Mark Plaster (R) and Father Jim Boynton ride through Port-au-Prince in the back of a pick-up
January 26: Where there are no doctors
Yesterday we just drove down the road and found an open area where we could set up a triage station. We pulled out a tarp, some line to hold everybody back, and just let people come through. We laid out our meds on a table and then just worked through the crowd. Most of the injuries were pretty minor but a couple of them were major, broken bones and such. We probably saw 3 or 4 major cases that morning.
Our team is going to places that haven’t had doctors yet. A man told us that a week ago he’d told the UN that they needed help out here but no one had come out yet. To be honest, I had no clue where we were. We drove about a half hour into the heart of Port-au-Prince, a very poor area, people living in tin huts and surviving off of Coleman camp stoves. But I also saw some big, wealthy houses around here. Some of them have fallen down. If it was poorly built it fell down and smashed people. The construction is terrible; they don’t have any construction rebar, they build with cinderblocks and they only have these tiny wires going through them. Even homes that look well made may only have a thin skin of concrete on the outside. One more aftershock and they may come down.
I haven’t made contact with the navy yet. We wanted to get a feel for what we needed and how difficult it was going to be. So far it looks relatively simple. Right now we’re just trying to find the people who are most sick. There are a lot of people coming in complaining of back aches that they’ve had forever, but since there is a doctor here they all show up.
We had a surgery team show up Sunday and they heard [that there was a need for surgeons]. They went to four different hospitals and all four said that they had all the surgeons they needed and refused to give them any space. Operating space is very limited. These guys are working very hard, 8am to 10 at night.
I’m concerned about follow-up. I asked one doc what he was working on and he told me that he was putting on external fixatures. When I asked him who would be taking these fixatures off, he said, “I don’t have any clue.” When I asked him what had happened to the patient he had just put a fixature on, he replied that she “went back out and lay on the ground.” Somebody, someplace is going to have to take that fixature off and they won’t have clear information on when it was put in. We’re talking 4-6 weeks down stream somebody has to take over these cases and they’re not even in the hospital. A lot of them have been lost to follow up. Like the little girl I saw today: the bandage I put on her will probably be the last bandage she gets.
Some states are having difficulty finding enough physicians to provide needed specialty care to patients who come to the emergency department. If a patient needs neurosurgery or trauma surgery and there is no one on staff that is able (or willing) to perform the necessary services, then the patient must be transferred to another facility. Sometimes the waits involved in arranging and performing the transfers can lead to bad outcomes for the patients involved.
In a recent Healthcare Update, I mentioned an article about Oklahoma legislation providing tax credits to physicians to provide on-call care.
A friend forwarded me an e-mail from ACEP that listed several states which are contemplating tax credits for on-call care.
Hawaii has a bill that would provide physicians who provide at least 576 hours of on-call services per year with a tax credit totaling 5 percent of the physician’s liability premiums. For a policy premium of $30,000 per year, the credit would be $1,500. Another bill in Hawaii would waive medical licensing fees (usually several hundred dollars) for physicians who treat more than 20 percent Medicaid patients. Missouri considered a bill that would exempt Medicaid payments from a physician’s state income tax (currently 6%). Keep in mind that Medicaid reimbursements are generally low, so the benefit isn’t as significant as the bill would make it seem. In a chart I have from 2006, Missouri paid a whole $15 for managing a high complexity (life threatening) patient in the emergency department – the same as it paid for treating a kid with a runny nose. In the entire country in 2006, Missouri reimbursed the least for providing high complexity care in the emergency department. By 2008, the rates it paid were up to $20.23 for low complexity and $60.01 for detailed complexity patients – a little more than half of what Medicare paid for the same patients. Oklahoma’s Senate Bill 1604 would provide a $100 state tax credit per day for on-call emergency coverage in rural areas – to a maximum credit of $5000 per year.
So what do you think?
What do you think about providing tax credits to physicians for performing on-call emergency department care?
I'm not a physician and it think it's a GOOD idea (62%, 78 Votes)
I am a physician and these tax incentives wouldn't make me want to provide more on-call care (24%, 30 Votes)
I am a physician and I would do more on-call care if I got these tax incentives (10%, 12 Votes)
I'm not a physician and it think it's a BAD idea (4%, 5 Votes)
The earthquake in Haiti has created a tremendous need for donations and support for the Haitian people. Emergency Physicians Monthly took the mission to heart. Editor Mark Plaster, MD went to Haiti and has been assisting in the relief effort since January 24.
In addition to my posts, I’m going to add Mark’s notes and pictures to this blog. They are a captivating insight into what is happening on the ground in Haiti.
The first edition is below.
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January 25: Getting to Work
When we got off the plane, Port-au-Prince was almost completely black. There is almost no light here. We unloaded the aircraft ourselves and it was just a giant scramble getting all the bags off. We had bags in seats and the inside of the aircraft was total chaos. It was shocking that we got all our gear off. We were met by a team Rubicon leader named Jake Wood, a 6′ 5″ ex-marine sniper who was now a medic. On his own, Jake had decided to come down to Haiti and help out. He’d grabbed a couple friends – some people he didn’t even know – grabbed some sleeping bags and flew to Santo Domingo, DR. They rented a car and just drove in to Port-au-Prince. They made a connection with a Jesuit Mission and just camped out in the mission yard and started seeing patients as fast as they could. They were cutting off limbs in the field . . . it was pretty chaotic when they first arrived. That’s when Jake Wood notified his father back in Michigan that they could use a second wave of team Rubicon. The team coalesced from all over the country – California, Texas, New York – and none of us know the other guys at all. We all just showed up and it’s been amazingly well organized. The team leader down here, Gary Cagle, is a medical logistics guy who worked with the U.N. He was able to put together a 501-c-3 in a matter of about four days and he raised about a quarter of a million dollars in order to bring a team down here and get the job done. So they showed up at the airport, we off-loaded all our gear and came over to the Jesuit Mission, everywhere was pitch black. They told us to throw our sleeping bags down on the ground and they’d introduce us in the morning when we could see everybody. All night long I could hear planes coming and going because the runway was so close. I could also hear babies crying, but it wasn’t until the next day that I learned that this was because the Jesuit mission is a refuge for the homeless.
Team Rubicon Bravo lines up for a photo before heading to Haiti.
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The Jesuit Mission itself is a gorgeous old Spanish-style building, but it is unusable. It’s about to fall down and nobody can actually go in it. It’s a tragedy. Everyone is now living and cooking out in the yard. There are about 40 of us here now but there is a whole group that is leaving today, surgeons who have been here for a while and have to go home. People are coming and going all the time. But it’s moving into a different stage at this point. We are now seeing wounds that were handled by people 5-10 days ago. I just took care of a little girl, probably three years old, who had her leg amputated traumatically and we were just cleaning up and redressing her wound. Whoever handled it initially didn’t try to do a true amputation they just kind of cleaned up the wound and took the rest of the leg off. We’ve seen fractures – I just treated a guy with a lower leg, tib fib fracture that was never set, never seen by anybody. Somebody just got him some crutches and he’s been limping around with an untreated fracture ever since. We’re using cardboard and duck tape to stabilize his fracture because it’s too late; we can’t get it to set at this point. The surgeons at the local hospital operated until 10pm last night and they had another 200 cases waiting for them. There’s a lot of open fractures down here, a lot of orthopedic work.
(pictured: Team Rubicon leaders Jake Wood (L) and Larry Cagle)
One serious problem down here is the lack of follow-up. Some docs are putting in external fixators, but they are leaving them with nobody scheduled to follow it up. A lot of people are walking around with X-rays and medical records and hoping that at some point somebody will take the bars off their legs.
Today we drove away from Port-au-Prince and found a place to park under some trees. We’ve got two trucks out here and just set up a bunch of chairs to see people. The people have been very obedient and calm, we just have to make sure we’re not passing out food and water. We don’t see starvation but people are certainly not happy. But at the same time in Port-au-Prince people are coming back out. They can be seen sitting outside eating and drinking.
A recent EMedHome Clinical Pearl sheds some light on the alleged relationship between “allergies” to radiocontrast/iodine and seafood allergies.
The pearl noted that iodine is found throughout our bodies and is added to most kinds of table salt used in the United States. Our thyroid glands need iodine to function properly. While seafood contains iodine, the allergies to seafood are due to muscle proteins, not to the iodine.
Because reactions to IV contrast are not IgE-mediated, they are not considered “anaphylactic” or “allergic.” Sensitization does not occur since the reactions are not immune-mediated. In other words, your immune system won’t “remember” a prior reaction to contrast material.
Administration of steroids has no effect on whether a severe reaction will occur. Since the reaction is not “allergic”, Benadryl probably won’t have any effect, either – although this was not specifically stated in the study.
Severe reactions to contrast media occur in 0.02-0.5% of cases and deaths occur in 0.0006-0.006% of patients (something else to consider when deciding whether to undergo repeated CT scans), but serious reactions and death are not related to allergies to iodine/seafood or to prior reactions to contrast media.
Could appendicitis be a viral illness … or be related to a viral illness? A recent Archives of Surgery article raises some interesting questions.Researchers performed a retrospective analysis of appendicitis cases and compared them to incidence of influenza, rotavirus, and gastrointestinal infections. Using 40 years of data, they noted that general trends for appendicitis and influenza tended to parallel each other through the years, although influenza obviously had more predominance in winter months while appendicitis rates remained fairly constant throughout the year. No such correlation was found between rates of rotavirus and appendicitis.
Researchers also noted that appendicitis tended to occur in “clusters” – with several citations to appendicitis outbreaks.
Most interesting to me was that “perforating appendicitis” – where the appendix ruptures – and “nonperforating” appendicitis – where the appendix becomes inflamed but does not rupture – had no correlation to each other or to any of the infectious diseases studied. The researchers stated that “our epidemiologic findings suggest that patients who have perforated appendicitis have a different disease entity than those with nonperforating disease.” The problem now is figuring out which ones will rupture and which ones won’t.
This study makes me wonder whether the lack of elevated WBC count in so many appendicitis cases may be due to the viral effects of the disease. It also makes me wonder whether there is a correlation between elevated WBC counts and “perforating disease.”
I wonder how many physicians have been successfully sued for being negligent in “delaying surgery” and “allowing a patient’s appendix to rupture” when the ruptured appendix may have been due to factors beyond the physician’s control. Cerebral palsy litigation comes to mind. Until we can distinguish between the two types of appendicitis – if two types of appendicitis really do exist – the emphasis will on be removing a patient’s inflamed appendix regardless of the cause of inflammation. If there are really two types of appendicitis, how many unnecessary surgeries are being performed to avoid liability for missing an appendix that perforates? Very interesting starting point for more studies.
Also of interest is that a USA Today article which cited the study mentioned a USC surgeon who reported that 70 cases of CT scan-confirmed appendicitis went away when treated with antibiotics – which screws up the whole notion of the “viral illness” theory but certainly adds to the “everyone is going to die from MRSA” theory.
According to a Canadian journalist who was recently hospitalized, one of the biggest problems facing hospitals in Canada is getting patients to leave. She describes some problems she had with her roommates hogging the bathroom and hitting the call light too often. But with a large amount of tax money going to fund Canadian health care, she’s calling for a two-tiered system similar to England and France.
More evidence that insurance doesn’t equal health care. Rural senior citizens in Arizona are having difficulty finding physicians who accept Medicare. Doctors state that they are reimbursed about 55 cents of every dollar they bill for Medicare patients, and they have to hire additional office workers to deal with all of Medicare’s paperwork. Instead of dealing with the bureaucracy and the hassles, the doctors just stop seeing Medicare patients.
Adding to the problems … Arizona has cut funding for graduate medical education, so less training spots are available. Result for the patients with “insurance”? Waits for 6 weeks to 10 months to see a physician. Some drive several hundred miles to Phoenix and pay for a hotel room to get sooner appointments.
With the 21% Medicare reimbursement cut about a month away, seniors can expect things to get a lot worse. I won’t hold my breath for a 21% cut in Medicare taxes being taken out of our paychecks.
Can being a party animal help you succeed as a doctor? Extroverts tended to struggle with studies early on, then excelled in their training as they spent more time with patients. Neuroticism was a “constant predictor” of poor academic performance. Hmmmm. This study explains a lot of things about my younger years.
What are hospital operating costs per patient? About $2800 if you’re in Oregon. That totals about $7.5 billion per year which is as much as is spent in Oregon on schools, universities, prisons, police and social services combined. More and more of that care is becoming uncompensated or undercompensated, leaving hospitals “very definitely in trouble.”
The article even includes a breakdown of sample charges from Legacy Good Samaritan Hospital in Oregon including $203 to inject medication through an IV line and a $10.15 charge for a medication that costs less than 10 cents wholesale. The entire cost for a four day stay in the hospital for a colon infection was $12,674.
Sometimes you wonder why a mom brings her 6 year old daughter with cerebral palsy into the emergency department at 2:00 in the morning for a fever. What were they doing up at 2:00 AM anyway?
Sometimes you wonder whether parents even know how to take a temperature. The kid’s “fever” was 100.6 when she arrived in the emergency department.
Sometimes you wonder what you’re supposed to do when the mother tells the triage nurse that the child “isn’t acting herself.” How exactly are we supposed to test to see who the child is acting like that evening?
Sometimes you wonder why it always seems to take so long to get vital signs on children. How hard can it be?
Sometimes you wonder why the pulse oximeter doesn’t seem to work on kids. Her fingers are cold. We’ll get another reading when she warms up.
Sometimes you wonder if the techs even know how to use the pulse oximeter. What do you mean that the best oxygen saturation reading you can get is 78%?
Then you go into the room and notice that the child is only breathing 6 times per minute. And you notice that the child appears dusky. And you can’t feel a pulse.
Sometimes you wonder why things never seem where they should be on the pediatric code cart. Where is the damn Broselow tape?
Sometimes you wonder whether or not such a small Ambu bag can really deliver proper ventilations to an intubated child. Ventilate faster.
Sometimes you wonder how long it has been since someone checked the batteries on the intraosseous needle drill. Get rid of this thing and give me a Jamshidi needle. What do you mean “Where is it?”
As you do your best to keep the blips going on the cardiac monitor, and you see them come less and less often, sometimes you wonder what you’re going to tell the child’s family.
When you pronounce the child dead, sometimes you wonder whether your own children are safe and whether you told them you loved them before you left for work.
When the patient’s mother comes back into the room and you tell her that her child has died, sometimes you wonder how much sorrow a person can endure.
As you watch the mom sit in a chair holding her dead child and kissing her goodbye, sometimes you wonder what more you could have done.
When the coroner calls you the next day and says that the child died from overwhelming pneumonia in both lungs and that there was nothing anyone could have done to save her, sometimes you wonder whether he was just saying that to make you feel better.
Sometimes you even wonder why you ever wanted to be an emergency physician.
Then you remember all the people that you do save. And you try to remember all smiles that you have gotten from patients whose lives you have made better. And you try to remember that the power to heal that you’ve been given doesn’t work on every patient.
You try to remember that just because a child died at your hands, you’re still human and you did your best.
Had a recent patient encounter that just underscored the importance of Dr. Edwin Leap’s recent article on patient satisfaction.
A demented patient was brought by ambulance from the nursing home. He was allegedly short of breath, but, when asked, stated that nothing was wrong. He was clinically stable, we diagnosed him with pneumonia, and I told the patient’s family that I planned to admit him.
Even though his primary care physician was on staff, the family wanted him transferred to the university hospital because in the past when the patient was hospitalized for pneumonia, he got worse and had to be put on a ventilator.
I told the family that the patient was stable and that we had the capabilities to manage his pneumonia, so a transfer at this point probably would not be considered medically necessary. I told them that I would be happy to transfer him, but they would have to sign a federal ABN form stating that if Medicare did not pay for the transfer, the family would be responsible for paying out of their own pockets whatever Medicare did not pay.
The family didn’t want to accept the possibility of paying for the transfer, so they agreed to have him admitted to our hospital.
I got a nice little note from the attending that a few hours after the patient’s admit, his respiratory status worsened. Eventually he needed to be put on a ventilator. Even though we have an ICU and intensivists, the family demanded transfer to the university hospital. The attending transferred him to avoid further complaints. And the family made sure to get the proper spelling of that emergency doctor’s name so that they could write a letter of complaint.
When hospitals overemphasize the results of patient satisfaction surveys, it may come back to bite them.
Rather than deal with the hassles and potential complaints involved with doing the right thing, some docs take the path of least resistance and do things solely to please the patients. Then Medicare refuses to pay for tests/procedures/transfers that aren’t medically appropriate and the hospital eats the cost of the care. Guess who those costs get passed on to?
“[I]f being liked and producing satisfaction on paper is the end-game for this great adventure of medicine, then we are seriously off course, and we can simply throw out all research and focus on the science of pleasure. Medicine can become one great big house of ill repute.”
Couldn’t agree more.
The bigger question is: Will the house of ill repute take my insurance?
Mississippi GovernorHaley Barbour wrote this on his Twitter page, “Glad the Legislature recognizes our dire fiscal situation. Look forward to hearing their ideas on how to trim expenses”.
An administrative assistant at the University Medical CenterSchool of Nursing who had apparently heard from several UMC employees that the governor scheduled off-hour appointments for medical care then twitted back: “Schedule regular medical exams like everyone else instead of paying UMC employees over time to do it when clinics are usually closed.”
Several days later, the administrative assistant was accused of violating HIPAA laws and was “encouraged to resign.”
C’mon. The administrative assistant was passing on second hand information and didn’t even mention the governor by name.
And besides, it’s not like she told the world that Haley Barbour was going to a psychiatric clinic appointment to learn how not to make stupid suggestions on his Twitter page.
The hospital is stretching HIPAA laws way too far. False and/or uninformed allegations of HIPAA violations are becoming the new quick and easy way to get rid of employees. The lawyers providing the hospital with advice should be the ones fired.
Am I violating HIPAA if I redisclose that Lindsay Lohan is in rehab? I am a covered entity and the fact that she is/was in rehab is protected health information. How is this different from the Haley Barbour case?
Oh yeah, guess my job is in jeopardy because I mentioned that Conrad Murray provided propofol to Michael Jackson.
Oh, and I saw a patient … in the gift shop at my hospital … buying … throat lozenges … for a sore throat! Shhhhhhh. Don’t tell.
Then my car got hit in the parking lot, but I couldn’t call my insurance company to file a claim because, according to MUMC attorney logic, it is a HIPAA violation to disclose that the patient’s car was in the hospital parking lot.
So when families call University of Mississippi looking for a patient, do hospital operators tell you “we can neither admit nor deny the existence of this patient in our facility” to avoid further HIPAA violations?
Hey – rules are rules. [eye roll]
P.S. Mississippi Governor Haley Barbour allegedly goes to the UMC clinics after hours and the University has to pay overtime to employees for his routine physical examinations. Pass it on.
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A recent ![en_Appendicitis[1]](http://www.epmonthly.com/whitecoat/wp-content/uploads/2010/01/en_Appendicitis1.jpg "en_Appendicitis[1]")
Could appendicitis be a viral illness … or be related to a viral illness? A 
Good doctors say “No”
Monday, January 18th, 2010Emergency physician blogger Edwin Leap has a great post about patient satisfaction over at Kevin’s blog.
“[I]f being liked and producing satisfaction on paper is the end-game for this great adventure of medicine, then we are seriously off course, and we can simply throw out all research and focus on the science of pleasure. Medicine can become one great big house of ill repute.”
Couldn’t agree more.
The bigger question is: Will the house of ill repute take my insurance?
Now that’s some coverage.
Posted in News Commentary | 4 Comments »