Archive for April, 2010
Tuesday, April 13th, 2010
If you read this blog regularly, you know that I am an advocate of free market medicine. Force medical providers to advertise their prices like all the other businesses, let insurance cover catastrophic costs instead of everyday costs, and let market forces go to work.
In order for the free market concept to work, though, we have to get rid of the third party obfuscation, though. Right now, not many people care about the cost of a product because they aren’t paying for it. Third party “middlemen” are paying for the product.
I read a post on Kevin MD’s blog that puts free market principles into play.
Take all of those who are suffering from low back pain. You want to know if something might be wrong. Do you need an MRI? That depends. Is the pain acute or chronic? Are you having any “red flag” symptoms? Will you be willing to undergo surgery if something is wrong? You may need to see a primary care physician to see whether an MRI is warranted.
That’s another thing I would change with the system, by the way. Do away with the concept of requiring a physician’s order to obtain testing. You want an x-ray? Go to the radiology department, plop down your credit card, and get your x-ray. We can buy pregnancy tests, HIV tests, and glucose testing supplies over the counter, why can’t be buy urinalysis test strips or tests for strep throat? Why do we need a doctor’s order to have blood testing done? Don’t give me the song and dance about the dangers of x-rays, either. We allow tobacco companies sell lung rockets to any patient with a nicotine addiction as long as the packets have a label stating that the surgeon general has determined that cigarette smoking is bad for your health. Everybody is hereby warned that the surgeon general has determined that excess radiation is bad for your health. Done.
It would make the practice of medicine a lot easier and a lot less expensive if we didn’t erect so many barriers for patients to get testing done. Sorry about the tangent. Off the soapbox and back on topic.
Let’s say you get the prescription for an MRI of your low back. You lost your job and lost your COBRA coverage. You have to pay for everything out of pocket and you know how expensive MRIs can be. Where do you go to have your back MRI done? According to LesliesList.org, you can have your MRI done at Northwestern Memorial Hospital in Chicago for$3800 plus the cost for the radiologist to interpret the films.
Or, if you want to have the exact same test done at the Lincoln Imaging Center in Chicago, according to LesliesList.org the test and reading fee together would cost you $325. That’s more than a twelvefold difference in price … in the same city … for the same exam.
Now maybe you want the university radiologists to read your scan and you’re willing to pay extra. Or maybe the Lincoln Imaging Center sees that the prices it is charging are too low and increases them to reflect the market pricing. The whole point is that prices will take care of themselves once customers begin voting with their feet and their wallets.
Hopefully LesliesList.org will be one of many resources that patients can use to decrease the costs of medical care.
Thumbs Up. We need more sites like this.
Posted in Funding Crisis, Insurance | 31 Comments »
Monday, April 12th, 2010
 A 52 year old intoxicated lady gets brought in by ambulance after getting in a fight with her ex-boyfriend. She had been thoroughly punched and kicked in her face. Both of her eyes were black and blue and were significantly swollen. One eye was swollen shut, the other was open just enough so you could see the subconjunctival hemorrhage about her iris. One of her teeth was knocked out and her breath smelled like someone poured Pabst Blue Ribbon and rotten eggs into someone’s sneaker and then she drank out of it. Literally corrosive.
She went into the bathroom, looked in the mirror and began bawling. “I look like a Star Wars character!” I had to admit that she made a good analogy given her rather impressive blood alcohol level.
Later in the evening, I went to tell her about the results of her CT scan and walked in the room to catch her and her new boyfriend in the midst of a passionate french kiss while laying on the bed. The thought of Wookie breath made me retch.
Can’t you wait until your shuttle takes you back to Naboo, there Chancellor?
Posted in Patient Encounters | 9 Comments »
Sunday, April 11th, 2010
 Since we were with other family members this weekend, we decided to take a trip to a museum.
As we walked through the exhibits, we stopped to read descriptions of all the displays.
My 9 year old nephew was becoming impatient because he wanted to see more exhibits and spend less time reading about them. So he began ad-libbing some of the descriptions as we walked through.
“Lion – King of the Jungle. Eats men if they get in his way.”
“Giraffe – tallest animal in the wild.”
“Wild ass – named for a person’s butt.”
The best description was of the orangutan …
“Prehistoric woman – this is what women looked like before they invented hair care products.”
Posted in Random Thoughts | 7 Comments »
Friday, April 9th, 2010
Also see the Satellite Edition of this week’s update over at ER Stories.
Miami Medical — a successor to the “ER” series? This critic says “not”.
Another consideration for infantile seizures in the emergency department … licking the plate after mommy got done cutting up her crack cocaine for sale.
Canadian attorney calls for criminal investigation against emergency department staff after patient death waiting in the emergency department.
In other news, emergency department staff calls for criminal charges against government that won’t provide sufficient emergency department resources.
Georgia passes hospital tax to fund state’s budget shortfall with Medicaid patients. Tax hospitals more so that you can turn around and pay them a little more to take care of Medicaid patients?
How does a physician specializing in palliative care respond when she is diagnosed with terminal breast cancer? The answer might surprise you. Read the compelling story here. Also see the commentary in which the physician’s husband clears up misconceptions in the NY Times article at Buckeye Surgeon’s blog. Even more compelling. She sounded like a wonderful and compassionate lady.
Why was this man standing in a restaurant parking lot punching himself in the face before going to a hospital emergency department? Even more perplexing … he wasn’t drunk. The surgeons fixed the problem – and it wasn’t a laughing matter.
Open pricing and free market will decrease utilization. “We know how much electricity costs us and we know how much our groceries cost, but, as patients, costs of our healthcare remain vague … The complexity of the medical and billing systems have prevented consumers from understanding how best to utilize healthcare options to contain costs.” Researchers surveying 1500 Massachusetts employees determined that patients who were informed about the costs of care tended to use doctors offices more and emergency departments less. “More transparency about costs of healthcare services could help both employees and employers contain their respective expenditures on health services.”
Only fly in the ointment is access to care. How can you decrease emergency department utilization if there aren’t enough primary care providers?
Not guilty? Good. Now lets get out of here. Jury in medical malpractice case reaches verdict in 5 minutes. Plaintiff attorney complains that the quick verdict undermined the plaintiff’s right to a fair trial.
Illinois Supreme Court justices that overturned malpractice reforms now may have a new problem … keeping their jobs. Four of the seven justices are up for retention this year. Sixty percent of voters must choose to retain them or they won’t get their jobs back.
Largest medical malpractice judgment in the history of Tennessee awarded to woman and her husband last week. A jury awarded Bette Donathan and her husband more than $22 million after surgery for the woman’s fractured leg left her partially paralyzed. Medical staff inserted an epidural catheter to help the woman with post-operative pain control. Ms. Donathan was taking blood thinners at the time and the catheter caused a spinal bleed that left her paralyzed from the waist down.
This judgment tops the previous record-setting judgment in Tennessee of $12 million awarded less than 12 months ago.
With costs at 25% of the total state budget and patient loads expected to double in the next 2 years, Florida legislators try to control costs by putting all Medicaid patients into managed care programs. Legislators are considering a program that would pay private companies a set fee for covering all necessary medical services for a set patient population – similar to an HMO.
I give those companies about 6 months until they pull out. If payments to providers are abysmal, then few providers will want to take care of them. What happens when the patients can’t find a primary care physician (or don’t want to wait for a primary care appointment) and just go to the emergency department? The theory of an HMO is that there is a financial penalty if you go out of system or if you go to the emergency department. HMOs aren’t the answer when patients don’t have any financial disincentive to go outside of the system. Costs will just continue to rise.
The $2,374 bandage. Treatment for a cut in an emergency department gets a rather surprising bill. The person receiving the bill wasn’t “freaking out about it” because the insurer paid for it. The comments section to the blog has an interesting discussion about free market system in medicine.
Posted in Healthcare Update | 15 Comments »
Thursday, April 8th, 2010
I keep a list of medical blogs sorted by category over in the righthand margin. If you have a medical blog and want it listed, please e-mail it to me at whitecoat-at-epmonthly-dot-com and I will add it to the list.
During down time over the past week, I had an opportunity to read some blogs that I haven’t visited as regularly as I used to.
First, I’m saddened to say that almost all of the blogs that motivated me to start blogging are now gone or dormant. While they’re gone, they’re definitely not forgotten:
MonkeyGirl – my official big sis who still can’t distinguish impotence from emergency departments
Nurse K – now carrying a clipboard and working for JCAHO
Scalpel – sipping tropical drinks somewhere on an island after opening an acute care clinic and getting out of the ED
Ten of Ten – stresses of administrative medicine became too great
PandaBear, MD – now working as an advisor to the Republican party
ER Nursey – blog boarded up and vanished from the blogosphere
Only one of my original motivators still remains: GruntDoc. I’m sure that more people visit his blog than visit mine, but in case you’re one of the few that has things backwards, add him to your list of daily reads.
But below are some of the blogs that have had some good posts of late that are definitely worth a read.
Girlvet posts regularly about her interactions with patients. She’s sassy, on point, and makes some kick-butt jewelry to boot.
StorytellER Jim already won two friggin Medblog Awards and he’s only been writing for 5 months. Read through his patient stories and you’ll see why.
If you miss Graham Walker’s old blog at OverMyMedBody!, you’ll be happy to know that he’s blogging again over at ACEP’s blog The Central Line. Lots of good content there now from a lot of emergency physicians.
The ACP Internist blog has also grown its content significantly and has lots of good commentary about medical studies and articles. Keep up the good writing!
GuitarGirl is up and blogging again. I thought she stopped blogging. Welcome back!
Tex keeps churning out the parody songs about the ED. He also has a lot of good patient stories. One of the nurses in my department recently sent me a link to one of his songs about “50 ways to get free pain meds.” I wrote her back and said “Hey! I read that guy’s blog!” If you want to sit at your computer and laugh all afternoon, a complete list of his songs is here.
SerenityNow Hospital still makes me laugh on a regular basis.
A friend recommended Lockup Doc’s blog – written by a psychiatrist in a correctional institution. Well written posts about the profession and an inside look at correctional centers.
I don’t know how Ramona Bates is able to keep up all the informative posts about surgery while making amazing quilts and still running a plastic surgery office. Just don’t stop.
And let’s not forget one of my favorite non-medical blogs — CrankyLitProf. So she drops f-bombs once in a while. She still makes me want to go back and be a student teacher just so I could go have beers with her and laugh.
Posted in Random Thoughts | 10 Comments »
Tuesday, April 6th, 2010
 Just read about a case involving the next step down the slippery slope of criminal prosecution of physicians.
First Michael Jackson’s physician gets prosecuted when his physician gives him an unintentional overdose of an anesthetic medication when trying to help him sleep. According to a previous discussion on this topic, most people seemed to think that prosecutors were justified in those charges.
Now, Dr. Mathew Wallack is being criminally investigated for illegally prescribing excessive doses of narcotics.
Who should be responsible when a patient dies from an overdose of medication and a physician allegedly prescribes “too much” of that medication? Oh, and how do we define “too much”?
Then who should be responsible for making sure that patients aren’t getting multiple prescriptions from multiple physicians – which could result in an overdose and death?
Then who should be responsible if physicians don’t have access to that information – preventing them from determining whether their prescription, combined with the patient’s other prescriptions, may lead to overdose and death?
Then who should be responsible if physicians prescribe a one-month supply of medications and the patients take them all within a week and die?
This is why I think criminal prosecution of physicians who make mistakes is a bad idea. We may be able to pick out the “outlier” cases that might warrant criminal prosecution, but should we subject those practicing medicine to criminal prosecution by using vague definitions? Take their licenses away. File civil actions against them. Jail time shouldn’t be part of the paradigm.
The further we travel down the road of criminalizing medicine, the more difficult it will become to draw a line between what is and is not considered “criminal” behavior … and the fewer physicians that will want to practice medicine.
Posted in Medical-Legal, News Commentary | 56 Comments »
Monday, April 5th, 2010
Maintaining our sanity in the emergency department sometimes means that we do silly things like giving patient reports in an Arnold Schwarzenegger voice, talking like a pirate, or repeatedly singing “Pants on the Ground.”
No one thought too much of it when one of our nurses started a new trend by in the nursing station by spontaneously saying “mmm-huh” after every sentence.
“It’s going to get up to 70 degrees today, mmm-huh.”
What’s wrong with you?
Nothing at all, mmm-huh.
So I started thinking. Did I say mmm-huh to someone? Was this some new YouTube video or song that I hadn’t seen or heard yet? What started this new little fad?
Grabbed the next chart and went into see a little old lady who came in with mental status changes.
I walked through the door. “Hey there, I’m Dr. WhiteCoat. I understand you aren’t feeling quite yourself lately?”
The patient didn’t answer.
The patient’s family member was in the room and said “She hasn’t been acting right lately, mmm-huh.”
I looked over at her. “Are you a relative?”
“I’m her daughter, mmm-huh.”
At that point I felt my face get red and had the incredible urge to laugh. I held the chart up in front of my face while I was writing. I got myself under control and started asking the patient questions even though she wasn’t answering me, so her daughter wouldn’t keep talking. Her daughter butted in anyway.
“She hasn’t mentioned any weakness to me, mmm-huh.”
My upper lip started to quiver and all I could do was fake a cough and say “hmmmm.”
At that point the ED tech came in to draw blood. He accidentally dropped the tourniquet on the ground. That was the excuse I needed. I busted out laughing.
Everyone looked at me – even the patient. I tried to stop laughing, but I couldn’t. Every time I thought I had it under control, I’d start laughing again.
“Sorry, but it’s kind of a running joke how clumsy Jeff can be at times.”
He looked at me as if to say “What the hell are you talking about”?
I just laughed more.
Once I was done in the room, I walked out and the nurse was standing at the nursing station with a smug little grin on her face.
“How did it go in there, mmm-huh?”
“You are so gonna get it … mmm-huh.”
Posted in Patient Encounters | 12 Comments »
Sunday, April 4th, 2010
It is appropriate that this incident happened in the early morning hours of Easter …
A guy gets brought in by ambulance when he was found “unresponsive” in the front yard by two relatives. According to one of the relatives, all had been drinking to celebrate the Easter holiday. Didn’t know Easter was one of those “drinking” holidays, but that is beside the point.
Relatives called 911. The ambulance arrived within minutes. As the paramedics rolled up to the scene, their headlights illuminated one man laying on the ground flailing his legs, another man holding his arms and pinning him to the ground, and a third man doing chest compressions on the flailing man.
“Thank GOD you guys are here!” says Moe.
“Is he stable now?” asks Larry.
“F***ers! Now my chest hurts!” yells Shemp.
“Looks like you saved him,” says the paramedic – between giggles. “We need to take him to the ER, STAT!”
Thirty minutes later … a lobby full of inebriates wanting to know if we’re going to transfer him to a specialty hospital.
I hereby refuse to work the night before Easter anymore.
Posted in Patient Encounters | 7 Comments »
Saturday, April 3rd, 2010
Suppose you want to try out a new Windows program but you don’t want to mess up your registry. Or suppose you need Windows XP to run a program, but you don’t want to install Windows XP on your computer. What if you want to leave absolutely no traces of your computer activity? Or maybe you want to use a program but aren’t sure if it has a virus.
There are a lot of uses for “sandboxing” operating systems or programs. Here are three free programs you can use to protect your computer.
Microsoft Virtual PC is an updated version of a product that was initially introduced by Connectix. Virtual PC is a program that runs virtual hard discs on your computer. You create a virtual hard disk, then you install an operating system just as if you were installing the operating system on your regular computer. Once the system installation is complete, you can open a window and run an operating system within your operating system. I routinely run Windows XP (and even Windows 98) from my Windows 7 machine. You can choose the amount of disc space and memory to allocate to the program in the preferences. If you don’t want to save the changes to your virtual system, then you can just make a menu choice when you shut down the program and any changes will be discarded.
Virtual PC is incorporated into Windows 7 Pro, but you can get almost the same functionality for no cost by downloading Virtual PC 2007.
Sun VirtualBox works in a manner similar to Virtual PC with a few differences. First, VirtualBox is open source software. Virtual PC is proprietary (although still free to use). VirtualBox runs on Windows, Linux, Macintosh, and Solaris where Virtual PC only runs on Windows machines. Virtual Box commits all changes to the virtual operating system when you exit the system – you don’t have the choice to abort the changes like you do with Virtual PC. I get around this shortfall by making more than one copy of my virtual disk image and saving the “originals” in a zipped folder so they don’t get corrupted. VirtualBox also allows you to install more operating systems than Virtual PC – including Windows, DOS, Solaris, and OpenBSD where Virtual PC is limited to installing Windows (it is still possible to install Linux systems on the Virtual PC platform).
Finally, Returnil Virtual System takes a little different approach to virtualization. Instead of creating a program window with a virtual system,Virtual System creates a clone of your current operating system and all of your activity takes place on this cloned system. If something happens and you want to erase the changes, you simply restart your computer and the system returns to the most recently-saved clone. Paid versions of Virtual System also allow you to save changes to your actual hard disk if you so choose. This system is a nice option if you want to see whether drivers will cause a problem with your current system configuration or if you want to try a program on your system without worrying about how the installation files will change your registry.
I have used all three of these programs and they all work well. As is shown in the screen grab above, I can run Windows 7 on my base computer, Linux Ubuntu on one program and Windows XP on another program – all at the same time.
All of the programs I have mentioned are available for free, although Virtual System also has several paid versions requiring yearly licensing fees from $29 to $39 per copy.
Disclosures: I get nothing from any of the companies for this post.
Posted in Computers | 7 Comments »
Friday, April 2nd, 2010
ERP from Erstories.net here for a quick post while White Coat is out for a little while.
Some people have bad luck. I mean, it is bad enough luck to fall down in the bathroom when you are 70 years old because you don’t get around so great any more. But to fall onto an old-style toilet paper holder and have it impale you in your perineum, penetrating through into the vagina really is horrible.
And no, get your minds out of the gutter – this was not one of those “I don’t know HOW this could have happened!!” excuses when someone inserts some foreign body into an orifice and has to make up some weird story. She just had bad luck – for real!
Luckily she was successfully patched up in the OR.
Posted in Patient Encounters | 18 Comments »
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More on Criminalizing Medicine
Tuesday, April 6th, 2010First Michael Jackson’s physician gets prosecuted when his physician gives him an unintentional overdose of an anesthetic medication when trying to help him sleep. According to a previous discussion on this topic, most people seemed to think that prosecutors were justified in those charges.
Now, Dr. Mathew Wallack is being criminally investigated for illegally prescribing excessive doses of narcotics.
Who should be responsible when a patient dies from an overdose of medication and a physician allegedly prescribes “too much” of that medication? Oh, and how do we define “too much”?
Then who should be responsible for making sure that patients aren’t getting multiple prescriptions from multiple physicians – which could result in an overdose and death?
Then who should be responsible if physicians don’t have access to that information – preventing them from determining whether their prescription, combined with the patient’s other prescriptions, may lead to overdose and death?
Then who should be responsible if physicians prescribe a one-month supply of medications and the patients take them all within a week and die?
This is why I think criminal prosecution of physicians who make mistakes is a bad idea. We may be able to pick out the “outlier” cases that might warrant criminal prosecution, but should we subject those practicing medicine to criminal prosecution by using vague definitions? Take their licenses away. File civil actions against them. Jail time shouldn’t be part of the paradigm.
The further we travel down the road of criminalizing medicine, the more difficult it will become to draw a line between what is and is not considered “criminal” behavior … and the fewer physicians that will want to practice medicine.
Posted in Medical-Legal, News Commentary | 56 Comments »