Archive for October, 2011
Monday, October 31st, 2011
Also see the Satellite Edition of this week’s update over at ER Stories.net.
Many good Halloween safety recommendations from emergency department staff at UC San Diego Health System. Take a look before you go trick or treating.
Interesting infographic regarding emergency department visits, including the most common reasons for visits to the emergency department (not what I guessed), percentage of patients less than 25 years old, and percentage of visits that were not urgent (again, not what I would have guessed).
Nursing pays. Nurse in California earns $270,000, including overtime.
Walter Olson of Overlawyered.com fame creates an interesting piece at Cato’s blog. Why is it that courts won’t let physicians and patients contract around medical malpractice issues? For example, “Could you set this broken arm? I promise not to sue you for more than a half million if something goes wrong, nor for anything short of gross negligence, and yes, I agree to arbitration.”
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Posted in Healthcare Update | 11 Comments »
Saturday, October 29th, 2011
Remember how the government health care wonks at the CDC thought random HIV testing in the emergency department would be such a great idea?
Things didn’t quite turn out that way in France.
A study in France published in the Archives of Internal Medicine showed that out of 138,000 emergency department visits, 21,000 patients were offered testing and 12,754 actually received testing.
Out of those tested … drum roll … a rocking 18 patients received a new diagnosis of HIV. That’s 0.14%. Or .1400000000% if you want to thumb your nose at JCAHO.
But wait … that’s not all! Of those 18 patients, most were in high-risk groups, had previously been tested for HIV, and were in late stages of the disease. In other words, the patients probably knew that they had HIV before the testing and the docs probably could have told them they had a high probability of having HIV before doing the test.
An HIV test costs $200. Multiply $200 times 12,754 tests and you get $2.5 million spent on testing alone. Then throw in all the wasted nursing and lab time performing the testing instead of providing medical care. That money could provide a whole lot of childhood immunizations.
Oh, and while you’re at it, screen every patient for domestic violence, tuberculosis, substance abuse, heart disease; type everything into a computer so we can measure how quick you’re performing your tasks; see more patients with less resources and higher patient loads; make sure you wash your hands 100 times per day (which would require roughly 1/5 of your entire 8 hour shift to do so); fill out all the other ancillary paperwork involved in creating a safe work environment; and do anything else we think might make people safe but haven’t proven yet. Got all that?
But studies cited by the CDC in the US show that the rate of new diagnosis for patients at hospitals in Los Angeles, Oakland, and New York was between 0.8 and 1.5%. Does that mean that patients in those areas have ten times as much risky behavior as patients in France? Ten times the drug use? Ten times the unprotected sex? Maybe it’s just those French people creating false data trying to make the CDC look bad.
Every patient entering our rural hospital’s obstetrical ward has to either consent to testing for HIV or has to sign a refusal. So far, we’re batting .000 in catching those early asymptomatic cases of HIV.
Cost effective and medically necessary health care. These can be the only result of “safety” directives imposed by government agencies. Kind of like a directive to perform blood cultures before instituting treatment for pneumonia. Oh, wait, I don’t recall seeing any scientific evidence showing the benefit of that directive, either.
Policymakers wonder why health care costs and delays in care are skyrocketing?
Its own mandates are the rocket fuel.
Posted in Medical Studies, Random Thoughts | 4 Comments »
Friday, October 28th, 2011
I just read an article in American Medical News about medical malpractice insurance costs. Included in the article was a small graphic about how much internists pay for medical malpractice insurance.
Internists in Dade County, Florida paid medical malpractice insurance premiums that were 1400% higher than internists in the state of Minnesota. Illinois internists in Chicago paid more than 12 times as much in malpractice insurance premiums as their Minnesota counterparts. In other words, internists in select Florida and Illinois counties pay more for malpractice insurance in one month than internists in the state of Minnesota pay for an entire year.
There are similar premium disparities for general surgeons and obstetricians, with Long Island, NY and Las Vegas NV also consistently being on the list for high malpractice premiums
Does that mean that the Florida and Illinois physicians were 1200% to 1400% more negligent than doctors in Minnesota? Doubtful. It just means that Miami, FL; Chicago, IL; Las Vegas, NV; and Long Island, NY are places where insurance companies have determined that it is much more risky to practice medicine.
When doctors search for the best states in which to practice medicine, they should consider the medical malpractice environment when making that decision. Given these statistics, doctors should not practice in Miami, Chicago, Las Vegas, or Long Island if they want to reduce their medical malpractice risk.
Yet Florida lawmakers reach out to news stations and claim that the state “desperately needs more doctors.”
Suing your way to better health care doesn’t work very well, does it, Senator Nelson?
Posted in Medical-Legal, News Commentary | 3 Comments »
Thursday, October 27th, 2011
I really don’t like it when people call me “doctor.”
The only time that I ever refer to myself as “Dr. WhiteCoat” is when I first enter a room and introduce myself to a patient. That way they know that I’m not some schmuck off of the street who wandered into the wrong room. Patients came to the emergency department to be evaluated by a doctor and, like it or not, I’m that guy.
However, almost all of the staff that I work with call me “Whitey” and many patients call me by that nickname. The rest call me “Dr. Whitey” apparently because they feel uncomfortable addressing me without the “Doctor” moniker.
Personally, it annoys me to no end when people correct others and demand to be called “Doctor”.
I met a child’s parent at a football game and introduced myself.
“Hi, Mr. Smith, I’m Thaddeus WhiteCoat. Nice to meet you.”
“It’s Doctor Smith. Dr. Mark Smith.”
“Oh. My apologies. What’s you’re specialty?”
“I have a PhD in psychology.”
“Oh. Nice.”
In the back of my mind I was thinking about saying something like “Unfortunately, we’re in football stands so I can’t genuflect in front of you. Please forgive me.”
Enough rambling.
In the NY Times a couple of weeks ago, there was an article about nurses who want to be called “doctor.” Actually, the nurses in the article earned the title. They have doctorates in nursing or other PhD degrees.
Is it good public policy to allow a non-physician to use the title “doctor” in a medical setting without having a medical degree?
Personally, I don’t care what people want to call themselves. If your ego is that fragile, call yourself Grand Exalted Supreme Poobah Doctor Nightingale for all I care. Introduce yourself that way at dinner parties. Command people to address you that way. Knock yourself out.
When someone introduces themselves as “doctor” in a medical setting, it evokes a specific and consistent response from just about any patient: The person in front of me is a physician.
Whether the patient thinks the “doctor” is intelligent or a quack depends upon multiple other issues, but the presumption is that “doctors” have gone through a lot of medical training and are capable of independently evaluating, diagnosing, and treating the medical condition for which the patient is seeking care.
In my view, calling oneself “doctor” when one is not a physician is misleading. Think about it. What if you bought a “hybrid” car, then opened up the hood to find a regular engine with a “hybrid” soybean growing in a crevice. Hey, it is a hybrid, isn’t it ? Or what if you bought a “Big Mac” and unwrapped a sandwich with two buns and a piece of cheese that was made by some guy named “Big Mac”?
States tend to frown upon nurses and physicians assistants referring to themselves as “doctor” as well. Many state Medical Practice Acts, Nursing Practice Acts, and Physician Assistant Practice Acts prohibit non-physicians from leading a patient to believe that they are capable of independently providing medical care. There have also been lawsuits against physician assistants who have not disclosed their credentials.
Maybe the increasing number of non-physicians who refer to themselves as “doctor” will create a “caveat emptor” environment where consumers will inquire about the credentials of a health care provider before seeking care. I see that as a good thing.
Maybe hospitals will use the idea to enhance their advertising: “This hospital emergency department is staffed exclusively by board certified emergency department physicians.”
We haven’t reached that tipping point, yet, though.
Given the current medical practice environment where providers are attempting to cut costs by employing non-physicians, I don’t think it is appropriate for non-physicians to refer to themselves in a medical setting as “doctor,” even if they have earned some other doctorate degree.
If non-physicians want to demand that others call them “Doctor” at dinner parties, go through the explanation about how they are not a physician but have completed a doctorate in some other course of study, garner the eye rolls that go along with the explanation, and then deal with the whispers about how he or she is not a “real” doctor, hey … be my guest.
What do you think?
Posted in News Commentary, Random Thoughts | 40 Comments »
Tuesday, October 25th, 2011
After finishing a shift today, I had several pertinent thoughts that came to mind while driving home.
First, when a helicopter is coming in to land on the hospital helipad, standing on the helipad to take pictures with your camera phone and refusing to move will likely end up in you being tackled by a security guard and causing your phone to be broken. Threatening to sue the security guard for the cost of the phone will likely end up in the security guard getting ticked off and using his functioning cell phone to call his friend on the police force and have his friend come to arrest you for trespassing.
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Posted in Random Thoughts | 7 Comments »
Sunday, October 23rd, 2011
I was forwarded an article that seems boring, but had an interesting catch to it.
You may not have known this, but denitrosylation of HDAC2 by targeting Nrf2 restores glucocorticosteroid sensitivity in macrophages from COPD patients.
The study showed that in some forms of chronic inflammatory diseases, such as COPD/emphysema, acute respiratory distress syndrome, asthma, rheumatoid arthritis, and inflammatory bowel disease, a chemical reaction within a transcription factor called NRF2 within the cells causes them to be less sensitive to steroid therapy. When study patients with COPD were given either glutathione or sulforaphane, the chemical reaction was reversed and macrophages within the alveoli of the lungs became significantly more responsive to steroids.
One food that is high in both glutathione and sulforaphane is … broccoli.
Did a little extra research on the internet and found that glutathione is also contained in asparagus, potatoes and many green leafy vegetables and that sulforaphane is also contained in cabbage, cauliflower, bok choi, and those same green leafy vegetables.
And … one of the things that depletes glutathione in the body is Tylenol.
Also ran across a study in 2009 showing that the Nrf2 factor also plays a role in Helicobacter pylori infections and that ingestion of broccoli sprouts decreased byproducts of H. pylori infection by 40%.
Makes me wonder whether these chronic inflammatory diseases may have some type of bacteriologic basis.
Now they just have to do a study to find out many people would rather have COPD exacerbations than eat broccoli or green leafy vegetables every day.
Posted in Medical Studies | 5 Comments »
Wednesday, October 19th, 2011
 Interesting but sad case that bypassed the ED but about which we later heard.
An elderly female with previous coronary artery disease, diabetes, and hypertension called EMS for chest pain. Then she has a syncopal event in front of her husband.
Medics arrived and found the patient in ventricular tachycardia. They cardioverted her back to sinus rhythm, but she was still hypotensive. EMS transports her as a sudden cardiac arrest to a STEMI facility.
The patient is taken directly to cath lab which had already been activated due to the EMS report of a “code STEMI.”
During the angiogram, the patient remained unstable, went in and out of ventricular tachycardia, and remained markedly hypotensive, requiring fluid resuscitation and pressors. The angiogram showed severe three vessel disease.
Cardiologists couldn’t get the patient stable despite pressors, IV fluids, multiple defibrillations, and ACLS drugs.
Then the cardiology fellow notes that the patient’s abdomen seemed to be distended – moreso since the case started. They directed the cardiac catheter down the aorta and injected dye while doing cineangiography. It showed contrast material going into the patient’s peritoneal cavity.
Shortly afterwards, while making arrangements for the patient to be taken to surgery, she died on the table.
The rest of the history came out when the husband was informed of his wife’s death. The night before, the patient had been seen at a different hospital for evaluation of abdominal pain. They diagnosed her with “obstipation” and sent her home.
Some of you are probably wondering how cardiologists missed the ruptured abdominal aneurysm when they inserted the catheter into the groin and advanced it up the aorta into her heart. Radial access is all the rage these days, so initial access was through the arm and not through the leg. Therefore, the catheter didn’t pass through the lower aorta.
So why was the patient in ventricular tachycardia? The cardiologists surmised that the hypotension led to low cardiac perfusion, which, in the setting of severe CAD, caused chest pain, cardiac ischemia, and the arrhythmias.
The patient probably wouldn’t have survived surgical repair of her aneurysm, but one of the down sides to that holy grail of a short door to balloon time is that it is more difficult to obtain a complete history.
Ironic that sometimes hospital boards and/or administrators care more about their numbers than they do about the actual patients. When hospital boards or administrators pressure medical staff to meet unreasonably high standards for “door to balloon times,” perhaps lawyers need to start looking at the administrators and board members for reckless decisions that result in adverse patient outcomes.
This and all posts about patients may be my experiences or may be submitted by readers for publication here. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.
Posted in Patient Encounters | 7 Comments »
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Man Cuts Arm Off with Guillotine
Friday, October 28th, 2011“I tried to think of a witty comment to this story … but I was stumped.” So begins the comments section to the story about a Washington man who was rushed to the emergency department after cutting off his arm with a homemade guillotine. While the story is sad, many of the comments are amusing … in a morbid kind of way.
A picture of the actual guillotine is here.
Then there’s this article about whether the patient may have Body Integrity Identity Disorder. A related story describes a man who wanted to cut his arm off with a table saw but who lost his … nerve.
Aaaaugh. Make it stop.
Posted in News Commentary | 8 Comments »