May 24th, 2013
New study shows that emergency department workers are on Facebook quite a bit. They spend an average of 4.3 minutes per hour on Facebook during day hours, which is just under an hour out of every 12 hour shift. However, during night shifts when the study hospital was busier, the staff spent an average of almost 20 minutes per hour — just on Facebook.
So are the results good news based on other studies showing that engaging in brief mindless tasks decrease worker fatigue and stress while increasing worker productivity and happiness? Or are the results bad news suggesting that patients aren’t getting full attention?
I also wonder about how the study determined active use of Facebook. Researchers set limits of 3 minutes for each interaction with Facebook, so someone checking their status for a few seconds would have been deemed to have spent 3 minutes on Facebook, as would someone who surfed Facebook for the entire shift. My guess based on my observation of computer use in my emergency departments is that the methods caused the times of use to be overestimated.
And the study also reminds us of another important point … when you’re on a work computer, what you’re doing is being watched.
May 15th, 2013
More HealthCare Updates from around the web are at my new digs at http://drwhitecoat.com.
“Dear ER staff. Our friend is drunk. Fix him.” Unconscious Arizona college student who was “turning blue” left in hospital lobby with Post-It note stuck to his body after losing “drinking contest” at frat house. Nice friends.
If you decide to follow the link, turn down the volume on your computer. Gannett’s KSKD.com has an auto-start video ad that will blow your ears out.
Irish emergency department so crowded and busy that it has to pull an ambulance up to the front door to act as an extra resuscitation room for a patient. To be fair, there were five patients all needing resuscitation at the same time. I actually think that the doctors were pretty resourceful in coming up with the idea.
Nice article on how University of Michigan is decreasing medical malpractice expenses by disclosing errors and compensating patients before lawsuits are filed. Open claims have declined to 63 from 262. Lawsuits have declined to 0.75 per 100,000 patients per month from 2.13. Claim resolution time also has declined to 0.95 years from 1.36, costs to defend lawsuits have dropped to less than $1 million per year in 2009 from $2.2 million in 2001, and the amount needed for reserves has fallen to less than $16 million in 2009 from $72 million in 2001.
They seem to be on to something.
Nice article in the Atlantic about the decline of emergency care. Emergency department visits have increased by 44% while emergency departments have closed at a rate of 11%. In addition, 339 trauma centers have closed. A 10% increase in the number of African Americans treated correlated with a 41% increased risk of the emergency department closing.
If you’ve got nothing to do for a few hours, you can read the 4951+ comments on Reddit that were posted after an emergency physician offered to answer any questions that the readers might have.
The UnAffordable Care Act may leave cancer patients requiring “specialty drugs” with a hefty bill. Some states will require patients to pay up to 30% of the cost of their medications – which could total thousands of dollars each month.
Wisconsin hospital offers machine that dispenses prescription medications. Bad news is that patients need a credit or debit card to pay for the medications … no cash allowed. In addition, you have to visit the hospital’s own ED or acute care clinic – no other prescriptions work in the machine.
Interesting social experiment in New Zealand proves the obvious. Patients don’t use the the emergency department because they can’t afford to see a primary care physician – they use the emergency department because it is convenient. Patients were eligible to receive vouchers to obtain free appointments with primary care physicians for non-urgent complaints. Not one voucher has been handed out this year.
There was a wide belief that people used the emergency department because it was free, but the “clinical head” of the ED stated “that’s probably not as strong as a driver as you might think.”
Bullhokey. Institute a $20 co-pay for each emergency department visit and see how quickly ED patient volumes decrease.
May 7th, 2013
More HealthCare Updates from around the web are at my new digs at www.drwhitecoat.com.
Annals study shows clinical signs that necessitate admission in patients with ALTE (when newborns appear to stop breathing): “obvious need for hospitalization (they used persistent hypoxia as one example of this), significant medical history, and more than one ALTE in 24 hours.
Dual energy CT scan can diagnose knee ligament tears more effectively in the emergency department.
Is it necessary to definitively diagnose ligament tears in the emergency department, though?
And how long will it take until government officials blast doctors for ordering these tests?
You know all of those hospitals that advertise their emergency department wait times? Now those ads may end up biting hospitals in the rear. Nevada patient chooses hospital based upon advertised average wait time of 17 minutes, then waits five and a half hours before getting treatment. Newspapers publish statements suggesting that the signs may be “false advertising.”
Will consumer fraud cases against hospitals based on these advertisements be too far behind.
Florida House tries to improve medical malpractice environment by passing bill that would require experts to be in the same specialty as the physicians about whom they are testifying and that would allow ex parte communications between lawyers and a patient’s treating physician.
I still wouldn’t practice medicine in Florida.
Conditions at California’s Contra Costa Regional Medical Center are endangering patients according to the emergency department staff. Examining patients in the lobby and behind screens in the hallways are alleged as the emergency department is seeing twice as many patients as it was designed to accommodate.
So what do hospital administrators do in response? They hire a consultant to tell them the same things that the staff is already telling them.
What? Did you expect rational thinking?
Hospitals finding that they can cut costs by catering to emergency department “superusers”. For example, homeless patient Dennis Manners was treated in the emergency department 337 times in less than two years, amassing charges of more than $626,000. The hospital found him an apartment, assigned him a primary care doctor, and enrolled him in a drug treatment program.
I think that what the hospitals are doing is great, but why should this financial burden fall on the backs of private enterprises when government should be providing the services for its citizens?
Social media strikes again. Picture from Cumberland Infirmary in England shows that the hospital isn’t meeting the government targets for patient throughput.
May 1st, 2013
For those of you who don’t know what alarm fatigue is, think of a car alarm. The first time you hear it going off, you run to your window to see who’s breaking into a car. Maybe you run to the window the second time and the third time, too. By the tenth time the alarm goes off, you’re thinking that the alarm is broken and someone needs to get that fixed. After about thirty false alarms, you’re feeling like going out there and busting up the car yourself – especially if the car alarm wakes you when you’re asleep.
So alarms can be good, but if there are too many “false positives” – in other words if they go off too much when nothing is wrong – people tend to become tired of listening to them and eventually ignore the alarms. On the other hand, if there are too many “false negatives” – meaning that they don’t go off when something is wrong – then the alarms aren’t fulfilling their purpose.
The same problem holds true for multiple types of alarms. Think about virus alerts on your computer. If they are set to alert you about everything, the first few times you freak out, then, after investigating, you dismiss them. If they alerts keep occurring too often, eventually you figure out a way to disable them. If the alarms don’t alert you when a virus is trying to hack into your computer … then what good is it to have the software?
With electronic medical records, medical providers are often alerted to multiple types of medical problems with each patient. No recent tetanus shot. Haven’t asked whether the patient is abused at home. No allergy information available yet. Time that patient was first evaluated not entered. Did you review vital signs? The list seems endless sometimes. Some of these alerts are useful. Most just serve to document some government mandated question that we must answer in order to receive payment for billing or to look like we provide better care on some database that only hospital administrators and reporters ever look at.
It was busy as heck during a shift and I kept getting knocked off task by alarms which are supposed to be helping us. A patient is having an acute heart attack. I try to put in orders for basic treatments and labs. Once I get logged into the patient’s chart, that takes a minute or so. Then, before the system will accept the orders, I get the alerts.
“No medical allergy information had been entered for this patient. Medication orders will be canceled.” The only button to hit is “OK” on that screen. Well, he’s a new patient. So I have to spend another few minutes clicking through a dozen or so screens to tell the computer that the patient has an allergy to sulfa drugs (causing him to have an upset stomach) and to iodine (which gave him a “warm” feeling when he received dye for a CT scan once).
Phew. Close call.
Then I spend another few minutes re-entering all of the medications I want the patient to receive. I have to enter all the medications by hand now instead of clicking on the boxes since the computer system won’t let me enter the same “order set” twice on the same patient.
First, let’s give the patient some aspirin. Everyone knows that’s an important treatment for patients having a heart attack.
Alarm. Now I have to go through a few more screens and enter my password to confirm that I dare to give aspirin to a patient who gets an upset stomach when he takes sulfa medications. Where the connection is … GOK.
Well, I’ve dodged that bullet. Now let’s start an IV so that we can give him some IV fluids and have access to give him other medications if he needs them.
Alarm. Now I have to go through more screens and enter my password to confirm that I dare to give salt water to a patient who felt warm after receiving CT scan dye. Where the connection is … GOK. Salt water contains three things: sodium, chloride, and water.
Now that I’ve averted that disaster … oh yeah, the patient has a history of GI bleeds and was pretty anemic last time he was admitted to the hospital. Let’s get a type and screen on him too, just in case he needs blood.
“Reflex order: Blood transfusion.
“How many units of blood will patient receive?” Um … zero. We’re just doing the preliminary stuff if he should need blood.
“Should patient receive Lasix with blood?” Um … no. We’re not transfusing him yet.
Nevermind. Cancel the blood. Cancel. Cancel. Cancel. Yes, I’m sure I want to do that. Confirm.
OK, now let’s … wait a minute. Where was I? Oh yeah. Trying to take care of the patient having a HEART ATTACK.
In creating a “safe” environment for patients, the medical records have delayed me from providing necessary and time-sensitive care to a patient.
Now imagine going through the same or similar scenario multiple times each shift. Every shift.
Ready to go bust up someone’s car yet?
April 23rd, 2013
More HealthCare Updates from around the web are at my new digs at www.drwhitecoat.com.
Diagnostic errors account for most paid claims in medical malpractice cases. Errors in diagnosis were the most common type of claim and also amounted to the highest proportion of total payments. The total inflation-adjusted amount of diagnosis-related payouts was $38.8 billion over 25 years.
Remember, these statistics represent just the payouts. On average, two of three medical malpractice lawsuits end in no payment to the plaintiff.
And we still wonder why doctors do so many “unnecessary” diagnostic tests?
Missing bamblance. University of Virginia is on the lookout for a stolen ambulance after the driver left the ambulance unlocked with the engine running.
Another missing bamblance. This one was from University of Alabama Birmingham ED ramp. The ambulance company executive said that it “wasn’t clear how or why someone took the vehicle.”
How – The driver obviously left the keys in it.
I agree with him on the “why” part.
Ex-boyfriend kidnaps patient from hospital room. Waited until she was called back to the treatment area from the waiting room, then stuck a gun in her ribs and made her leave.
I can’t make this stuff up.
Another application of federal EMTALA law. Everyone coming to the emergency department must be evaluated and treated – even if they just bombed the Boston Marathon.
Cases like this come up every once in a while and it is very difficult for the emergency department staff to set aside their feelings.
Another story on the topic here
Surgical complications good for a hospital’s bottom line. With insured patients, hospitals made an extra $39,000 per patient who had post-surgical complications. Medicare patients with post surgical complications earned the hospital about $1750 more. Hospitals lost money on Medicaid and private pay patients with post-op complications.
Don’t believe people who try to draw the conclusion that “errors” and “complications” are the same thing – they aren’t.
April 17th, 2013
Interesting issue brought to my attention by a reader in South Carolina.
One of the hospitals in South Carolina wanted to post a sign in its emergency department waiting room stating the following:
Prescribing Pain Medication in the Emergency Department
Our Emergency Department staff understands that pain relief is important when one is hurt or needs emergency care. However, providing pain relief is often a complex issue, especially when pain is a chronic or recurrent process. Mistakes or misuses of pain medication can cause serious health problems and even death. Our Emergency Department will only provide pain relief options that are safe and appropriate.
• The primary role of the Emergency Medicine provider is to look for and treat an emergency medical condition. We will use our best medical judgment when treating pain, following all legal and ethical guidelines.
• You may be asked about a history of pain medication use, misuse, or substance abuse before prescribing any pain medication.
• We may ask you to show a photo ID, such as a driver’s license, when you check into the Emergency Department or receive a prescription for pain medications. We may also research the statewide prescription data base regarding your prescription drug use.
• We may only provide enough pain medication to last until you can contact your doctor. We will prescribe pain medications with a lower risk of addiction and/or overdose when possible.
For your safety, we do not:
– Give pain medication shots for sudden increases in chronic pain, or aggravation of chronic pain syndromes.
– Refill lost or stolen prescriptions for medications. You must obtain refill prescriptions from your primary care provider or pain clinician.
– Prescribe missed methadone doses, or provide prescription refills for chronic pain management.
– Prescribe long-acting pain medications, such as OxyContin, MSContin, fentanyl patches, or methadone for chronic, non-cancer pain.
– Prescribe pain medications if you already receive pain medication from another doctor or emergency department.
The Centers for Medicare and Medicaid Services (CMS) had a different take.
EMTALA requires that every patient seeking care in the emergency department receive a “screening exam” and then receive “stabilizing treatment” of any emergency medical condition. In other words, if you are having a heart attack, the emergency department is required to stabilize you regardless of your ability to pay. If you have a runny nose or other non-emergency condition, the emergency department still has to examine you, but then doesn’t have to treat you. In either case, the hospital isn’t allowed to discourage you from seeking care.
CMS therefore wrote a letter to the South Carolina Hospital Association [.pdf flie] and advised it that hospitals displaying such a sign would likely “unduly coerce[ patients with legitimate medical needs] to leave the ED before receiving an appropriate medical screening exam.” Therefore, CMS considered such signs as potentially constituting an EMTALA violation.
I disagree with a lot of things about EMTALA. It is an unfunded mandate. Its reach has progressed far beyond the initial intent of the statute. But unless and until we repeal it, we are stuck with it.
I’m interested in your opinion, though.
Should a sign like the one above be considered an EMTALA violation?
Is it any different than hospitals that advertise their wait times? After all, a patient with an emergency medical condition may see the advertised wait time as being too long and might not go to a hospital because of it.
Vote below and leave a comment.
April 15th, 2013
See more HealthCare Updates from around the web at my new digs at www.drwhitecoat.com.
More of a free market approach to medical care. Australian private hospitals noting a large uptick in emergency department patients as patients opt to pay for emergency services rather than wait for care at the public hospitals. Some emergency departments are recruiting highly regarded specialists to further increase patient demand for services.
Another article about Australian medical care. Patient goes to hospital complaining of the “worst headache of his life.” In many cases, that translates into doctor speak for “order a head CT scan to rule out bleeding”. The patient had a head CT nine days before going to the emergency department which showed the presence of an aneurysm. He was discharged from the emergency department and died the next day.
More arrests for oxycodone prescriptions. In this case, a physician wrote prescriptions for more than 500,000 pills over 2 years. The prescriptions were filled in New Jersey – even though they were written in New York. Other allegations surfaced as well.
The investigation was sparked by an overdose death where a prescription bottle bearing the doctor’s name was found at the scene.
More Unaffordable Care Act follies. Smoking is considered a “pre-existing condition” under the Act and smokers therefore can’t be charged higher rates than non-smokers for insurance. Which means that non-smokers will be charged even more to cover the cost of treating smokers.
I’m getting the impression that the government wants the insurance industry to fail.
Get your healthcare now while you still have insurance, folks.
“Sounds good my man, seeya soon, ill tw …” The University of Northern Colorado student sending this text message never got to finish it. He was driving while texting, drifted into oncoming traffic, jerked the steering wheel, and rolled his car. He died from the resulting injuries.
His parents published pictures of his phone with the message hoping that they can keep others from texting and driving. I hope that every parent prints this article and discusses it with their children.
April 12th, 2013
So much to rant about today.
The girls are doing a dance competition this weekend. I’m trapped in my own little version of Dance Moms. Aaaaauuuuuggghhh. Somebody help me. One daughter complains because she’s in the back of one dance the whole time. Another daughter is upset because people are mad at her because she’s in front during one of her dances. Glitter is all over our fricking kitchen and it doesn’t come up with wet wipes, either. We have to purchase hair extensions with curls for $25 for the girls, and we have to make SURE to purchase the color that most closely matches the girl’s hair. We can’t just curl the girls’ hair because judges can apparently tell the difference between real curled hair and fake curled hair and that makes a difference on how they grade the performance. Sounds like a Joint Commission inspection.
I just keep thinking that they couldn’t pay me enough to participate in a reality show based on this crap.
Junior WhiteCoat is ramping up lacrosse season. He’s loving it. Playing in a huge tournament at Notre Dame next weekend. Junior was also one of the main characters in a movie that won first place and multiple other awards at an indie film festival last week. He’s now getting requests for auditions with some bigger movies. Hear that, Adam Sandler? Pick him and your movie could grace the pages of WhiteCoat’s Call Room.
On the doggie chew list for the past week include a Jenga block, a decorative pillow from the couch, a garbage can in the office, the leg from a “Monster High” doll (since when did it become cool for young girls to go from modeling themselves after Barbies to modeling themselves after zombie high school kids, anyway?), and the middle of her doggie bed. The last one is most interesting. You see, she’s chewed half of the inside out of her own bed and now she no longer wants to sleep on the bed. So when it gets dark out, she runs upstairs to the bedroom and lays on the other dog’s bed before he gets there. That means that the innocent dog is stuck sleeping on a disaster of a dog bed that he had no part in creating. After the first couple of times that happened, I started moving the doggie garbage disposal off the good bed and letting our other dog lay on his bed. By the morning, though, there was more foam filling sitting on the floor, Chewmeister was laying on the good bed, and our other dog was laying on the floor. I’m getting to the point that I’m going to start making little Chewy sleep in a cage … on her own frigged up bed.
Then I thought to myself … those beds are a lot like, say California and Texas right about now. Read the rest of this entry »
April 11th, 2013
A young lady comes to the emergency department and wants to be evaluated for a … somewhat nonurgent … problem.
Chief complaint: “I’ve lost 50 lbs in the past month.” She felt a little weak as well, but she had just lost too much weight. No other symptoms.
The patient weighed 132 pounds. Her skin wasn’t sagging. Her jeans didn’t appear to be new and they seemed to fit pretty well. Nothing about her seemed abnormal on exam. But she insisted that she weighed 180 pounds just a month earlier.
No old records in the computer.
I asked her if she could show me a recent picture of herself on her iPhone. She briefly stopped texting to check, but she couldn’t find any.
I asked her to show me her drivers license. Nope. Didn’t have that, either.
I was quickly developing an opinion that this was a snipe hunt.
Snipe hunts like this are an example of another conundrum that many physicians face.
We are often expected to prove a negative.
Clinically, I can say that the patient did not appear to have lost 50 lbs in the past month. I can even say that it is unlikely [although not impossible - don't comment with all your weight loss feats] that any patient could lose 50 pounds in a month.
But what if …?
What if the patient had cancer that caused some type of weight loss and I didn’t evaluate her for it? What if the patient had a bad outcome from a metabolic problem that I didn’t screen for?
What if, as a result of weight loss, the patient had developed an severe electrolyte abnormality or other blood abnormalities?
Retrospectively, if the patient suffered a bad outcome, it would be easy to allege that weight loss is an obvious symptom of [insert bad outcome here] and that Dr. WhiteCoat was careless because he didn’t evaluate the patient for this problem.
I suppose that the same issue holds true for a febrile child. If a three year old with a runny nose had a fever of 102 at home, but looks fine and is afebrile in the emergency department, he’ll probably get a pass on the workup. But if an afebrile 27 day old infant reportedly had a fever of 102 at home, get the lumbar puncture tray ready.
A physician must have a certain degree of risk tolerance in choosing whether or not to do testing to evaluate an odd complaint, but where should we draw the line between “necessary” and “unnecessary” workups?
And in case you were wondering, yes, I did labs and a chest x-ray on the incredible shrinking woman. She was anemic. Her hemoglobin was 10.5. Not enough to hospitalize her, but enough to recommend that she follow up with the on-call physician for a more thorough weight loss/anemia evaluation.
I’m going to be eating my words if she comes back next month weighing 80 pounds.
April 10th, 2013
Second time in a week.
The first episode, the patient from the assisted living facility came in with sharp anterior chest pain. She said that she was sleeping and woke up with sudden onset of pain. When she opened her eyes, her roommate was standing over her with a crazed look in her eye. Sticking out of her right breast was a ball point pen. Fortunately, the injury was to adipose tissue only and didn’t require any surgical intervention.
On her most recent visit, the same patient returned after waking to her roommate’s friend beating her with a cane. She tried to fend off her attacker and fell to the floor where the friend repeatedly pounded her in the stomach with said cane. She had a lip laceration and multiple bruises to her abdomen.
I feel so bad for this patient because she’s doing nothing wrong and getting beaten in her sleep. It’s not like a loan shark is trying to collect on a debt or anything like that.
Definitely time to find a new roommate.
Or a new facility.
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.