Sorry about the site being down most of the day yesterday and today.
Bandwidth issues.
Now corrected.
 Archive for January, 2009Growing PainsSaturday, January 31st, 20092009 Influenza UpdateFriday, January 30th, 2009Think you’ve gotten by this season without getting the flu? Think again. The worst of this year’s influenza season hasn’t hit yet. CDC statistics show that between 1983 and 2008, the peak influenza activity is more than twice as likely to occur in February than in any other month. Most states were starting to see “sporadic” influenza activity in mid-January – the latest data available right now. Google Flu Trends is showing a slow but steady rise in inquiries. It also shows that January and February are typically the most active months for web searches about influenza year after year. It’s almost heeeere… Hope you got your flu shot. Living Where You WorkThursday, January 29th, 2009
I live about 40 miles from a fairly large city. Instead of working in the hospital nearest to my home – which is quite convenient and kind of “cushy,” I choose to make the trip to the city to work in the larger city hospital. Part of me likes the adrenaline rush of being in the action. There’s more to it than that, though. If my neighbor comes in on my shift after being in a major car accident, I don’t want that family’s relationship to me suddenly being forever linked to the outcome of the neighbor’s case – good or bad. I don’t want to repeatedly have to look that family in the eye everywhere I go if I can’t save their loved one. I don’t want there to be a discussion about how good (or bad) my skills are perceived as being every time I see the family in public. Worse yet, I don’t know that I could ever code my own family member if they get brought to my ED. I don’t know how I could get the visions out of my mind if I wasn’t able to save them. Mrs. Dr. WhiteCoat doesn’t have that same philosophy. Mrs. Dr. WhiteCoat learned another lesson while we were at Junior WhiteCoat’s wrestling practice not too long ago. The wrestling team is huge and we don’t know a lot of the parents. While we were sitting down and watching the practice matches, a woman comes in the room, looks around, and sits down next to my wife. No, honey, they’re not taking applications at my hospital and it’s too late anyway – the patients already know you. Me? I’m just the guy who schleps around in jeans and a ratty T-shirt Avoidable Medical MistakesWednesday, January 28th, 2009Emergency Emily sent me a link from Woman’s Day Magazine titled “25 Most Avoidable Medical Mistakes” The article is actually pretty good, although the title is a little misleading. It actually contains 25 “self-help” tips that patients can use to improve their own medical care. Don’t double up on medications, get a living will, keep your personal health records up to date, fight insurance denials, get a primary care physician (if you can find one) are just some of the recommendations. Out of 25, the only one I “kind of” have an issue with is recommendation not to ask for antibiotics for sniffles. The article is very clear about stating that antibiotics don’t work for a cold – even putting the statement in italics. The article also correctly notes that the increase in inappropriate antibiotic use contributes to a widespread increase in drug-resistant bacteria. But it drops the ball when it states that “If you develop a persistent fever, or have discolored phlegm or sinus pain, you probably need antibiotics.” Discolored phlegm and sinus pain may be signs of sinusitis or they may not. But even if you have a true “sinus infection”, antibiotics are not proven to help. Bust out the nasal decongestants and nasal washes. The comment section to the article also has some other good ideas, including having a “patient advocate” if you are hospitalized. Unfortunately, some of the other comments to the article also show how far the respect for the medical profession has fallen in the public’s view. Sad. Picture BreakTuesday, January 27th, 2009This post has nothing to do with medicine. Photography is one of my hobbies and, while surfing, I came across a picture of the inauguration that I had to pass along. From this article at CrunchGear.com, check out this 1.5 GIGApixel picture of Obama’s inauguration speech. That’s 1500 MEGApixels. It isn’t as impressive until you begin to zoom in. Then zoom in some more. Then some more. Amazing. Can you find Bruce Springsteen? Rush Limbaugh? Then check out George HW Bush’s stylin’ tuque. Then there are a couple of more boring pictures from my humble abode. You know it’s cold out when you open up the refrigerator in the garage and you see this:
At least the Red Bulls are safe. I’m leaving the clean-up until Spring, dammit. You Get What You Pay ForMonday, January 26th, 2009An article in yesterday’s Los Angeles Times titled “Pediatric care shrinks across California” shows that as funding for pediatric care has decreased in California, so has the number of hospitals that are willing to provide pediatric care. California’s reimbursement rates for children’s health care is ranked last in the country. It shouldn’t come as a shock that more and more hospitals are focusing on treating adults – because they get paid more for doing so. In the last decade, the number of children in California has increased, but the number of inpatient pediatric beds dropped by 19% – more than 800 beds. Sixty five hospitals either eliminated their children’s units or shut down altogether. The article states that “most counties north of Sacramento now lack even a single dedicated pediatric bed.” What happens when your child becomes severely ill and there are no pediatric ICU beds within several hundred miles? LA County – USC Medical Center dropped from 135 pediatric beds 2 years ago to just 55 beds now. There is now a question as to whether the LA County will be able to provide care for the 7,000 foster children treated annually at the Medical Center. The cuts may also affect pediatric training programs. The hospital now reportedly has the smallest university-affiliated pediatrics teaching program in the nation. The LA County Supervisor states that the program will become “noncompetitive to intern applicants except the poor performers from low-ranked medical schools.” One parent who brought her child to a hospital emergency department with no licensed pediatric beds describes waiting for 11 hours for her son to be seen and then noted that the medical providers “seemed unaccustomed to treating infants and had difficulty inserting an IV.” A Stanford children’s health policy researcher was quoted as saying “In California, things are a mess”. Once the balance billing issue takes full effect and emergency physicians are paid even less for the care they provide, I predict that medical care in California will be an even “bigger” mess. Is everyone starting to get the idea that you get what you pay for? Death By “Unvaccination”Monday, January 26th, 2009
There were five kids diagnosed with the disease last year and one 7 month old died from the disease – the first death from the disease in Minnesota since 1991. The article noted how Hemophilus influenza is “a disease that had been nearly wiped out across the United States after a vaccine that is given to babies in the first months of life was introduced in the early 1990s.” This CNN article also notes that “Before vaccines became widely used, about 20,000 HiB cases were reported each year in the country. After children began receiving the vaccinations in the early 1990s, CDC officials said, there was a 99 percent drop in cases.” Yup, you guessed it. Three of the five kids, including the 7-month-old who died, “had not been immunized because their parents did not want them vaccinated.” One of the other kids hadn’t received all doses of the vaccination, and the last child had an immune deficiency – making it less likely that the immunization would work. Should parents who fail to take steps to prevent a largely preventable illness be held accountable if their children suffer a bad outcome? As an aside, does anyone know the specifics of the “religious exemption” that some parents use to avoid vaccinating their children? Isn’t that kind of like stating that my religion prevents me from paying taxes? The Art of IntubationSunday, January 25th, 2009Perusing other blogs and came to this entry on the Trauma Bay where an EM resident was describing how difficult it can be to intubate patients. During his first rotation in the operating room, he had a success rate of 9 for 13, or 69%. The post made me think and it made me laugh. As our country transitions toward non-physicians in the emergency departments, will the lack of training in certain procedures cause an increase in morbidity or mortality? The flip side is that even some attending emergency physicians aren’t that good at intubating. That’s what made me laugh. I had to deal with one of those attendings once. One of the attendings I worked with was a solid doc, but he couldn’t intubate for nothing. If a patient needed intubation, he called anesthesia. Oh, he’d try to get the tube in, but he hit the esophagus 95+% of the time. Would have been a great gastroenterologist. Everyone razzed him about it. Even people who had no idea what it meant to “intubate” someone. They just knew they could get under his skin about it. Sometimes he would snap and start screaming at people. Finally it caught up with him. A family and a new EMT both complained about him to hospital administration in the span of a week – both about him not being able to intubate. I drew the short straw and had to figure out a way to diplomatically tell him that he needed to get some remedial training. So one day when I relieved him on a shift, I told him I needed to talk to him about someting and brought him back to the doctor’s room. I went out into the ED to start seeing patients. He caught me off guard this time. I started plotting a way to record his next tirade – next time I would be expecting. That way everyone could laugh about it. Maybe I’d even put it up on YouTube. Ten minutes later, he comes out of the doctor’s room eating an apple and nonchalantly says – as if nothing ever happened – “So you know when next month’s schedule is coming out?” Lithium works well for bipolar disorder, bud. Unfortunately, he didn’t stay with the hospital long enough for me to ever get him on video. Identification GameFriday, January 23rd, 2009For those of you with good visual skills, see whether you can identify these objects. First, what’s this?
. . Answer: That would be close-up of a kidney stone. . . . . . . Now what’s THIS?
. . . Answer: That would be a close-up of a stone at the UV junction. . . . . This was e-mailed to me in a long line of forwarded e-mails, so I do not know to whom to credit. Whoever you are, you’ve got a great sense of humor. . . . . P.S. All the scattered “dots” are for formatting. For some reason, WordPress mangles this layout when I try to do it without the dots as placeholders. |
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I have this philosophical thing about not living near where I work.
An 
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No Health Care
Saturday, January 31st, 2009Three recent published articles about the health care crisis caught my attention while surfing the internet.
First, in the article “Forget good; any doctor is hard to find,” a mother laments because she has to drive all over the Coachella Valley in California to find a doctor to evaluate her 2 year old child with a cough. After going to four different providers, she finally went to the emergency department and was seen by a PA because “a good doctor is hard to find.”
I sympathize with her, but if you read the article, it wasn’t that she couldn’t find a physician to see her child (although a couple of the clinics she went to didn’t see children under 3 years old). The problem was that the physicians that *were* available didn’t take her insurance and she didn’t want to pay out of pocket. The article did not say what type of insurance she had, but my guess is that the insurance was MediCal. Given the low payments MediCal makes to physicians, fewer and fewer physicians are willing to accept it. This mother’s ordeal just highlights the fact that universal coverage doesn’t mean much if no one takes your insurance. Kind of like having $10,000 worth of Japanese yen in your pocket and trying to buy a hoagie in downtown Pittsburgh with them.
Another article that caught my eye was from Canada, where protesters were planning a sit-in at a hospital emergency department because the hospital will longer perform emergency surgeries and will instead ship the emergency cases to another hospital across town. If there is no incentive to provide emergency surgeries, then it is difficult to force a hospital to continue performing them. The article also notes that several other hospitals in the area have already stopped performing emergency surgeries – also deciding to ship them to different facilities. As fewer and fewer facilities perform emergency surgeries, more and more emergencies will pile up. At some point it will be a case of “when everything is an emergency, nothing is an emergency.” Think that care will be good?
But at least the care is free … right?
Then finally was the article from Florida’s Gainesville Sun, titled “ER care for kids ‘stinks’“.
Fewer and fewer specialists are willing to take call from the emergency departments and there is difficulty finding emergency specialty care for children. The unfunded federal mandate EMTALA is backfiring. If you’re an “on call specialist”, EMTALA requires you to provide emergency stabilizing treatment for any patient that needs your services – even though many patients needing emergency services will never pay their bill and can sue for millions of dollars if the care they receive is not deemed adequate.
So specialists just stop taking emergency calls. Now emergency physicians treating people with emergencies scramble to find emergency specialist care when in some subspecialties, there is little or no emergency care nearby. Neurosurgery, obstetrics, and psychiatry are just a few of the specialties in very short supply in some states.
In trying to legislate “perfect” and “equal” care for all, now more and more people are finding that there is “no” care for anyone.
Posted in Funding Crisis, Health, News Commentary | 28 Comments »