Archive for June, 2010
Tuesday, June 29th, 2010
 Between about 6PM and 9PM on most Sunday evenings, our emergency department seems to become more crowded with kids and their parents. It used to be less because Sundays were school nights, but now that the kids don’t have to be in school the following morning, the numbers seem to be increasing.
I’ve also noted a trend in the presenting complaints.
You see, due to many court orders governing divorced parents with custody rights, said custody of offspring must change hands at some point in the week. In our county, it appears that the courts like the children to be transferred between parents at 5PM on Sunday evenings.
Of course, after being in the custody of that other evil parent all week (or all weekend as the case may be), the parent with the halo then notices a plethora of bite marks, bruises, fevers, scratches, ravages of vermin, and potential sexual assaults that were inflicted upon their children while those children were not under the watchful eye of the good parent. Emergency documentation of such evidence must be obtained immediately – both to prove that the alleged injuries occurred during the care of the transferring parent and to also prove that the alleged injuries did NOT occur during the care of the receiving parent.
The other problem with these visits is that they induce more visits. If mom is trying to prove that dad is not taking care of the kids, then when dad gets the kids back he sure as shootin’ is going to bring them to the hospital and get pictures to show that mom is really the one who is sexually assaulting the kid AND causing those bruises. As possession of the children changes, so does possession of the halo worn by the parents.
Normal exam. Check.
Alleged hyperdefecation. Check. No I will not say that it is because his mom spanked him. No I don’t want to see pictures of your toilet bowl and I’m not putting pictures of someone’s stool into the chart, either. Not once, not nevah. You can save those mementos and hang them on your fridge next to the calendar.
Normal exam. Check.
Alleged sexual assault. Normal physical exam. Check. No I can’t test for DNA to determine whether anyone’s fingers have been down there besides hers.
Skin rash – resolved. Check. No, there is not a rash there now and it does not matter if we shine a light on it. The rash isn’t there, ma’am.
Insect bite. Check. No it is not a rat bite and no he does not need a rabies shot. If you think her house has rats in it, call the health department. I don’t do house calls.
Bruise to shin from bicycle accident. Check. No I’m not commenting on whether you think his father knew he wasn’t wearing a helmet at the time. You weren’t there. No I’m not writing “severe” bruise. It’s not severe. You have to look at it twice to see it once. My kids have worse bruises than those.
Come to think of it …
Honey … how exactly do you discipline the kids while I’m gone?
Posted in Patient Encounters | 11 Comments »
Monday, June 28th, 2010
 A recent article in the New England Journal of Medicine touches off another salvo about how nonclinicians have no problems judging the abilities of clinicians in the world of medicine.
The article begins by presenting the case of a woman who awoke with facial paralysis and then went to the emergency department. On arrival, she received CT scans and MRI scans of her brain. When those were normal, she was diagnosed as having Bells Palsy. Two weeks later, she developed hair loss and other symptoms and it was found that during her first ED visit, the radiology department mistakenly exposed her to 100 times the normal dose of radiation for a brain CT scan. She now has a federal class action suit pending against the CT scanner manufacturer and a medical malpractice lawsuit pending against the treating physicians.
It appears that the case cited may be this one. More information here.
The author of this article then uses her own calculations to conclude that the “risk of cancer from a single CT scan could be as high as 1 in 80 — unacceptably high.” The study she cites shows that radiation doses for the same tests vary – as they should. Giving the same dose of radiation to a 90 pound grandma and a 500 pound grandson would result in at least one uninterpretable study. Based on the 4 hospitals they studied, they disputed the risk of cancer being 1 in 2000 from a CT scan and stated that the risk to a 20 year old woman from a single chest CT or single multiphase abdomen and pelvis CT could be as high as 1 in 80.
The paper advocates lessening and standardizing radiation doses for examinations, noting that the improved image quality obtained with higher radiation doses often has no change in clinical outcomes. Diagnostic accuracy would not be affected if the radiation dose were reduced by 50%.
The paper also suggests tracking a patient’s dose of radiation over time and including that measurement in the medical records. Great idea, but how is a radiation dose from someone living in California going to help me when the patient has a potential cervical spine injury in my town while she’s on vacation?
Finally, the author suggests that we need to reduce the number of CT scans being performed. Each year 10% of the population receives a CT scan and 75 million scans are conducted each year – with the rate growing more than 10% annually. At the heart of the increased number of scans is “increasing ownership of machines by nonradiologists” and the resulting “self-referral” which increases the use of the scanners. Those bastard non-radiologists. Only radiologists should be able to self-refer and get away with it.
In general, I think that Dr. Smith-Bindman is on point with her suggestions. It would be great if patients’ total radiation doses could be tracked throughout their lives. However, assuming that could happen, would a high dose of radiation make any difference in determining whether an 80 year old lady with abdominal pain got a CT scan? How about in determining whether a hypotensive unconscious 50 year old trauma victim should undergo CT scanning? What about deciding whether the obese 30 year old complaining of severe difficulty breathing should get a chest CT to rule out a pulmonary embolism?
Can we reduce radiation dose at the sacrifice of less clear scans? That’s a radiologist’s call. Is Dr. Smith-Bindman following her own suggestions? If we missed a small nodule that later became metastatic cancer, would the defense that “at least the patient didn’t get as much radiation” be a sufficient defense in a medical malpractice trial?
The suggestions are good, but they don’t apply to clinical practice.
In addition, while the FDA does regulate “radiation-emitting electronic products” including diagnostic x-ray equipment, telling patients how many diagnostic radiographic studies they may “safely” obtain is likely an area of mission creep for the agency – akin to regulating how many hours of television people may watch in a day (yes, television receivers emit radiation) or how many hours George Hamilton may spend under his radiation-emitting sunlamp. I’m not so sure that having the FDA limit the number of scans a patient can receive is a good thing.
I also take issue with Dr. Smith-Bindman’s statistics that demonstrate greater than a 1% incidence of developing cancer from a single CT scan. If 1 in 80 patients can get cancer from a single CT scan and almost 80 million CT scans are performed every year, each year we are causing close to 1 million cases of cancer in US citizens. According to the American Cancer Society, it is estimated that 1.5 million total cases of cancer will be diagnosed in the US in 2010. Is our use of CT scans really causing more than half the cases of cancer in the US each year? Even if we cut the incidence in half, causing 500,000 new cases of cancer each year is a hard allegation to substantiate.
While the number of CT scans is allegedly increasing at 10% per year, the number of new cancer cases in the US was 1.22 million in 2000 and is 1.53 million in 2010 – hardly an increase of 10% each year over 10 years. Those increases in new cancer cases also paralleled an increase in the population size – from 281 million in 2000 to 305 million in 2009. On a per capita basis, the incidence of newly diagnosed cancer went from 4.3 per thousand to 5 per thousand during those nine years.
Dr. Bruce Hillman wrote an accompanying article citing how “an unknown but substantial fraction of imaging examinations are unnecessary and do not positively contribute to patient care.” As some causes of the unnecessary use of diagnostic imaging he cites patients who “pressure their physicians to refer them for imaging studies even when imaging is unlikely to provide any value.” He also cites defensive medicine, self-referral, medical training programs that ingrain “shotgun” diagnostic testing to confirm diagnoses with the “greatest possible certainty.” He also acknoledges that radiologists also share in the blame for fueling the explosion in diagnostic imaging.
His ideas for changing the system are much more realistic and include tort reform, better physician and medical student education, engagement of radiologists as consultants, and “a change in mindset among physicians.”
I agree with Dr. Hillman on every point except the last one. Physicians have a “mindset” that is created by attorneys and by the public. In most cases, physicians are expected to be perfect or to exhaust all possible testing in finding a diagnosis (I still haven’t had one person who disagrees with me on this point present me with a diagnosis that it is OK to miss). If a diagnosis is missed, the lack of “appropriate” testing that would surely have made the diagnosis is a central theme in the physician’s malpractice trial.
We don’t need to change the physician’s mindset. We need to change the public’s mindset. If less testing is performed, more people will have diseases that won’t be diagnosed … or that won’t be diagnosed early enough. That is an inevitable result of reducing the use of diagnostic radiologic testing. Will the public and the juries sitting in medical malpractice trials accept this fact? Can we say that a 95% possibility you don’t have a deadly disease or severe injury is “good enough” and non-actionable? Until society makes the commitment to lower the bars over which clinical physicians must jump, the incidence of diagnostic imaging – and all the radiation that accompanies it – will go up and not down.
There were many news articles published about this study, including USA Today and Forbes.com.
I didn’t see any clinical physicians interviewed in these articles – only radiologists. That should be the first clue that something is amiss — news articles with non clinicians commenting on how clinicians should do their jobs. How confident would we be if USA Today encouraged readers to pick up the paper next week when USA Today will have chemical engineers commenting on how mechanical engineers should stress test products more thoroughly? Hey – they’re both engineers, right?
The money quote from Dr. Hillman in a Reuters article really irked me, though:
“We need to convince physicians that a quest for certainty is impossible, costly and is harmful because of indirect diagnoses.”
If radiologists are so certain that diagnostic imaging doesn’t need to be done, then cancel the test. That’s right. You think a test is a prospective waste of radiation? Refuse to perform it. Right now, you’re talking the talk, but you’re doing a face plant on the concrete when you try to walk the walk.
How about this: When the dumb ER doc orders the next total body scan, walk over to the emergency department, examine the patient, and come up with your own diagnosis without using your deadly CT scanner. Get rid of your hindsight bias and make a prospective diagnosis without having the benefit of a “normal” diagnostic test sitting on the computer screen in front of you.
Isn’t as easy as your little news sound bites make it seem, is it?
Want to regulate something to really stop the flow of radiation into patients? How about making the American College of Radiology start regulating the number of diagnostic radiology reports from their members that contain phrases such as “cannot rule out underlying lesion, recommend CT scan for comparison”, and then “CT scan non-diagnostic, recommend bone scan for further clarification”. We could cut down on costs if radiologists would stop recommending “MRI for clinical correlation”, also.
I’m betting that we won’t see too many sound bites about the implications from this radiology report lingo hitting the headlines any time soon.
Posted in Medical Studies, News Commentary | 58 Comments »
Thursday, June 24th, 2010
A man in his mid-30′s gets brought by ambulance with palpitations. His mom arrived right behind the ambulance.
The patient was obviously anxious and was dripping with sweat. We hooked him up to the monitor and he’s in SVT up to the 160′s.
No medical problems. Occasional alcohol. Smokes half a pack a day. No drugs. This same thing happened to him a year or so ago, the doctors did a bunch of tests and didn’t find anything.
Nothing out of the ordinary on his physical examination.
We ordered some labs and gave him an IV calcium channel blocker. His heart rate came down to the low 100s. He still appeared anxious, so I have him a little bit of a benzo to calm him down. Soon he was feeling better.
His labs came back normal – everything except his positive marijuana screen. He’s lying because he had a bad reaction to his marijuana and we just did a ton of medical testing on him. I grabbed the drug screen result off the chart and headed into the room to confront him about the lying and the drug use.
I opened the door and he and mom were watching TV.
“I got your lab tests back.”
“Listen. Um. I figured I may as well tell you since you’re my doctor and all – I was smoking a blunt of hash at my friend’s house about a half hour before this happened. You think that may have caused my heart to go so out of control?”
“Ummm. Yeah, I do. I had the lab results right here. I was going to ask that your mom leave the room before telling you about your positive drug screen.”
“It’s OK, she knows.”
“Well then she can remind you that you need to stop using drugs.” Mom nodded her head up and down.
“Yeah, I’ve had people tell me that before.”
“You can go home now. Just stay away from the dope,” I said as I left to go finish his discharge instructions.
Then the patient yelled “Hey doc!”
I turned around.
“You’re not going to call the police about this are you?”
“You mean about you using the drugs?”
“Yeah.”
“No. We don’t call the police for drug use …” I hesitated for a second, thinking about whether I should say what else was on my mind. Heck with it. I’m not going to beat around the bush with this guy.
“… but I can give your mom some numbers for funeral homes and some cool sayings to put on your tombstone if you do it again.”
The patient just sat quietly on the stretcher and stared at his toes. The rhythmic beeping of the cardiac monitor and the muffled sounds of a child crying in a room down the hall were all that was audible.
I was standing at the desk finishing writing up his chart as they left the room and headed toward the exit. His mom patted me on the back and whispered “Thank You” in my ear as they were leaving.
Hopefully one type of blunt will stop the other type of blunt.
Posted in Patient Encounters | 12 Comments »
Tuesday, June 22nd, 2010
 Freddie came in as a drug overdose.
The medics couldn’t get a line on him. He was unresponsive and his skin tone was somewhere between blue and purple.
A sternal rub didn’t do much to awaken him. We artificially ventilated him with an Ambu bag. His pupils were barely visible. Track marks were on his arm. Yup. He’s an overdose.
The nurses worked flawlessly as a team – applying the cervical collar, inserting IVs, checking blood glucose, then injecting Narcan.
“Watch out,” I told the nursing student who was putting on the EKG leads, “things are going to go wild in about 15 seconds.”
Fifteen seconds went by. Nothing happened.
Damn.
Twenty seconds. The nursing student looked at me.
I shrugged my shoulders. Hmmm. Maybe this wasn’t an overdose after all. What the hell else could this guy …
“rrrRRRR AHHHHHHH! GET THE F*** OFF OF ME!” Arms were flailing. EKG leads were ripped off. The cervical collar was gone in less that 10 seconds. Welcome to the Metro General Rodeo Minute. I marveled how everyone stopped what they were doing (including the secretary) and literally flopped on the patient to hold him down. Everyone except me and the nursing student.
“Slow circulation,” I mumbled as I winked at the nursing student and nodded my head.
We drowned in a sea of F-bombs for another minute or so until Freddie calmed down. Then he asked where the “f” he was and what the “f” happened to him. We told him that he overdosed on heroin. He denied using drugs.
I should have known. Must have been the evil girlfriend.
Freddie’s girlfriend then came into the room. She sat there caressing his hand and organizing the EKG leads so they were all in the same direction going across his chest and over to the monitor. That lasted about 15 minutes. Then she came out of the room and loudly announced:
“We need some water in here.”
I said “Not yet. He just got some medication that may make him throw up. How about a few ice chips?”
“He’s f***ing thirsty.”
Ooooh. Aren’t you the dainty little specimen. So eloquent in your choice of words, too. OK, Mrs. Freddie F-Bomb. No problem.
“Fine, he can have a small cup of water.”
Ten minutes later, Mrs. Freddie F-Bomb was back yelling in the hallway.
“If I go to Wendy’s to get him a hamburger will someone let me back in?”
I was sitting at the desk and responded “He can’t eat anything right now. I don’t want him to throw up. We’ll get him a food tray later.”
“He isn’t eating any of this nasty f***ing hospital food, and if he can keep the water down, he can keep food down.”
I had to agree with her on the “nasty” comment, but I wasn’t going to give her the satisfaction.
“Listen ….”
Almost as if on cue, Freddie then proceeded to hurl all over his bed. Franks and beans looking kind of picture. Maybe some chips, too. I looked back at Mrs. F-Bomb.
“Exactly the reason I don’t want him eating anything.”
“Yeah, well if you were so worried about him puking, then why the f*** did you give him water to drink?”
Have a nice wait in the waiting room, ma’am. Be sure to visit us again real soon.
Oh, and you don’t get a patient survey, either.
Nyaaah.
Posted in Patient Encounters | 8 Comments »
Monday, June 21st, 2010
 Following up on my previous post about Joint Commission micromanagement, we got word of another big “no-no” according to JCAHO’s rules.
We have now been informed that according to Joint Commission rules, in association with EPA studies, there is entirely too much drug contamination in the nation’s water supplies. Therefore, hospitals must now separate waste into multiple bins and dispose of such waste appropriately in order to avoid being fined by the EPA and sanctioned by JCAHO. And JCAHO will go through the garbage during its inspections to make sure that you are complying with the rules, too!
Regular waste goes into a blue bag. Blue bags comprise most of the waste in the hospital.
“Hazardous waste,” must be put it into a black hazard bag. Hazardous medications include epinephrine, phenylephrine (i.e. Neo-synephrine nasal spray), insulin, silvadene, nitroglycerin, prednisone, and silver nitrate sticks and others. Next time you go to the store to buy any of these products, make sure that you wear special gloves and gown. Then when you’re done purchasing them, make sure you read how hazardous they are in the product handouts and how you can only dispose of them in a black hazard bag that you must now purchase from JCAHO-licensed distributors. Oh. Sorry. These drugs are only treated as hazardous inside of hospitals. Carry on.
“Infectious waste” must go into a red bag. Infectious waste includes anything that comes into contact with bodily fluids. All you mommies who throw your kids diapers in the “regular” garbage and anyone who throws used facial tissues in the “regular” garbage is breaking JCAHO laws. Stop it now or you’ll be fined and may possibly be decredentialed.
“Dual pharmaceutical waste” means that waste is both infectious and hazardous. That must go into a purple hazard box immediately. If anything in the “hazardous waste” category comes into contact with any bodily fluid, then it fits this category. If you spray Neo-Synephrine up your nose and then blow your nose into a tissue, find a purple box immediately. The tissue may spontaneously combust.
“Non-compatible waste” must be placed in a special black bag with an orange triangle. We must then contact the pharmacy for a special waste pick up. Non compatible waste includes any asthma inhalers – due to the propellants contained in the container. In other news, the US Government is currently developing a secret group of mercenaries that will take a couple of puffs off of an asthma inhaler, spray Neo-Synephrine up their noses, cough and blow their noses into a tissue, and then throw the tissues at selected targets. Biologic warfare at its finest. Watch out Al-Qaeda. We mean business.
Controlled substances must be flushed down a toilet while another person watches and then must documented on a special sheet by the toilet. Apparently the risk of polluting our waterways pales in comparison to the threat of someone getting ahold of a couple of drops of extra morphine lying around in a syringe.
Oh yeah, and sharps have to be put in the red sharps container. BUT … if there is medication in the syringe, it must be squirted into a gauze pad and then deposited into the appropriate bin (or flushed down the toilet) as described above before the syringe is discarded.
I keep getting confused about what to do if someone pees on an asthma inhaler or what to do if a kid spits out Tylenol with codeine elixir and hits his mother’s purse.
Sitting dejectedly underneath the doctor’s desk is the lonely metal trash can with its non-JCAHO-approved clear plastic liner.
The whole colored trash can idea reminds me of my childhood.
We-he-he-he-lllll boys and girls. I’ve got a special game for you today. Here’s a pen that looks like a syringe, an asthma inhaler that was dropped in the hospital waiting room, a tissue with an unknown yellow substance on it, a shoelace, and a piece of gum chewed by someone who just immigrated to this country from Congo. Let’s play MEDICAL Bozo BUCKETS!
Stay tuned after the commercial so you can watch JCAHO teach doctors how to run their hospital medical staff.
Ho Hooo NELLLLY!
Posted in Joint Commission | 30 Comments »
Saturday, June 19th, 2010
I got a request for information about poison ivy and decided to repost an article that I initially published a couple of years ago.
Links have been updated accordingly.
Dr. Ramona Bates put up a post on her Suture For A Living blog about poison ivy. I was planning on doing the same thing, but she beat me to the punch. Her post did more than scratch the surface, but since we’re just starting to see poison ivy creep into the ED lately (ooh I’m on a roll), I wanted to add a few things.
Blistering or a rash that is in a line suggests some sort of contact dermatitis – usually from a plant or something stationary. Imagine walking past a plant and the edge of the leaf dragging against your skin. If you look at the picture on Dr. Bates’ site, the man’s arm has blistering in a line that is typical of poison ivy exposure. Another example is here.
While touching someone else’s rash generally won’t give you a rash (poison ivy isn’t “contagious”) sometimes you can get secondary contamination from things that have come into contact with the poison ivy plants. If you were walking in patches of poison ivy, it is possible to transfer the plant resin to your hands when you take off your shoes. If you pet your dog after your dog walked through poison ivy, you can transfer the resin from the dog’s fur to your hands. Then if you itch your face with your contaminated hand, you may develop a rash on your face.
The chemical that causes the reaction, urushiol, isn’t easy to wash off. If you get to it in the first hour or so after exposure, soap and water may remove it. After that, it penetrates into your skin and binds to the proteins in your skin so that ordinary soap and water will have little effect in removing it.
Once you get the rash from poison ivy and start itching, treatment involves getting the chemical off your skin and relieving the symptoms.
Tecnu and Zanfel are commercial products that wash away the chemical urushiol from the skin. If you use them early enough, you can significantly lessen your symptoms, although they reportedly have some effect for several days after exposure. Store brand products may work just as well and are considerably less expensive. Interesting point from another site is that Tecnu was initially developed to remove radioactive fallout dust from the skin and is a distillate of gasoline. This site also states that other organic solvents such as rubbing alcohol may work as well as Tecnu for removing urushiol – when rinsed with copious amounts of water.
Ivy Block blocks the urushiol from coming into contact with the skin and actually absorbs some of the urushiol. Lather up before you go out into the bushes and you may save yourself from even getting the rash. Just remember to rinse the Ivy Block off and reapply if you’re out for more than 4 hours.
One trick I learned for any kind of a bad itch is to use an ice cube to do the itching. The ice won’t scratch (and therefore irritate) your skin and the cold will help to get rid of the itch. When you’re done, you just throw out what’s left of the cube. Repeat as often as you want.
Domeboro solution (or Burow’s Solution) will help take away the itch. Mixing the packet with a small amount of warm water to dissolve it and then adding cold water to reach the proper dilution will create a cool compress that will help relieve the itching even more.
Use of steroids to treat poison ivy rash of poison ivy is debated. Some people swear by them, some people swear at them. I’m in the latter category. I generally don’t prescribe steroids due to the incidence of “rebound” symptoms if they are discontinued early. In this case, “early” is considered less than 2 weeks. That’s right – the books recommend that someone be on steroids for two weeks if the steroids are used to treat poison ivy. Sometimes you need steroids if the symptoms are severe or involve the eyes. On the other hand, I have seen multiple cases of rebound symptoms when a patient’s primary care physician gives a patient a Medrol DosePak for mild symptoms, the patient runs out over the weekend, and then the patient comes to the ED worse than when they started.
If you still have questions, this is a fairly comprehensive article on poison ivy for non-medical types and here is an article from eMedicine for the more medically-inclined.
Remember: Leaflets three -> let it be. Berries white -> poisonous sight. [Picture credits here]
Posted in Medical Topics | 4 Comments »
Friday, June 18th, 2010
No wait emergency departments. Great business model or way to encourage more abuse of already crowded emergency departments?
Nice shackles. Memphis Med now changes policy so that prisoners wait in the waiting room like everyone else – with police escorts. Problem is that police are now paid to sit in the ED waiting rooms for six hours rather than fight crime on the streets.
Minnesota nurses strike. More than 12,000 nurses walked off the job for one day to protest working conditions and inadequate pay raises. Hospital forced to pay $1600 to $2200 to hire replacements for two days and to cut inpatient volumes.
Tweeting your doctor for advice. Nice in theory, but would you pay 50 bucks for the privilege?
Remember the chatty juror who asked the defendant doctor for medical advice? He got off with a stern warning and no jail time. Probably also got out of future jury duty.
Job security for British emergency physicians … brainiacs in Wales are trying to get drunk by pouring shots of vodka into their eyes. Talk about beer goggles.
Meet the latest member of the “you need an emergent Foley catheter” club. Intoxicated weenie gets brought to hospital emergency department then hits the doctor and nurse.
Check out the new electronic underwear that sends a text message to your nurse when you piss yourself. I’m betting that they probably cost a little bit more than a package of Depends, though. Will the new health plan cover them?
Another Canadian emergency department closing. Two doctors moved from the area leaving only one doctor capable of covering the emergency department at Wakaw Hospital in Saskatoon, Saskatchewan.
Curbing unnecessary trips to the ED. Go to the emergency department too many times for routine care in Utah and you won’t be able to get your prescriptions filled unless you see a primary care physician. Innovative idea – until someone has a bad outcome because they weren’t able to get a timely appointment with the primary care doc. Then again, probably be a little more difficult to sue the state for implementing the policy.
Don’t try this at home. Woman shoots herself in arm so that she can get treatment in the emergency department for pre-existing shoulder pain.
Fill ‘er up. Downtown New York hospitals see spike in emergency department patient visits after St. Vincent’s hospital closure. One emergency physician at Beth Israel Hospital was handling 19 patients at the same time, stating that the scenario was “like a regular day.” Juggling 19 patients at the same time is an invitation to disaster. Try remembering 19 different patient histories, physical examinations, medication lists, sets of allergies, sets of lab tests, and then coming to a rational decision about each patient – all while being interrupted a few dozen times with questions about all the other patients. I work in an ED with 40 beds plus a lot of other hall beds and managing 19 patients – even with the help of residents – is crazy. The AAEM recommends a maximum of 2.5 patients per physician per hour in a moderate acuity emergency department.
Tort reform? Nah. Let’s just charge more for auto insurance and homeowners insurance to keep the only two malpractice insurers in New York from going bankrupt. As the two-year rate freeze on malpractice premiums is set to expire later this month, New York is having difficulty figuring out how to “reduce the bonanza trial lawyers get from the system.”
Bloggers have been screaming about it for years and now all of a sudden it’s on Washington’s mind. Washington spends a whole tenth of a percent of the yearly health care budget to encourage docs to go into primary care medicine, including spending $336,000 per physician to train an additional 500 primary care physicians over the next 5 years. Forget the fact that the American Academy of Family Physicians states that to meet the need for primary care physicians in 2020, the US would have to train 3,725 family physicians and 714 osteopathic physicians per year (or more than 22,000 primary care physicians in 5 years).
Oh and by the time those 500 primary care trainees are ready to see patients (4 years of medical school plus three years of residency), the whole health system will have collapsed.
But it was a nice thought.
Off duty cop storms hospital ICU and takes hostages, then announces “You can leave now. This was just a drill!” Whiskey Tango Foxtrot? Is it OK to point a gun at someone if it is “just a drill”? Last time I checked, that was called “assault with a deadly weapon” and was a crime. Next time why don’t you go try this at the police station … or the courthouse … or the airport … or the firing range? They need to have drills, too. [via GruntDoc]
And last but not least … if you want a positive spin on what’s going on in medicine right now, check out the Positive Medical Blog. Three great bloggers – Lockup Doc, Chrysalis Angel, and SeaSpray – have gotten together to start this new blog and I know that the posts will be a combination of information, inspiration, and fun.
Posted in Healthcare Update | 5 Comments »
Thursday, June 17th, 2010
It was a close vote, but here are the winners for WhiteCoat Challenge #6:
#14. A toast to MikeMD with the story about the boy who peed red wine
#18. Nurse K’s story about the hypochondriac who peed on his hand
#38. Hawkeye’s story about the patient’s vision that went from 20/20 to “just 20″
#42. Dr. JC’s story about the woman whose genetalia had a stroke
#46. Michael Kirk’s history of one personality stabbing the other in the genitals with scissors.
#56. Gregsky’s chief complaint of “coughing up small animals and scrotums”.
Winners please visit EP Monthly’s online catalog, pick a prize, and e-mail your choice and where you want the prize sent to editor-at-epmonthly dot com.
Thanks to everyone for their stories. You made this challenge another great success!
Posted in Uncategorized | 3 Comments »
Thursday, June 17th, 2010
 Remember the movie Rainman where Dustin Hoffman whipped out his red book and wrote on his “Serious Injury List” how Charlie Babbitt “squeezed and pulled and hurt my neck“? If not, you have to rent that movie and watch it. One of my favorite all time movies.
Well, the lab supervisor recently descended upon the emergency department with her notebook of Serious Offenses in hand.
“Where’s the tech named ‘Maryann’?”
“She’s not here today.”
“I need to speak to her immediately.”
“What’s the problem?”
“She wrote the results of a patient’s pregnancy test on a patient’s chart, initialed them … AND SHE’S NOT QUALIFIED TO READ PREGNANCY TESTS! The Joint Commission will see this and we’ll get cited if this isn’t corrected! Can you call her at home?”
“Um. No. Can’t one of us sign it off?”
“No. I need to know who the nurse was taking care of the patient and have the nurse document on the patient’s chart that she was aware of the findings and notified the doctor of the findings.”
[With evil smirk in eye] “We can’t do that. That would be a HIPAA violation.”
The Overseer of All Lab Discrepancies Real or Imagined then developed a perplexed look on her face and left the emergency department.
Twelve year old kids can purchase a pregnancy test and interpret the results.
Visually impaired people can purchase a pregnancy test and interpret the results.
Three year old children can tell the difference between a plus sign and a minus sign.
Yet trained professionals need to be “certified” that they can tell “plus” from “minus” on pregnancy tests under the threat of JCAHO sanctions.
Unbelievable.
Oooh. That reminds me.
I have to renew my Medical Office Building Lightswitch User Certification and my Drinking Carbonated Liquids Through A Straw accreditation. Phew. Almost forgot.
Posted in Joint Commission | 10 Comments »
Wednesday, June 16th, 2010
A 26 year old female comes in complaining of chronic neck pain for the past 6-8 months. She was seen in the emergency department 4-5 months ago for the same pain and was diagnosed with a neck strain. Since that time, she has had intermittent pain.
She states that the pain is worse when she tilts her head forward or backward and also worse when she coughs.
There is no history of trauma. She has had no fevers or difficulty swallowing. Her vital signs are normal. Her teeth are in good shape with no signs of abscess. Oropharynx is also normal. No meningeal signs are present. She can move her head about fairly easily, but does notice some pain when flexing her head forward. Neurological examination is normal.
She came to the emergency department this time because when she woke up, the pain was worse and she had tingling down her back and into her fingertips when she was bending over to tie her shoes.
Xrays of her cervical spine are below (the AP view was unremarkable).
What is the abnormality on the x-rays? What is the name of the clinical sign that she was demonstrating? Given these two pieces of information, what was her diagnosis?
I’ll post the answers under the x-rays in a couple of days.
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Final Answer:
The patient was indeed exhibiting Lhermitte’s Sign. More common in multiple sclerosis, it can also be caused by other etiologies, including trauma. The presence of this sign and her pain with coughing were what prompted me to order a c-spine x-ray.
Scanman hit the x-ray results right on the nose. Atlantoaxial instability with posterior fusion of C2 and C3. The predental space (between the posterior arch of the atlas and the anterior surface of the dens) should be no more than 3mm. See more about interpreting C-spine x-rays in this AAFP article. In this patient, the predental space was 7 mm. The instability and the patient’s symptoms resulted in a sphinchter tightening moment while we scurried around to find a cervical collar.
Final diagnosis from our ED was shown on CT scan below – odontoid fracture. Probably subacute, but a fracture nonetheless. This occurred in the rural ED where I moonlight, so she was shipped to a tertiary care center.
By the way – I remember from my trauma training that coughing exacerbates the pain of a c-spine fracture, but was unable to find a name to go along with this sign. Anyone know of it? This is the third time I have caught an occult c-spine fracture because the patient complained of pain in the neck with coughing.
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Posted in What's the Diagnosis? | 17 Comments »
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Regulating Radiation
Monday, June 28th, 2010The article begins by presenting the case of a woman who awoke with facial paralysis and then went to the emergency department. On arrival, she received CT scans and MRI scans of her brain. When those were normal, she was diagnosed as having Bells Palsy. Two weeks later, she developed hair loss and other symptoms and it was found that during her first ED visit, the radiology department mistakenly exposed her to 100 times the normal dose of radiation for a brain CT scan. She now has a federal class action suit pending against the CT scanner manufacturer and a medical malpractice lawsuit pending against the treating physicians.
It appears that the case cited may be this one. More information here.
The author of this article then uses her own calculations to conclude that the “risk of cancer from a single CT scan could be as high as 1 in 80 — unacceptably high.” The study she cites shows that radiation doses for the same tests vary – as they should. Giving the same dose of radiation to a 90 pound grandma and a 500 pound grandson would result in at least one uninterpretable study. Based on the 4 hospitals they studied, they disputed the risk of cancer being 1 in 2000 from a CT scan and stated that the risk to a 20 year old woman from a single chest CT or single multiphase abdomen and pelvis CT could be as high as 1 in 80.
The paper advocates lessening and standardizing radiation doses for examinations, noting that the improved image quality obtained with higher radiation doses often has no change in clinical outcomes. Diagnostic accuracy would not be affected if the radiation dose were reduced by 50%.
The paper also suggests tracking a patient’s dose of radiation over time and including that measurement in the medical records. Great idea, but how is a radiation dose from someone living in California going to help me when the patient has a potential cervical spine injury in my town while she’s on vacation?
Finally, the author suggests that we need to reduce the number of CT scans being performed. Each year 10% of the population receives a CT scan and 75 million scans are conducted each year – with the rate growing more than 10% annually. At the heart of the increased number of scans is “increasing ownership of machines by nonradiologists” and the resulting “self-referral” which increases the use of the scanners. Those bastard non-radiologists. Only radiologists should be able to self-refer and get away with it.
In general, I think that Dr. Smith-Bindman is on point with her suggestions. It would be great if patients’ total radiation doses could be tracked throughout their lives. However, assuming that could happen, would a high dose of radiation make any difference in determining whether an 80 year old lady with abdominal pain got a CT scan? How about in determining whether a hypotensive unconscious 50 year old trauma victim should undergo CT scanning? What about deciding whether the obese 30 year old complaining of severe difficulty breathing should get a chest CT to rule out a pulmonary embolism?
Can we reduce radiation dose at the sacrifice of less clear scans? That’s a radiologist’s call. Is Dr. Smith-Bindman following her own suggestions? If we missed a small nodule that later became metastatic cancer, would the defense that “at least the patient didn’t get as much radiation” be a sufficient defense in a medical malpractice trial?
The suggestions are good, but they don’t apply to clinical practice.
In addition, while the FDA does regulate “radiation-emitting electronic products” including diagnostic x-ray equipment, telling patients how many diagnostic radiographic studies they may “safely” obtain is likely an area of mission creep for the agency – akin to regulating how many hours of television people may watch in a day (yes, television receivers emit radiation) or how many hours George Hamilton may spend under his radiation-emitting sunlamp. I’m not so sure that having the FDA limit the number of scans a patient can receive is a good thing.
I also take issue with Dr. Smith-Bindman’s statistics that demonstrate greater than a 1% incidence of developing cancer from a single CT scan. If 1 in 80 patients can get cancer from a single CT scan and almost 80 million CT scans are performed every year, each year we are causing close to 1 million cases of cancer in US citizens. According to the American Cancer Society, it is estimated that 1.5 million total cases of cancer will be diagnosed in the US in 2010. Is our use of CT scans really causing more than half the cases of cancer in the US each year? Even if we cut the incidence in half, causing 500,000 new cases of cancer each year is a hard allegation to substantiate.
While the number of CT scans is allegedly increasing at 10% per year, the number of new cancer cases in the US was 1.22 million in 2000 and is 1.53 million in 2010 – hardly an increase of 10% each year over 10 years. Those increases in new cancer cases also paralleled an increase in the population size – from 281 million in 2000 to 305 million in 2009. On a per capita basis, the incidence of newly diagnosed cancer went from 4.3 per thousand to 5 per thousand during those nine years.
Dr. Bruce Hillman wrote an accompanying article citing how “an unknown but substantial fraction of imaging examinations are unnecessary and do not positively contribute to patient care.” As some causes of the unnecessary use of diagnostic imaging he cites patients who “pressure their physicians to refer them for imaging studies even when imaging is unlikely to provide any value.” He also cites defensive medicine, self-referral, medical training programs that ingrain “shotgun” diagnostic testing to confirm diagnoses with the “greatest possible certainty.” He also acknoledges that radiologists also share in the blame for fueling the explosion in diagnostic imaging.
His ideas for changing the system are much more realistic and include tort reform, better physician and medical student education, engagement of radiologists as consultants, and “a change in mindset among physicians.”
I agree with Dr. Hillman on every point except the last one. Physicians have a “mindset” that is created by attorneys and by the public. In most cases, physicians are expected to be perfect or to exhaust all possible testing in finding a diagnosis (I still haven’t had one person who disagrees with me on this point present me with a diagnosis that it is OK to miss). If a diagnosis is missed, the lack of “appropriate” testing that would surely have made the diagnosis is a central theme in the physician’s malpractice trial.
We don’t need to change the physician’s mindset. We need to change the public’s mindset. If less testing is performed, more people will have diseases that won’t be diagnosed … or that won’t be diagnosed early enough. That is an inevitable result of reducing the use of diagnostic radiologic testing. Will the public and the juries sitting in medical malpractice trials accept this fact? Can we say that a 95% possibility you don’t have a deadly disease or severe injury is “good enough” and non-actionable? Until society makes the commitment to lower the bars over which clinical physicians must jump, the incidence of diagnostic imaging – and all the radiation that accompanies it – will go up and not down.
There were many news articles published about this study, including USA Today and Forbes.com.
I didn’t see any clinical physicians interviewed in these articles – only radiologists. That should be the first clue that something is amiss — news articles with non clinicians commenting on how clinicians should do their jobs. How confident would we be if USA Today encouraged readers to pick up the paper next week when USA Today will have chemical engineers commenting on how mechanical engineers should stress test products more thoroughly? Hey – they’re both engineers, right?
The money quote from Dr. Hillman in a Reuters article really irked me, though:
“We need to convince physicians that a quest for certainty is impossible, costly and is harmful because of indirect diagnoses.”
If radiologists are so certain that diagnostic imaging doesn’t need to be done, then cancel the test. That’s right. You think a test is a prospective waste of radiation? Refuse to perform it. Right now, you’re talking the talk, but you’re doing a face plant on the concrete when you try to walk the walk.
How about this: When the dumb ER doc orders the next total body scan, walk over to the emergency department, examine the patient, and come up with your own diagnosis without using your deadly CT scanner. Get rid of your hindsight bias and make a prospective diagnosis without having the benefit of a “normal” diagnostic test sitting on the computer screen in front of you.
Isn’t as easy as your little news sound bites make it seem, is it?
Want to regulate something to really stop the flow of radiation into patients? How about making the American College of Radiology start regulating the number of diagnostic radiology reports from their members that contain phrases such as “cannot rule out underlying lesion, recommend CT scan for comparison”, and then “CT scan non-diagnostic, recommend bone scan for further clarification”. We could cut down on costs if radiologists would stop recommending “MRI for clinical correlation”, also.
I’m betting that we won’t see too many sound bites about the implications from this radiology report lingo hitting the headlines any time soon.
Posted in Medical Studies, News Commentary | 58 Comments »