week – and those are just the incidences that make the news. Little threats come even more often than that.
Most of the time we just laugh the threats off.
One patient was a little more convincing than some of the others, though. It wasn’t just some idle threat. This overly intoxicated patient repeatedly yelled at the doc in a loud voice reminiscent of Yosemite Sam that “I’m going to kill you.” He would randomly spout out his intended modus operandi with such phrases as “I’m going to blow your head off” and “I’m going to slit your throat.” The doctor he threatened was a nervous type and the threats got to him. He talked about what a “lunatic” the patient was that day and he made sure the patient had plenty of Ativan and stayed sedated for the remainder of his shift. Eventually, the patient slept off his alcoholic rage and was sent home with his significant other.
The following day, Doctor Ativan returned for another day at work. About half way through the day, one of the male nurses started his afternoon shift.
Dr. Ativan was in a side room dictating. The nurse witnessed what occurred the day prior and decided that he was going to play a joke on the doctor. So he went to the end of that hall and said in a loud gruff voice “Where’s that Doctor Ativan? I’ve got a score to settle with him!”
“Where IS he? I know he’s working today…. Have YOU seen him?”
All of a sudden you could hear things falling on the floor in the dictation room. Dr. Ativan busts out of the room, runs into the wall across the hall, then starts running down the hallway in as much of a serpentine pattern [see below] as the walls would allow with his hands covering his head. He ran out the emergency exit, setting off the fire alarm, jumped in his truck, and sped away down the street. It took about five minutes to reach him on his cell phone and get him back to the department.
Good thing it was a slow afternoon.
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.