Archive for November, 2009
Sunday, November 29th, 2009
Grandpa was brought in by ambulance after being found “unconscious” on the floor of the kitchen. He either got the deal of a lifetime on candy canes at Walmart that night or he hit the peppermint schnapps a little too hard. His garbled sentences and my diagnostic acumen led me to choose the latter reason for his reported unconsciousness. He was moving all extremities, was saying “please” and “thank you” and didn’t have any signs of injury. We hooked him up to a monitor and let him sleep it off.
Grandpa’s wife comes to the window wanting to know how grandpa is doing. She’s bawling and howling and throwing her hands up in the air. One whiff of her confirmed that she must have eaten some candy canes, too. Grandpa’s wife was 40 years younger than Grandpa. After Mrs. Grandpa calmed down, we let her back to be with her husband.
Then a female and male who also live in Grandpa’s trailer with Grandpa and his wife come to the window, also smelling of eau de peppermint. They were let back to see how Grandpa was doing.
The two females get into an argument in the room. Young male walks out. Female friend follows him out into the hall, yells “HEY!” and pulls up her shirt when he turns around. He leaves anyway. Female friend then goes back into room and starts tongue kissing Grandpa on the ear, making wife mad. They start yelling again and both are asked to leave. Wife walks out. Female friend objects to leaving, saying that she’s “not being ignorant” and that she’ll “leave when she wants to, bitch.”
Security is called, but cannot come because security is fighting with another patient up on the floor who was admitted for intractable vomiting, who has not vomited once since she was admitted, and who was infuriated because her boyfriend was not allowed to sleep in the bed with her. Instead of enduring the horror of sleeping alone for the night, she decides to “sign the f#@$ out of this f#@$ing hospital.”
Emergency department secretary calls police. Female friend hears secretary call police and makes untoward comment about secretary’s mother. I tell female friend to leave now. She flips me off and yells “F#%@ YOU!” I tell her that now she has to leave AND she can’t come back. “Nyahhh nyahhh.” Everyone watching what is happening laughs.
Female friend then points her finger at me and says “I’ll wait for YOU after work.” Because her sentence was ambiguous regarding the term “work,” I had a puzzled look on my face as she was escorted out the door by the nurse. Did her pepperminty dog breath and tongue kisses to Grandpa’s ear constitute her “work” for the evening and she was seeking to meet me when she was finished? Or did she want to meet me when I was finished with my shift to carry out some nefarious yet-to-be-mentioned plans? Looks like I might need to request a police escort out of the hospital when I was done with my “work” – just to be safe.
In the parking lot, police showed up and female friend got all Jerry Springer with one of the officers. She was dragged, kicking and screaming, into a waiting car by Grandpa’s wife and was performing pantomime performances of her favorite four letter words in the passenger window of the vehicle as she was being driven off the premises.
Police then walked into the waiting room and arrested someone sitting there on an outstanding warrant. Because the offender was due to have surgery on a broken hand the following day (and he had his preoperative papers with him), they let him go.
Police officer put his last $5 into a vending machine for a Diet Coke and the machine ate his money. Belch. Staff took up a collection of quarters so that he could purchase what amounted to a $6.50 bottle of soda.
Just another night in the emergency department.
Can’t wait to see the patient feedback scores.
Posted in Patient Encounters | 7 Comments »
Saturday, November 28th, 2009
From the steamy comment section of Nurse K’s blog comes IglooDoc’s link to an article showing how a state agency in Arizona is heading in the right direction in the war on drugs.
Effective Tuesday, the Arizona Department of Economic Security started performing urine drug testing on individuals whom officials had “reasonable cause” to suspect were using illegal drugs. Get caught using and you’ll lose your welfare check for a year.
Before you start applauding, the requirement has a lot of loopholes:
The test only happens when you reapply for assistance — it is not a random test.
When you do reapply, apparently “reasonable cause” is determined by peoples’ answers to a three question questionnaire. I’m bubbling over with anticipation to see how many people will answer “yes” to the “do you use illegal drugs” question.
If you are one of the unfortunate few to be selected to take the urine drug test, you have to submit your sample within ten days – by which time it is likely that, if you can control your habit for that long, most drugs will be out of your system anyway.
So the Arizona requirement is largely toothless, but at least it is a step in the right direction.
There was an e-mail going around not too long ago saying that if working people are subject to random drug tests while earning money at work, people who are earning money from welfare should be subject to the same random drug testing. Don’t want to give up your civil liberties and privacy to the contents of your bodily secretions? Then don’t take the money.
Now if only more state governments would get the hint.
Posted in News Commentary, Policy | 31 Comments »
Friday, November 27th, 2009
Premature baby dies, then goes missing for 6 days. The infant’s body was mistakenly put in a pathology department refrigerator, being mistaken for an ice pack. Rrrrright.
In other news, the hospital pathology department is congratulating Ms. Deborah Peel on delivering twins — a baloney sandwich and bottle of Evian.
In still other news, JCAHO has now banned all refrigerators from hospitals as a patient safety measure so that things like this don’t happen again.
What’s a few more rads of radiation between friends? New studies are showing that chest CT scans are effective at ruling out heart attacks. Between 80 and 90 percent of patients getting either CT scans or radionucleotide scanning were found to have clean coronary arteries and were able to be sent home. CT scans were just faster and less expensive.
Memorable ED survey quote: “After seeing the bill for your services, I needed your services again.” This anesthesiologist expresses sticker shock at how much he was charged for a trip to the ED for a face laceration. Hey pal, during the birth of our last child, the fee an anesthesiologist charged for my wife’s epidural wasn’t exactly a bargain, either.
Can you guess the amount of the bill? Hint: one of the charges was $360 for a tetanus shot with a wholesale cost of $27 (and why is an anesthesiologist buying tetanus boosters, anyway?). Of course, the hospital bill was “barely understandable” — a pet peeve of mine which I think is a crime in itself.
Coming to a neighborhood near you? Feds and states slash budgets for mental health care. As a result, more patients with mental illness are put back out on the streets. Police then respond to remove patients from camping out in condemned housing or to investigate complaints about paranoid schizophrenic patients that walk the streets yelling at children to the point that parents won’t let their children play alone outside. Police arrest some patients on “disorderly conduct” charges just so that the patients can get plugged back into the mental health system.
On the horizon? You guessed it. More budget cuts ranging from 10-30%
Wonder if the same budget cuts would occur if mental health patients were released in the lawmakers’ neighborhoods … maybe walked up to their kids while waiting for the school bus … said “Hi” to them … wearing a placard that said “I’m on early release from a mental health facility due to state budget cuts.”
Where are Mulder and Scully when you need them? British scientists trying to learn more about the new deadly infection that is killing victims in the Ukraine and turning their lungs black “like they have been burned.”
AMA is “uneasy” in support of ObamaCare, but goes along with the charade anyway.
In other news, AMA members becoming “uneasy” in support of AMA.
Really … it’s all about protecting patients from bad doctors. A Las Vegas patient gets a $5.75 million arbitration panel award when she developed reflex sympathetic dystrophy in her arm after a surgery. A law passed in Nevada limited the contingency fees that lawyers can receive and was applied retroactively, so the patient’s attorney got “only” $800,000 from the settlement. Now former med mal plaintiff attorney Robert Vannah is suing, stating that he should receive $2.3 million instead of that measly $800,000. According to the article, he now refuses to let his firm take any more medical malpractice cases.
In other news, Mr. Vannah was reportedly later seen pouting, kicking his rattle across the sidewalk, and stomping his feet up and down on the courthouse steps.
This medical malpractice plaintiff is being sued by the City of Grand Rapids, Michigan. The patient dove into shallow water and suffered a spinal cord injury. Later he settled a medical malpractice claim for about $2 million. After attorney’s fees, the patient was left with … oh … about $16.27. Ooops. No. Sorry. This case was in Michigan, not Las Vegas.
Anyway, Grand Rapids had a taxpayer-funded plan that covers medical expenses for employees and their dependents which paid for most of the patient’s care. Now Grand Rapids is suing, stating that it is entitled to recover the money that it spent in caring for the patient. Former Las Vegas med mal plaintiff attorney Robert Vannah had no comment on the matter.
“Dead or in jail.” Sobering statistics from upstate New York. Young victims of violence brought to the emergency departments will, on average, return three times. Within five years, 20% of those teenagers will be dead. Hopefully the new interventions undertaken in NY will change these statistics.
A Colorado company is marketing an iPhone app called iTriage that “allows people who are experiencing sudden health problems to look up likely diagnoses and then find the closest appropriate medical center to get treatment.” Apparently, the program works quite well. Type “sore throat” and “nausea” into the application and it instructs you to go directly to the nearest cath lab.
The American Association for Justice is now working on a partner application called “iNeedAPlaintiffAttorney” for when the iTriage program gives you wrong advice.
Congress is now going to regulate emergency medical helicopter transports. The number of deaths during helicopter transport increased from 7 in 2007 to 29 in 2008. The number of transports has substantially increased, so the “accident rate per hour flown” has been relatively steady despite the increased number of deaths. Studies show that “pilot error, bad weather, darkness and difficult terrain” contribute to 75% of all helicopter accidents. The NTSB recommends night vision gear, terrain avoidance equipment, and cockpit data recorders in all helicopters to improve safety.
In other news, JCAHO has demanded that hospitals remove all storm clouds, trees, and mountains within a 10 mile radius of patient transport areas as those things constitute patient safety threats.
Posted in Healthcare Update | 46 Comments »
Wednesday, November 25th, 2009
 The Lung Flute.
Interesting concept. A small reed within the contraption vibrates when a patient blows into the mouthpiece and the vibrations are transmitted into the lower lungs, changing the viscosity of sputum in the lower airways. Video of the device in action is here.
Seems odd that such small device would have such a significant effect.
Call me crazy, but I’d try to come up with a better name than the “lung flute”. Maybe something cool like the “mucinator” or something scientific like a “mucociliary clearance device.”
I just couldn’t see writing an order for a stat “lung flute” to a patient’s bedside.
.
Also check out the Littman 3200 stethoscope. For a mere $700+, you can upload patient heart sounds via Bluetooth to a computer and use the included computer program to analyze the tones for arrhythmias and for murmur analysis. Video here. The device is reportedly much more sensitive than a physician’s ears at picking out abnormal heart sounds.
Which leads me to the question … if this device is so much better than physicians at hearing murmurs, then why do they still put earpieces on it? They just ought to sell the handle portion with its computer screen readout.
Maybe they’re planning to turn it into a hybrid device – like a telephone. Put the earpieces in your ears and talk into the bell to answer pages when you’re not listening to patients’ hearts.
Or maybe it will sync up with your iTunes account so you can pretend like you’re listening intently to a murmur when you’re really jamming to Linkin Park.
Wonder if they make a hack for it to check e-mail.
Posted in Medical Studies | 9 Comments »
Tuesday, November 24th, 2009
 John Ritter died from a ruptured thoracic aneurysm. His family sued the emergency physicians for allegedly failing to treat him quickly enough.
Now another celebrity is suing emergency physicians. James Woods, brother of deceased Michael J. Woods, is suing a hospital and its emergency physicians for failing to treat Mr. Woods quickly enough.
Michael Woods went to the “fast track” part of the emergency department complaining of nausea and a sore throat. He began “sweating profusely” told doctors that he was having an “anxiety attack.” A doctor in the “fast track” side of the emergency department examined Mr. Woods’ throat and then sent him to the main emergency department when his throat was not inflamed.
When taken to the emergency department, the nurses attempted to give him medications and he stated “Stop doing this, I don’t need all this. This is ridiculous.” Eventually he allowed the medications to be given. An EKG was performed that showed “alarming” changes (that were never fully described in the articles) and cardiac monitoring was ordered, but the rooms with monitors were all full. Mr. Woods was then placed in a hall gurney next to the nurse’s station. Ninety minutes later, Mr. Woods slumped over in his bed and went into cardiac arrest. CPR was performed for nearly a half hour, but he was not able to be resuscitated. A coroner’s report showed that Mr. Woods had severe cardiovascular disease throughout his coronary arteries.
Experts alleged that Mr. Woods should have been placed on a monitored bed immediately and that the failure to do so cost Mr. Woods his life.
From what we are being told, this is just another example of a fallacy being fed to the jurors. There is nothing special about cardiac monitors. They alarm if there is an arrhythmia. They don’t warn medical providers of impending heart attacks or cardiac arrest. By putting Mr. Woods on a monitor, all that would have changed is that the medical staff may have gotten to him 30 seconds earlier when he slumped over in his bed.
From the testimony described, the care that Mr. Woods received was by no means perfect. The law doesn’t require “perfection.” The law requires that medical providers act “reasonably.” How do we quantify “reasonableness” when emergency providers are overwhelmed with patients or when there are not enough supplies available to meet the needs of patients?
What is reasonable in the midst of chaos?
I just hope that jurors keep the “reasonableness” standard in mind when deciding this case.
A link to multiple posts about the Woods trial, being held in Rhode Island, can be found on the Providence Journal site at www.projo.com using this link:
http://news.beloblog.com/cgi-bin/mt/mt-search.cgi?blog_id=1078&tag=Michael%20Woods
Posted in Medical-Legal | 34 Comments »
Monday, November 23rd, 2009
 A guy comes in for evaluation of rectal bleeding.
After dealing with patients like this, I have a healthy respect for people who complain about rectal bleeding.
The first thing I noticed was that he had changed out of his pants and into a gown. His bloody underwear were sitting on the floor. Not good.
“I just woke up this morning and thought I crapped my pants. Instead, there was a bunch of blood there.”
Nothing abnormal in his history. His vital signs were normal. Nothing abnormal with his physical exam … until I got to the rectal region.
A whole lot of blood and clots were present. When I wiped those away, I saw the reason for all the blood.
He had an inch-long laceration and some bruising to his perirectal area. Nothing abnormal on the inside as far as I could tell and his stool had no blood, so damage was probably limited to the outside.
“Ummm. Were you putting anything up there?”
“WHAT!?!? NO! That’s disgusting!” There was a moment of awkward silence while I turned to wash my hands. Then he continued.
“I think I know what happened, though. I was cleaning out my shed yesterday and was pulling old bottles off of a shelf to throw them away. Some of the broken glass probably fell into my mouth and I swallowed it. It must have cut me this morning when it came out the other end.”
Uh huh. And I’m Dr. McDreamy.
Use latex products next time.
Posted in Patient Encounters | 10 Comments »
Sunday, November 22nd, 2009
If you haven’t done so, please take a few minutes to complete the survey about health care patient satisfaction surveys located at the following link:
If you have already taken the survey, thanks!
Posted in Uncategorized | 11 Comments »
Friday, November 20th, 2009
The director of our group was called to the administrative offices to explain why our Press Ganey scores had dropped eight percentage points. A slightly larger than normal proportion of patients rated us as “good” rather than “excellent” for the past couple of months. Now the hospital wants answers.
It wouldn’t be so bad if the hoops we had to jump through were rationally related to the care that we are providing. They aren’t. The things that are useful measures such as “quality of care” and “medical decisionmaking” are intangibles that can’t be measured and plugged into a spreadsheet. Try it. Describe what “quality care” is and then figure a way to quantify it.
Is quality care adhering to published guidelines? What if there aren’t any guidelines for your patient’s situation?
Does quality care amount to less complications than the other practitioners in your specialty?If so, then a large percentage of physicians will cherry-pick healthy patients who are less likely to suffer complications. What happens to doctors who care for the severely ill patients?
Maybe quality of care is equivalent to low cost. If we use that definition, then we’re going to be creating an incentive for doctors not to order “unnecessary tests” and not to find diseases. The old saying goes “if you don’t go fishing, you won’t catch any fish.”
It is nearly impossible to come up with a quantifiable definition of “quality care.”
So what happens? In some specialties, we allow our worth as physicians to be measured based on data that can be quantified: Our ability to make patients happy. When speaking specifically about emergency medicine, the measurements don’t start there, though. First, the system throws patients into situations that tend to make people mad or frustrated — in need of medical care and forced to wait, sometimes for an excessively long time, with a bunch of other people who are also in need of medical care — THEN we start measuring physician worth.
Sometimes patient happiness isn’t related in any way to the physician’s care, but the staff gets blamed anyway.
There are the creature comfort complaints like “the room was too cold” or “the food was horrible.” Patients may get blankets, but sometimes decreased satisfaction scores still carry over to the provider side of the survey.
Then there’s the “I saw my doctor the next day and he said that you should have given me antibiotics for my cold.” Great. The follow up doc is both a backstabber and an idiot. Doesn’t matter that the patient would have gotten better even if the doctor prescribed soap suds enemas because nothing is going to make a viral infection go away except time. Nevertheless, the physician providing medically appropriate care gets lower marks because of another doctor’s inappropriate medical treatment.
There are other examples, but you get the picture. The best similarity I can come up with is using a ruler to measure how cold it is outside. The instrument you’re using has little bearing on what you’re trying to measure.
Then I did some studying and found out additional information about patient satisfaction surveys in general.
To get an adequate sample size, for 1000 patients, you need about 280 respondents to have a 5% margin of error and you need 400 respondents to have a 1% margin of error. That’s between a 28% response rate and a 40% response rate for statistically valid data. Larger sample sizes need less response rates, but these numbers are just to give a general idea. Know what the response rate for a well-known patient satisfaction survey company is? Between 8% and 10%.
Then there’s the statistical term called “standard deviation.” The bell curve for any data set can vary. If 10% of people taking a test each got grades of 10, 20, 30, 40, 50, 60, 70, 80, 90, and 100, then the bell curve would be very flat and wide like a sprawling hill. If 10% got grades of 45, 80% got grades of 50 and 10% got grades of 55, then the bell curve would be very steep and narrow like the Washington Monument. The steeper that the bell curve, the less variation in the data. Often patient satisfaction data has a very steep and narrow bell curve. Therefore a small change in the data from one facility – such as a few more people than usual rating you as “good” rather than as “excellent” – can have a profound and potentially misleading effect on where your facility falls on the bell curve.
So I’ve decided to create a survey of my own … about the surveys.
Please pass along the link to your friends and colleagues. I’m looking for input from patients, administrators, and health care professionals. The more input, the better the results. There are at most about 20 questions, so it shouldn’t take more than 5 minutes to complete.
I’ll publish the updated results on this site weekly for the next few weeks.
By the way, please make sure that your answers are accurate since you’ll be asked different questions based upon what answers you give. I want to try to make the results as reliable as possible.
THANKS!
Posted in Policy, Random Thoughts | 18 Comments »
Thursday, November 19th, 2009
A 39 year old male with a 1 pack per day smoking habit presents with acute onset of shortness of breath and right-sided chest pain. You obtain an x-ray that is shown below. What is the diagnosis?
If you said “pneumothorax”, you’re right.
You decompress the pneumothorax using a Cook catheter and Heimlich valve. You hear a rush of air through the needle as the patient breathes out. You obtain a second chest x-ray to confirm that the lung is re-expanded. The result is shown below. Now what is your diagnosis?
Scroll down for the answer.
.
.
.
.
.
Bullous Emphysema with Pneumothorax
When I initially saw the second x-ray, I was going to put in a second chest tube, suspecting that part of the pneumothorax had become walled off or loculated. Then I saw small septations in the right lung field and conferred with the radiologist who agreed that there was no further pneumothorax present.
Absence of lung tissue is noted in the right lower lung field in the first x-ray.
In the second chest x-ray, a small catheter can be seen in the right lateral 5th interspace. The remaining lung tissue is expanded, but multiple large bullae remain in the upper lung field, simulating a persistent pneumothorax.
See additional information about bullous emphysema here: Link #1, Link #2, Picture link
Posted in What's the Diagnosis? | 2 Comments »
|
|
Drug Testing Welfare Recipients
Saturday, November 28th, 2009From the steamy comment section of Nurse K’s blog comes IglooDoc’s link to an article showing how a state agency in Arizona is heading in the right direction in the war on drugs.
Effective Tuesday, the Arizona Department of Economic Security started performing urine drug testing on individuals whom officials had “reasonable cause” to suspect were using illegal drugs. Get caught using and you’ll lose your welfare check for a year.
Before you start applauding, the requirement has a lot of loopholes:
The test only happens when you reapply for assistance — it is not a random test.
When you do reapply, apparently “reasonable cause” is determined by peoples’ answers to a three question questionnaire. I’m bubbling over with anticipation to see how many people will answer “yes” to the “do you use illegal drugs” question.
If you are one of the unfortunate few to be selected to take the urine drug test, you have to submit your sample within ten days – by which time it is likely that, if you can control your habit for that long, most drugs will be out of your system anyway.
So the Arizona requirement is largely toothless, but at least it is a step in the right direction.
There was an e-mail going around not too long ago saying that if working people are subject to random drug tests while earning money at work, people who are earning money from welfare should be subject to the same random drug testing. Don’t want to give up your civil liberties and privacy to the contents of your bodily secretions? Then don’t take the money.
Now if only more state governments would get the hint.
Posted in News Commentary, Policy | 31 Comments »