 Archive for September, 2009Welcoming a New Blogger to EP MonthlyWednesday, September 23rd, 2009ERP from ER Stories has passed an extensive background check and has had multiple writing samples vetted by the staff. We’re happy to announce that he will be doing some regular guest posting on this blog to break up the monotony of my drivel. Welcome! Healthcare Roundup 9/23/2009Wednesday, September 23rd, 2009Do we need to be giving charcoal to overdose patients in the emergency department? This excellent article from Detroit Receiving’s ED gives the lowdown on when charcoal is useful and when it is not. The bottom line is that charcoal isn’t as useful nearly as often as we think. Book ‘em, Dumbo. It’s a start …. Should malpractice damage caps be a part of health care reform? A pro and con argument is worth reading at the Atlanta Journal Constitution. Personally, I think that $350,000 caps aren’t fair to patients who are seriously injured, but I also think that $60 million verdicts aren’t fair to anyone. Perhaps caps of $1 million to $1.5 million would be a reasonable compromise. In the same vein, should Americans be forced to purchase health insurance? One Florida hospital system is posting its emergency department wait times on highway billboards. Wonder what effect it will have on business. Washington State’s Supreme Court threw out a law that required potential plaintiffs to obtain a “certificate of merit” from a physician before filing a malpractice case. Will this move result in more frivolous cases being filed? Perhaps. My gut tells me that most law firms consult with a doctor to determine whether a case has merit anyway – unless some of the attorneys in the firm can channel messages from unborn children confirming a doctor’s negligence. Which is cheaper – treating an illegal immigrant in the emergency department or giving them a round trip ticket to Paris to be seen in one of their EDs? Massachusetts is a model for health reform according to its governor. After all, over 97% of Massachusetts residents are insured and Massachusetts residents “now have better access to preventive care in lower cost primary-care settings.” The article also states that health-care reform “has only added moderate incremental costs to the state budget” and has resulted in “a decrease in demand for costly emergency-room care.” Some would call bullshit. Here and here and here and here and here and here. More violence in the ED. A gunman walks into a Chicago VA Hospital and fires shots. SWAT team moves in. More news at 11. You’re DEAD!Tuesday, September 22nd, 2009
A pediatric patient is brought in by ambulance for evaluation of suicidal and homicidal ideations. Great. Did I mention that the child was THREE YEARS OLD? The parents and social worker became concerned when he bit his sister on the leg and punched her a couple of times. One of the nurses called me at home to tell me about the patient. I had to talk to the other nurse, the secretary, and the EMT that was there to do the transport just to confirm that they weren’t BS’ing me. I still have my doubts. The kid can’t even put together a sentence and the parents and social worker are saying he has suicidal ideations. Maybe it’s me. Maybe he’s half Tasmanian Devil and can kick his parents’ collective asses with nary more than the sharp edges of the buckles from his car seat. Maybe was told that he’s got multidrug resistant peptostreptococcus on the six teeth that have managed to rupture through his gums and, with that knowledge, told his sister in baby language “Now you DIE!” before he bit her. Right after that he told his parents in some variant of non-Mandarin Chinese baby talk that his Similac was really insecticide and that he was going to drink it so he could die of a cholinergic toxidrome. The parents must have called the AT&T Language Line to confirm before calling the social worker and 911, but by that time the child was faking as if he couldn’t really speak. Oh yeah, and to finish the plan, after he would drink the hidden insecticide but before he vomited, salivated, urinated, and defecated all over himself, he ga-ga goo-gooed his intent to beat the family chihuahua to death with his sister’s Hannah Montana microphone. Back when I was a kid, punishment for hitting your sibling used to be a butt-whoopin from your parents. If you got in trouble at school, it was nothing compared to the trouble you got in when you got home. These days, school teachers are afraid to discipline kids because of lawsuits. Now proper punishment when kids get home is a time out – maybe some dish soap or Tabasco sauce in the mouth for biting or swearing. Apparently now the paradigm is changing yet again. Soon we’ll be seeing papers on how the most effective form of punishment is a three day stint in the children’s psych ward. BYOD – bring your own diapers. Maybe they’ll start him on some kiddie Haldol just for good measure. That’ll teach ‘em. Picture credit hereUPDATE: Why Healthy Young Adults Should Fear The Swine FluMonday, September 21st, 2009
“I always get the flu after I get the shot” – injections are killed viruses containing only surface antigens and subvirons, so flu shots can’t cause infection. The intranasal sprays are weakened (“attenuated”) viruses which do have the potential to cause mild symptoms. Maaaybe you can say you got the flu from the spray – not from the shot. I heard someone use the last excuse recently and had to remind that person about a unique feature of the novel H1N1 virus (aka the “swine flu”). A disproportionate number of patients who died from H1N1 were young and relatively healthy. According to this Reuters article, 90 percent of the seriously ill victims in Mexico were less than 50 years old and most of those patients were previously healthy. In addition, 87% of those who died were aged 5 to 59 — compared to a usual average of 32% for seasonal flu. All of the patients who died had “multiple organ failure.” Here is another article from the Washington Post about increased H1N1 influenza deaths in young healthy victims. Why are young healthy patients the ones dying from H1N1? One theory is that the patients’ own immune systems are killing them. In younger children, the immune system hasn’t fully developed. In older patients, the immune system loses some of its effectiveness. The theory is that immune systems in young healthy people are “too good” and go out of control. Scientists call the theory “cytokine storm.” I”ll attempt a simple explanation of a cytokine storm, but realize that the process is more complicated than what I am trying to explain. When a virus infects the body, the body produces extra immune cells to combat the infection. Some immune cells attempt to kill the virus, others analyze the virus and produce antibodies. Some immune cells produce inflammatory chemicals called cytokines that serve several functions. Included in the function of cytokines is an inflammatory response – an increase in inflammation throughout the body. Normally, the body holds the inflammatory response in check – similar to the way that the thermostat in your home regulates the temperature. When the temperature in your house hits a certain set-point, the furnace shuts off. In a cytokine storm, the immune response is so intense that the feedback systems become overwhelmed. Cytokine production continues out of control and a generalized inflammatory response occurs in the body. Similar responses occur in anaphylactic shock and sepsis. Think of the difference between controlling a few bees buzzing around a picnic looking for food and a swarm of bees defending a hive. More information about cytokine storm can be found here and here. One study noted that gemfibrozil (Lopid) – a cholesterol medication – doubled survival rates in mice that had severe influenza infections. Apparently gemfibrozil has an inhibitory effect on inflammatory cytokine production. Not saying that every young healthy adult who gets swine flu is an automatic ICU admission. Death rates for H1N1 are low, but are still about 3 times the rate of that for seasonal influenza. Just noting how strange it is that a healthy immune system may cause an increased risk of death from H1N1 virus. Still want to skip that flu shot? Oh yeah, and cover your mouth when you sneeze. While looking for a picture for this post, I found a video showing how many goobers are sprayed from the mouth during one sneeze. Blecch. Emergency Medicine QuoteSunday, September 20th, 2009A reader forwarded me some material published by the Emergency Medicine Residents Association regarding the choice of emergency medicine as a specialty. One of the quotes from Dr. Brian Keaton, a past president from ACEP, caught my eye.
Surgery Circa 1930Saturday, September 19th, 2009A subscription to Wired Magazine is about the best ten bucks I spend every year. A recent post on their blog shows some wild videos from 1930s British archives demonstrating brain surgery, removal of a large ovarian tumor, sterile technique, and how to deliver a baby by Caesarean section. Probably not something to watch if you have a weak stomach. The baby coming out of the C-section is looking a little floppy to me, by the way. Also strange to think that the baby being delivered – if alive – is almost 80 years old now. SmilesThursday, September 17th, 2009Every once in a while you run across a patient that just makes you smile for no particular reason. For me, usually it’s a little kid. This time, it was someone at the other end of the age spectrum. A 98-year-old grandmother was brought by ambulance because she was found in a nursing home laying on the floor beside her bed. She didn’t complain of any pain. She was just laying next to her bed … singing. Because she was suffering from Alzheimer’s Disease, the nursing home sent her to the emergency department for evaluation because they couldn’t determine whether or not grandma had hurt herself. When grandma arrived in the hospital, she was smiling and calm. She was a little hard of hearing, so we had to raise our voices to talk to her. As she was being transferred from the ambulance cart to the bed, I introduced myself and told her that I was going to check things out to make sure that she was okay. Then she started singing and stopped making sense
This little old grandma serenaded the staff, the x-ray technician, and the lab technician with her soft little voice. We did an x-ray of her hip and pelvis and everything was fine. “Everything looks just fine. You’re going to be able to go home so you can have some dinner now.” We’re happy now too, grandma. Survey on Health Care ReformWednesday, September 16th, 2009Emergency Physicians Monthly just published the results from a survey that it performed on health care reform. The results show something that most physicians already know. ED physicians were asked how many tests they could have eliminated in an 8 hour shift without compromising the quality of care. Most said that they could eliminate at least 1 or 2 CT scans, and 27% said that they could eliminate more than 4 lab tests per shift. Two thirds of physicians responding to the survey estimated the potential cost savings at more than $500 per shift. The survey also explores suggestions that emergency physicians have for improving health care, including creation of physician boards to determine the standard of care, tax rebates for charity care, copayments for all medical services, and implementing caps on non-economic damages in lawsuits. Interesting read. Message from Nurse KSunday, September 13th, 2009Nurse K sent me an e-mail and wanted me to let everyone know that she is dealing with a “rock” issue. She’ll be back. Check out some of the other great medical blogs in my Blog Links at the right while you’re waiting for her return. Or if you have a medical blog, leave your link in the comments and I’ll add you to the list. |
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This wasn’t my patient, because if it was my patient I would have spent the whole shift looking for people videotaping me to catch the looks on my face and the phrases coming out of my mouth.
I’ve heard a lot of reasons why people don’t want to get influenza vaccinations.
Healthcare Roundup 09-14-2009
Monday, September 14th, 2009When a hospital ED closes, it’s no big deal – until it happens to be the only hospital within a 22 mile radius of your home. Residents of the western NY town of Westfield are worried that if their hospital emergency department closes they will have no access to timely care in emergencies and won’t be able to get to other emergency departments during winter snow storms (last year the area got 273 inches of snow). Because there are no paid ambulance services available, there is also an issue whether volunteer EMTs will be able to take 3 hours off from their jobs to transport patients to outlying hospitals. And what happens if there is more than one emergency call at a time?
Another article on how Japan is trying to rain in health care spending. Japanese health care spending amounts to 8% of its gross domestic product – half as much as the US – but at what cost? You’re less likely to have a heart attack in Japan, but if you do have one, you’re twice as likely to die from it. Their system is starting to feel financial strains as more patients live longer and develop “expensive” diseases such as strokes, cancer, and Alzheimer’s disease. Now Japan is looking for answers to its problem. One of the commenters to the article noted that Japan is forcing citizens to “put some skin in the game” by paying up to 30% of their health care bills.
While we’re looking at health care around the world, here’s a blog entry about what a good experience one patient had in a Canadian emergency department. I haven’t seen too many posts like that around the blogosphere.
More than half of all Americans uninsured? According to a study by US Treasury officials, 57% of all Americans were uninsured at some point between the years of 1997 and 2006. President Obama used this statistic in his speech, stating that no one should have to worry about going without health insurance, “and once I sign my health reform plan into law – they won’t.” Remember the lesson from Massachusetts, though – having insurance doesn’t equate to having health care. Insurance doesn’t mean much if no one takes the insurance.
A healthcare WTF moment: NJ pharmacy employers arranged a fake holdup where a masked gunman burst into the pharmacy demanding OxyContin and saying that he had taken a worker hostage. Ha ha. Now they’re getting sued.
Drink the Kool Aid. Even though some argue that defensive medicine “doesn’t exist”, a Reuters poll shows that most people are getting the idea that health care isn’t the only thing that needs to change in this country
- 83% of those surveyed wanted tort reform to be part of any health care reform plan
- 72% of voters think the fear of being sued often changes the way doctors deal with patients
- 67% of voters favored special health courts deciding medical malpractice cases
“And in a stunning indictment of the American legal system,” only 43% of Americans had confidence that a lawsuit “without merit” that was filed against them would be resolved in their favor, and only 30% had confidence the lawsuit would be resolved quickly and efficiently
To be fair, the poll was conducted by an independent firm, but was conducted on behalf of Common Good which advocates tort reform.
Someone needs to pass President Obama a glass of the Kool Aid, though. According to a CBS “60 Minutes” interview, he doesn’t believe that malpractice reform will be effective in curbing costs of medical care.
With medical malpractice, is “honesty the best policy”? The University of Michican health system thinks so. Instead of litigating every malpractice case, it began settling some cases and apologizing up front. By doing so, it decreased the number of yearly claims against the 40 hospital system from 262 to 83 in just six years.
I’m not sure that its fair to insinuate that medical providers “lie” when defending a case. Errors occur, but even excellent care can result in a bad outcome. Intuitively, it would appear that having a reputation of settling claims would increase the number of patients making claims. I would like to see whether their “number of claims” statistic also includes the settlements that they have entered into.
Smelling blood in the water? The “sharks” … er, um … plaintiff attorneys are in a feeding … er, um … advertising frenzy lately. Television advertisements for medical malpractice plaintiff law firms rose by 1400% in four years and spending for those ads increased from $3.2 million to $62 million. Why?
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