 Archive for May, 2009You’re Full of …Wednesday, May 20th, 2009Literally. See for yourself.
Newest Crime: “DWT”Monday, May 18th, 2009
The picture at the right was taken of the driver in a delivery van that swerved over the midline – in the rain – while I was driving down the street behind him. We got to a light and he has his little phone in his hand texting away. Then, an aunt of mine (by marriage) and three people in her vehicle, including the 17 year old driver, were recently killed in a terrible car accident. Two others in the vehicle survived with serious injuries. They were traveling late at night and initially police thought that the driver fell asleep at the wheel. After speaking with one of the survivors, they discovered that she was trying to send a text message to a friend while driving down the road at 70 MPH. I’ve seen my share of serious injuries in the ED resulting from accident victims doing the same thing. On a news feed that I get, one of the articles this morning was about how the Missouri legislature just passed a bill outlawing those 21 and younger from “Driving While Texting” or “DWT.” The comment section to the article has many people arguing that there is too much government regulation already. One commenter writes “What’s next? Picking your nose, eating a cheese burger, changing cd’s, maybe even yelling at your kids? And don’t you dare look at the navigation unit that comes from the factory installed on your car!” Some argued that the law needed to be expanded to everyone, not just those less than 21 years old, while others argued that such a law would be unenforceable. It’s tempting to say that if people who “drive while texting” die or are maimed in a car accident, their injuries are “punishment enough.” Those sentiments don’t take into account the financial toll that their medical care takes upon the families or the government. Nor do those sentiments account for the injuries that distracted drivers cause to other parties when they broadside a minivan because they’re too wrapped up in their text messaging. For crying out loud, if you’re going to communicate while driving, just call someone already. Hey BFF … the close up view of a tractor trailer bearing down on your windshield at 70 MPH isn’t a “LOL” moment … U KNOW? The Magic Band-AidSaturday, May 16th, 2009It isn’t hard to tell when a child is scared in the emergency department. Most little kids aren’t too fond of doctors to begin with. To many of them, the terms “doctor” and “shot” are synonymous. They clutch onto their parents when you walk in the room. They cry when you get close to them. Doesn’t matter how much you smile or talk nice to them, a lot of the time little kids want nothing to do with you. One such 4 year old tyke in “Incredible Hulk” slippers was carried in by his mother after slamming the tip of his middle finger in a door. The mother kind of freaked out when it bled, but fortunately for the kid, the door just clipped the very tip of his finger. Small piece of skin ripped off, but nothing needing stitches and no broken bones. Convincing the kid of this was another story. He had his finger wrapped in gauze and had his hand buried underneath his opposite armpit. He was using his good hand to clutch his mom’s arm and sweater for dear life. “Can I take a look at your finger?” I asked. He just grabbed onto his mother more tightly and started to whimper. Ahhhhh … progress. “OK, you take the bandage off so I can look at it. I don’t want to hurt you or anything.” As I was explaining discharge stuff to the mom and washing my hands, the nurse walked in the room to see what was happening. “Hey, show the nurse your magic Band-Aid,” I told him. What other job lets you turn a scared kid into a stand-up comedian in the span of 5 minutes? I’ll probably get a call from administration about it when he flips off his dad or some pre-school teacher, but it was worth it. What Do Hypertension and Ulcers Have In Common?Thursday, May 14th, 2009Answer: They were both thought to be due to “stress” at one point, but were later linked to infectious processes. Most ulcers are now known to be caused by Helicobacter pylori, or H. pylori for short. Now a new study in the Public Library of Science shows that hypertension may be caused by cytomegalovirus infections. CMV apparently increases inflammation in the blood vessel walls and increases the secretion of both renin and angiotensin II – both known to contribute to hypertension. CMV infection plus a high cholesterol diet also caused atherosclerosis in the aorta while CMV infection without high cholesterol did not. Any pharmaceutical company that has a hypertension medication on patent is not going to be happy about this study. Then again, Roche stock is probably going to make a nice little jump as Roche makes ganciclovir and valganciclovir – both medications used to treat CMV. Roche also makes a little-known drug called Tamiflu. Wouldn’t it be wild if all the hypertensive medications were rendered useless by an antiviral drug? I’d be interested to see whether HIV patients on chronic treatment for CMV retinitis are any less likely to have hypertension. Additional news stories from: How To Make A Nurse Jump A DeskWednesday, May 13th, 2009I was actually being serious for a change. An elderly patient came in with abdominal pain. She was put on the cardiac monitor and we drew labs. Then I went in to examine her. I pressed on her stomach and she had a little pain. Didn’t feel any masses. Then I put my hand on her stomach and jiggled it a little. All of a sudden, the monitor beeped then a tech and two nurses busted through the door panting. Each one had a look of shock that was more dramatic than the next. “Damn you, WhiteCoat!” They all yelled in unison. I shrugged my shoulders and finished my physical exam. When I walked out of the room, they threw an EKG strip at me and then mimicked me “What did IIII do?” Have to admit, shaking the patient’s abdomen to check for rebound tenderness did make the middle of the strip kind of look like this or even this. But I really didn’t mean to do it … this time.
Ten Years In the Greybar MotelTuesday, May 12th, 2009Dr. Phil Astin pleaded guilty to a 175 count federal indictment against him alleging that he indiscriminately prescribed multiple pain medications and other narcotics to known addicts for years. According to the indictment, “at least two of Astin’s patients died because of his lax oversight of what medicines they were taking.” One of Dr. Astin’s patients was Chris Benoit, the professional wrestler who murdered his wife and child, then committed suicide in 2007. Today, Dr. Astin was sentenced to 10 years in prison. The federal investigation into Dr. Astin’s practice discovered that he often wrote prescriptions without conducting physical exams, gave multiple simultaneous prescriptions for strong pain medications, and prescribed combinations of multiple pain medications that would have an additive effect such as Percocet plus Oxycontin plus Vicodin. Many of the prescriptions were deemed not to have been written for “legitimate medical purposes.” Most doctors would agree that practices such as those above are inappropriate. But there are exceptions. And sometimes it is difficult to draw the line between what is “legitimate” and what is not “legitimate” for pain management. In the hearing on Dr. Astin’s sentencing, U.S. Attorney David E. Nahmias made the statement that Dr. Astin engaged in “illegal drug dealing.” Then there was Assistant U.S. Attorney John Horn, who, according to this article, reportedly made the idiotic statement that “Medical doctors know that after a period of time, if the prescriptions are not working, you get them off.” “Sorry, ma’am, I know you have advanced metastatic bone cancer and your progressive pain is not being controlled by your Duragesic patches and Percocets, but because Assistant US Attorney John Horn says so, I have to “get you off” all your medications so you can die in agony. Wouldn’t want to go to prison, you know.” The whole case brings up a difficult ethical issue. On one hand, some bad apples are prescribing narcotics for fun and profit. On the other hand, some patients really need large doses of pain medications to control their pain. If the facts of the case are as stated in the news articles, Dr. Astin deserved a harsh penalty. I can’t comment on the whole prison thing other than to mention that if you think doctors practice defensive medicine to avoid lawsuits, watch and see what happens if they think there’s a possibility they could go to prison for prescribing pain meds. I continue to believe that we need to do a better job policing physicians that prescribe medications in the manner that Dr. Astin did. Part of the problem lies in oversight. How is it that the feds have to wait for someone to die before they investigate a physician that is prescribing medications in this manner? If federal investigators can get the prescription records years after the fact, they can get them shortly after the prescriptions are written and/or filled. The DEA and/or state licensing boards should be more proactive in this regard if there are concerns. On the other hand, when everyone hears some ill-informed statement like that made by John Horn, what effect do you think will have on doctors being willing to prescribe pain medications for patients who are in legitimate pain? WhiteCoat Challenge #4Monday, May 11th, 2009Had a lot of fun with previous Whitecoat Challenges. Links are here, here, and here. My latest idea for this challenge got put on hold after a comment made by a little old lady not too long ago. She told the nurse that she was taking “peanut butter” to help stop her seizures. I’ve heard a lot of malapropisms over the years. ERP posted several good ones last year on his blog at ER Stories. So give me the best ones you have heard – from patients, friends, family members. Three best responses as chosen by EP Monthly editors will get their choice of any of the products at EP Monthly’s Online Store. Challenge winners announced Monday, May 18. UPDATE MAY 20, 2009: WINNERS Honorable mentions get a free EP Monthly coffee cup and are Please drop an e-mail to info@epmonthly.com to arrange to get your prizes. Thanks again to everyone for playing along. Anybody Wanna Buy A Bridge?Sunday, May 10th, 2009MSNBC posted an article stating that “Top representatives of the health care industry plan to offer $2 trillion in cost reductions over 10 years” to satisfy President Obama’s plans to overhaul the health care system. Does this mean that they’re going to spend $200 billion less each year for the next 10 years? Doubt it. I’ll wait to hear the plan in depth, but my cynical side is getting the better of me right now. I’m betting that the plan will just be pulling the ol’ grocery store trick of marking a 79 cent can of beans up to 99 cents then putting it on “sale” for 89 cents so that everyone thinks they’re getting a bargain — when in fact they’re actually paying more. With health care spending at $2.4 trillion in 2007 and rising each year, I imagine the plan will go something as follows: “We were projecting that we would have to spend $40 trillion for health care over the next 10 years, but, through a complex mathematical model, we’ve figured a way to spend only $38 trillion instead. Check us out … Now where’s that stimulus money at?” So True …Sunday, May 10th, 2009Reading through EM Resident – the official publication of the Emergency Medicine Resident’s Association and came across the comic below. Got a good chuckle since just yesterday I had a patient who wouldn’t take off his sunglasses when I was getting a history or when I tried to examine him. Asked him if he would mind and he said “yes”. Like he’s Geordi La Forge or something. I stepped out of the room, got a face mask, and came back in wearing a mask to finish doing his exam – just for the heck of it. Plus … the comic describes the “Next Gen ED Doc”. Our numbers are growing. Resistance is futile.
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Several events came together in a weird way confirming to me that this post just needed to be written.
Health Care Policy Roundup 5-19-09
Tuesday, May 19th, 2009The Dallas Morning News has an article stating that the current Obama plan to reorganize medicine may be a foot in the door to get medical malpractice reform. Based on the number of former plaintiff attorneys in Congress, one commenter doesn’t think so.
It seems as if the more that we want to implement electronic medical records, the more that we see how the technology just isn’t ready for prime time.
Incorrect information inadvertently entered into or imported into one’s medical record can have long-lasting effects. Because “coding” involves turning a bunch of non-standardized medical conditions into a set of standardized numbers which are easier for computers to recognize and categorize, inaccurate CPT coding can also cause problems with medical treatment and medical insurance.
A reader e-mailed me a link about an Australian hospital that actually banned electronic records in their emergency department when the electronic system failed twice in three days. The article also noted how electronic charting was decreasing the productivity of the physicians: More charting = less patient care = “patients put at risk.” Where have I heard that before?
An Indiana man gets thrown in jail for five visits to the emergency department in one day. The doctors apparently wouldn’t give him any pain medication on the fourth visit and he became unruly. Police were called, told him to leave and he did so. When he returned for the fifth visit, the po-po threw him in the hoosegow.
Before everyone starts remarking about how ED abusers should be arrested, remember that this woman was placed under arrest in the ED and was being transported to a police car when she became unresponsive and died. Doesn’t make for a very strong defense at trial.
Sick of all my posts comparing US healthcare to the Canadian system? Here’s a comparison between the US and French systems. Even the French system is running into budget shortfalls and is now starting to pull some pages from the US system. French citizens pay an average of 40% in income taxes compared to an average of 25% in the US. One big problem according to a French physician: “Consumers are too used to the idea that health care should be free. Many people in France would think less about going [to the emergency department] than they would to go to a café.” No matter what country you’re in, health care reform won’t work if consumers have no skin in the game.
Dr. Nortin Hadler is deservedly getting a drubbing in the comment section on ABC News after stating that we overtreat medical problems in the US when there are no studies to show that treatments are effective. According to Dr. Hadler, we need to rethink our use of oral hypoglycemics, CABG and angioplasty, screening mammography, and surgery for low back pain. I actually agree with the last one – unless there is cord or nerve root compromise.
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