WhiteCoat

Healthcare Update — 04-11-2011

Scranton attorney “scores” $10 million medical malpractice verdict after client with spinal cord compression is misdiagnosed as having Lou Gehrig’s Disease.

Man gets brought to emergency department after going to bathroom in WalMart and being unable to get up from toilet. Seems that someone lathered the toilet seat up with glue the night before. They had to remove the seat from the toilet in order to transport the patient to the hospital. Cute … until the prankster gets caught. Police are ready to charge him/her with second degree assault.

Maine medical providers supposedly “flabbergasted that undercover police have been able to purchase a variety of prescription drugs — including Percocet, Vicodin, Ritalin, methadone, and suboxone — on the streets” and that the drugs “are easier to obtain than illicit drugs and they are paid for by the state.” Police chief states that availability is due to overprescription of the medications. Doctors say “but look at my Press Ganey scores!”

New Mexico man brings woman to hospital and asks hospital staff to come outside to help his sick friend. She really was sick – she had been dead for more than a day and was starting to decompose.

Use of CT scans on children in emergency department visits “skyrockets” – especially for complaints such as head injuries, abdominal pain and headaches. One reason for the increase: Fear of lawsuits. “If you send a kid home [without a CT scan] and it turns out you missed an abnormality, not many juries are going to be sympathetic,” says the lead author of the study. Does suing our way to better healthcare still count if doctors pick up one needle in the haystack diagnosis but cause cancer in a handful of kids by significantly increasing the number of scans being performed?

Bad news is that you’ll wet yourself. Good news is that Depends is coming out with designer adult diapers for the club scene. Study shows that chronic users of the club drug ketamine – also known as “Special K” more likely to end up incontinent of urine. Gotta love Google AdWords. Cracks me up that a Depends ad pops up next to the news story. How many people on the Hong Kong club scene are going to click on that ad?

Naked man running through neighborhood “ringing doorbells” brought to the emergency department for evaluation after head-butting a deputy in the jaw when the deputy was trying to arrest him.
In other news, the Joint Commission on Accreditation of Police Organizations (JAC-A-PO) cited the deputy for failure to wear a padded helmet that would have prevented the injury to the patient’s head during the head butt. The Florida State Police must now come up with an action plan on how to prevent such injuries in the future or risk being decredentialed as law enforcement officials. Oh, wait. Sorry. Only medical institutions are subject to inane rules like this.

How’s that insurance for all thingie working for ya? President Obama’s new health care law doesn’t necessarily allow Americans to keep their existing health care coverage. The National Association of Health Underwriters has now confirmed what I stated would happen a long time ago. Seventy percent of brokers have seen employers decrease health care coverage for their employees and more than half of brokers have seen their clients completely drop employee health care coverage — to cut costs. In addition, 40% of brokers have seen employers eliminate jobs and 57% have seen employers reduce hiring due to health care reform. Some insurance companies are pulling out of the health insurance business and others are prepared to pull out of certain markets.
So when employers lay off workers or stop offering coverage and when fewer insurance companies offer policies, the number of people really able to keep their existing health care coverage becomes less and less. Nice smoke and mirrors. At the same time, the number of people who will get thrown into that Ponzi scheme of a Medicaid program grows larger and larger.

Remember the Minnesota “patients gone wild” psychiatric patient who assaulted an emergency physician, knocking the physician unconscious and breaking the physician’s ribs? Now the patient’s family is speaking out about their version of the story. They’re upset that the patient’s name was published in the paper and that he is being treated like a criminal. They also stated that patients shouldn’t be stuck in a room “and wait and wait and wait” and that the emergency physician should have just sedated the patient before the violence occurred. Unfortunately, the family’s response just shows how treatment protocols (see JCAHO policies about sedating patients) and “insurance” problems (more and more psychiatric facilities closing or scaling back beds due to poor reimbursement) imposed by government agencies sometimes get in the way of necessary medical care. Regardless of the reason for an outburst, being upset due to a wait doesn’t justify violence. Would the family be as accepting if the physician got upset at the mother, knocked her unconscious, and broke her ribs?

Either we’re real smart because we’re such technogeeks or we’re real dumb because we have to keep looking up so much information. At 40% adoption rate, emergency physicians are the highest users of mobile technology of any medical specialty.

23 Responses to “Healthcare Update — 04-11-2011”

  1. Matt says:

    “. . . but cause cancer in a handful of kids by significantly increasing the number of scans being performed?”

    Are you saying kids can get cancer from having a single, or even a couple, CT scans?

  2. Steve says:

    Re: CT scans on kids…I am waiting on the lawsuit where an ER doc gets sued for a “missed” intracranial hemorrhage that gets no neurosurgical intervention…or the one where you documented an extensive conversation with the parents regarding the risks and benefits of CT and they agree with you but the kid bounbces back…it’s coming

    Even worse than the risk of cancer- there’s evidence out there (based on kids who get whole brain radiation and Hiroshima studies) that we should worry about causing developmental delays and lowering IQs with head CTs. That could be the next tidal wave of lawsuits.

    Re: mobile devices. EM physicians use them the most because no other specialty out there needs to have the breadth of knowledge that EM docs do. Yes, there are some things that never seem to stick in my head but I’m equally as likely to be on uptodate.com as epocrates during an average shift.

    • Matt says:

      There’s always someone predicting the next “tidal wave of lawsuits”. Still waiting on the fatty foods ones, which were predicted, oh, about 5 years ago.

      So are you comparing exposure at Hiroshima to the amount of radiation a kid would get from even a couple CT scans? The linked article cautions about hospitals not paying attention to the settings, but are you saying even an adult sized dose given twice is comparable?

      Or is this just a bunch of hyperbole?

      • Dave says:

        I actually agree with Matt on this one. How many kids are getting several head CT’s a year? I don’t think one or two is that huge of a risk. Plus we are getting better and better at various MRI scans. The things that can be done with MRI increase all the time (I’m currently involved on a clinical DTI study). In fact, MRI scans are actually better at detecting most head/brain things, though they are more expensive, slower to get, and less available.

      • VA Hopeful says:

        You have to sedate most kids for MRIs, that’s tricky business and most places won’t do that.

        The Hiroshima/CT scan/brain irradiation for cancer are all based on total exposure by kids in Japan based on their radiation exposure. There’s some debate on whether this is a decent way to do things as we’re comparing one massive dose in Japan vs. several dozen smaller doses via CT scan.

        The radiologists say we should be careful, and so we will be. They’re the experts after all.

      • Matt says:

        They are the experts, true. But WC and Steve, presumably smart guys up on this sort of thing, are saying that we might be causing cancer in kids by the one, maybe two CT scans a kid might have in their life. And Steve is comparing it to exposure at Hiroshima.

        Is that true? Or just hysterical nonsense?

      • Steve says:

        Depending on your source, the estimate is somewhere between 1 in every 1200 to 1 in every 2000 kids will get cancer from a single head CT. (Note: this is what I have been hearing in the recent debates but I don’t have the time to look up the exact numbers now. I can say that it is in the area of 1 in a few thousand. If someone has the citation for these, please post it).

        However, this is with some caveats…and I don’t believe all that hype…I was using the hiroshima and whole brain radiation example to point out that we are worried about cancer but maybe we should be concerned about knocking off serious IQ points as well.

        Let me expand on that- The younger you are, the more harm it does because the risk is cumulative over your lifetime. For example, it takes a lot for me to CT a 2 year old because they have another 76 years (based on normal life expectancy) to develop cancer and/or get more CT scans to further increase their risk of cancer. On the flip side, it takes very little for me to CT a 90 year old because the chance they will develop cancer before they die of something else is next to zero.

        However- this has never been studied with CT scanners- these numbers are extrapolations from the Hiroshima radiation exposure studies. Although the nuclear physicists insist that the math is right- I won’t believe it until I see it. It is going to take a large cohort study of people with CT scans and no other radiation exposure and follow them for 20, 30, 40 or more years down the line to determine if all the CTs we are doing is truly causing cancer.

        There are dire predictions from physicians that this is the next tidal wave of litigation that will surpass asbestos. There are some who say it isn’t a big deal. The truth is probably in the middle. In the meantime, I think we have an imperative to “image gently” and use our clinical judgment to weed out those people that we believe don’t need a CT as a part of their medical care because right now (as in a lot of medicine) we can’t be sure of the exact risks involved.

        If having faster and more accessible MRIs are the solution to this problem then I am all for it. I think we are seeing trends in that direction. Some major medical centers have MRI techs 24/7 now whereas they were on-call during off-hours just 5 or 10 years ago. One day we may see this trickle down to the community hospitals (I don’t see why not). The same thing happened with CTs- that used to be an on-call kind of thing, now its routine to have 24/7 coverage at all but the smallest of hospitals.

        One last thing- just so we are clear- I’m no expert- just a 2nd year EM resident who is training in a time when this is a hotly debated topic. If I have said something medically inaccurate, please correct me.

      • Matt says:

        I wouldn’t think of correcting you on a medical issue. You’re the one with the training.

        As far as physicians predicting dire consequences in terms of lawsuits, well, that’s just what physicians do. Most of their understanding of legal matters is pretty limited, and generally consists of regurgitating insurance propaganda. Even if this were to result in litigation, it’s very unlikely to be anywhere near as widespread as the asbestos litigation. And it’s unlikely that there are the terrible, terrible documents in the hands of the manufacturers like there were with asbestos.

      • WhiteCoat says:

        See the article.
        http://www.nejm.org/doi/full/10.1056/NEJMra072149
        They’re the ones comparing radiation from CT scans with the nuclear bomb blasts from Hiroshima.

      • Matt says:

        So you do or do not think it’s a legitimate comparison?

      • EDL says:

        Yikes — what state are you in?

  3. Kipper says:

    It seems a little strange that health care reform is on the hook for layoffs and cost cutting during a recession. Like that is the *single* pressure on employers right now? And the cost of health insurance was otherwise going to stay level?

  4. Nurse K says:

    My favorite all-time idiotic pediatric head CT was a toddler who threw a Cadbury Easter egg at his 5-year-old brother and hit him in the head with it. He had, what we would describe as a “small boo-boo” from it. Kids were running around the room unruly-like.

    They should AT LEAST offer families the option of donating some of their own cells for the BMT for the leukemia they’re going to get in 15 years when they order head CTs like this.

    • KT says:

      How about just giving the family the ED bill, plus a quote for the CT outright and maybe make them reconsider bringing someone into EMERGENCY for this sort of “incident”.

      I mean…what the hell were the parents thinking let alone the freaking doctor?

      • Nurse K says:

        I haven’t ever seen a pediatric head bleed that wasn’t associated with a pretty serious injury with LOC or, at least, mental status changes. Maybe someone else has, but not me. Usually it’s the baseball bat to the head or the shaken baby syndrome or similar.

  5. [...] talk about med-mal reform [The Hill] Ringing the bell: Roundups of more big med-mal verdicts [White Coat, [...]

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