WhiteCoat

An Argument With No Clear Winner

November 23rd, 2014

Fingertip Amputation“You’re going to the hospital.”
“I’m NOT going to the hospital. There’s nothing they’d do and it would cost us thousands of dollars for nothing. Besides … we have to leave. We’re already late.”
A husband was attempting to attach the family’s camper onto the trailer hitch of the family’s truck when the trailer slipped. His middle finger didn’t make it out of the way and got caught between the ball of the trailer and the top of the hitch. When family members helped him pull the camper back off of the hitch, they saw a lot of blood. Then the last portion of his middle finger dropped from inside the trailer hitch onto the leaves.
“Dammit.”
The wife raised her voice. “Get in the truck. We’re going to the hospital.”
The husband wrapped his bleeding finger in a Brawny paper towel he had retrieved from inside the camper. He raised his voice louder. “YOU get in the truck. We’re going to the CABIN.”
“Paul, don’t be silly. You’re bleeding. The tip of your finger is sitting on the ground. If we get to the hospital quickly, maybe they can reattach it.”
“They’re not going to do anything except sew this up and charge us thousands of dollars to do it. I’m NOT going to the hospital. I’ll have Doc Welby call me in a prescription for antibiotics. We can pick it up on the way out of town.”

So the patient shows up in triage with a blood soaked paper towel wrapped around his finger. It was obvious that he’d rather be about anywhere else than sitting in the emergency department at that point.
The finger was amputated just past the distal interphalangeal joint – meaning that the tip of the finger, the nail, and the end of the bone were missing. Clean wound. There were some extra flaps of skin to the sides of the finger which would make it easier to repair the wound. I did a digital block to numb the finger so that we could clean it and we used a commercial tourniquet to stop the bleeding.
The wife softly asked “Is there any chance that the end of the finger could be reattached?”
I started to respond “I don’t think so …” when the patient let out a loud “HEH” and smirked at his wife.
“You were saying, doctor?” She continued.
“I was saying that I didn’t think so, but I can ask the hand surgeon. Do you have the end of the finger with you?”
“Tell him what happened to the end of your finger, Paul.”
“We couldn’t find it.”
“Tell him what really happened to the end of your finger, Paul.”
“It’s gone.”
“Paul didn’t want to come to the hospital. I told him that you may be able to reattach the end of his finger. Paul had a temper tantrum, picked up the end of his finger, and threw it into a field. Isn’t that right, honey?”
Paul folded his arms and looked at the opposite wall, maneuvering his tongue to pick an imaginary piece of food from a tooth. He pretended he didn’t hear what she had said.

OK, then.
So I called the hand surgeon. He came down, looked at the patient’s finger, and arranged to send the patient to outpatient surgery to repair the injury.
Just as the patient had predicted, he was probably charged thousands of dollars to sew up his finger. He was discharged later that day.

For the rest of the day, I kept thinking how that husband and wife dispute ended up in a draw. They were both right. The wife was right that he needed to come to the hospital for evaluation, but he was right in that the surgeon probably wasn’t going to do much except sew up the injury.

OK, I also wondered how many times during their vacation that the husband held up his hand and waved the dressing on his injured finger in front of his wife’s face … as in “see which finger I injured, honey?” … but the irony of their argument was still pretty compelling.

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

Healthcare Update Satellite — 11-04-2014

November 4th, 2014

Ebola PictureBack with more of the Ebola Chronicles …

Ebola fears causing discrimination problems all over the US. Thomas Duncan died from Ebola. Now his fiancee is having difficulty finding a place to live as landlords are refusing to rent to her. People of African descent are facing discrimination just because they are from Africa. Mothers of some school children told one African cafeteria worker to leave the school because she “might have Ebola.”

In Liberia, bleeding patients are often refused medical care due to Ebola fears. The picture at the link shows a picture of a woman who was bleeding heavily from a miscarriage and who was unable to find treatment at multiple clinics.

Hospitals developing policies on what care may not be provided to Ebola patients. Invasive procedures, hemodialysis, endotracheal intubation, and CPR are all being reviewed to determine whether the risk to health care workers is worth the benefit to patients. For example, if an Ebola patient suffers a cardiac arrest and it takes a half hour to don protective gear, will doing so benefit the patient?

The CDC says it is unlikely (.pdf file), but other infectious disease experts assert that Ebola can already spread by aerosols and droplets. Even vomiting creates an aerosol which can transmit gastrointestinal viruses.

Tori Spelling's Ebola Nervous Breakdown Picture Of The Week

But at least Tori Spelling is OK. She was hospitalized with “symptoms of Ebola” which ended up being a nervous breakdown caused by her husband cheating on her. Took selfies of herself in her hospital bed with Twitter hashtags written on a facemask she was wearing. We need to have a 21 day media blackout on any celebrities that pull this crap. Make that a 21 week media blackout.

And some other select news …

Support for California’s Proposition 46 drops almost in half once voters actually learn about the ballot language.

Patients gone wild. Former police officer gets drunk, gets brought to emergency department, assaults nurse, then tries to take Taser from the police who responded to the scene. He got a smackdown by police officers before being arrested for disorderly conduct and attempting to disarm a police officer.

Alabama jury awards family of patient $4 million for missed MI resulting in patient’s death. 40-year-old man went to the emergency department complaining of abdominal and chest pain after eating breakfast two days prior. He was diagnosed with gastrointestinal problem, was sent home, and died of an MI two days later. Plaintiff attorney argued that full cardiac workup should have been performed and hopes that the large verdict “sends a message to doctors, particularly emergency room physicians.”

Remember, marijuana is a harmless drug. Adolescents who use cannabis were 63% less likely to complete high school, 62% less likely to earn a college degree, eighteen times more likely to develop cannabis dependence, eight times more likely to use other illicit drugs, and seven times more likely to attempt suicide.

Science journalist describes how she suffered a broken heart … literally. She was diagnosed with Takotsubo cardiomyopathy

British woman has cosmetic procedure performed during medical tourism trip to Thailand. She was unhappy with the results, so she returned to the clinic for corrective surgery and died under anesthesia.

Healthcare Update Satellite — 10-21-2014

October 21st, 2014

More medical news from around the web on my other blog over at DrWhitecoat.com

Study from University of Maryland proves that emergency physicians are idiots … at least when treating pediatric extremity injuries. Splints were placed improperly in 93% of suspected pediatric fractures treated in emergency departments. “The researchers found that the most common reason for improper placement of a splint was putting an elastic bandage directly on the skin, which occurred in 77% of the cases. In 59% of the cases, the joints were not immobilized correctly, and in 52%, the splint was not the appropriate length. Skin and soft-tissue complications were observed in 40% of the patients.”
Of course, I’m sure that the orthopedists evaluated the patients immediately after the splints were placed to make sure that the patients had not readjusted the splints prior to their orthopedic follow up. That almost never happens.
This study makes a good case for requiring orthopedic evaluation in the emergency department for every pediatric patient suffering from any type of bone or joint injury – regardless of the time of day or night.

What no one is telling you about Ebola … from a Hazmat Trained Hospital Worker. The gear used to protect providers from Ebola is difficult to put on, difficult to remove, and can usually only be worn for 30 minutes at a time. The medical providers in Dallas who contracted Ebola had no protocols in place and this author believes that the “system failed them.”

Patients apparently believe that being in the same hospital as an Ebola patient is bad for their health. Patients at Texas Health Presbyterian Hospital are canceling outpatient procedures, no one is walking in the hallways, and the ED wait times have dropped from an average of 52 minutes to … zero.
“It feels like a ghost town,” said one vendor who recently visited the hospital.

Ketamine has almost immediate positive effect on anhedonia and depression associated with bipolar patients who are resistant to other treatments. The more remarkable thing is that the effects can also be seen on PET scans and effects from a single dose of medication last for over two weeks.

Another example of why doctors should be wary of treating VIP patients. Former NFL running back sues orthopedic surgeon after alleging that his Achilles tendon tore during Baltimore Ravens tryout. Alleges that the surgeon misrepresented the fact that the Achilles tendon had fully healed after his prior Achilles surgery.

Ambulances line up outside North Wales hospital waiting to drop off emergency patients. At one point the line was 13 ambulances long and the wait was hours just to get into the emergency department. One of the government administrators recommended that patients go to NHS Direct or pharmacies for speedy health advice.
At least the patients are covered by insurance, though — just like many of the patients in the US now.

Australian nurses want penalties to be imposed on hospitals if patients aren’t seen within four hours in emergency departments.
If this penalty materializes, a few things will happen. First, nurses will be penalized by hospitals for not effectively moving patients through the emergency department. Second, there will be massive fudging of statistics during busy times. Third, patients who have exceeded the four hour threshold wait will be passed over so that patients who have been waiting less than four hours can be evaluated within the threshold.
When you pay for a statistic, you get the statistic … not necessarily the intended benefits behind the statistic.

From comments at Overlawyered.com
Employee of a surgicenter goes to facility for a colonoscopy. When he wakes up, he was wearing pink underwear. As a result, he suffered extreme emotional distress, humiliation, loss of wages and loss of earning capacity. He is now suing.
While I probably would have laughed off a prank like this, I can understand why some people would have been upset. But suffering a loss of earning capacity from being dressed in pink panties as a prank? I’d like to see how that happened.

Healthcare Update Satellite — 10-13-2014

October 13th, 2014

More medical news from around the web on my other blog over at DrWhitecoat.com

So what are medical providers supposed to do if they are faced with a potential or actual Ebola victim? Who knows?

Here’s a case you don’t see every day … Patient transferred to University of Alabama Medical Center after having what was thought to be a hand grenade embedded in his thigh. He wasn’t allowed in the emergency department, but was instead treated in an ambulance in the parking lot for more than six hours as a military consultant advised medical personnel how to remove it. Eventually was determined to be the 40 mm ammunition for a smoke grenade that reportedly was embedded in his leg when the smoke grenade went off.
I’m not sure I would have been treating him in an ambulance in the parking lot, though. Gasoline tends to make explosions worse, not better.

Medicare enrollment can be so difficult that even a journalist who has been writing about Medicare for almost 40 years needs help from an insurance expert to understand the process. Open enrollment starts soon, so get those appointments for experts now.

Patients gone wild. Arizona schmuck steals an ambulance parked outside a hospital, takes it on a joy ride, refuses to pull over for police … and then parks the ambulance outside his home. I can just see him saying “it wasn’t me” to the police as they arrested him.

You think you’re good at multitasking? You aren’t. In fact, you’re probably worse at multitasking than people who don’t multitask. Interesting study showing how multitasking significantly affects performance. Unfortunately, Forbes’ contributor must have been multitasking while writing the article. His story was based on a study that was published five years ago.

Emergency nurses want to become board certified. Article doesn’t say what board is doing the certifying, but all of the extra training is sure to save lives … and enrich the certifying organization.

Hospitals in Louisiana are charging rape victims for emergency medical care. The National Organization for Women alleges that when private hospitals charge patients for medical care related to sexual assault, it becomes “a form of political extortion to discourage the pursuit of prosecution of crimes of sexual assault.” While Louisiana has a victim compensation fund, it doesn’t provide compensation to all crime victims and under state law, victims who do not file a police report “are to be treated as regular ‘emergency room’ patients.”
Rape is a horrible crime, but is it fair for NOW to demand that companies and medical personnel provide their services for free because those companies and personnel try to help crime victims? Once we start down that slippery slope, where do we stop? Shouldn’t all crime victims receive things for free? And if they’re receiving free medical care, shouldn’t they also receive other things for free as well? Free replacement clothing from any clothing store? Free food from any restaurant if they are hungry? Free child care while attending court hearings or while meeting with police? Free travel back and forth to appointments?
If states want to provide compensation for crime victims (and many already do), then that’s the state’s prerogative. Demanding that private businesses and private citizens provide services for free solely because someone was a crime victim is rather Draconian. NOW‘s position just doesn’t make a lot of sense.

Indigent patients still using emergency departments for their dental problems. Now Minnesota is licensing dental therapists – midlevel providers of dental care than can clean teeth, fill cavities, and care for other dental problems. Other states considering doing the same.

One in ten Canadian seniors who are admitted to a hospital is kept in an emergency department for more than 31 hours before being transferred to a medical floor. “They have no privacy, no toileting facilities. Their basic human needs are unmet, largely because emerg staff are trained to deal with the constant flow of sick people.” But at least the patients all have insurance – just like us.

Healthcare Update Satellite — 09-30-2014

September 30th, 2014

Pittsburgh police taser a reverend who was praying over his dead stepson in the emergency department. His stepson had been shot and was dead. The hospital stated that the reverend was interfering with attempts to revive the patient, but the video shows no such attempts taking place. Now the reverend has filed a lawsuit against the police.

Waits of two days to receive treatment in the emergency department. Frequent misdiagnosis. Lack of resources to treat simple problems like asthma. Hospitals that run out of medications regularly, forcing patients to purchase the medications at private pharmacies. 20% the amount of emergency physicians needed to provide services to patients.
Welcome to health care at King Faisal Specialist Hospital & Research Centre in Saudi Arabia.
Is this the kind of care that we can look forward to with our new “insurance”? We’re already seeing “narrow networks” where insurance companies fail to have sufficient primary care and specialty physicians to care for their patient populations.

Need an MRI and have insurance? That’s great. You still have to pay up front for your testing. With deductibles from $2000 to $5000 on the most common Obamacare plans, hospitals may have difficulty getting deductible payments after procedures have been performed. More hospitals are therefore requiring that patients pay for testing before it is performed.
The good news is that in order to require payment up front, the hospitals have to disclose their charges, which will lead to greater transparency – and hopefully downward market pressure when prices are compared. Up front pricing will also begin demonstrating to many people that medical care comes with a cost that’s more than just a $20 copay.
The bad news is that patients who can’t afford testing may not get necessary health care unless they … go to the emergency department where, by law, hospitals can’t require up front payments.

Thought provoking article on the decline of mental health care in America. The author, a psychiatrist, doesn’t cite his sources, but note that the number of psychiatric beds in the US has shrunk from 340 psychiatric beds per 100,000 population to 11 beds per 100,000 population – a net loss of 1 million psychiatric beds. As a result, 3.5 million severely mentally ill patients remain untreated. Many are arrested and housed in prisons and jails. Others use public libraries as “day care programs.” Cook County Sheriff Thomas Dart noted that with the systematic shut down of so many mental health facilities, his jails have “become the de facto mental health hospital.”

Michigan oncologist pleads guilty to administering unnecessary cancer treatments to patients who were either in remission or who had terminal disease. Government also alleged that he would deliberately misdiagnose patients with cancer in order to justify cancer treatments and would fabricate diagnoses of fatigue and anemia in order to justify unnecessary hematology treatments. He submitted $109 million in Medicare claims between 2007 and 2013.

Your data is safe, really. Healthcare.gov web site reportedly hacked twice earlier this year, but CMS didn’t tell anyone until this month. And the GAO warned that the system still remains fulnerable to unauthorized access, disclosure of confidential data, and data manipulation. Check your credit reports and your medical histories from the MIB. It’s getting to be an every man for himself atmosphere out there.

One member of Parliament when Canada’s health care system was adopted in 1966 ends up waiting in the emergency department on a stretcher for 48 hours before hospital bed opens up. Later dies in the hospital.
One commenter to the article noted that “at least he got to experience the health care system he helped create for us.”

Nice special report in the Seattle Times about the operations in Harborview Medical Center’s emergency department. Some of the pictures are quite thought-provoking.

This article mocks some of the entries in the government’s new ICD-10 coding scheme. For example, “Bizarre personal appearance” is actually a codeable diagnosis. Estimates are that the costs for a doctor’s practice to change to the new coding system will average from $56,000 to $226,000. And sure, being required to differentiate between Orca bites and piranha bites or between first and subsequent run-ins with a lamp post may seem idiotic to most people, but if the coding isn’t accurate, it gives the government the ability to allege that there was false billing and to levy huge fines or even imprisonment. That’s no laughing matter.

How To Discourage A Doctor

September 26th, 2014

Doctor

This post should be required reading for every physician in this country.

A physician finds a document on a chair in his hospital executive’s waiting room and reads through it, then realizes it is a manifesto on how to disempower physicians and put hospital administrators in control of patient care. The document’s title: How to Discourage A Doctor

While the physician implies that he transcribed the information from memory, the formatting breaks and text errors in the document make it appear as if the document was scanned and then the text pasted.

Transform physicians from decision makers to decision implementers. Convince them that their professional judgment regarding particular patients no longer constitutes a reliable compass. Hiring, firing, promotion, and all rewards should be based on conformity to hospital-mandated policies and procedures”
Increase physicians’ responsibility while decreasing their authority. For example, hold physicians responsible for patient satisfaction scores, but ensure that such scores are influenced by a variety of factors over which physicians have little or no control, such as information technology, hospitality of staff members, and parking. The goal of such measures is to induce a state that psychologists refer to as “learned helplessness”.
“Above all, introduce barriers between physicians and their patients. The more directly physicians and patients feel connected to one another, the greater the threat to the hospital’s control.”

Whether the entire backstory of the article is true or more of a parable, the concepts described are being implemented … and they are a serious threat to the health care in this country.

Look at some recent medical research.

This survey showed that hospital ownership of private physician practices has increased dramatically in the past 6 years. In 2008, 62% of physicians owned private practices. This year, only 35% of physicians maintain independent private practices. Only 9% of physicians “mostly agreed” that hospital employment of physicians would increase quality of care and decrease costs. 81% of physicians described themselves as “overextended” or at full capacity.

This survey showed that government regulations regarding electronic medical records are being implemented but that 75% of physicians believe that the electronic medical records increase costs and do not save time. 68% of physicians do not believe that the regulations improve productivity and 48% do not belive that the regulations support coordination of medical care.

This study showed that time lost in dealing with electronic medical records was “large and pervasive”, costing physicians an average of 48 extra minutes a day – during which they could have been performing other tasks such as patient care.

I’m sure that hospitals, their administrators, and their attorneys will all deny that they are trying to discourage physicians or to drive a wedge between physicians and their patients. Draw your own conclusions.

However, as more physicians move to hospital based practices and exhibit less autonomy, think about who stands to gain and who stands to lose from such transitions.

Healthcare Update Satellite — 09-22-2014

September 22nd, 2014

More updated from around the web at my other blog at DrWhiteCoat.com

Study in the journal Pediatrics shows that about 10,000 children are hospitalized each year for accidental medication ingestions. Three quarters of those hospitalizations involved 1 or 2 year olds. Twelve medications were responsible for 45% of all pediatric emergency hospitalizations for accidental drug ingestions. Opioids were not surprisingly the top classification prompting hospitalizations, but buprenorphine and clonidine were the top two medications – responsible for 15% of all hospitalizations. The rate of hospitalization for buprenorphine products was 100 times greater than that for oxycodone-containing products.
Keep in mind that we’re not talking about overdose rate, we’re talking about hospitalization rates.
I looked up suboxone which seems to be a major source of buprenorphine prescriptions, but didn’t see anything that would suggest more of a danger over other opiates. Can any tox folks out there comment on why hospitalization rates are so much higher for buprenorphine ingestions?

Not a good day for this Iowa emergency department patient. Goes to the emergency department with abdominal pain. Apparently doesn’t like the treatment he’s receiving, so he tries to call an ambulance to come and get him inside the emergency department. Then prepares to spit on a security guard and gets sprayed with mace as a result. Police called and find out that he has warrants for his arrest. Handcuffed and runs out of the emergency department, then falls and scrapes his back all up. Eventually ends up in the Greybar Motel.

Attempts to keep the NYU-Langone Medical Center open appear to be falling through. The hospital was losing money and the current owners of the facility can’t find a health care provider to operate the emergency department. New York Mayor Bill de Blasio then makes the idiotic statement that it is SUNY’s “responsibility to ensure that people who relied on LICH in the past will continue to have access to the care they need.”
Actually, Mayor de Blasio, that’s YOUR responsibility. Maybe you and Governor Cuomo could put a little more emphasis on providing health care to the citizens in your city and state.

New study shows tort reform savings are mythical. LA Times investigative reporter Michael Hiltzik cites “copious evidence” (which his investigation doesn’t identify) that defensive medicine accounts for only 2-3% of all US healthcare costs before concluding that tort reform savings are a myth and that tort reform is really just “nastiness” intended to defund Democratic party supporting trial lawyers. Now there’s a new article in JAMA that Mr. Hiltzik mentions to bolster his arguments, but even that article doesn’t say what Mr. Hiltzik asserts. The graph in the article which is reproduced in Mr. Hiltzik’s column shows that “defensiveness” can play a role in more than 60% of a physician’s orders and that 28% of orders and 13% of all healthcare costs were at least partly “defensive.” A little more than 2-3%, but don’t let statistics get in the way of a good story.
And if tort reform is bad and full liability for all one’s actions is good, then why is there government immunity for medical treatment of our veterans and why is there full immunity for legislators, prosecutors, and judges?

Fortunately, there was an investigation into the events at the Phoenix department of Veteran’s Affairs. That report concluded that officials could not “conclusively assert” that delays in care at the VA caused more than 40 patient deaths. However the “conclusively assert” statement wasn’t included in prior versions of the report. The former medical director of the clinic calls the report “at best, a whitewash, at worst, a feeble attempt at a cover-up.”
How would the investigation have been different if the incident didn’t involve a government-run facility?

Should states make it easier to get medication to treat heroin overdoses? Pennsylvania is debating the issue now. Should police and firefighters be allowed, or required, to carry and administer naloxone? Should other users have immunity from prosecution if they are using heroin with the victim and call for help?
Why not just make naloxone over-the-counter and solve all the problems with access?

What if you’re a female in Saudi Arabia, you have a medical emergency at home, and need to go to the emergency department? Whatever you do, don’t get in your car and drive to the hospital. One Saudi woman who was recently caught driving herself to the hospital was pulled over by police and fined. It is forbidden for women in Saudi Arabia to drive because, according to an Islamic cleric’s interpretation of the Quran, driving causes women to lose their modesty, allows women to leave the house when their “homes are better for them,” allows divorced women to go wherever they want, and would lead to “overcrowding in the streets.”

Proponents of California’s Proposition 46, which would increase damage limits in malpractice cases to $1.1 million and would require drug testing of all physicians, put out an ad using assertions and statistics that are deemed “mostly misleading” by the Sacramento Bee.
Then again, opponents of the Proposition put out an ad that is also deemed misleading by the Sacramento Bee.

Dr. Steven Passik, a PhD lecturing at “PAINWeek” Conference recommends doing risk assessment for opioid abuse before reaching for their prescription pads. If you have risk factors for drug abuse such as “younger age, male gender, comorbid psychiatric problems, a history of substance abuse, a family history of substance abuse, [or] a history of smoking,” maybe you get drug tested every visit or maybe you just don’t deserve to have your pain treated.

Another Example of Defensive Medicine

September 18th, 2014

The ultrasound images above show a circular clot in the superficial femoral vein. The image on the left is without compression and the image on the right is with compression. Normally blood vessels flatten out when compressed. Since the vessel did not flatten with compression it confirmed the presence of a blood clot.

While discussing a case with one of the nurses with whom I work, I saw how once again defensive medicine had affected my medical practice.

I gave a few examples of defensive medicine in a post several years ago and I also mentioned how sometimes doctors have to prove a negative when dealing with patients. Both of those posts are pertinent to this case.

A patient with a history of a clotting disorder has arthroscopic knee surgery. He has had two prior blood clots in his leg and one prior blood clot in his lung, so he’s on lifelong Coumadin. His doctors told him to stop taking the Coumadin for the week prior to his surgery to prevent bleeding during surgery. The surgery went well and he was discharged the same day.

The following day he started taking Coumadin again. However, he also noticed some pain in his calf. The pain was there after his surgery, but it seemed to be a little worse the following day. He took some pain medication and kept ice on it.

Two days out from his operation he was still having some pain in his calf, so he called the orthopedist. The orthopedist told him to go straight to the emergency department for an ultrasound of his leg to make sure that he didn’t have another blood clot. The possibility of a blood clot worried the patient, so he followed the doctor’s recommendations.

When I saw him, based on his clinical exam I could tell – with a reasonable degree of medical certainty – that he didn’t have a blood clot. His leg wasn’t red or swollen. We measured the circumference of both legs at the thigh and at the calf. His normal leg was actually a centimeter larger in diameter than the leg that underwent surgery. The pain was in the belly of the calf muscle – where orthopedists will sometimes apply pressure to get the leg in the correct position during a surgery. There was no thigh pain and there were no palpable cords.
It was a Saturday evening, so doing an ultrasound to look for a blood clot meant that we would have to call in the ultrasound tech from home and the patient would have to sit in the emergency department for at least a couple of more hours.

I told him “Based on my exam, it is pretty unlikely that you have a blood clot in your leg. Keep taking your Coumadin, keep putting ice on the tender area, keep taking your pain medications, and follow up with your doctor on Monday.”
He said “I have a history of blood clots in my leg before, it feels like a blood clot now, and my orthopedist said I need an ultrasound. You need to do the ultrasound.”

Now if there wasn’t any concern about liability or other repercussions, I probably would have told him that the ultrasound wasn’t indicated and that we didn’t need to do it that night.

But there is a concern about liability and other repercussions.

Even if the patient didn’t have a blood clot on this visit, what would happen if the patient developed a blood clot the following day? And what if that blood clot broke off, caused a pulmonary embolism, and the patient died? How could I prove that there was no clot present when I evaluated the patient – especially when purported “expert” witnesses testify under oath that it is “grossly negligent” to miss a diagnosis of pulmonary embolism in a teenager after knee surgery? It is much easier to order a test than it is to defend your reasonable and evidence-based approach for not ordering the test in the event of a bad outcome.
What if the patient had a clot despite the lack of physical findings for a blood clot? We often hear the phrase “nobody’s perfect”, but if you don’t order testing and miss a diagnosis, there is really not much tolerance for less than perfection in cases like this. It is much easier to order a test than it is to defend your reasonable and evidence-based approach for not ordering the test in the event of a bad outcome.
I’ve seen more than a few specialists and primary care docs who send a patient to the emergency department for testing and who then complain to hospital administrators that the dumb emergency physicians don’t do the tests that they wanted.
And let’s not forget that sending a patient home without getting the tests that the patient wanted is a sure way to tank your patient satisfaction scores.

So we ordered the ultrasound and called in the ultrasound tech.

A few hours later we got back the report from the radiologist showing no DVT. The patient got to go home and I’m sure that he slept better.
I’m sure that the orthopedist was able to sleep better, also.
The whole episode didn’t have much of an effect on my sleep pattern. I knew the patient didn’t have a blood clot when I first examined him … but now I had objective proof of my clinical findings and everyone got what they wanted.

Just think, it only cost the system a few thousand extra dollars.

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

Healthcare Update Satellite — 09-15-2014

September 15th, 2014

Don’t have as much time to do it as I used to, but I still post additional updates over at DrWhiteCoat.com if you’re looking for more medical news from around the web.

Enterovirus 68 is confirmed in seven states. Worried parents bring children to emergency departments with “even mild symptoms” to make sure that the children are OK. Now hospitals are at full capacity and wait times increase. When kids do get tested for the disease, many are negative.

Box

North Carolina’s Levine Children’s Hospital emergency department diverts patients and calls in a bomb squad called for … a box outside of the emergency department. According to the article, you may be able to earn money from Crime Stoppers if you call and tell them who left it there.

Speaking about boxes, I just love it when people think outside the box. And I find it fascinating how there is so often the possibility of a chemical or bacterial basis for disease. In this case, a pharmaceutical company Agios created a drug that, instead of killing cancer cells, transforms acute myelogenous leukemia cancer cells back into normal cells. The back-story is what interests me. About 15% of patients with AML have a genetic mutation that affects how molecules are broken down in the Krebs Cycle. Remember that? Instead of isocitrate being broken down into alpha-ketoglutarate, the mutation creates an abnormal enzyme that causes isocitrate to break down into 2-hydroxyglutarate – which inhibits the ability of cell nuclei to mature. Agios’ drug, AG-221, binds to the abnormal enzyme and prevents an accumulation of 2-hydroxyglutarate. Preliminary trials of AG-221 are promising. With traditional treatment, the five year survival in AML is less than 25%. Phase I trials of AG-221 showed a 50% disease remission rate.

Here’s a novel concept. Want to understand why patients return to the emergency department? Just ask them. Study from Thomas Jefferson Hospital in Pennsylvania (.pdf) interviewed 60 patients and discovered that the most common concern prompting a return ED visit was fear or uncertainty about their condition. Patients tended not to follow up with their primary care physicians – even though most had primary care physicians – because the emergency department was more convenient and provided quicker evaluations. A common complaint about the emergency department care was that patients were often unsatisfied with their discharge diagnosis or the explanation of their chief complaint.
This study should be required reading in every emergency medicine residency in this country. In fact, the concepts in the studies should be tested on the emergency medicine board exams.
Now if the study only compared the type of a patient’s insurance with the likelihood of emergency department recidivism.

How else can the media try to tarnish this guy’s reputation? The doctor who oversaw Joan Rivers’ fatal endoscopy was once *sued* 10 years ago. Gasp.
The former patient’s attorneys are really trying to create their 15 minutes of fame. They alleged that 10 years ago the patient received no informed consent prior to a surgery and then vomited during surgery and developed pneumonia because of it. The jury found otherwise and exonerated the doctor. A spokesperson for the endoscopy clinic also noted that the surgical complications in the case 10 years ago occurred because the surgery was performed as an emergency. In one breath, the patient’s lawyers denied that the surgery was emergent, but in the next breath they stated that the patient was “put under before he could tell the doctors he had been fed two meals earlier in the day.”
If the surgery wasn’t an emergency, then why didn’t the patient (who happened to be a retired physician) have time to tell the doctors about his meals?

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One way to keep patients from overcrowding the emergency department: Bring the emergency department to them. Colorado ambulance company teaming up with emergency physicians to create mobile emergency departments with supplies to run basic lab tests, insert stitches, and prescribe medications. If patients require higher level of care, they’re transported to the emergency department as with traditional ambulances. Only problem is that the service costs $500 or so per visit and insurance companies aren’t paying for the extra services.

Emergency department nurses call for immediate changes to hospital’s emergency department management to “avoid further harm to patients.” Them’s fighting words. The nurses issued a press release stating that the emergency department is “chronically overcrowded with inadequate levels of appropriate personnel and security” and that management has “refused to take action to rectify the situation.” They’re holding a news conference to describe the unsafe conditions they have been documenting over the past five months.
In other news, there was a law passed so that everyone will have insurance … which we were told would cause the number of patients going to the emergency department to decrease. Phew.

I’m going to regret publishing this. I know it. Study shows that viral infections really can turn into bacterial infections. Well – not really “turn into” bacterial infections, but can make them more likely. When researchers inoculated a child’s nostrils with both influenza and strep pneumonia, they found that the influenza virus inflamed nasal tissue, increased the number of bacteria present and increased the likelihood that the bacteria would travel up the Eustachian tubes into the middle ear.
So when patients come to you and say “this runny nose always turns into pneumonia, I need antibiotics” now there’s at least a tangential basis for that statement.

Kanye West has severe headache after playing basketball before a show in Australia. Gets rushed to the emergency department at Epworth Hospital. Then the fun begins. Kanye’s personal physician, who was called a “diva,” told hospital staff that no one would be “following protocol or filling out forms” in the main area of the hospital. Patients were kicked out of the MRI suite so that Kanye and his entourage could get some privacy. Then Kanye himself was wheeled into the suite on a stretcher playing peek-a-boo with a sheet and guarded by six security guards.
Hours later, Kanye was performing at his concert – where he stopped singing until everyone stood up – and then belittled two people because they remained sitting. He began a chant “stand up” and got the crowd to boo at the people – until learning that both were disabled and one was in a wheelchair.
Or maybe they just had severe headaches after playing basketball … or after listening to Kanye’s “music.”

Fighting MRSA and other drug-resistant infections with … honey? Researchers discover lactic acid-producing microbes in honey that were able to kill MRSA, VRE, pseudomonas, and enterococcus.
If you’re interested in the research behind the studies, there’s a good discussion thread on Reddit with microbiology graduate students who are studying the antimicrobial effects of honey.

Healthcare Update Satellite — 09-08-2014

September 8th, 2014

Think a patient is faking alcohol withdrawal tremors? Yeah. There’s an app for that. Canadian researchers develop app that uses iPod’s built-in accelerometer to determine whether or not tremors are more than seven cycles per second. 75% of true alcohol withdrawal tremors have rates faster than that. Only one in six volunteers could fake tremors that fast.

Malpractice fees in British Columbia set to double. Physicians pay anywhere from $2,000 (for family physicians) to $20,000 (for obstetricians) in a defense fund every year in order to offset the costs of malpractice defense. The reserve requirements for the fund have doubled in the past year, which means that the fees will likely double as well. Median payouts to malpractice plaintiffs was $161,000 while the median costs for malpractice defense was $43,000.

Speaking about British Columbia, a 20 year old woman goes to a local emergency department with back pain. Gets a muscle relaxant to treat her back pain and her back pain resolved about 6-8 hours later … when she delivered her baby. While in the emergency department, she gave a urine sample which showed she was pregnant. Doctors then performed an ultrasound which showed that she had a full term pregnancy and was in labor. The patient had no idea she was pregnant.

Mutant cold virus sending hundreds of children to hospitals with respiratory difficulties. At Denver’s Children’s Hospital, more than 900 kids presented with cold symptoms in the past two weeks. While most cases of the infections are mild, about 10% of patients required admission. The infection seems to affect children with asthma more than others.
CNN report notes that the organism is enterovirus EV-D68 which is uncommonly diagnosed, but also uncommonly tested for.
And no, antibiotics still won’t help. Using antibiotics on viruses is like using Raid on dandelions. The best prevention is frequently washing your hands and avoiding touching your hands to your eyes, nose, and mouth.

Want to be admitted to the hospital just to be “safe”? New study shows that each day spent in the hospital increases your risk of contracting a multidrug-resistant infection by about 1%.

Interview with EP Monthly’s own Mark Plaster about his book “Night Shift” which is a compendium of some of his best EP Monthly columns from over the years. He has book signings in the Annapolis Bookstore this month and next if you happen to be in the area and want a signed copy.

Judges question the state medical malpractice reserve in Wisconsin. Does it really need to be more than $1 billion?

You have to admire the courage of a mother who allows a recording of her son’s death to be published in an online video campaign for road safety. Her son was driving a motorcycle at 97 mph when a car turned in front of him and he didn’t have time to react. He was killed on impact and his helmet cam captured the entire incident, including him lying motionless in the grass next to the road after being thrown from his bike. It’s a tough video to watch, but it makes its point.

Minneapolis VA Medical Center falsifies patient records to hide appointment delays. Some patients who needed colonoscopy appointments for cancer follow up were marked as refusing appointments when, in reality, they were never even contacted. Administrators instructed workers to keep a secret waiting list so that no delays would be apparent in the VA’s VISTA medical records system. VA Director Patrick Kelly denies seeing any evidence of wrongdoing at the VA, yet e-mails to the Director show that he was aware. When whistleblowers went to the news to expose the wrongdoing, they were both fired.
If something like this happened in civilian practice, the doctors and administrators would be thrown in jail. Watch Patrick Kelly get promoted.
Keep in mind that this is the type of system to which the entire country is transitioning.
Boy am I glad I’m a doctor.

CMS plans to release data about eight “Hospital Acquired Conditions” on its web site. It used to call these conditions “Never Events” but changed the terminology.
Note how CMS doesn’t include government hospitals in the data it releases. Instead of leading by example, it hides its failures.

CEO of Ireland’s Beaumont Hospital writes letter to staff stating that overcrowding in the emergency department and delays in discharging patients are making the hospital “unsafe” for patients. When the letter was written, there were 58 patients waiting in the emergency department and 73 admitted patients on waiting lists for “step-down” facilities such as nursing homes. The hospital’s clinical director resigned earlier this year due to “significant clinical risks” at the facility.
Wait a minute. Delays in treatment. Waiting lists. Where else have I heard that occurring?

Neurosurgeon orders one type of dye for use in implanting a spinal stimulator, pharmacy gives him another dye that was labeled as not to be used for spinal procedures. Injects dye twice during procedure. Patient wakes up with severe pain and seizures, then dies the following day. Neurosurgeon admits to patient’s family that a mistake was made and apologizes. Eight months later, Tuft’s Hospital attorneys write a letter to family denying that any negligence occurred. However, once the story hit the newspapers the hospital’s insurance company quickly made a settlement offer.

Oregon patients “bitter” when they have long waits in emergency departments due to overcrowding. Newspaper story discusses one patient who went to the hospital at 9:30 PM with “severe abdominal pains” and who was not seen until 6 AM the following day. Eventually, she was diagnosed with ovarian cancer. The patient was understandably upset, but thought she should have been seen before the patients in front of her. Oh, and the nurses were rude, too. Oh, and the patient didn’t have insurance which probably didn’t “help[ ] her situation either.”
First of all, overcrowding and long waits are going to become the norm in the emergency departments. Emergency departments all over the country keep closing and volumes in the remaining emergency departments keep increasing. More patients with less resources inevitably lead to longer waits. When states cut funding for emergency services and emergency medical care, those services will always become less available. Remember this fact when voting in November.
Second, it sucks that you had to wait. I get it. We do the best we can in the emergency department with the staffing and beds that we have and trust me, we all feel as much stress as you do when the emergency department gets that overcrowded. It’s not like we’re sitting in some back room playing poker and drinking tequila. But picking out every little thing you could find wrong with your experience and drawing insinuations that your long wait must have been related to your lack of insurance is a bunch of crap.
Finally, I agree with several people commenting in the article that they should investigate administration and staffing issues to get to the root of the problem However, even if a department is overstaffed, if the rate-limiting step is getting admitted patients out of the emergency department and up to the medical floors, the patient flow will grind to a halt.

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