Archive for March, 2011
Friday, March 18th, 2011
I’m going to be away at a wrestling tournament with the family for the weekend. Hopefully Junior WhiteCoat will do well and we won’t be back until Sunday evening.
So this weekend will be devoted to your questions, comments, rants about anything medically-related that interests you. Just leave a post in the comments section. Other readers feel free to chime in and answer, comment more or rant more.
Only rules are that comments have to be medically-related and that there are no personal attacks.
Hopefully I will be back Sunday to respond to all the questions/comments.
Posted in Random Thoughts | 22 Comments »
Wednesday, March 16th, 2011
A breast cancer patient presents with painful rash to her hands and feet for the past 24 hours. The palms and soles were warm and she had a horrible “burning” sensation that didn’t improve with pain medications. Putting ice on her hands and feet seemed to provide her with temporary relief.
She started several new medications recently including an an ACE inhibitor, prednisone, pyridoxine, and Vicodin. She had finished one round of chemotherapy and did not have a satisfactory response. Her oncologist had therefore started her on a different regimen several days prior to her emergency department visit.
Vital signs were stable. The rash stopped at the wrist creases and the ankles and was nowhere else on her body. CBC and basic chemistries were normal. She had mild relief with IV morphine. The dermatologist on call said that it sounded like contact dermatitis and that he would see the patient in his office the following day.
What’s the diagnosis?
Why does the rash occur?
What is the treatment?
I will post the answer in the comments section in a couple of days.
 
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Posted in What's the Diagnosis? | 17 Comments »
Monday, March 14th, 2011
Patients gone wild. Patient gets upset at wait and goes “berserk” on emergency department physician, breaking ribs and giving the doc a concussion.
I told you it was cold in here. More patients gone wild. Las Vegas woman sets fire to a trash can in emergency department restroom. Burning plastic from the garbage can filled the emergency department with thick black smoke, forcing the ED to close for several hours. Now patient is charged with arson and six counts of attempted murder.
Why does Reading Hospital want a police officer stationed in the emergency department 4 nights a week? Could it have anything to do with the fact that 54% of all health care violence occurs in the emergency department? The hospital estimates that 4 nights of security from 7PM to 3AM each week will cost an extra $100,000 to $150,000 per year. Security is getting paid between $60 and $90/hour at a hospital? To heck with medicine. I want to know where I can sign up for that job.
Courtroom doors are valued more than emergency medical personnel in Kentucky. In Kentucky it is a felony (.pdf file) for a person to bash one’s head on a courtroom door and break glass, requiring emergency medical treatment. However, beating the crap out of personnel once in the emergency department is only a misdemeanor (.pdf file).
Effects of health reform in Texas. The number of doctors applying to practice in Texas has increased by 60 percent, at least 20 underserved counties now have an emergency physician and 12 counties have an obstetrician for the first time in their history. In short, “we’re seeing medical professionals return to high-risk specialties.” The seven Texas state representative authors of the article are now calling for Texas to create a loser-pays litigation system.
Tort reform doesn’t work. It’s all propaganda. Don’t believe a word of it. All it does is screw the injured and line the pockets of the insurance companies. Those new doctors were planning to move to those counties before tort reform. The Dallas Cowboys football team motivated them to move to Texas, not tort reform. The numbers are skewed because the population in Texas was increasing anyway. The authors of the article can’t be trusted. They have an agenda.
Any arguments from the plaintiff’s bar that I’m forgetting?
Tort reform in North Carolina. Will changing the standard of liability to clear and convincing proof of negligence allow doctors to focus on patient care or should it be considered legislative malpractice?
Pet trauma center modeled after human emergency department. Only a matter of time until … Guess Praney scores get vets fired unless doggie’s tails are always wagging … catnip overdoses start showing up by the boatload and … lawyers sue vets for more than the clinic is worth if the parakeets don’t live to 107 in birdie years.
Other countries taking lead from US. High-value judgments are up 900% in South Africa. A risk services client manager was quoted as saying that the problem has been exacerbated by attorneys actively pursuing medical negligence claims due to their “high earning potential.”
Posted in Healthcare Update | 32 Comments »
Saturday, March 12th, 2011
 A 27 year old woman is brought in by ambulance. The call comes in as “patient having a stroke.”
When the patient arrives, she is dressed up with nice clothing, makeup, and high-heel shoes. She looks like she was out at the clubs. In fact, she was drinking at home with her boyfriend and was getting ready to go out to a bar.
Then there was an argument. The patient was able to “feel her blood pressure going up.” She demanded that her boyfriend apologize for the things he said to her. He refused. She sat in a chair, grabbed her head with both hands, and went “unresponsive.” She didn’t “wake up” until she arrived in the emergency department and had no idea what happened.
It must have been a stroke. She was sure of it, because this was her eighth stroke and she was on full disability from all of her other strokes.
Eight strokes at age 27. How horrible.
I did a pretty good neuro evaluation and found nothing abnormal on her exam. No weakness. No speech problems. No coordination issues. Maybe some alcohol on the breath, but no neurologic problems.
Seeing an essentially normal patient in front of me, I asked “Soooooo …. exactly what part of your body was affected by all those strokes you had?”
She looked back at me, rolled her eyes and said “My BRAIN, duh.”
Ooooh. Good one. Obviously your sarcasm center wasn’t affected.
It ended up being a very long night.
Posted in Patient Encounters | 11 Comments »
Tuesday, March 8th, 2011
Our emergency department switched over to a voice recognition program and got rid of the transcriptionists (and the expenses) for dictating patient charts.
Problem is that transcriptionists pick out errors in dictation that Dragon NaturallySpeaking doesn’t. The computer program has no idea bad certain transcription errors can look in the chart. If you’re dictating and not careful, something really embarrassing can show up. Twice today I almost finalized charts with … um … strange … transcriptions.
First, when describing my examination of a patient’s hip, I dictated “pain with internal rotation.” Dragon typed out “Pain when internist hit patient.” No, his name wasn’t Happy.
Later, when doing a follow up note on a different patient, I dictated “On re-evaluation, pain is better”. The voice recognition spit out “On re-evaluation, anus better.”
It’s not like I traumatize patients when I do rectal exams.
Ooops.
Maybe this program reads medical blogs.
Posted in Random Thoughts | 16 Comments »
Monday, March 7th, 2011
Absolutely amazing story. Man falls to ground inside of a rural Minnesota grocery store. Unconscious and no pulse. One customer inside begins CPR. Store clerk calls 911. Other people start to gather. For 96 minutes, more than 20 bystanders rotate turns doing CPR until a helicopter arrives. Airamedics shock the patient 12 times and get back a pulse. The man is taken to Mayo Clinic and had suffered a heart attack. Not only did he survive, but ten days later he is discharged. Emotional reunion at a town fire station occurs when he returns home.
Another absolutely amazing story. Trauma resident rides with helicopter to save a bicyclist hit by a car. When he arrives at the hospital to transport the victim, he learns that the patient is his wife.
Woman who punched and bit hospital emergency department staff gets 4 years probation. Another patient in same ED also charged with aggravated assault for spitting blood in a nurse’s face. Spokesman from hospital where incidents occurred apparently believes that physical assault is part of the job description for emergency department personnel. “In all emergency rooms that are extremely busy, you will have this from time to time.” Wonder if you’d be so dismissive if the patients gone wild were sent to your office when they arrived in the emergency department.
Meanwhile, New York patient gets “combative” with emergency department staff and yells at other patients after crashing his van in a drunk driving accident. Multiple charges pending.
Yep, there’s more. Virginia man leaves emergency department and doesn’t have ride home, so he hops into an ambulance parked in the ED bay and takes off. A half hour later, they find him tooling down I-64. Never did make it home that day. Now he’s charged with grand larceny.
How government regulation is causing a shortage of needed medications and will cause further shortages of necessary drugs – explained by Walter Olson at Cato.
I’d like a coffee latte with one squirt of Island Mocha, three squirts of Vicodin, and some penicillin sprinkled on top … to go. Canadian hospital uses adjacent coffee shop as temporary emergency department when its own emergency department gets too full. More links here and here. According to the British Columbia Health Minister, that’s the way the system is supposed to work. Glad we have that cleared up. According to Google Maps, there’s a pharmacy, a sushi place, a Subway sandwich shop, and a Mexican restaurant, and a grocery store across the street. If patients need anesthetic, the hospital can just commandeer the sushi place and make the patients drink sake instead. And it would give the phrase “cleanup in Aisle 6″ a whole new meaning, wouldn’t it? Why don’t we have forward-thinking Health Ministers like that in the US?
Charlie Sheen live-in “goddess” Bree Olson crashes her Lexus, gets taken to hospital , then pulls down her pants and tries to urinate on the ED waiting room floor. Alcohol had nothing to do with it. Really.
Can’t get seen in the emergency department quick enough? Call the local TV news station. Still won’t get you seen any quicker, but at least you can talk to someone after a 30 hour wait. New Mexico Hospital blames the wait on “unusually heavy” patient loads in the ED. People in the comments section of the article blame “illegals” for all the problems.
Follow up article shows that patient volumes are up all over Albuquerque – with some waits for more than two days to see a physician. One hospital saw 50 trauma patients in one day when it averages one trauma patient per day. Comments to the follow up article blame not only the illegals and their “anchor babies” but also blame the “intoxicated Indians” and Obamacare for the problems.
Tufts Medical Center in Boston settles malpractice lawsuit for $2.5 million after child’s parents intentionally overdose child on psychiatric medications. Public outrage and calls for criminal charges against physician for diagnosing a 4 year old with ADHD and bipolar disorder and for prescribing clonidine and depakote to begin with. Grand jury declined to indict child’s psychiatrist for any crimes. Psychiatrist gets immunity before testifying at trial.
Indiana jury awards man $2.5 million after physician allegedly fails to do proper testing to diagnose colon cancer. Due to statutory caps on Indiana malpractice cases, the verdict will be reduced to $1.25 million. Take it away, Matt ….
Medical malpractice insurance premium rate freeze in New York State is set to expire in June. According to the article, several insurers in the state are writing new policies even though they don’t have the capital to pay claims, and “the commercial insurance industry has essentially abandoned New York State.” If rates go up, will physicians be able to afford the premiums? If rates don’t go up, will the insurance companies remain solvent?
A case of “money talks?” Top 110 plaintiff’s law firms donate $7.3 million to political campaigns in 2010 – almost exclusively to Democrats, then score “total victory on health care reform” pushed through Democratic Congress and signed by a Democratic president with no changes to the malpractice tort system.
Posted in Healthcare Update | 34 Comments »
Sunday, March 6th, 2011
Kevin MD published an op-ed in USA Today titled “Violence is a symptom of health care dysfunction” which discusses patient frustrations as one source of violence against health care workers. I’ve been busy this week and the comments section is apparently closed on Kevin’s post, so I didn’t get the chance to put my 2 cents in … yet.
The premise of Kevin’s post is that our system is broken and we need to better protect our health care workers. Agreed.
A second premise is that there is a deterioration of the doctor patient relationship. Also agreed.
But Kevin then says that “Patients are rightly frustrated, and some are lashing out.” The way this sentence is phrased almost makes it seem as if it is OK for patients to lash out when they are frustrated.
Kevin ends his op-ed piece by stating that health care providers could use more empathy and that patients need to realize that health care professionals are doing the best they can and should avoid violence.
Again, the impression that I was left with after reading the last couple of paragraphs in the article was that health care providers need to empathize with patients in order to stop the violence.
So I have a couple of thing that I need to set straight.
First of all, it isn’t just patients that are frustrated about the health care system. Providers are just as frustrated about the state of affairs. Patients think they’re frustrated? Take that level of frustration and multiply it times 24 hours a day, 7 days a week. Now put yourself in a position where federal agencies are micromanaging you, where the people you are trying to help have the potential to wig out and injure you, where your payments are being decreased, where your liability is being increased, and where you often work way more than 40 hours per week. Welcome to medicine. Not only do we have your frustrations, but we also have a plethora of other frustrations on top of that.
Second, some of the patients commented in Kevin’s op-ed about wishing they had an old-school doctor patient relationship. If you’re expecting a Marcus Welby experience in the emergency department, it isn’t going to happen. Most of the time is you show the staff a little respect, chances are good that you’ll get respect in return. Not all the time, mind you. Everyone has a bad day, so you might not have the warm fuzzies after every emergency department visit. However, if you come across as a foul-mouthed, demanding, bad attitude wretch, I can almost guarantee you that you will be treated as a foul-mouthed, demanding bad attitude wretch.
But I also have some good news. If you want a Marcus Welby relationship with your physician, you can have one. Find a doctor you like and actually stick with the doctor. Stop playing hopscotch with your doctors every year when your health plan changes and then complaining when the new doctor you see once or twice (before you change doctors the following year) hasn’t committed your complete medical history to memory. Yes, I know that doctors move and that residents graduate, so patients aren’t always at fault. But I see a whole lot more of the former scenario than I do of the latter scenario.
I don’t care if patients are “rightly frustrated” about the health care system. Never should society accept violence against another person as an outlet for those frustrations. It isn’t OK to punch a police officer because you’re “rightly frustrated” about your speeding ticket. It isn’t OK to threaten a judge because you’re “rightly frustrated” with his ruling. I’ll bet that even hospital administrators would agree that it isn’t OK to stab them with a knife if you’re “rightly frustrated” about the way that they are running a hospital. Violence can never be an acceptable outlet for frustrations.
Kevin has become a prolific medical blogger because his opinions are consistently well-grounded and well thought out. I agree with his position 99+% of the time which makes me think that the way he phrased some of the statements in his op-ed piece did not express his true intent and created an unintended picture in the minds of many readers, including me.
The fact that so many health care organizations and so many health care providers tacitly accept violence against health care workers as an outlet for patient frustrations just shows how low our health care system has sunk.
Even Marcus Welby couldn’t fix that.
Posted in Policy, Random Thoughts | 12 Comments »
Wednesday, March 2nd, 2011
Me: Hi. I’m Dr. WhiteCoat. What brings you here this evening?
Patient: I’m stressed and I haven’t slept in 5 days because those bitches at work don’t keep up with their work and so I have to do their work AND my work so finally I had it the other day and started punching one of them in the face while I was shaking the other one by the hair which is how I broke my wrist [holds up her wrist splint] so now my boss wants to fire me but I think that is really because Enrico talked to him because I turned Enrico into the Feds for drugs and now Enrico is hiding out from them, but he’s also trying to hunt me down to kill me for narcing on him, so I travel light and stay with a lot of friends and I never sleep in the same place more than one night – not that I’m sleeping – in fact I got this bruise on my leg when I saw that sonofabitch looking in the window at the house I was staying at and I jumped out of the window to chase his ass down, but he hid in the bushes like some little girl and I couldn’t find him because it was dark and theeeeen my leg was sore when I was practicing pirouettes ever since I saw the Black Swan and I got off balance and twisted my foot and the bone nearly broke through the skin but I set it back because I dated a medic once so I know how to set bones and now my foot hurts but not as bad as the burn on my lip where I was a dumbass and not paying attention and tried to put the wrong end of a lit cigarette in my mouth and hit my lip by mistake so now every time I write I chew on my lip it hurts so now I can’t concentrate and now I have to spend six hours per day writing my memoirs instead of four hours per day and don’t ask me what they’re about because they’re private and their mine and when I publish them they’ll be anonymous and after I’m done, I’m going to court and legally changing my f***ing name so no one knows it’s me that wrote them until they get picked up by Oprah or something … if I don’t die from an aneurysm first because my damn doctors keep prescribing me medication that gets taken off the market because it probably causes aneurysms to explode in your brain but the government never tells you and the doctors never tell you bad stuff until its too late and if it happens it’s not from me using drugs because I haven’t used any drugs in 4 weeks and you can test my piss to prove it and I’m not telling you what I used to use and it’s blacked out in your computer so don’t even bother looking it up. In fact, I’m not telling you a damn thing. Not one … thing. You hear me?
Me: Can I just ask you one question?
Patient: What?
Me: How long have you been off your lithium?
Patient: Who the hell told you I was taking lithium?
Me: [Resisting inner urge to say "Enrico"] Just a hunch.
Posted in Patient Encounters | 21 Comments »
Tuesday, March 1st, 2011
We have had a run on very sick children in our emergency department lately.
One 2 year old patient had a seizure and just didn’t look good.
Blood glucose good. Blood pressure good. Temperature 101.2 degrees. Not super high, but is this meningitis or is the temperature up from the constant seizing? I ordered antibiotics to be safe.
Then comes the lumbar puncture.
Damned if I didn’t hit the “Vein of WhiteCoat”.
If you haven’t performed a lumbar puncture on an infant before, the rest of this post isn’t going to make much sense to you. On the other hand, if you have performed a lumbar puncture on an infant, you’ll realize what I’m talking about.
The Vein of WhiteCoat runs along inner lumbar vertebrae of every child under 1 year of age. It is nearly impossible to miss the Vein of WhiteCoat when performing a lumbar puncture. You must first hit the Vein of WhiteCoat and allow a few drops of blood to escape through the spinal needle in order to decompress the Vein of WhiteCoat before you can obtain spinal fluid from an infant. It is just a rule of emergency medicine. Most of you docs out there probably didn’t know that I had dibs on that eponym, but now you have a completely logical explanation as to why nearly every spinal tap on an infant results in a few drops of whole blood from the needle before you reposition the needle and actually get spinal fluid. Go ahead and write it in the charts. A quick internet search will let everyone know what you’re talking about.
If you happen to get spinal fluid without decompressing the Vein of WhiteCoat first, then the child just has some anatomical abnormality. No worries. Carry on.
This patient’s spinal fluid looked good during the procedure. Of course the microscopic exam came back with 44 red cells.
Curses.
Posted in Random Thoughts | 4 Comments »
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