WhiteCoat

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.

———————–

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.

Healthcare Update Satellite — 08-28-2014

August 28th, 2014

Good news is that the number of medical malpractice cases in Pennsylvania is decreasing. Bad news is that if you practice medicine in the Philadelphia area, you’ve got a big target painted on your back. Philadelphia accounts for only 12 percent of the state’s population yet in 2013, 40 percent of medical malpractice trials resulting in verdicts took place in the city. Philadelphia medical malpractice plaintiffs won 45% of trials, more than any other jurisdiction and significantly higher rate than the national average.
Looks like we’ve found another place to avoid when looking for your next place to practice medicine.

Regulating a longstanding practice out of existence. Remember going to your doctor’s office and seeing those walls full of pictures of babies that the doctor delivered? Yeah, that’s illegal. Violates HIPAA.

Travelers from Liberia still being transferred via commercial flights to Delhi and Mumbai. A few with fevers were quarantined … after they arrived … while the others were required to be tracked daily by local authorities for the following month.
Meanwhile, most major airlines are suspending service to the “crisis zones.”

With the ebola hysteria comes hysterical actions. Woman on a Delta Airlines flight in Florida was kicked off the airplane because she “looked tired and drowsy.” Staff stated that if she did not get off the flight, they would call the authorities. Delta gave her a $20 voucher for tea and soup, then let her on the next flight. Because tea, soup, and an hour wait in the lovely airport atmosphere are more than enough to kill any potential communicable diseases that cause people to look tired and drowsy.

Study in Journal for Healthcare Quality shows that diagnostic errors double the odds of malpractice payout totaling $1 million or more. There were 6,130 such “catastrophic payouts” between 2004 and 2010 and those payments amounted to .05% of the total health care expenditures each year. Years of practice and number of prior paid claims had no bearing on the odds of a catastrophic payout.
However, failure to order diagnostic testing absolutely contributes to diagnostic errors. Kind of flies in the face of the whole “lets cut back on testing” mantra, doesn’t it?

Obamacare mandates having an effect even on Major League Baseball. Cubs grounds crew hours cut to keep them under 130 hours per month so that they don’t meet “full time worker” criteria and get insurance coverage under Obamacare. During rain delay at a recent Cubs game, the understaffed grounds crew wasn’t able to get the tarp properly positioned on the infield – leading the umpires to call the game off due to poor infield conditions.

Neat idea in Singapore to curb non-urgent emergency department care. Hospital and local primary care physicians teamed together to create a “GP First” scheme. If a patient goes to their primary care physician for a problem and then has to be referred to the emergency department, they get $50 off of the $108 emergency department bill. So far, the hospital has seen a decrease in non-urgent cases by 10-12%. The resulting decrease in patient volume also caused about a 20% decrease in emergency department wait times.
Now why wouldn’t such a plan work in the US?

Flying drone delays medical helicopter’s landing at Ohio’s Miami Valley Hospital. What are we going to ban after this incident?
Once we had a guy taking pictures/video with his phone who wouldn’t get away from the helipad in the hospital parking lot while the chopper was landing. Security literally had to tackle him and drag him away.

Louisiana pays extra $18 million to keep Baton Rouge General’s emergency department open. The hospital emergency department is seeing an additional 400 uninsured patients per month with numbers of uninsured psychiatric visits up 60% and number of uninsured surgery patients up 70%. After Louisiana State closed its Earl K Long Medical center in an attempt to privatize charity hospital care, the patients had to find other care. Now Baton Rouge General is losing $1 million per month. Another story on the topic here.
I’ve been saying this for years. When hospitals close, the patients going to those hospitals don’t just disappear. They seek care elsewhere. The costs of providing uncompensated and poorly compensated (Medicaid and “Obamacare”) care at the remaining open hospitals then compounds on itself until the next hospital closes under the weight uncompensated care. Every hospital that closes causes a decrease in access and decrease in available medical care.
Wait. Wasn’t that what the “Affordable” CARE Act was created to solve?
Louisiana better write at least double that $18 million into its yearly budget. It’s trying to cure a hemorrhage by using a Bandaid and we all know how well that will work out.

Another hospital shooting near Philadelphia. Man pulls gun in hospital room then kills wife and shoots himself. Fourth hospital shooting in the Philadelphia area this year. Wait. Isn’t this the same place that has such the high rate of successful malpractice cases? Another reason to consider whether you really want to practice medicine in the Philadelphia area.

Joan Rivers goes into cardiac arrest during throat surgery and is brought to the Mt. Siani emergency department. Reportedly stable. Good job, team!
I can’t wait to hear all of the jokes about this incident.

Driving With A Foot Out The Window

August 21st, 2014

Driving With Foot Out Window

I saw this while driving down the road recently. A person just tooling down a major road with their foot hanging out the window.

What possesses people do drive with their feet out the window? I see it every once in a while from both drivers and passengers. This time my daughter just happened to be in the car with me so she could catch this picture.

I did a quick search of the internet and of the medical literature and wasn’t able to find any specific literature on the potential downsides from driving like this.

I was, however, able to find other pictures/posts/comments …
calling a driver doing this a “jackass,”
noting that the practice was awkward and potentially dangerous,
stating that a person driving in this manner is “white trash skank,”
stating that driving this way is illegal in Delaware,
noting that a driver in Australia who was pictured with both feet out a window had been charged with “reckless conduct endangering life, failure to have proper control of a vehicle, careless driving, and limbs protruding from a vehicle,” and
a comment noting that the practice was something worthy of circus people.

So if driving with your feet out the window doesn’t hurt anyone and it feels nice to have a breeze blowing on your bare feet while traveling at 50 MPH, then why shouldn’t we do it?
Here are some of my thoughts.

First, you look like a freak when you drive with your foot out the window. It isn’t cool. It isn’t funny. It looks low class and smarmy. Yes I’m old and out of touch with the younger generation. You still look like a smarmy whippersnapper when you drive with your foot out the window.

Next, when you drive with your foot out the window, your foot and/or leg is blocking your view of the driver’s mirror. That makes you less able to see your surroundings and more prone to getting into an accident.

With your leg in that position, you are probably less able to shift your body to turn and look in your blind spot when changing lanes or making a turn. That makes you more likely to hit a vehicle approaching you on your driver’s side.

Finally, pretend for a moment that you get into an accident with your foot hanging out the window. Think of what will happen to your body …

If you rear-end someone and your air bag deploys, momentum will carry your body forward while the airbag forces your hanging leg into flexion and external rotation. Ever popped a chicken leg off a cooked chicken?
Your knee will probably hyperextend as well, so you’ll be in a position where you’ll potentially have no knee ligaments and no hip joint.
The anterior force on your driving leg combined with the posterior force on your leg out the window will cause a shearing force on your pelvis which may be enough to snap your pelvis like a pretzel. Pelvis fractures are potentially life threatening, tough to rehab, and carry multiple serious complications.

If you’re involved in a rollover accident, it’s even worse. You won’t have time to pull your foot back in the vehicle and the edge of the window will hold your foot in place as the several tons of car rolls on top of it, mangling your foot if you’re lucky and just ripping it from your leg if you’re not so lucky. If the roof collapses from the rollover impact, then your knee and lower leg will get caught up in the mangled metal – which may prevent you from getting out of the car.

Look at the bright side, though. If you survive a serious accident with your leg hanging out the window, at least they have a lot of advanced leg prosthetics you can choose from.

Anyone got any stories about trauma from drivers or passengers with their feet out the windows?

Healthcare Update Satellite — 08-12-2014

August 12th, 2014

** CLEAR! **
Not dead yet. Having withdrawal symptoms from lack of blogging and actually violating a cardinal rule of blogging by posting from work. Now that travel is done and life is getting back to normal, will hopefully have more time to write.

Sabrina Kropp had damaged the cartilage in her nose from all of her cocaine use. She went to a plastic surgeon who repaired her nose and who then published anonymous before and after pictures of her nose on his web site. Ms. Kropp then sued the doctor for violating her privacy. The pictures pretty much isolate the patient’s nose, so it appears unlikely that anyone would be able to identify the patient just based upon the pictures. Now that she’s filed a lawsuit, everyone can identify her both as a plastic surgery patient and as a cocaine abuser.
Paging Barbara Streisand

Patient in Maryland’s Calvert Memorial Hospital emergency department steals $4600 in medical equipment from room, is discharged and then goes to a local car dealership and tries to sell the equipment to customers shopping for a car.

Genetic therapy may revolutionize treatment of heart failure. Study in London involves infusion of genetically engineered virus to increase production of SERCA2a protein that in turn increases contractility of heart muscle. Studies show good improvement in animal models and in laboratory human heart models. Human studies beginning soon.

Medical apps worrying doctors? Not me. If people are dumb enough to think that some app on an iPhone can accurately measure their blood pressure or blood oxygen levels without any additional sensors, then they deserve to lose their money. Of course they’re probably related to the same people who think satisfaction survey statistics are valid.
Paging PT Barnum

New services such as Pager and Medicast allow patients to summon physicians for house calls. No insurance, though. You’ll have to pay a minimum of $199 in cash for the convenience — more if you request the service at night, on weekends or on holidays.

Nice story about an emergency physician leaving the comfort of the emergency department to help patients in Haiti and then Tanzania before hopefully joining Doctors Without Borders. Good on you Dr. Benzoni

Number of emergency department visits related to synthetic marijuana in NYC has more than doubled in past year. Can this be related to the “safety” of marijuana?

Staten Island physician found dead in hospital bed. When article notes that the doctor specialized in pain management, commenters to the article jump to the conclusion that he must have overdosed on something.

Conflict of interests? Singapore hospital begins a palliative care service in the hospital emergency department.

Welcome to the Abercrombie and Fitch Emergency Department. Ohio U builds new 43,000 square foot emergency department, increases beds from 50 to 70 then to 100, initiates bedside registration and adds doors to rooms instead of curtains. Believes that these measures will decrease crowding and improve wait times.
Talk to me in a year and see how well that works. If you build it, they will come.

Healthcare Update — 07-24-2014

July 24th, 2014

Busier may be better* … at least for for patients with life-threatening medical emergencies. When comparing very high volume emergency departments with very low volume emergency departments, a study in Annals of Emergency Medicine shows that patients with medical emergencies were about 0.4% less likely to die when they were treated at the nation’s busiest emergency departments. These statistics reportedly translate into about 24,000 lives saved each year if patients received the kind of care that was provided in the nation’s busiest emergency departments.
* A small disclaimer is in order, though. The study was performed by University of Michigan medical school. University of Michigan Hospital’s ED has more than 80,000 visits per year and is considered high volume.
I think a good idea for a similar study would be to compare mortalities in communities before and after the closure of emergency departments in the areas. This study might suggest that mega-hospital care is better, but is immediate care in small volume emergency departments better than delays in care during travel to a mega-hospital … or no care at all because patients can’t get there?

This may explain why doctors are so good at practicing defensive medicine. During their careers, doctors spend more time in the courtroom than in the classroom.
The headline is misleading since during a lawsuit, doctors aren’t in the courtroom 40 hours per week as they are during medical school. The point is that for 11% of their careers, an average physician has a lawsuit hanging over his or her head.

Johns Hopkins gynecologist admits to secretly recording patients during gyne exams. Police search home and find computer servers with naked pictures and videos of up to 8000 patients. Doctor then commits suicide.
Johns Hopkins has just agreed to a $190 million settlement with the involved patients.
If the lawyers get 30% of the settlement, they’ll net $63 million. If the remaining funds are divided equally among the affected patients, they’ll each receive about $16,000.

Kourtney Kardashian’s boyfriend can’t handle his liquor and has to go to the emergency department for alcohol poisoning. Not sure why this is news, but now you can click the link and gouge your eyes out, too.

There may be some truth to the statement from patients with chronic back pain who say “that sh*t doesn’t work with me.” Study published in the Lancet shows that there is no difference in time to resolution of symptoms between patients using Tylenol and patients using sugar pill placebos. There was also no difference between the groups in pain, disability, symptom changes or quality of life. And the strange thing is that 75% of patients were happy with their treatment regardless of whether they took Tylenol or a sugar pill placebo.

Oakland police repeatedly beat Occupy protester and Army Ranger Veteran with a nightstick, then throw him in a cell and ignore his complaints for help. When he begins vomiting, one officer told him to stop using heroin. Another officer videotaped him. Friends finally bail him out and bring him to the hospital … where he underwent surgery for a lacerated spleen.
Why does it seem like the names of public citizens accused of crimes are published in newspapers but the names of law enforcement officials who commit crimes against the public are kept hidden?

Understaffing in British Columbia hospitals frustrates patients who had to wait 4.5 hours in emergency department before they could get treatment for their infant son’s severed finger. Waiting room was packed with dozens of patients and only two doctors were on duty. Called several other hospitals that also had long waits in their emergency departments.
But at least the care is free.

9 year old patient with history of congenital heart defect and prior endocarditis goes to emergency department for a fever and “seeming sick.” Doctors give him motrin and discharge him without performing testing after he appears better. Returns two days later and diagnosed with endocarditis. Develops complications during surgery and ends up paralyzed on the left side of his body, blind in the left eye, and with garbled speech. Jury awards patient $17 million.

Laparoscopic hysterectomy begins uneventfully, then bleeding from the uterine artery is noted and the procedure is immediately converted to an open procedure. Towels packed into the abdomen to stop the bleeding and the patient’s life was saved. A month later, the patient has fever, discharge, and abdominal pain. Repeat operation showed that one of the towels had been left inside the patient. Patient required several additional surgeries and later sued. Jurors award $7.2 million. Important point in the case is that the defendants began pointing fingers at each other. The surgical techs blamed the surgeon and the surgeon blamed the surgical techs. As the author of the article noted, “once jurors see “dueling defendants” they most often assume the worst happened and find blame all around”

Jury finds that Alabama doctor and nurse midwife were not liable for birth injuries to an infant who was born a quadriplegic. Case gets overturned after attorneys discover that, when questioned about a potential deadlock, the judge sent jurors a note to “please keep deliberating” — without informing the attorneys or parties.

For a completely non-medical link that had me both appalled and laughing at the same time, check out this model citizen who became upset because McDonalds didn’t serve chicken nuggets in the morning.
Even though this video was posted last year, according to TSG, the event occurred in 2010.
A little more searching showed that the original video had no audio and that the audio was dubbed in later for amusement purposes.
And I just kept thinking that this is the type of patient whose low Press Ganey satisfaction survey scores would be the source of a monthly meeting because the emergency department staff isn’t meeting all of its patients’ needs.

Healthcare Update Satellite — 07-14-2014

July 14th, 2014

Practicing telemedicine may just get a whole lot easier. Federation of State Medical Boards creating an interstate “compact” that would reduce barriers by providing an “expedited license” to physicians who wish to practice medicine in multiple states. The physician has to establish a state of “principal license” and then may apply to the “Interstate Commission” to receive a license in another state after the “applicable fees” have been paid. The hundreds of dollars per year paid to each state to maintain licensure don’t appear to be one of the barriers that is being reduced.
Most recent draft of the compact can be found at this link (.pdf)

Remember the infant who was “cured” of HIV after receiving high doses of antiretroviral drugs shortly after birth? She was taken off her medications and didn’t have any evidence of HIV in her bloodstream for several years.
Unfortunately, doctors recently announced that the child is now showing signs of HIV infection.
And the hunt for an elusive cure to HIV continues.

Milwaukee woman goes to emergency department with abdominal pain, rapid heart rate and fever. Spent nine hours in the emergency department and was discharged around midnight with instructions to follow up in the morning with her gynecologist for fibroids in her uterus. Later collapses at home and treated for septic shock which caused her to lose both arms and both legs. Sues hospital and plaintiff attorney argues that none of this would have happened if she just got a “$25 antibiotic.” Jury awards $25.3 million, saying that physician assistant and emergency physician who treated her should have provided her with a complete differential diagnosis of her symptoms prior to her discharge.
Attorneys expect that this case will get to Supreme Court as more than $16 million of that judgment would be subject to Wisconsin’s $750,000 medical malpractice cap.

Do you have any Kleenex? I need to blow my … back. Paralyzed woman has stem cells taken from her nose and undergoes stem cell transplant to try to cure her paralysis. Eight years later, she has pain at the surgical site. Undergoes exploratory surgery and doctors find a 3 cm growth of nasal tissue that was secreting mucous which was pressing on the woman’s spine.
Surgeons note that this type of complication is uncommon, occurring in less than 1% of patients.
Case report in the Journal of Neurosurgery is here.

Patients gone wild. Australian police are “investigating” after patient attacks five nurses, a security guard, a paramedic, and an elderly patient. One nurse required hospitalization. No one notified the hospital staff that the patient had previously attacked a nurse.

What are the conversations like in a rural emergency department waiting room with “country folks”? Pretty darn funny column about it by Lauretta Hannon in a suburban Atlanta newspaper. How *did* Aunt Carrie get hooked on them Oxycondoms, anyway?

Kaiser Health reports on newly implemented Dignity Health network policy where emergency department patients can “pay to go to the front of the line.” Hey – Southwest Airlines does it and so many people think that emergency departments should be more like other businesses, right?
But when hospitals start providing preferential treatment to those with money and internet connections, they’re running afoul of EMTALA laws.

Venezuela’s University Hospital of Caracas closes its emergency department in protest for 72 hours after gunmen break into an operating room and kill a patient during a surgery to extract a different bullet. The gunmen also killed the patient’s brother who was waiting in the hospital.

Improving access to health care won’t save money. Nice article in the NY Times about how increased access to medical care increases costs. My favorite quote is a variation of my “Pick Any Two” post:

One of the most important facts about health care overhaul, and one that is often overlooked, is that all changes to the health care system involve trade-offs among access, quality and cost. You can improve one of these – maybe two – but it will almost always result in some other aspect getting worse. You can make the health care system achieve better outcomes. But that will usually cost more or require some change in access. You can make it cheaper, but access or quality may take a hit. And you can expand access, but that will increase cost or result in some change in quality.

And one point on which I differ with the author is his assertion that “The A.C.A. was primarily about access: making it easier for people to get insurance and the care it allows.” The Affordable Care Act was never about access. It was all about insurance. And few if any doctors are willing to accept the miniscule payments offered by government insurance. Health care insurance doesn’t guarantee you health care access any more than auto insurance provides you access to a car.

Occupy Wall Street protester jailed in Rikers Island accuses prison of medical negligence. One inmate with Hepatitis C was reportedly coughing up chunks of her liver before she died in prison.

 

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