WhiteCoat

Archive for June, 2009

Healthcare Policy Roundup – June 2, 2009

Wednesday, June 3rd, 2009

EMTs – “we bring the emergency room to your living room.” Cool article that makes you think about how much these guys and gals are underappreciated.

Want to get first hand experience of what it’s like in the ED? Try the newest game for the Wii and DS - Hysteria Hospital: Emergency Ward. Players will have to reach desperate patients and demanding doctors within a set period of time. The frenzy inside the hospital will increase as the game progresses with more and more demanding patients desperate to be cured!” And that’s a challenge … how? We do it every day.

According to a report by Families USA, insured families pay a “hidden tax” of more than $1017 to pay for health care of the uninsured.

That hidden tax isn’t cutting it in Washington State, though. Washington’s legislature just enacted $1 billion in health care spending cuts that will leave almost 40,000 additional people without care, including elderly patients, the disabled, children who need vaccinations, and those who need drug treatment.

Back to problems with emergency care in the Canadian system. Snooore … right? But look at the similarities to the US system. There is a shortage of primary care physicians in “almost every community in Ontario.” Many patients are now crowding into the emergency departments “for care that they would normally get from their family doctors.” What’s the Canadian government doing about it? They’re throwing more money into the emergency care system to “add physician assistants to emergency rooms” (i.e. encouraging more people to come to the emergency department for routine care); “improve information technology” (i.e. implement EMRs that decrease productivity and decrease patient throughput); and promote health-care alternatives to the emergency room (i.e. doing exactly what the University of Chicago got blasted for doing in the media). Be interesting to see how this experiment plays out.

Have an emergency in Canada? “Don’t bring a book, bring a library.” The average stay in a Montreal emergency departments has decreased to only 19 hours and 48 minutes. At Maisonneuve-Rosemont Hospital, the average stay is 34 hours 18 minutes. But the care is free, right?

The medical system in South Africa is also collapsing. Public sector physicians are working more than 80 hours per month overtime and government pay is less than adequate. Experienced specialists are “leaving the public sector and moving to the private, leaving very few top senior specialists to continue training us and improving the standards of care in South Africa.” The public is stating that physicians should choose to study medicine “because of the greater cause — to help people” and that the physicians should not be fighting for more money. In other words, the public expects that some of the brightest students in the country pay for 8 years of education, then work at less than minimum wage during their internship and residency, and go hundreds of thousands of dollars in debt so that they can then treat people for free. Yeah, that will work real well.
Flash forward 10-15 years and this public/private battle is what I foresee happening in the US.

Aussie courts don’t put up with any crap. A patient went to the emergency department there complaining of back pain, yelled at the staff after not being seen for several hours, then called the Australian equivalent of “911″ four times demanding that police come to the hospital to intervene on his behalf. The last time he called, he threatened to kill the 911 operator.
He was arrested and fined $1500. The judge stated that “The hospital staff have a difficult enough job to do without patients being intoxicated and causing extra trouble.” Booyah!

The Trial of a Whitecoat – Disclaimer

Tuesday, June 2nd, 2009

Wow.

Congratulations to everyone on making yesterday’s post the most popular blog post I’ve had in a while. The only time I can remember having more hits in one day is when one of my vaccination posts got picked up by Glenn Reynolds at Instapundit.

I appreciate everyone’s good wishes. The blogosphere is a great place where I’ve made a lot of friends and probably a few enemies, but the former far outnumber the latter.

Nurse K, ERP and Ten are right. The trial is over. I know all about Flea and don’t intend to repeat history.

Medical malpractice is a game where neither side wins. On one side, patients suffer bad outcomes – some due to medical negligence, some not. On the other side, an accusation of medical malpractice cuts to the soul of any medical provider (read this story about Philip Ticktin to see what I’m talking about). During the many years inherent to any malpractice litigation, both sides are forced to relive these bad moments over and over again. Both sides are forced to listen to other people question their actions and accuse them for being at fault. It isn’t a matter of who wins in a lawsuit, it’s a matter of who loses least.

The death of a patient is especially troubling because many people, physicians included, fail to remember that death is a part of life. Death is not some abberancy that we can stave off with a futuristic handheld scanner dreamed up by Gene Roddenberry. Death can happen at any time and in any place. Just because death happens does not necessarily mean that someone else is to blame.

The story I will tell is a story that needs to be told. I’m past it now. I’ve licked my wounds and they are healed. It isn’t about me any more. It’s about every other health care professional who has been on the receiving end of a summons who doesn’t know what to feel and who doesn’t know where to turn. You aren’t a bad person. Even if you made an error, you’re human. Sometimes I wish patients could understand that more.

So to those worried that what I write will be used against me by some future plaintiff attorney, let them try. You’ll be reading about them in this blog in the future.
To those who think the HIPAA police will come and lead me away in handcuffs, file a complaint. Here’s the link. The information in this case has been de-identified, facts have been changed, and it is no longer subject to HIPAA laws.
Defamation? Truth is an absolute defense. What isn’t true hasn’t harmed anyone and my observations and opinions aren’t actionable.
Legal scholars want to debate whether it is “unethical” for me to talk about a malpractice trial? Go for it. The more discussion, the better. If this series is what it takes to bring the issues involved in medical blogging to the next level, I’ll be the fall guy. I won’t live my life in fear of what some evil attorney might sue me for.

So …

I’ll try to put up at least a post a week about what happened. I was going to put them all up back-to-back, but thought that readers would become bored. There are a lot of twists and turns in the whole series of events, and I took good notes.

Now stop worrying so much and enjoy reading, will ya?

The Trial Of A WhiteCoat – Part 1

Monday, June 1st, 2009

This is the first in a series of posts I’m going to do about my malpractice trial.
Names and minor facts about the patient and his family have been changed.
Everything else is the real deal.

—————————–

I was in the middle of writing admission orders on a patient when the secretary told me that someone needed to see me in the front.

I headed toward the triage desk when a security guard ran up, grabbed my arm and stepped in my path. “What the hell is going on?” I thought to myself. He told me that the person who wanted to see me up front was a process server. He said that he could keep her from coming back and that I could sneak out the back door after my shift if I wanted.

I thought about it for a few seconds and realized that it would only delay the inevitable. I thanked him for “having my back” and walked out to see the woman. When she saw me, she fiddled with her briefcase for a moment, finally got the latch undone, opened the briefcase, and handed me some ruffled papers. I asked her if she wanted me to sign for them and she raised her eyebrows, making it seem as if my offer was not something ordinarily done. She handed me another piece of paper. I scribbled my signature on it and walked away.

The front page of the stack of papers was a summons commanding me to appear in court. I turned the page and saw the name of a Plaintiff as the executor of the estate of another person. Not a good sign. Someone died. Below that was my name, the name of the hospital where I had previously worked, the names of a few other doctors, and a couple of nurses. As I paged through the complaint, I had no idea who the patient was. All I knew was that everyone allegedly delayed diagnosis of a surgical problem in the hospital emergency department and that the patient walked into the hospital, but didn’t walk out.

The rest of my shift that day sucked. I looked at patients as adversaries rather than as people needing help. I ordered more tests than I probably needed to. Wasn’t for defensive medicine purposes or anything like that. Everyone knows that defensive medicine doesn’t exist. Maybe it helped me feel better about “not missing anything.” Maybe I didn’t want to get named in another lawsuit a few years from now. My head wasn’t in the game at that point. My brain was full and I wanted to go home. The shift couldn’t end quick enough.

When I got home, I wasn’t myself, but I didn’t say anything about the lawsuit to my wife. Still hadn’t gotten over the shock and I didn’t want her worrying about me. Didn’t get much sleep that night.

The next day was a day off, so I canceled plans to take my kids to the park and went to my old hospital to review the patient’s chart. “Had some important business suddenly pop up,” I told my wife. I could see the concern on her face, but I just wanted to be alone, so I gave her a peck on the cheek and took off. Tooling down the highway with Motown blasting on the car stereo helped me take my mind off of things for a little while. I even caught myself singing to a couple of the songs.

The chart had been placed in a secured area and I was only able to review it with a member of the medical records department watching me go through it. Like I’m going to write extra notes in it or something. You know that the attorneys already have copies of the whole thing. Otherwise they wouldn’t be able to tell what had been done to the patient. Do I look that dumb to make a change in the records now? The staff member looked around at the walls and paced in the room as I flipped through the chart.

The patient had come by ambulance with a nonspecific complaint. Soon after he arrived, he began to complain of severe back pain. He got pain medication and then went into shock shortly afterwards. While treating his shock, we also looked for the cause of his nonspecific complaint. It took several hours, but we finally made the correct diagnosis in the emergency department. Unfortunately, the patient’s disease had progressed too far. He died from sepsis the next day.

After reading through the chart, I remembered the patient. Nice older fellow who was laughing and joking with the staff when he first came in. I also remembered the patient’s daughter. As soon as she arrived, she began questioning everything we did and everything I ordered. I remember asking her if she had any suggestions for her father’s care. She wanted him transferred to his regular doctor at a hospital across town. By the time she made that request, he was already in shock and we couldn’t transfer him. That made her even more upset. Fortunately, because of the daughter’s animosity, I documented that chart very well.

Once I had read the chart, I felt the need to validate the care I provided. I spent the rest of the day in the medical library reading through all the sources I could find about the patient’s diagnosis and about management of patients in shock. The more that I read, the more that I thought my care was entirely appropriate. I got angry. If I missed something, that’s one thing. But we diagnosed a very obscure problem and provided excellent care. I couldn’t wait to see what the “expert” said that I should have done different.

I notified the group I was working for at the time and they notified our insurer.

The following day, I got a call telling me that I had been assigned a malpractice attorney.

—————-

See other posts in this series here.

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