Archive for June, 2009
Sunday, June 28th, 2009
Some parties against the institution of tort reform argue that fully or partially immunizing physicians from liability will encourage them to practice sloppy medicine.
I’m not aware of any studies on whether adverse outcomes increase in states where physicians have greater immunity for their actions, but intuitively, I don’t think the argument holds water. Do physicians who work in free clinics and who provide free care to indigent patients in exchange for immunity from liability routinely maim and neglect the patients they treat? Do physicians who work in both fee for service and charitable environments practice medicine in a Jekyll and Hyde manner? Doesn’t make sense without some data to back it up.
However, if we’re going to make the argument that immunity encourages bad professional practices, we need to make the argument on both sides of the professional coin.
If judges were not immune from lawsuits, would things like this still happen during trials?
Posted in Medical-Legal, Trial | 47 Comments »
Sunday, June 28th, 2009
Can’t link directly to the cartoon, so am posting a low-res image below and you can go to cartoonist RJ Matson’s site to find the full-sized version. Both insightful and sad at the same time – and likely a reason that any government-run system will not be an improvement on the current system.
Posted in Comics, Funny, Policy | 7 Comments »
Saturday, June 27th, 2009
A stepdad brings in his 15 year old stepdaughter after she suddenly started having “excruciating” lower abdominal pain. She is doubled over when walking into the emergency department and is crying.
The mother is finishing up her night shift and comes to the emergency department to meet her daughter and husband. When she arrives, she takes the patient to the bathroom and reports that girl is starting her period.
After using the bathroom, the patient’s pain decreases to 6 of 10 intensity.
Because the patient just started her period, I ordered a catheterized urine specimen so that there was no urine contamination from menses. The patient’s nurse refused, saying I was being “unreasonable.” She went in and talked to the family, then came out and said that the family also refused. Instead, she obtained a “clean catch” urine that showed 1+ bacteria and 10-20 WBCs per HPF.
I told the nurse that we needed to get a catheterized specimen. She yelled at me stating that she’s “not going to put a 15 year old through that.” “You know damn well that the pain is just from her period,” she said.
“Explain to me why there are bacteria and white blood cells in her menses, then.” I demanded.
“I don’t know.” She replied.
“OK, then why are you giving me such a hard time when you’re ignoring information sitting right in front of your nose?”
“I’m still not doing the catheter. You can do it yourself.”
“If the family doesn’t want it done, they can sign out against medical advice.”
“They won’t do it because insurance won’t pay for the visit.”
I handed her the chart and said “Then you can write the discharge orders, because the ED is full and I’m not arguing about it with you any more.”
“Well …” she started.
“We’re DONE discussing this patient.”
Eventually obtained catheterized urinalysis that showed some bacteria and a few WBCs. I treated the symptoms as a UTI, even though I wasn’t entirely convinced that the patient had a UTI and would ideally have done a pelvic exam.
I told the family that the patient had a mandatory follow up the following day for re-evaluation. The patient said “like hell” as she walked out the door.
You all give me a good reality check.
Was I being unreasonable?
Posted in Patient Encounters | 40 Comments »
Wednesday, June 24th, 2009
Here’s a post for the medical brainiacs out there.
It used to be a “pimp” question during medical rounds: Why don’t you give calcium to someone taking digoxin?
Answer: It could either cause an arrhythmia or could cause tetany of the heart, also known as “stone heart.”
A clinical pearl just out from eMedHome.com shows that there have been only 5 reported cases of fatal dysrhythmias with concomitant digoxin and calcium use. The pearl also notes that theoretical and extremely rare risks of administering calcium in patients with digoxin poisoning must be weighed against the increased mortality in patients with digoxin toxicity who remain hyperkalemic. Since calcium exerts an antiarrhythmic effect in hyperkalemia, it is often recommended in the stabilization of someone suffering from high potassium levels. The question then becomes: Which is worse, giving the calcium or risking an arrhythmia?
One of the studies cited in the eMedHome article by Levine et al. showed that among patients with digoxin toxicity, calcium administration non-significantly increased mortality (22% versus 20%). On the other hand, each 1 mEq/L rise in serum potassium concentration made it 1.5 times more likely that a patient would die. Note that the study only included 161 patients and that only 23 of those patients received calcium, so the “n” isn’t huge. Still a judgment call, but it appears as if calcium in hyperkalemic patients with digoxin toxicity may help more than it hurts.
References used in the eMedHome article are below
(1) Levine M, et al. The Effects of Intravenous Calcium in Patients with Digoxin Toxicity J Emerg Med 2009 Feb 5.
(2)Fenton F, et al. Hyperkalemia and digoxin toxicity in a patient with kidney failure Ann Emerg Med 1996;28:440-441.
(3)Van Deusen SK, et al. Treatment of hyperkalemia in a patient with unrecognized digitalis toxicity J Toxicol Clin Toxicol 2003;41:373-376.
Posted in Medical Studies | 7 Comments »
Wednesday, June 24th, 2009
A promising new test for appendicitis involves only a patient’s urine sample.
In an Annals of Internal Medicine article published June 23, 2009 (still not online at this time), researchers at Children’s Hospital in Boston have found that the body excretes many proteins during acute inflammation of the appendix. The protein that was found to be most consistently present in acute appendicitis cases is called leucine-rich alpha-2-glycoprotein, or “LRG” for short. According to the Time article, the protein is specific to immune cells in the appendix, and LRG testing has “statistically negligible rates of false results,” meaning that it was very good at separating those who had appendicitis from those who did not. Unfortunately, the test has only been validated in children thus far, so more testing is necessary to see whether the test can be validated in adults.
The implications of this test are huge. Appendicitis is one of the more difficult diagnoses to make clinically and missed appendicitis is an often-litigated issue, prompting many physicians to order expensive CT scanning in anyone with right lower quadrant pain. As many as 30% of appendectomies end up showing no appendicitis. If LRG testing has a low false positive rate (i.e. test is positive when there is no appendicitis) and a low false negative rate (i.e. test is negative when appendicitis is really present), it would save a lot of unnecessary surgeries, would decrease the number of CT scans being performed, and would significantly reduce the transit times in ED patients who have lower abdominal pain.
Unfortunately, as GruntDoc often says, “the devil is in the details.” I suspect that other inflammatory conditions of the bowel such as diverticulitis, colitis, and even gastroenteritis will also cause extra amounts of the protein to be secreted, causing “false positive” tests. My guess is that LRG testing will be similar to D-dimer testing for pulmonary emboli in the future – useful to exclude appendicitis if it is “normal” but requiring more testing to definitively pin down a case of appendicitis in an adult if it is positive.
Nevertheless, this could be one more bullet in a physician’s diagnostic arsenal that will hopefully improve patient care. I just hope it doesn’t become one of those things that gets ordered as part of a battery of tests on an abdominal pain patient while docs just do a CT scan anyway.
Kudos to the researchers at Children’s Hospital in Boston for thinking outside the box on this one.
Posted in Medical Topics, News Commentary | 4 Comments »
Tuesday, June 23rd, 2009
WARNING – GROSS PICTURE BELOW
You probably know what this is, but can you spell it? What are risk factors for it? And how do you manage it?
Think about it for a minute and then scroll down for the answer.
Answer: Wound dehiscence with evisceration (the bulge from the wound at the 1:00-2:00 position is bowel)
A good nursing article about wound dehiscence is here.
The following are excerpts about wound dehiscence taken from Sabiston’s Textbook of Surgery, 18th ed.
Wound dehiscence occurs in approximately 1% to 3% of patients who undergo an abdominal operation – usually 7 to 10 days postop.
It may be related to technical errors in placing sutures too close to the edge, too far apart, or under too much tension.
A deep wound infection is one of the most common causes of localized wound separation.
Many factors contribute to wound dehiscence including technical errors in fascial closure, emergency surgery, advanced age, wound infection, obesity, chronic steroid use, previous wound dehiscence, malnutrition, radiation therapy, and other systemic diseases such as diabetes or renal failure.
Dehiscence may occur without warning. Evisceration, such as in this case, makes the diagnosis obvious. Serosanguinous drainage precedes wound dehisence in 25% of patients. Probing the wound with a sterile, cotton-tipped applicator or gloved finger may also detect the dehiscence.
Treatment depends on the extent of fascial separation and the presence of evisceration or significant intra-abdominal contamination (intestinal leak, peritonitis). A small dehiscence may be managed by packing the wound with saline-moistened gauze and using an abdominal binder. If evisceration occurs, cover the intestines with a sterile, saline-moistened towel and contact the surgeon immediately. The patient will require urgent surgical closure of the wound.
Management of wound dehiscence may involve placing absorbable mesh, skin grafts, and/or flaps to reconstruct the abdominal wall.
Wound vacuums remove interstitial fluid, lessen bowel edema, decrease wound size, reduce bacterial colonization, increase perfusion, and improve healing. Successful closure of the fascia can be achieved in 85% of cases of abdominal wound dehiscence.
Posted in Medical Topics, What's the Diagnosis? | 11 Comments »
Friday, June 19th, 2009
When my oldest daughter was in preschool, she brought me home a rock as a father’s day present. She described in great lengths how she had spent all day painting it and she beamed as she handed it to me. A picture of it is at the right.
That was almost 8 years ago and the rock has sat above my computer monitor ever since.
The reason the rock sits above my computer monitor is because it reminds me of the story below. When faced with an option, if I’m sitting at my computer, as I often am, my daughter’s gift reminds me to always choose my rocks.
Unfortunately, I just discovered that one of my rocks requires my full attention.
Hopefully it will only be a short-term issue, but I have no way of knowing at this point.
I’ll be back as soon as I can.
By the way, you may get the honor of a special guest blogger in my absence.
UPDATE JUNE 22, 2009
The rock is better for now – thanks for all the good wishes.
Will have to take a planned leave of absence next month to deal with it further.
—————————————-
A philosophy professor stood before his class and had some items in front of him. When the class began, wordlessly he picked up a very large and empty mayonnaise jar and proceeded to fill it with rocks about 2″ in diameter.
He then asked the students if the jar was full. They agreed that it was.
So the professor then picked up a box of pebbles and poured them into the jar. He shook the jar lightly. The pebbles rolled into the open areas between the rocks.
He then asked the students again if the jar was full. They agreed it was.
The professor picked up a box of sand and poured it into the jar. Of course, the sand filled up everything else.
He then asked once more if the jar was full. The students responded with an unanimous — yes.
The professor then produced two cans of beer from under the table and proceeded to pour their entire contents into the jar — effectively filling the empty space between the sand.
The students laughed.
“Now,” said the professor, as the laughter subsided, “I want you to recognize that this jar represents your life. The rocks are the important things – your family, your spouse, your health, your children – things that if everything else was lost and only they remained, your life would still be full. The pebbles are the other things that matter like your job, your house, your car. The sand is everything else. The small stuff.”
“If you put the sand into the jar first,” he continued, “there is no room for the pebbles or the rocks. The same goes for your life. If you spend all your time and energy on the small stuff, you will never have room for the things that are important to you. Pay attention to the things that are critical to your happiness. Play with your children. Take time to get medical checkups. Take your husband or wife out dancing. There will always be time to go to work, clean the house, give a dinner party and fix the disposal.”
“Take care of the rocks first — the things that really matter. Set your priorities. The rest is just sand.”
One of the students raised her hand and inquired what the beer represented.
The professor smiled. “I’m glad you asked. It just goes to show you that no matter how full your life may seem, there’s always room for a couple of beers.”
Posted in Uncategorized | 21 Comments »
Wednesday, June 17th, 2009
Here I go with EMTALA again.
I wanted to flesh out an issue that Matt and Chris raised based on my previous post.
A proposed Ohio law states that a physician who provides emergency medical services is “not liable in damages to any person in a tort action for injury, death, or loss to person or property” based on the services unless there is “willful or wanton misconduct” involved (thanks to Max for the link).
Chris’ MedCity News published an article yesterday about the same law. The response from both sides of the issue is predictable. Malpractice plaintiff attorneys state that such a law would remove any incentives for quality control (as if JCAHO regulations suddenly wouldn’t apply once the law took effect). The Ohio Bar Association will come out with its official opinion in a couple of weeks, but for those of you who can’t stand the suspense, I can summarize it right now:
We believe that a law restricting the rights of citizens to sue is in direct conflict with the Constitution and would essentially give emergency physicians free reign to kill and maim the very subset of our population we should be protecting the most – those who are suffering from medical emergencies.
Proponents of such a law state that emergency physicians are “easy pickins” for lawsuits. They can’t refuse to evaluate any patient seeking care (unlike any other specialty – in fact, unlike any other profession that I can think of), the patients often come to the emergency department in extremis or with vague symptoms, there is usually little time to develop a physician patient relationship, there is very little follow up, oh, yeah, and if you don’t do everything the patient and family want and there is a bad outcome, they have the number to Dewey, Cheatem and Howe on their cell phone speed dial.
So allegedly, those physicians who provide emergency medical care (both emergency physicians and on-call specialists) are getting fed up with the threat of lawsuits and are leaving states where there is a high incidence of medical malpractice claims. I have not researched the issue, so I can’t cite any specific numbers.
The MedCity News article does cite a link about the projected shortfall of surgeons available to provide emergency care in Ohio. The MedCity News article also notes that many states have either passed or are considering such legislation including Arizona, Michigan, Minnesota, Utah, North Carolina, Florida, Georgia, Texas and South Carolina.
I commented on this topic in one of my posts on how to improve the house of medicine.
So in answer to Matt’s question about “why we would want a policy insulating ER docs from their negligence, even gross negligence,” I offer the following response from my previous post.
Granting medical providers immunity would throw everyone’s legal rights out the window, right? No profession should have immunity for their actions, should they? Funny. Judges have complete immunity for their actions. No one even questions the concept of “judicial immunity” any more. One quote I found here showed why the US Supreme Court feels that judicial immunity is important:
To render a judge liable to answer in damages to every litigant who feels aggrieved during the course of judicial proceedings, “would destroy that independence without which no judiciary can be either respectable or useful.” Bradley, 80 U.S. (13 Wall.) at 347.
It is OK for a judge to be grossly negligent and wholly biased in their duties. Litigants have no recourse whatsoever. The judges are immune from liability. At some point our nation is going to have to decide whether poor access to care, long waits for care and declining overall health is preferable to tort reform.
Perfect care or available care, Matt. You choose.
Will increasing the threshold of liability improve the practice of emergency medicine?
Have to wait for further data from states that have already enacted it. Anectdotally, Texas seems to be doing pretty well with its influx of physicians after implementing tort reform.
Posted in Access to Care, EMTALA, Medical-Legal | 33 Comments »
Tuesday, June 16th, 2009
Want fries with that? Stanford Hospital experiments with the first drive-thru emergency department. Examining people sitting in their driver’s seat may “keep them from infecting others” but it will also keep doctors from fully examining a patient. Would be interested to see outcomes measures with this idea. If outcomes are similar, what is the big leap between drive up EDs and telephone medicine? After all, you can just ask a patient to put the telephone receiver to their heart for a moment …
Ohio is breaking new ground in its tort reform attempts. According to this article, the legislature is seeking to make it harder to file lawsuits against emergency physicians and against obstetricians (text of bill here). Other states such as Florida and Georgia have already passed such laws. Good idea?
What’s with violence in the EDs lately?
A Washington man walks up to the emergency department doors and shoots himself in the head while ED staff watches on the security camera.
A cop cuffs a stabbing victim to a wheelchair in the ED and then beats him with a sap. Smile, bud, you’re on Candid Camera. That lapse in judgment will get you a few years in the Greybar Motel.
One way to reduce wait times in the ED — order sets. Instead of waiting for the physician to see a patient to order tests, nurses order tests at triage and have the test results ready before the doctor goes into the room. This Canadian hospital reduced wait times by 50% after implementing such a system.
A hospital in the lower Florida Keys used to receive a subsidy to treat indigent patients who were not eligible for Medicaid. Now the subsidy is gone. So is a lot of the care.
UTMB in Galveston is reopening its hurricane-damaged emergency department effective August 1, 2009. Second article here. Previously commented about UTMB’s decision to close its emergency department and open an urgent care clinic, therefore being able to skirt EMTALA requirements. One commenter to the article jokingly wonders whether a forecast for a hurricane to hit the area on August 2, 2009 had any bearing on the opening date.
Another Texas hospital is using a nursing call-in line to direct patients to “the right place to go.” They’re apparently trying to direct non-urgent patients away from the emergency department. But is their idea of doing phone triage on patients already in the emergency department going a little too far?
OK, ACEP and Chicago Tribune, dust off your pitchforks. The nation flipped out about the University of Chicago’s plan to discharge non-urgent patients from its emergency department if the patients could not or would not pay for their medical care. Now HCA, the nation’s largest for-profit hospital chain, is planning to do the exact same thing. In a pilot study at several of its hospitals, HCA noted that 40% of ED visits were classified as non-urgent. When given the opportunity to pay in advance to receive medical care, only 1% of the non-urgent patients decided to do so. Lest you had any doubts … in the article, the Chief Operating Officer of HCA assured everyone: “It isn’t about the cash.”
Posted in Access to Care, Policy | 14 Comments »
Sunday, June 14th, 2009
Very poignant article in Yahoo news about how the federal government is failing to meet the needs of many patients in the Indian Health Services – and the disastrous effects the broken promises are having.
- A five year old with stomach pain who stopped eating who visited the clinic ten times and was diagnosed with “depression.” Later the family discovered she had terminal cancer. She died at age six.
- Another patient was given cough syrup for his congestive heart failure and sustained damage to his heart. He died while waiting for a transplant.
- Another patient visited the clinic with stomach pains for 4 years and was diagnosed with possible tapeworms and stress. Later, she discovered she had metastatic cancer.
- Yet another patient couldn’t get a prescription filled despite repeated trips to a clinic because of lack of appointments. She died before she was able to see the doctor.
Few doctors are willing to work in remote reservations, there is a lack of funding (some reservations warn “don’t get sick after June,” when the federal dollars run out), and care is rationed. In fact, one third more funding is provided for the health care of felons in federal prison than is provided for American Indians on reservations.
Then read this Yahoo news story about the massive budget cuts that are coming down the pike in the healthcare reform package.
Not too hard to connect the dots.
Posted in Access to Care, Funding Crisis, News Commentary | 12 Comments »
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Think You Have Appendicitis? Here, Pee In This.
Wednesday, June 24th, 2009A promising new test for appendicitis involves only a patient’s urine sample.
In an Annals of Internal Medicine article published June 23, 2009 (still not online at this time), researchers at Children’s Hospital in Boston have found that the body excretes many proteins during acute inflammation of the appendix. The protein that was found to be most consistently present in acute appendicitis cases is called leucine-rich alpha-2-glycoprotein, or “LRG” for short. According to the Time article, the protein is specific to immune cells in the appendix, and LRG testing has “statistically negligible rates of false results,” meaning that it was very good at separating those who had appendicitis from those who did not. Unfortunately, the test has only been validated in children thus far, so more testing is necessary to see whether the test can be validated in adults.
The implications of this test are huge. Appendicitis is one of the more difficult diagnoses to make clinically and missed appendicitis is an often-litigated issue, prompting many physicians to order expensive CT scanning in anyone with right lower quadrant pain. As many as 30% of appendectomies end up showing no appendicitis. If LRG testing has a low false positive rate (i.e. test is positive when there is no appendicitis) and a low false negative rate (i.e. test is negative when appendicitis is really present), it would save a lot of unnecessary surgeries, would decrease the number of CT scans being performed, and would significantly reduce the transit times in ED patients who have lower abdominal pain.
Unfortunately, as GruntDoc often says, “the devil is in the details.” I suspect that other inflammatory conditions of the bowel such as diverticulitis, colitis, and even gastroenteritis will also cause extra amounts of the protein to be secreted, causing “false positive” tests. My guess is that LRG testing will be similar to D-dimer testing for pulmonary emboli in the future – useful to exclude appendicitis if it is “normal” but requiring more testing to definitively pin down a case of appendicitis in an adult if it is positive.
Nevertheless, this could be one more bullet in a physician’s diagnostic arsenal that will hopefully improve patient care. I just hope it doesn’t become one of those things that gets ordered as part of a battery of tests on an abdominal pain patient while docs just do a CT scan anyway.
Kudos to the researchers at Children’s Hospital in Boston for thinking outside the box on this one.
Posted in Medical Topics, News Commentary | 4 Comments »