 Archive for February, 2009Another ED Waiting Room Death?Sunday, February 8th, 2009I spoke to someone who mentioned that they had heard a news report about a patient who was brought to the University of Chicago emergency department by ambulance, who was triaged, and who then later died in the waiting room. Looked for the story on the internet, but wasn’t able to find anything. Anyone have any other information? Osteoporosis and Compression FracturesSaturday, February 7th, 2009
The more dense the bones, the “whiter” they appear on x-ray. These bones are fairly thin. The lower two vertebrae in the x-ray are a fairly normal height. At the red arrow is a vertebrae that has been “crushed” – a compression fracture. Imagine taking your fist and just pushing down on the edge of a cereal box until it collapses. That’s what happened to the bone. At the green arrow is the result of a kyphoplasty – which involves injecting a bone filler material into the bone to expand it. Kyphoplasties have mixed results as can be seen in this x-ray – the height of the vertebrae hasn’t increased a whole lot. The two best ways to keep this from happening to you are to make sure that your diet includes calcium and to perform resistance exercises (lift weights). In more severe cases, your doctor can prescribe a class of drugs called “bisphosphonates” that will make it more difficult for your body to reabsorb the calcium in your bones. Overcoming BiasFriday, February 6th, 2009I had a patient write me about a problem and ask for advice on how to prevent the problem from happening. The patient has a medical condition – bipolar disorder. The patient has also been to the emergency department a few times and perceives that, once the staff learns that he is bipolar, a bias develops. To quote him,
The patient asks whether the bias really exists (“is there a tendency to immediately give I don’t think that anyone can say they don’t develop some type of bias from a patient’s history. Some instances of bias are worse than others, but they all go back to the healthcare worker’s previous experiences. For example, if a young child is attacked by a dog, that child will have a future fear of other dogs – no matter how friendly the dogs are in the future. Previous experiences have shaped future perceptions. We have one schizophrenic patient who frequently comes to the emergency department for “antibiotics” to get rid of the “infection” caused by his previous interactions with various tadwry women in his life from years past. He believes that he is unable to get their “secretions” (my word, not his) off of his body. So once a month or so he comes in for his antibiotic shot and he leaves after getting a shot of “norMAL sahLEEN” or the really good stuff – “dihydrogen oxide” – which are “normal saline” or “H2O” respectively. And getting those medications helps him. Really. He’s happier. He thanks us, and he goes on his way. But my experiences with that patient do give me a bias when I see in someone’s history that they are schizophrenic. I can’t help wondering – are they going to be like “him”? No matter what I do, that’s the bias that I sometimes start with. When I meet a patient, their actions either refute or confirm any bias that exists. In other words, I may be inclined to think one way, but my mind isn’t set in stone. Be pleasant with me, interact normally, say “thanks, doc” and the bias is gone. Swear at me, pretend that you’re passed out from severe pain, or engage in floor throwing and the bias is substantiated. I guess the bottom line is that I do believe a bias exists toward certain aspects of a patient’s history. I don’t believe the bias is huge, although with some providers – and depending on the complaint - I suppose it could be. How to overcome the bias? Hope this helps. The OutlierThursday, February 5th, 2009I came across this article in the Charleston Gazette about an osteopathic surgeon named John King who went a little overboard filing lawsuits. According to the article, first he sued a state medical board when it took away his medical license, then he sued Putnam General Hospital and other defendants for $72 million when he was kicked off the staff at Putnam General. Then the article states that he filed suits against many of the hospitals that revoked his privileges, stating that these entities “conspired to ‘destroy [his] personal and professional life,’ to intentionally ‘inflict extreme emotional distress’ and to make it impossible for him to be paid for his medical services from Medicare and Medicaid.” Here’s another article on Dr. King’s lawsuits against lawyers who didn’t properly sue his other lawyers for inadequate representation. Maybe a little, shall we say, on the “litigious” side. Something tells me that he wouldn’t have filed as many suits if there was a “loser pays” rule in place, but that’s another post. The thing that raised my eyebrows in the article was that Dr. King allegedly “generated 124 medical malpractice lawsuits while on the staff at Putnam General between November 2002 and June 2003 ….” 124 medical malpractice lawsuits in 7 months? That’s more than one lawsuit every two days. That’s prolly more than were filed against doctors in my whole state during the same time period. Dude (or “dood” if you’re Nurse K), I’m sorry, but if you get sued that many times, you have way more problems than some hospital officials being mean to you and giving you “anhedonia.” Just don’t sue me for writing about you. Then I’d have to hire force Matt to defend me — under ELRALA. UPDATE – ELRALAThursday, February 5th, 2009
WHEREFORE, there is a disparity in the ability of the citizens in this country to obtain legal representation, and WHEREFORE, every citizen in this country has a right to legal representation, and WHEREFORE, a federal law guaranteeing access to legal representation in this country will advance the legal interests of the underserved clients, THEREFORE, BE IT RESOLVED THAT there shall be a new law enacted in this country titled “ELRALA” – the Emergency Legal Representation and Active Litigation Act. The substance of this Act shall be as follows: 1. Any person that “comes to a law office” must receive a legal screening exam (“LSE”). Notes: ———————————————– Hey – the Emergency Medical Treatment and Active Labor Act (“EMTALA”) has been such an overwhelming success in guaranteeing medical care for patients in this country, we really need to expand it so that every person in this country is guaranteed to receive other essential services. Up next: The Emergency Hunger Treatment and Active Thirst Act – “EHTATA” – requiring all restaurants or people owning a stove to provide emergency hunger treatment to anyone that comes to their abodes or places of business complaining of being hungry and/or thirsty. The Emergency Shelter Provision and Active Housing Act – “ESPAHA” – requiring all hotels and homeowners to provide emergency shelter for anyone coming to their abodes or places of business complaining of not having a place to live. Any I’m missing? Boo!Wednesday, February 4th, 2009Can a person really be “scared to death“? Prosecutors are trying to charge a bank robber for murder after he broke into a little old lady’s home and hid there. The little old lady apparently found him in her home and died from a heart attack. Police are trying to say that the cause of the heart attack was “terror” from the adrenaline rush the lady experienced when she found the hiding felon. I’m not buying it. Maaaaybe in theory. Maaaaybe we’ll see this scenario on some future episode of “House.” In reality a prosecutor is going to have a hard time proving beyond a reasonable doubt that an adrenaline rush caused a woman to die. If her heart was that fragile, how do we know that it wasn’t just her walking up the stairs to change the channel to “the Price is Right”? If we’re saying that sudden CNS stimulation is causing sudden death, are coffee cans and Starbucks cups going to have to post a disclaimer that “this stuff can kill you”? Just don’t get rid of my Red Bull. Yes, This IS A JokeTuesday, February 3rd, 2009One of the reasons our ED runs so smoothly is because we’re like a family. There’s very low turnover in our department and there’s a waiting list for nurses who want to work down here. I like to think it’s because of the high quality emergency physicians that work there. Everyone knows how everyone else works and a lot of things get done without anyone even having to ask. We know how to take advantage of each others’ strengths and doing so improves patient care. Even though we’re a great team, just like a family, we pick on each other. My kids do it about their little idiosyncrasies – like purposely changing the TV channel just before Pokemon or Wow Wow Wubbzy comes on (actually I’ll change the channel myself just because I can’t stand that Wubbzy song). One of the nurses has this habit of saying “or whatever” at the end of every one of his sentences. We razz him about that … or whatever. One secretary has been “going to quit” smoking for about 5 years. She catches flak about that every time she puts her coat on for a break. Another nurse has internal temperature regulation disorder and has to keep the temperature in the ED colder than a meat locker. So there are temperature wars with the thermometer. Then there’s the nurse with partial accurate spelling disorder. She’s kind of a recent grad, so she’s still learning the ropes. She has trouble spelling some medications and spelling some diagnoses we commonly use in the ED. She’s already learned not to ask me how to spell things because she never knows if I give her the right answer. Then she gets embarrassed and looks up the words in the medical dictionary. Then she gets ticked off when she can’t find them. Then she gets someone else to ask me how to spell something and hopes that I don’t realize that it is really her that wants to know how to spell it. Doesn’t work. One of the multiple Medical Marijuana Advocates (my pet name for the “Joint Commission”) mandates for “patient safety” is that every time a patient comes to the emergency department, you have to write out a complete medication profile. Now I’m not actually sure that this is an actual Medical Marijuana Advocates mandate, but I can’t look it up online because the only way that you can find their mandates is to buy them. Getting sidetracked. Sorry. So the nurse with partial accurate spelling disorder picks up a patient with low risk chest pain, gets the history, and starts writing out a patient’s medication list. After she had finished, I grabbed the chart and went in to see the patient. The patient brought all of his pill bottles along, and one of them included the over-the-counter supplement at the right. Only the pills at the right weren’t listed as being one of the medications he took. Instead, the nurse had listed some other medication … “Flaccid Oil.” Unfortunately, I can’t actually post a picture of the medication list the nurse had written out because when I walked out of the room laughing, she grabbed the list out of my hand and scribbled out what she had written – once she found out what I was laughing about. But danged if, after checking the bottle, I didn’t have an itch on my arm. When I scratched my arm after handling the bottle, I must have gotten some pill residue on my arm and my arm went “flaccid.” Then I scratched my lip and my lip wouldn’t move. I started having slurred speech. The horror! What would I tell my wife if I had to go to the bathroom? By the end of the day, most of the staff must have gotten Flaccid Oil residue on themselves because everyone seemed to have random episodes of periodic paralysis – arms, legs, necks – every time the nurse walked by. Man that stuff is hard to wipe off. Yep. I love my job and I love the people I work with. If you ever hear giggling in the ED when you’re a patient, chances are that it’s something like this. No, This Is Not A JokeTuesday, February 3rd, 2009The first time it happened yesterday, I thought someone was just pulling a phone gag. Then it happened a second time today. I just don’t get it. Patients call the emergency department and ask the secretaries to call 911 for them. The second time I know it wasn’t a joke because we told the lady to hang up and dial 911, then we heard the call go out on the radio a short time later. When you call 911, the caller is identified by the telephone number. If the ED calls 911, the ambulance would technically get dispatched to the ED (don’t laugh, I’ve heard stories of upset patients in waiting rooms calling 911 for an ambulance transport to a different hospital). Unless you’re like me and you can’t find the number “11″ on the telephone key pad (which is also the reason you should tell children to dial “nine one one” and not “nine eleven”), don’t look up the number to the hospital in the phone book, call the switchboard, get connected to the ED, and then ask us to call the EMTs. Just dial 9-1-1. |
|
Had a patient come in with back pain and obtained an interesting x-ray of the lumbar spine showing what osteoporosis can do to one’s bones.
More Evidence That Tort Reform Works
Wednesday, February 4th, 2009This article from the Dallas Business Journal, quotes the Texas College of Emergency Physicians as stating that the number of emergency physicians increased in 76 Texas counties since tort reform passed in that state six years ago. Almost all of the counties experiencing growth in emergency physicians were previously partially or fully “underserved” for emergency care. In addition, the article states that 22 rural counties which previously had no emergency physicians now have “ER-type assistance” since tort reform was passed.
I won’t fall into the logical fallacy of “post hoc, ergo proper hoc” (“after therefore because of” – i.e. just because the sun comes up after the rooster crows doesn’t mean that the rooster caused the sun to rise), but I do believe it is more than a coincidence that an increase in emergency physician coverage can be added to the list of so many positive changes that have occurred in Texas since tort reform was passed in that state.
Posted in Medical-Legal, News Commentary, Policy | 2 Comments »