Archive for March, 2010
Wednesday, March 17th, 2010
ERP here from Erstories. A little quick post while I am out skiing.
Yes, I admit I get a little juvenile on occasion during a shift. Other staff members do as well and I think this is a good thing. It lighten things up. A little silly laugh because someone said something that conjures Beavis and Butt-head – style snickering helps our blood pressures come down. Of course there is a fine line between jokes and harassment but if everyone laughs when someone says something that is unintentionally of sexual connotation, who would complain?
Some of the things I have heard or had said to me:
“Hey ERP, do you have a measuring tool”?
“Who was that new doctor? He pissed me off by getting all up in me.”
“Holy Moly, it is busy. I have never seen such a patient load.”
“Yes, Doctor Newbie, I can help you get that DVD into the slot.”
“Hey ERP, the new patient in room 5 has priapism, go help him take care of it.”
People need to lighten up in the work place. Sometimes things are just funny!
Tags: ERP
Posted in Funny | 12 Comments »
Wednesday, March 17th, 2010
A middle aged woman walked up to the emergency department registration window and loudly announced that her mother was in the car and needed help.
Several people ran out to the car to assist the woman’s mother. It appeared that her mother was suffering from ATATPA. Unfortunately, she also weighed at least 300 pounds and … she was dressed in a nightgown.
The patient was awake and was looking around at everyone, but she wouldn’t get out of the car. We asked the daughter what was wrong with her and the daughter told us that her mother was moaning at home. Sadie, the patient, had suffered a previous stroke so she couldn’t talk to us, but she would moan and nod her head every once in a while. No matter what we said, Sadie wouldn’t get out of the car.
Sadie’s daughter had come back out to the car and loudly asked “Well? Isn’t someone going to help my mother?”
We couldn’t coax Sadie out of the car, so, after several minutes of trying to do so, one of the techs and one of the security guards grabbed Sadie by the arms, pulled her out of the car, and eased her onto the ground. Then we scooted her onto a backboard, lifted her onto a stretcher, and wheeled her into the emergency department.
Once Sadie was in the bed and her vital signs were taken, she moaned – just like the moan that she had while sitting in the car. Her daughter got up and stood next to her, rubbing her arm. Then she said,
“Can you believe that they dragged you onto the ground like that? How humiliating. Did that security guard hurt your arm? He did, didn’t he? I’ll have to have a talk with his supervisor.”
At that point, Sadie moaned again. This time I think it was from all the other people in the room simultaneously gritting their teeth.
I left a voice message with the security guard’s supervisor giving him a head’s up and letting him know that the security guard did everything right.
Still, the fact that we even have to worry about covering each others backs like this just goes to show you that sometimes you can’t win for losing.
Posted in Patient Encounters | 10 Comments »
Tuesday, March 16th, 2010
 In addition to calling it the “ER,” using cell phones in said “ER,” and engaging in baby talk, we can now add “scientific studies” like this to the list of things that drive me friggin batty.
The American College of Radiology published this study that purported to analyze the “appropriateness” of outpatient CT and MRI scans ordered from primary care clinics at an academic medical center.
In the study, researchers at the University of Washington used “appropriateness criteria from a radiology benefit management company” to determine whether CT scans and MRIs ordered by the lowly primary care physicians met “criteria for approval.”
Then researchers compared studies that did meet “criteria for approval” with those that did not meet “criteria for approval” and found that 26% of the studies ordered were considered “inappropriate.” The authors listed several examples of “inappropriate” studies such as obtaining a brain CT for chronic headache, obtaining a lumbar spine MR for acute back pain, ordering knee or shoulder MRI in patients with osteoarthritis, and ordering a CT for hematuria during a urinary tract infection.
Here’s the thing, though. The study states that “only” 24% of the “inappropriate studies” had positive results and affected patient management. In other words, if the researchers had not performed the “inappropriate studies”, they would have missed clinically significant findings in a quarter of patients. The conclusion of the “study” is that because the sensitivity of appropriate studies is higher than that of inappropriate studies, primary care physicians need help to “improve the quality of their imaging decision requests.”
Want some help? Here’s some help for you: Stop the Monday morning quarterbacking and create a policy at your academic institutions so that none of the lowly primary care physicians can obtain a diagnostic radiology test without the esteemed radiologist’s approval. Lowly family practitioners can order the tests and you researchers just veto them when they cross your desk. Think of all the money and wasted testing you’ll save. Oh yeah … then you can be legally liable for the bad patient outcomes when you don’t allow the test.
Why doesn’t one of you suggest that as an official ACR policy at your annual meeting in April?
Those tests don’t look quite so “inappropriate” when you don’t have the benefit of a retrospectoscope, do they?
P.S. Have family practitioners ever done a study to determine how many of the additional radiographic tests recommended in a radiologist report (i.e. “hip fracture present, cannot rule out pathologic fracture, recommend MRI and bone scan”) were retrospectively “appropriate”?
Posted in Medical Studies, Random Thoughts | 18 Comments »
Monday, March 15th, 2010
I read this article and was going to put it in the next healthcare update, but decided to make it a separate post.
Immediate organ donation from the emergency department.
You’re involved in a serious car crash, the trauma team attempts to save you, but you end up dying. Instead of your body getting whisked off to the morgue, they take you to the operating room and harvest your organs.
Ethically, will doctors be doing their best to save patients, or will they be sizing up trauma victims to see which ones would make good organ donors? One ethicist in the article calls the concept “ghoulish.”
This is a tough call, but I lean more to the side of providing more organs.
That’s what I would want for someone else if I was the trauma victim.
Posted in Policy | 35 Comments »
Friday, March 12th, 2010
Little ol’ Marge came waddling up to the registration desk asking to see a doctor because she was urinating blood. In tow behind her was her obviously unhappy husband who was making it clear that the reason for his unhappiness was his wife’s trip to the emergency department.
“Great. Now we can sit in the waiting room so people can cough on us,” he said at the triage desk.
Marge and Charlie finally made it back to a room. Marge was having painless hematuria that began around dinner time. Painless hematuria in an elderly person generally isn’t a good sign. Through the whole history and physical exam, Charlie kept shaking his head and nose breathing.
When Marge gave us a urine sample, it was a medium shade of red in color.
“See what I mean?” She asked.
Charlie shook his head again. He’s going to have some serious guilt when this is all over.
While they were waiting for the lab results, Charlie hobbled to the bathroom. After the toilet flushed, he came out with even more of a frown. He walked back in the room and yelled at Marge.
“You HAPPY?!?! Now I’m pissing blood too. I told you before we left that it was the beets we ate for lunch. Now I got tuberculosis from sitting in the waiting room and we’ll get a thousand dollar hospital bill because you … don’t … listen!”
Charlie was right, it did end up being the beets.
This little interaction reinforced two firmly held beliefs of mine.
First, I will never willingly eat beets in my life.
Second, sometimes half the battle in medicine is asking the right questions.
Posted in Patient Encounters | 18 Comments »
Thursday, March 11th, 2010
I had planned to log on and write a quick post reminding docs that they have less than a week to decide whether or not to remain a participating provider in Medicare in the face of 21% payment cuts — and to encourage docs to drop Medicare.
Wait. Seven months of foregoing 21.2% cuts to physicians costs the government an extra $100 billion.
That means that 12 months of foregoing cuts would cost $171.4 billion (divide $100 billion by 7, multiply by 12)
Dividing $171 billion by 21.2%, we get a total Medicare payout to physicians every year of $808.6 billion dollars.
Mrs. WhiteCoat gets paid about $70 for an average office visit for a Medicare patient – usually after having to pay her office manager for a couple of hours of time to figure out why Medicare refused to pay the first three times the claim was submitted. Let’s round up. Say Medicare pays $100 for an average doctor visit. Dividing $808.6 billion dollars total physician payments by $100 per doctor visit means that the total number of doctor visits – just for Medicare patients – is a little more than 8 billion per year.
Eight billion visits divided by 50 million patients means that every single Medicare patient is seeing a doctor an average of 161 times per year – more than three times per week every week for the entire year.
Look at it another way. Dividing $808.6 billion by 50 million Medicare patients means that physicians are being paid an average of $16,172 each year for every Medicare patient in the country.
So what are all of us rich doctors complaining about?
How about politicians who are full of hot air.
Where’s the money really going?
Posted in CMS, Medicare, News Commentary | 23 Comments »
Wednesday, March 10th, 2010
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Dirtbag emergency department technician steals credit cards from plane crash victim’s wallet while other personnel try to save the man’s life. Then he buys himself some Armani clothes using the patient’s credit cards while the patient is dying in the hospital.
HIPAA violations that occur for personal gain are punishable by up to $250,000 in fines and 10 years in prison. You’ll have to make an awful lot of license plates to buy an Armani shirt in the Big House, there dimwit.
Emergency nurses: They’re overworked, underpaid, they get spit on, kicked, threatened with scissors, and are the front line for disasters. You’re paying them less than surrounding hospitals. Now their benefits are getting cut. It’s a tough economy.
When there aren’t enough specialists willing to provide on-call services, patients often have to be transferred to other facilities for specialty care. In some cases, finding a hospital with a proper specialist that is willing to accept a patient in transfer can take a long time. This patient with aortic dissection wasn’t able to get timely transfer for surgical repair and a suffered cardiac arrest before the dissection was fixed. An emergency nurse noted that the receiving hospital refused to accept the patient because he had no insurance. Now the patient is blind and disabled. Who’s to blame? The system? The hospital? The physician? The patient? (thanks to Max Kennerly for the link)
You hospitals want to save money? Stop treating low income patients in your emergency department. After implementing its Urban Health Initiative, the University of Chicago doubles it operating profits for the year. During that same time period, ED visits dropped 22% and admits dropped 8.5%.
One problem, though. If more hospitals take this approach, where are the poor patients going to get the more “mundane” medical care?
Minnesota Governor Tim Pawlenty suggests that one way to cut health care costs is to change federal EMTALA laws so that “not every ER is required to treat everybody who comes in the door, even if they have a minor condition.”
He’s now getting flamed all over the internet. See here, here, and here for examples.
The thing is, EMTALA laws don’t require every “ER” to treat every patient. Hospital emergency departments are only required to provide a screening exam to everyone and to treat emergency medical conditions. Pawlenty already has his wish, and it’s not so radical, folks. To wit: (I saw that phrase in a lawsuit brief and am getting a kick out of using it, so leave me alone)
More hospital emergency departments are jumping on the “pay before you see the doctor” bandwagon. Burke Medical Center in Georgia stated that it was “following the trend of other facilities” when it implemented a policy of paying your insurance co-pay or $100 before receiving treatment. If you don’t pay and don’t have an emergency condition, you’ll be given a list of outpatient clinics where you can go for care.
In the same vein, do doctors in America turn away the uninsured? Absolutely. Read this HuffPo article to get a good idea of how and why. Good insights.
Nebraska physician advocates personal responsibility as one way to improve this country’s health care problems. I agree.
“Do you know where your son spent the night?” College students go to emergency departments for intoxication and college calls parents to narc on them. “Sent to the hospital.” “Alcohol poisoning.” “Not the first violation.” The schools also call home every time a student is caught with alcohol. Some schools allege that “telling mommy” decreases the amount of binge drinking on campus, but isn’t there some type of privacy issue going on there, though? What’s next, a voice mail message at mom’s work if you don’t finish your carrots in the cafeteria?
If an administrator did this to me when I was in college, I would have followed him all over campus and followed him home, calling his mommy and his wife every time he rolled through a stop sign or looked at me crosseyed. Then I would have written an article to the school newspaper chronicling all of his transgressions. Then I would just randomly go to his office with a notebook, wait in the waiting area, sit there writing for 30 minutes at a time, then get up and leave. Can’t be too careful about those college administrators, you know.
Reserved parking for the four pronged canes to the left, leave your brown paper bags of medicine on the counter. A geriatric emergency department – the wave of the future or a flash in the pan? Will they remain viable with Medicare cuts to physician payments or will hospitals use them as a loss leader to draw in patients for more profitable procedures?
Posted in Healthcare Update | 58 Comments »
Tuesday, March 9th, 2010
Come on. Allergies to fresh fruit and vegetables?
Guess all the chemicals used in processing are good for the immune system.
Posted in Uncategorized | 12 Comments »
Sunday, March 7th, 2010
I’m in Washington DC doing some lobbying for emergency medicine.
It’s near the end of the day and I’m sitting at a conference surfing the internet between lectures.
I log in to this blog to jot down a quick post. As I’m writing, I get the feeling that I’m being watched. I look over my shoulder and there’s some guy watching me type. He remarks “YOU’RE WhiteCoat?!?!?”
I close up my computer. “Not cool, buddy,” I said.
After the lecture I’m walking back to my hotel room and this guy starts walking next to me trying to make small talk. I get out my phone and pretend like I got a phone call. He still doesn’t get the hint.
I walk in the hotel lobby and down the hall to the room. The guy stops in the lobby.
As I get to the door of my room, I hear the phone ringing. I got inside and walked over to answer it but it stopped ringing before I got there.
I tossed my bag on the bed and went to the bathroom. While I’m in there, someone knocks on the door.
“Dammit. Who is this guy?” I think to myself.
I get done in the bathroom, flush the toilet and hear someone say.
“He’s in there. I just heard him flush the toilet.”
Screw this. I grabbed my computer bag, opened up the window and started to climb out onto the fire escape.
Then someone grabbed my shoulder.
I yelled.
The security guard yelled.
“Wake up you lazy ass. There’s a patient with a toothache waiting to be seen.”
I sat there with a blank stare.
“You didn’t answer the phone and you didn’t answer the knock on the doctor’s lounge door. What’s the matter with you? There’s a patient.”
Damn. Why couldn’t I have made it out that window a little quicker?
Posted in Random Thoughts | 12 Comments »
Friday, March 5th, 2010
Question: Do you believe in “universal coverage”?
Answer: “Oh, sure. Look, it doesn’t make a lot of sense for us to have millions and millions of people who have no health insurance and yet who can go to the emergency room and get entirely free care for which they have no responsibility, particularly if they are people who have sufficient means to pay their own way.”
Can’t embed the video here, so you’ll have to go to MSNBC and start the video at about 5:35 to cut to the chase.
Hospital emergency departments provide medical care to patients just for the heck of it with no expectation of payment? Businesses just give you services and you don’t have to pay them for it? Great business model! Why didn’t I think of that?
In fact, I like that business model so much that I’ve decided to go to Massachusetts to take out a loan at a bank. Then I can get some “entirely free money for which I have no responsibility.”
On the way, I’ll stop at a car dealership where I can get an “entirely free car for which I have no responsibility.”
And I’m going to enroll my kids in some Massachusetts colleges where they can get an “entirely free education for which they have no responsibility.”
Oops. Better watch what I say before I get thrown in the Gulag.
Don’t laugh, using Mitt Romney’s logic, the “emergency room” docs in Massachusetts are already there.
Posted in News Commentary | 22 Comments »
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After hearing 
Medicare Cuts Delayed Again — PHEW
Thursday, March 11th, 2010That means that 12 months of foregoing cuts would cost $171.4 billion (divide $100 billion by 7, multiply by 12)
Posted in CMS, Medicare, News Commentary | 23 Comments »