Archive for October, 2009
Saturday, October 17th, 2009
Myth or no myth? Does a full moon cause more ED visits? I don’t care what the studies say. On nights of a full moon, the freaks are out in full force. Why do you think they call it lunacy?
Suck it up, America! Why are doctors becoming slaves to patient satisfaction scores?
Great discovery request, there Perry Mason. Michael J. Trentalange, a Florida medical malpractice lawyer, requested 75 years of incident reports before having his colonoscopy performed at Florida’s St. Joseph Hospital. He wanted to know “how many people [at the hospital] get perforated colons during colonoscopy” before having his own procedure done. Oh, and by the way, he’s also representing someone who died from sepsis after sustaining a perforated colon.
He didn’t limit his request to just colonoscopies, though. He wanted every single incident report in the hospital. Why? His response: “I could have a family member contemplating another procedure.”
The hospital sued him over his request. More doctors and hospitals need to fight back against BS like this. And people wonder why lawyers get a bad rap.
Phil Howard from Common Good scores an article in the Wall Street Journal about “Why Medical Malpractice is Off Limits” in the health care reform debate. Does it have anything to do with the fact that trial lawyers are “amoung the largest contributors to the Democratic Party”? One interesting quote:
Trial lawyers also suggest they alone are the bulwark against ineffective care, citing a 1999 study by the Institute of Medicine that “over 98,000 people are killed every year by preventable medical errors.” But the same study found that distrust of the justice system contributes to these errors by chilling interaction between doctors and patients. Trials lawyers haven’t reduced the errors. They’ve caused the fear.
We can’t sue our way to better health care.
Another interesting tidbit from the upcoming book “Architects of Ruin” regarding why tort reform isn’t part of health care reform. Several trial lawyers filed a class action suit against Citibank for rejecting a black woman’s loan application. The basis of the suit was that “racial bigotry, not poor credit histories, explained high rejection rates among minorities applying for mortgages.” Four years later, the case settled. The plaintiff received $60,000. The lawyers received $950,000 – more than 15 times as much money as the plaintiff. Among the lawyers receiving those fees was a young gent named Barack H. Obama.
Paging Dr. Scumbag … An emergency department physician steals a Presidential Rolex watch off the wrist of a patient who had just died from a heart attack. Busted by hospital security cameras and fired on the spot. Also indicted by a grand jury for the theft.
Who is at fault? A patient gets sedated for brain surgery and waits on the table for the neurosurgeon … who is out of town attending to an “urgent family situation.” The head of the department refused to do the surgery in his place. Among the things that the hospital and doctors are getting cited by JCAHO for is “the doctors operating did not pause to stop and check that they were operating on the right part of the body.” Was there some transrectal approach to brain surgery that I didn’t learn about?
Insurance doesn’t equal access. Another study out about the Massachusetts “insurance for all” program shows that “unless access to health care improves, many people will continue to treat emergency rooms as a substitute for a primary care doctor” and that “access problems in the community may play a significant role in ED use in Massachusetts.” Sounds like a plan. Let’s replicate this on a national level. Just what we need as more emergency departments close nationwide. Cue grandpa talking to grandson … “Yeah, sonny, I remember back when we only had to wait 9 hours to see a doctor in the emergency department.”
A powerful article in New America Media giving personal examples of how the richest country in the world can’t provide for the care of its citizens. What’s the answer?
Grady Memorial Hospital shuts its free dialysis clinics. Ninety patients in the program have nowhere to go. Many of the patients are illegal immigrants. Now the hospital is trying to ship the patients to other states so that they can get the dialysis they need. Hospitals can only provide free care for so long. A sign of things to come.
That’s why we call them “patients.” Canadian Health Minister Maureen MacDonald encourages people in Dartmouth General Hospital to “be patient” as the government “emergency room adviser” figures out how to solve the apparently recent development of hospital overcrowding. Here’s a hint: Step one is to bring a good book with you … maybe two.
Interesting point on the health care reform debate in Maine’s Kennebec Journal. The US fares poorly in the “quality of care” categories such as infant mortality and life expectancy, but the US does very well in success of medical treatment. Additionally, according to the WHO, the US is ranked highest among all countries in “responsiveness” of health care – how fast patients receive the care they need. Don’t foresee that statistic being favorable much longer.
Today there’s a double feature. Head over to ER Stories to see the Swine Flu version of the HealthCare Update.
Posted in News Commentary | 28 Comments »
Friday, October 16th, 2009
I finished a much busier than usual week at work after taking the first week of October off for the ACEP Conference. Well worth the trip.
Our ED has been overrun with influenza victims and volumes are going up significantly. Many patients with influenza and respiratory distress have been admitted to the ICU. We routinely get multiple patients in a row registering to be seen for fever/cough/sore throat/body aches. I ask every patient if they have received their flu shots. Only two patients out of many dozens had done so. Lots of patients are sitting in the waiting room coughing all over each other. If you don’t have the flu coming into the ED, you’ll have it by the time you leave.
One other thing about the flu – if you are going to get vaccinated, do so soon. Many places in our region are running low on seasonal influenza vaccine (H1N1 vaccine is just starting to be distributed). Don’t wait for an appointment a month away to get the seasonal flu vaccine – there might not be any vaccine left.
Working on several posts now. Going to do a Healthcare Roundup Double Feature. One part – exclusively about influenza – will be posted over at ER Stories, and the other will be posted here. Will try to have them up later today.
Posted in Uncategorized | 10 Comments »
Monday, October 12th, 2009
 Those bulky N95 respirator masks may not be any better than regular surgical masks in preventing influenza transmission.
According to this JAMA study, 446 nurses were assigned to use either regular surgical masks or the N95 respirator masks when caring for febrile patients with respiratory illnesses during the 2008-2009 influenza season. Of those nurses, 50 using plain surgical masks became infected with influenza and 48 using the N95 respirator masks became infected with influenza – a result that did not reach statistical significance.
Another interesting statistic in the study – roughly 70% of nurses who had influenza diagnosed by serology had no symptoms.
Not only does this study show that plain surgical masks and N95 masks are comparable in flu prevention, but it also shows the significant risk health care workers encounter when caring for patients with influenza like illnesses. Out of 446 nurses, 98 got influenza even when using masks. That’s a 22% transmission rate with mask use. According to this article in Science, transmissibility of influenza is estimated to be 27.3% without mask use. Based on these studies (and I haven’t done exhaustive research for others), the effectiveness of masks seems to make only a modest difference in reduction of influenza transmission.
The Science study showed that the largest factor in reducing transmission of influenza throughout the population was … immunization. According to the article, reaching 70% immunization, plus immunization of the high risk groups such as health care workers could avert a pandemic.
I have heard of several hospitals that require non-immunized staff to use N95 masks at all times during work hours.
The JAMA study made me wonder whether such a policy uses the masks like “nag screens” with computer programs: The masks may not affect influenza transmission that much, but they encourage workers to get immunized … just so they don’t have to keep wearing the masks.
Posted in Medical Topics | 15 Comments »
Sunday, October 11th, 2009
A patient was brought in by his boss after getting some sawdust in his eye while working at a distribution center for machinery parts.
As I examined the patient, the first thing I noted was his red eye. The second thing I noted was the fact that his breath smelled like he had just gotten home after a night out drinking at the bars.
“This just happen before you got here?” I asked, wondering if maybe he went out drinking after it happened.
“Yeah, went to the office and my boss drove me straight here. He’s sitting in the waiting room.”
I got the piece of wood out of the patient’s eye. The patient’s boss was in the room by the time the patient was getting ready for discharge.
“Does your company require drug and alcohol screening on injured patients?”
“Naw. Don’t worry about it.”
I walked out of the room and the boss followed me.
“You sure?” I asked.
“Listen. If we did drug and alcohol screens on every employee in our company, I’d lose at least half my workers.”
Note to self: In the future don’t lift machines by package handles when packaged in this area.
Posted in Patient Encounters | 17 Comments »
Saturday, October 10th, 2009
ERP here again while WC recovers from the revelling in Boston
Personally, I agree with medicare and insurance regulations that require that someone receive some REAL benefit in order to be covered for an admission to the hospital. Even the “social dispo” admits usually serve a purpose – preventing elderly or the otherwise helpless or nearly helpless from injuring themselves or insuring they get proper medical treatment like antibiotics or seizure medications. However, if you can be safely discharged from a medical AND social point of view (ie no admit-able diagnosis exists AND you can either care for yourself or someone is there to care of you (like in a nursing home), you should have to pay out of pocket if you (or your relative) demand you be admitted. You can’t just come in for “tests” or to see a “specialist” or to “recuperate”. I am sorry, if you are demanding and non-indicated admission, prepare to ante up.
The other day I had several situations where elderly, demented, bedridden, and or chronically ill elderly people from nursing homes were admitted solely because the entitled relatives refused to allow them to be transported back to the home. They had no acute diagnoses requiring admission but their relatives had such a fit that the PMD’s acquiesced and admitted them. Now, the hospital has to try to recoup payment from medicare. This is an epic waste of resources and public health care dollars.
Here is what I did. I documented that the patients had NO indication for admission and recommended the patient (ie family) be charged fully for the admission, thus destroying the hospital’s ability to bill medicare. My hope is that the hospital not even try for medicare reimbursement and instead submit their entire bill to the entitled family, and if they refuse to pay, send them to collections. Hopefully they will learn that there is no free medicare lunch. Who knows, maybe the hospital will reprimand me. Regardless, I had to do it.
Posted in Funding Crisis, Insurance, Medicare | 23 Comments »
Wednesday, October 7th, 2009
Hello all, ERP here.
What is the Quarterback offense? No, it is not some weird audible in football or a Quarterback sneak. It is a tactic used by plaintiff lawyers (and expert witnesses) to sack ER doctors in court. How does it work? Let me give you an example.
A guy I know who is an excellent ER doctor (and probably more cautious and careful than most) who was sued along with a neurologist for not giving TPA to a patient who presented with stroke symptoms to the ER within the three hour window for its use.
Now, there are MANY, MANY reasons to not give TPA to a stroke patient other than that they presented too late. The symptoms could be too mild to warrant its risks, there could be a contraindication such as having a coagulopathy, etc. Regardless, this guy presented to the ER with some RESOLVING symptoms (I can’t remember exactly but I think he had some slurred speech) that was virtually gone by the time he got put into a room in the busy ED. The ER doc assessed him quickly, and even though he thought himself that it was not appropriate to give the drug, he called the neurologist on call to run the case by him for confirmation. The neurologist agreed and the TPA was not given. The guy was admitted and, and the time of leaving the ED, he had zero symptoms. Perfect! Right?
Wrong. A few hours later up on the floor he suddenly stroked out big time and after a long deterioration, died. The ER doc and neurologist were sued for not giving TPA.
Now, this is related to the title of the post as such. The plaintiff-sponsored “expert” witness (an ER doctor whose smiling mug is frequently plastered across the pages of many Emergency Medicine magazine/journals as the “face” of a large contract management company. (Makes me nauseated)) claimed that my friend was not being a good “Quarterback” by FORCING the neurologist to come in and examine and thus administer the drug.
Now, we are supposed to send out a hit man squad to twist the arms of consultants I guess. Never mind that the guy would not have been given the drug by any prudent ER doc or Neurologist.
Well, the good news is that the jury thought this was silly as well and found in favour of the defense and my friend and the neurologist were exonerated.
What’s next? The Blitz? The Double Reverse? The Hail Mary??!??!
Tags: ERP
Posted in Medical-Legal | 51 Comments »
Wednesday, October 7th, 2009
I have spoken to people who didn’t want to go to the ACEP Scientific Assembly because of the cost of registration. Granted that a 4 day registration isn’t cheap, but you get a lot for your money. In addition to the educational opportunities, you also get your own mini-check up at the Wellness Booth. For twenty bucks you get comprehensive lab testing, flu shot, tetanus/pertussis shots, burnout evaluation and a body fat analysis. We won’t go there. I went from 19% body fat last year to 23% this year. I need to eat a little less sushi.
Lectures yesterday were again outstanding. Richard Cantor was both informative and funny when talking about peds emergencies. His quote about the “gene pool having no life guards” was only one of many jokes he cracked. Last night’s Master Clinician series on the Rapid Neuro Exam was also excellent.
I got to wander around the exhibits and was able to say hello to a couple of you readers. Always wonder if I really look like what people expect me to look like.
The exhibit floor was busy. Everyone walks around looking for free pens and other trinkets. When I called home, my kids didn’t tell me how much they missed me, they asked me what I got them. My suitcase is going to be stuffed full of junk just to make them happy. Funky pens. Highlighters. Yo-yos. Bags. Thanks to all the vendors for giving me FOUR of everything to avoid fights when I get home.
The legal picture of the day was at an ice cream stand. Sorry you docs in Minnesota, Vermont, or Massachusetts. Either your butts are too fat or there is some legal decision stating that ice cream cones may unduly influence your decision to prescribe medications.
Then there was the vendor trying to sell Conrad Murray’s old lab jacket. Get it? Michael Jackson … glitter … medical jacket? Never mind. Too many drinks last night.
Sunset picture for the day (only have a pocket camera on this trip, so couldn’t get the wide angle view for full effect) …
Posted in Uncategorized | 14 Comments »
Monday, October 5th, 2009
The first day in Boston was busy.
Got up early and wandered about the city. Generally pretty clean, people are friendly, architecture is unique.
Got to the conference and our new President Angela Gardener was speaking during the opening session. She is a very engaging speaker.
Watched Paul Begala’s opening address. I expected him to generate more controversy with his speach. Instead, he seemed subdued. He was entertaining, with many amusing anecdotes, but I thought his speech lacked substantive content. Kind of like sitting at a bar and talking politics. Entertaining, but I was looking for more.
Then I get back to the hotel and turn on the TV. Guess who is on CNN live. Right. Paul Baldyga. Same tie, too. It’s like some freaky Hitchcock film or something.
I have a friend that sits on the ACEP Council – which votes on resolutions and policies for the College. He told me that they did a poll of all the councilors asking whether health care was a right. Reportedly 49% of more than 300 physicians in the meeting believed that health care is a right.
That just amazes me. Then the thought just popped into my head. If health care really is a right, why don’t people who are refused health care file civil rights lawsuits against health care providers? If health care is a right in this country, those who don’t receive their right should have some recourse.
I sat through several lectures and the content was excellent. The quality of speakers at the conference has thus far been excellent. Thom Mayer is brilliant.
Met the Plaster family at the EP Monthly floor display. It looks like Mark – author of the Night Shift series – will start putting up some posts in the Call Room, too. Between ERP and Mark, I think I’m going to get muscled out on talent. Do have to admit that it was cool hearing someone mention what a great writer this “WhiteCoat” guy was while I was standing right there. Hopefully he didn’t see me kick the ground and say “aw shucks.”
Miss the family already. Junior WhiteCoat got in trouble in school and was hoping that I’d still bring him a souvenir.
Even got a cool picture of the Boston sunset.
Life is good.
Added bonus: My hotel is 1.5 blocks from a kickass Japanese restaurant. Sushi for dinner!
Posted in Uncategorized | 22 Comments »
Saturday, October 3rd, 2009
Leaving for the ACEP Conference in Boston and won’t be back until next week.
Posting will probably be light.
Stop by the EP Monthly exhibit and say “Hi” if you get the chance.
Posted in Uncategorized | 4 Comments »
Friday, October 2nd, 2009
A patient wanted me to drain a sebaceous cyst that was causing pain on his back. I told him that it would be better if it was removed intact by a surgeon, but he didn’t want to wait to have it done. OK, no problem.
I got out a needle to anesthetize the area, the patient took one look at the needle, and he nearly DFOed on the floor. Got all sweaty and nearly puked. We had him lie back on the table, but he couldn’t lay flat on his back because the cyst was hurting. So he laid on his side – facing the nurse.
I told him that I was going to start numbing up the area. Then I looked at the nurse whom he was facing toward, gave her a smile and a wink, and mouth the words “Now he can puke on YOU!” I made the universal puking hand gesture while sticking my tongue out just to emphasize my point.
The nurse curled up her lip at me and moved down toward the foot of the bed a little further.
I leaned over and cleansed the surface of the cyst, started to inject some of the lidocaine and then that old lady karma smacked me in the head.
As I was injecting, the extra fluid apparently increased the pressure inside of the cyst. The point of the cyst popped open and spit lidocaine and cyst fluid all over my face.
Got sebum in both eyes, up my nose, in my hair.
You can’t imagine what sebaceous cyst fluid smells like until you get some of it stuck to your nasal hairs. Like someone cracked an egg in an old tennis shoe and let it sit in the heat for a couple of days.
I sat over the sink flushing my eyes with water. I even squirted saline up my nose to get rid of the smell. Didn’t work. Sucked on mint Life Savers and all I could smell all day was peppermint Nikes. I didn’t even try to eat lunch.
When I walked out of the dirty utility room, the nurse was just standing there with a smirk on her face.
Laugh it up, sister.
Just remember that Karma Avenue is a two-way street.
Posted in Patient Encounters | 18 Comments »
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Healthcare Update 10-17-2009
Saturday, October 17th, 2009Myth or no myth? Does a full moon cause more ED visits? I don’t care what the studies say. On nights of a full moon, the freaks are out in full force. Why do you think they call it lunacy?
Suck it up, America! Why are doctors becoming slaves to patient satisfaction scores?
Great discovery request, there Perry Mason. Michael J. Trentalange, a Florida medical malpractice lawyer, requested 75 years of incident reports before having his colonoscopy performed at Florida’s St. Joseph Hospital. He wanted to know “how many people [at the hospital] get perforated colons during colonoscopy” before having his own procedure done. Oh, and by the way, he’s also representing someone who died from sepsis after sustaining a perforated colon.
He didn’t limit his request to just colonoscopies, though. He wanted every single incident report in the hospital. Why? His response: “I could have a family member contemplating another procedure.”
The hospital sued him over his request. More doctors and hospitals need to fight back against BS like this. And people wonder why lawyers get a bad rap.
Phil Howard from Common Good scores an article in the Wall Street Journal about “Why Medical Malpractice is Off Limits” in the health care reform debate. Does it have anything to do with the fact that trial lawyers are “amoung the largest contributors to the Democratic Party”? One interesting quote:
We can’t sue our way to better health care.
Another interesting tidbit from the upcoming book “Architects of Ruin” regarding why tort reform isn’t part of health care reform. Several trial lawyers filed a class action suit against Citibank for rejecting a black woman’s loan application. The basis of the suit was that “racial bigotry, not poor credit histories, explained high rejection rates among minorities applying for mortgages.” Four years later, the case settled. The plaintiff received $60,000. The lawyers received $950,000 – more than 15 times as much money as the plaintiff. Among the lawyers receiving those fees was a young gent named Barack H. Obama.
Paging Dr. Scumbag … An emergency department physician steals a Presidential Rolex watch off the wrist of a patient who had just died from a heart attack. Busted by hospital security cameras and fired on the spot. Also indicted by a grand jury for the theft.
Who is at fault? A patient gets sedated for brain surgery and waits on the table for the neurosurgeon … who is out of town attending to an “urgent family situation.” The head of the department refused to do the surgery in his place. Among the things that the hospital and doctors are getting cited by JCAHO for is “the doctors operating did not pause to stop and check that they were operating on the right part of the body.” Was there some transrectal approach to brain surgery that I didn’t learn about?
Insurance doesn’t equal access. Another study out about the Massachusetts “insurance for all” program shows that “unless access to health care improves, many people will continue to treat emergency rooms as a substitute for a primary care doctor” and that “access problems in the community may play a significant role in ED use in Massachusetts.” Sounds like a plan. Let’s replicate this on a national level. Just what we need as more emergency departments close nationwide. Cue grandpa talking to grandson … “Yeah, sonny, I remember back when we only had to wait 9 hours to see a doctor in the emergency department.”
A powerful article in New America Media giving personal examples of how the richest country in the world can’t provide for the care of its citizens. What’s the answer?
Grady Memorial Hospital shuts its free dialysis clinics. Ninety patients in the program have nowhere to go. Many of the patients are illegal immigrants. Now the hospital is trying to ship the patients to other states so that they can get the dialysis they need. Hospitals can only provide free care for so long. A sign of things to come.
That’s why we call them “patients.” Canadian Health Minister Maureen MacDonald encourages people in Dartmouth General Hospital to “be patient” as the government “emergency room adviser” figures out how to solve the apparently recent development of hospital overcrowding. Here’s a hint: Step one is to bring a good book with you … maybe two.
Interesting point on the health care reform debate in Maine’s Kennebec Journal. The US fares poorly in the “quality of care” categories such as infant mortality and life expectancy, but the US does very well in success of medical treatment. Additionally, according to the WHO, the US is ranked highest among all countries in “responsiveness” of health care – how fast patients receive the care they need. Don’t foresee that statistic being favorable much longer.
Today there’s a double feature. Head over to ER Stories to see the Swine Flu version of the HealthCare Update.
Posted in News Commentary | 28 Comments »