WhiteCoat

Healthcare Update — 03/12/2012

See more news stories from around the web at ER Stories.net and at Medbloggers.org.

Hopefully this is the beginning of a trend … California OSHA officials fine two hospitals nearly $100,000 in part for failing to protect from patient assaults and for inadequate staffing.
If hospitals can’t be made safe, then staff needs to make more OSHA reports.

West Virginia family files $2 million lawsuit against at least 15 defendants for failing to save family member from a disease that has a 60-100% mortality rate. In other words, most patients who develop the disease die despite the care that they receive.
Plaintiff’s attorney rants against teleradiologist: “It used to be that you could see a person face to face, shake his or her hand, not someone behind a curtain. These people are making decisions on our life. Now we don’t know who the hell they are.”
And the location of the person reading the scan matters how?

Why do medical procedures cost so much in the US as compared with other countries? The graph accompanying this article is startling. For example, an average MRI in India costs $138. The average MRI in the US costs $1080. An appendectomy in India costs $254. An appendectomy in the US costs $13,000. High education costs, liability, higher physician salaries, and governmental regulations all likely contribute to the costs.

“Now. Trauma suite.” Great story about how an emergency department teamed up to save a young infant’s life.

Feds brag that because of the Affordable Care Act, 105 million people now have no lifetime limits on their health insurance benefits. Does that statistic count employees who lose their insurance completely when their employer downsizes or moves overseas? The lack of limits don’t mean much if the patients have Medicaid and can’t find a doctor to take care of them, either.

White House helping to coordinate prayer vigils outside the Supreme Court during time that Court is scheduled to hear arguments about healthcare reform? Well, that whole separation of church and state thingee in the Constitution only applies to Congress, not to the executive branch of government, so it must be OK.
To me, government using religion to attempt to help preserve a law which needed a lot more vetting before being passed in the first place just doesn’t pass the “whiff test.”
What’s next? Organized incantations and voodoo doll demonstrations?

Interesting concept for a movie. The Waiting Room. The trailer looks very interesting. Going to San Francisco film festival later this month. Good luck!

Patients gone wild. Bayonne, NJ man doesn’t want to leave the ED after being discharged. Refuses to change out of his gown. Police called. Patient then threatened to kill one of the officers and to bring unspeakable harms to others in the emergency department. Arrested and charged for making terroristic threats and for disorderly conduct.

Patients gone wild – International Edition. Jerusalem prisoner punches emergency department nurse in face, breaking her nose. Emergency department temporarily closes in protest.

Federal and state cuts to payments for care of patients with Medicare and Medicaid “insurance” causes difficulty for patients seeking access to medical care. One physician is taking out personal loans to keep his clinic open, but states “if I only see them, I’m going to be out of business. So what do you do?”

10 Responses to “Healthcare Update — 03/12/2012”

  1. DataGirl says:

    Item 1 above…one of the scariest places I have been…the ED. I rarely go. But I had to. And there was this CRAZY man going apeshit out there. And during his screaming tirade he took a gurney and pushed it with all his wild might…and you guessed it…the damn thing became a battering ram to the door of the room in which yours truly was being seen. The doc jumped and I was speechless and scared to death thinking that man would run into my room and commit Lord knows what. The doc asked me if I wanted him to stand in front of the door. Uh, no, doc, because if this crazy fool decides to fling it open, well you are the first one to get hit. A few more minutes of screaming and things flying everywhere it went absolutely silent. It took a while for the heartrate to come back down. I never knew why they had so many damn cops there. Now I know. Stay safe.

  2. Matt says:

    In your link on the mortality rate in the WVa case, right after it gives that number, it says:

    “The successful outcome is dependent upon a high index of suspicion and prompt management.”

    Isn’t that the crux of this case as far as liability goes? Was the management prompt?

    The mortality rate might go to damages, but do you think it bears on whether the treatment or lack thereof was negligent?

    • WhiteCoat says:

      In a vast majority of cases, prompt management will have a negligible effect.
      First consider that median time from symptom onset to presentation is 24 hours – which already puts most patients in a category with much higher mortality.
      Of those patients that arrive promptly to the emergency department, they don’t come to the ED saying “I have a mesenteric clot.” They come to the ED saying “I have abdominal pain.” Standard initial workup for such patients includes labs, IV fluids, pain meds. If symptoms don’t improve, then the patient will likely have a CT scan. Depending on several factors, presentation to CT report will be another 4-6 hours.
      Then, if colitis is suspected, infectious causes are much more common than ischemic causes. Patient is started on antibiotics. GI consult called. Prepped for upper/lower GI the following day.

      Let’s say that we perform angiography on every patient with abdominal pain so that we catch the small proportion of patients that present within time to save their lives. Because the disease is quite rare to begin with, we’re going to do an awful lot of “unnecessary” testing – right? After all, when the result of a test was negative, the test probably shouldn’t have been performed, right?
      Now mesenteric angiograms are not without risks. You can actually cause a clot in the mesentery by injecting the dye. There are allergic reactions to the dye. The dye may cause kidney failure. Infections can develop. The catheter can perforate a blood vessel requiring urgent surgery to fix the problem. So we’re now introducing all of these risks to more than 99.9% of patients to try to save the one person who may present in enough time and who may be stable enough to take to surgery and who will be medically healthy enough to survive the high perioperative mortality rate.

      It takes a very astute physician to catch a case of mesenteric ischemia and even in those cases that are caught “promptly,” the outcomes are usually suboptimal.

      So if a patient with abdominal pain who doesn’t have mesenteric ischemia gets an angiogram and dies from the testing, then won’t lawyers vilify doctors even more for killing patients with an “unnecessary test”?

      • Matt says:

        I was just asking the question based on your link. It seems you would agree that it’s possible that there was negligence in this case. Therefore, I agree with you that we should wait until all the facts are in before saying who is wrong or right. Relying on press releases is probably bad practice.

        The lawyer alone can’t prove a physician is negligent. It takes another physician.

        ” then won’t lawyers vilify doctors even more for killing patients with an “unnecessary test”?”

        I don’t know. Have they ever before? Considering it would take another physician to opine as to the unnecessary nature of the test at trial, probably not.

  3. Tarl says:

    “prompt” for mesenteric ischemia, is an hour – assuming there is anything the surgeon could do, even if he had a knife inside her belly within that hour of the problem manifesting (note, manifesting, not arriving at ER).

    My understanding is that good outcomes for mesenteric ischemia are when they are caused by abdominal trauma (e.g., car accident), and are brought into the ER within minutes of the accident, and there is something the surgeon can do to repair circulation. When the problem is the result of a degenerative condition (e.g., arteriosclerosis), there isn’t the obvious justification to cut someone open as soon as they arrive at the ER.

    Which doesn’t mean the radiologist is off the hook – we don’t know if he should have seen something on the scan. But from the description we’ve seen of this case, that lady’s fate was probably sealed before she got to the hospital, let alone by the time the radiologist was called.

  4. midwest woman says:

    What’s your opinion of tele-radiology? Wouldn’t you want to know a physician co-worker?

    • WhiteCoat says:

      I don’t think that the locus of the services being performed (on-site versus off-site) makes any difference in the readings. If there is a critical finding, I get called either way.
      If others disagree with me, I’d like to get their feedback.

      And look at it from another perspective: In many cases – especially in rural hospitals – it is cost-prohibitive to have a radiologist in-house 24/7. Is it better to have 24 hour access to someone who can read the tests quickly or is it better to wait a day or more for the results to be read by the in-house radiologist?

      With all of the cost-cutting measures taking place in medicine right now, teleradiology/telemedicine is going to become more common, not less common.

      It is absurd for the plaintiff attorney in this case to be babbling to the media about off-site radiologists as if their location made any difference in the case.

    • Ed says:

      I live in a town of 9000 people. If I end up in the ED of the local hospital, I don’t give a rip where the person looking at my inards is so long as they know what they are doing.

      Think about it this way: small hospitals have a hard time supporting staff. What if you developed a firm of radiologists, all in one building, with HD monitors and a trunk line. You get a “film”, upload it to the firm, and their 24/7 staff send you a result.
      They should all be pretty good at what they do, if it is all that they do.

      Just a thought.

  5. Nick says:

    As a rural emergency physician, I would rather have a teleradiologist, than NO radiologist. That’s the choice, period.

    A dark room with a computer screen is about the same whether it is 50 yards or 500 miles away.

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