WhiteCoat

Healthcare Update — 04-01-2013

This case report is entirely bizarre. Patient gets awarded more than $800,000 after visit to doctor resulted in incorrect diagnosis of cancer when the patient really had pneumonia and caused patient to have amputation of her foot. A trial was held on the case four years ago with a verdict in favor of the doctor, but the judge declared a mistrial because Washington State jurors were referring to the plaintiff’s Japanese attorney as “Mr. Miyagi” and were making other racist comments against him.
Then, the article notes that the doctor had been disciplined by state regulators for making “erroneous diagnoses” and for prescribing methadone to drug-addicted patients. So now Washington State physicians’ licenses can be on the line for failing to perfectly diagnose patient symptoms and for prescribing medication for one of its intended uses.
I admit we don’t have all the information behind the license actions, but the article makes the Washington State Medical Board sound a little overeager to discipline physicians.

Congratulations! You delivered a healthy 6 month old! 15 lb 7 oz baby delivered vaginally in UK. More than 20 doctors reportedly assisted in the delivery.

Curing patients gone wild? Australian hospital emergency department guards petitioning to carry guns at work. Medical workers claim that it will make emergency departments more dangerous.

Australian patient held four days in emergency department waiting for psychiatric bed to open up. Shortage of beds creates high demand. Patient’s mother alleges that his condition worsened because of the long wait.
Not that anything like this could happen in the US. Oh wait. What a coincidence. LSU is closing their mental health emergency department, resulting in other hospital emergency departments having to care for “an additional 2,000 people who are a danger to themselves or others, who are desperately in need of stabilization and potential further hospitalization.”
When medical services are curtailed, the patients needing those services don’t just disappear.


Kevin Pho’s latest USA Today article advocates expanding New York-style limitations on opioid prescriptions to hospitals all over the country.
If we do implement strict opioid policies all over the country — just like when hospitals close their emergency departments — patients aren’t just going to disappear. If patients can’t get the medications they need at one facility, they’ll go to another facility where they can get the medications. Or they’ll visit the same facility multiple times to get the same number of medications which will increase costs to the hospitals when government “insurance” doesn’t pay its bills for the patient care.
Some will argue that the guidelines are voluntary [wink wink]. No uninformed journalists would write scathing articles about doctors who prescribed more than the limits suggested in the guidelines if a bad outcome occurred – especially if the bad outcome occurred in NY City, right? And no administrator would threaten a physician’s job for failing to strictly adhere to the “voluntary” guidelines, right?
One of the biggest problems that I have with this and so many other policies that are created for our own good is that they haven’t been vetted to see if they are effective. We wouldn’t start treating cancer with antibiotics just because some sphincter mayor thought it sounded like a good idea. We’d create studies and control populations then study the results to see if the proposed treatment achieved its desired benefit before implementing the treatment on a widespread basis.
We’ll have to see how things turn out in New York … if anyone is even going to look at the “before and after” effects.
Right now, I think this is an idea with good intentions that will have many unwanted unintended consequences.

Resident work hour limitations cause MORE errors – 15-20% more. In addition, shorter shifts have not improved young doctors’ mental health or the amount of sleep they get.
Study author cites “unintended consequences” of policies to decrease work hours because there “wasn’t good data to support them.”
Where have I heard that before?

Trenton, New Jersey’s emergency departments are “clogged” with patients who have no health insurance. One patient who has diabetes and kidney failure and who often left his dialysis sessions early ended up costing the system more than $1 million in one year.
Do people think that things will change for the better with “insurance” under the UnAffordable Care Act?

Cancer patient advocates for closing insurance loophole. Intravenous cancer medications are covered by a flat co-pay, oral cancer medications are covered on a percentage basis – leaving patients with huge medical costs that are allegedly based on the route of medication administration.

Making an appointment to have your emergency treated. More and more emergency departments are allowing advance online registration for emergency patients. According to this article, the only people who weren’t happy with the patient using the service “were those in the lobby watching as she walked right by them to be seen.”
Advance registration of emergency patients is such a big EMTALA violation it isn’t even funny.

Valley Fever is increasingly prevalent in Southwestern States. No, it doesn’t cause you to dress up in Spandex and repeatedly say “Oh my Gawd!” You’ll get a cough and some flu-like symptoms that don’t go away. It is caused by a soil fungus called Coccidioides and is most commonly seen in Arizona and California.

Man awarded $2.1 million after radiologist failed to report “destructive lesion” noted in patient’s spine. Surgery to repair the lesion was delayed by two weeks resulting in a compression to the patient’s spinal cord.

19 Responses to “Healthcare Update — 04-01-2013”

  1. Betty says:

    If you can make an appointment, it is not an emergency.

  2. CRT says:

    ” Australian hospital emergency department guards petitioning to carry guns at work.”

    Something is causing an increase in violence there and since they disarmed their citizens years ago (the law-abiding ones anyway), it can’t be that.

  3. CRT says:

    “Australian patient held four days in emergency department”

    I thought one of the upsides to Universal Health Coverage, which Australia has, was supposed to mean an end to overcrowded emergency departments, since everyone has free health cover and everyone would see their PCP rather than swamp the EDs.

    If only true emergency cases showed up at EDs, because everyone has their own doctor they can see for free for non-emergent issues, then how could they be so overcrowded?

    • ThorMD says:

      This guy had a psychiatric emergency and SHOULD have been in the ED. He needed to be admitted to the hospital and he was there for 4 days because there were no inpatient beds available.

      This has nothing to do with ED overcrowding. It has everything to do with not enough inpatient psych beds.

      The longest I ever had to hold a psych patient in the ED was 10 days.

    • WhiteCoat says:

      I think you’re both right.
      Overcrowding is worsened by room constipation as well as patient volumes. If there is a patient in a room for 4 days, that patient prevents dozens of other patients from being seen in that bed which slows things downstream.
      The reason that the psych patients have difficulty finding psychiatric beds is because of lack of funding. Do the psych patients then just go away? Of course not. Some end up in the ED. Some end up committing crimes and land in jail. Some cause problems with their families at home. But they don’t go away.
      Ten days for one patient in the ED, though? That’s crazy. My worst was a little less than 5 days and I thought that was extreme.

  4. Aesop says:

    Wait wait wait!
    ED guards with guns in Australia??
    That’s crazy talk! Australia banned private gun ownership (or nearly so) some years back, so clearly, there can’t be any violent crime there anymore. Right?
    Help me out…are crooks there actually disobeying that law?!? The nerve…!

    Over here, OTOH, I doubt guards with guns would be helpful. Whereas ED staff with them would have a salutary effect on the environment of care.

    Full disclosure though, I’ve already petitioned management (and been turned down) for that privilege, but in my defense I also included a whip and a chair in my proposed equipment list, particularly for outside triage.

    I say, like Seigfreid and Roy, it’s all fun and games to live in denial, until the day the tiger tries to actually bite your head off.

  5. DefendUSA says:

    WC…I am a bit ignorant, it seems. I thought methadone was used to wean people from heroin or other addictions. This doctor was negligent because of the way he prescribed the drug?

    • WhiteCoat says:

      The article doesn’t say, and you’re far from ignorant.
      Perhaps the doctor prescribed the drug inappropriately when treating patients for drug addiction, but the way that the article reads, the doctor was disciplined for using the medication for its intended purpose.
      Kind of like writing that the doctor was disciplined for using amoxicillin on strep throat patient.
      Not sure if it’s just bad reporting or a medical board that’s going waay too overboard.

      • Marnie says:

        It was my understanding that when the DEA came to his office and went through his patient files, he was allowed to only keep writing methadone for patients who were given it for pain vs. addiction (and needed supporting documentation).

  6. SeaSpray says:

    Okay …scheduling for an emergency department appt is just weird. It’s an EMERGENCY! And if it’s not …that is what TRIAGE is for.

    That’s like people calling to see if your busy in the ED. So if it is …you’re not coming in? NOT an emergency! Or when they threaten to or do leave to go to the other ED because they’re tired of waiting. NOT an emergency!

    And isn’t that for a clinic or medical office?

    Unless it is for fast track stuff – but then it’s not fair to those already waiting.
    ***************************
    It is unsettling to know that more errors are made with shorter shifts for residents. 15 – 20% is HIGH stats for medical errors. So every 15 – 20 patients out of 100 patients is at risk for medical errors by residents? or maybe some of those patients will absorb more of the 20% on any given day?

    CAN they FIX this now that they know?

    I admit – I didn’t read the article. Just seems wrong.

  7. Mandy says:

    “15 lb 7 oz baby delivered vaginally in UK.”

    I have an enduring mental image of our soaking wet just-bathed Saint Bernard attempting to escape to the back yard via the cat flap.

  8. Caitlin P. says:

    Here’s one for the #NHS files…

    They are setting up tents in which to store accident & emergency (ED) visitors in the UK now, and sending out regular cars to see to 999 (equivalent to America’s 911/ambulance service) emergency callers.

    Despite universal health coverage and free access to GPs, use of A&E (ED) departments in England has gone up by one million patients in just the last two years. As the USA has about 6 times as many citizens as England, this would be like our EDs seeing an extra six million patient increase over two years.

    I see a lot of Americans claiming that one of the benefits of Obamacare and everyone having health insurance will be that it will cut down on overuse of emergency medical services for non-emergency cases… people will not be “forced” to use the ED as their primary care provider, once they have insurance they will have their non-emergent issues seen to in traditional doctor’s offices during traditional office hours. Colour me dubious.

  9. Psyguy says:

    4 days, 10 days in an ED for a psych patient? I wish I had that luxury. In this state you can only legally hold them in the ED for 24 hours before transferring them. The hardest psych patients to place are the children. Adolescent inpatient emergency psych units are almost non-existent and those that do exist are often hours away.

  10. Caitlin P. says:

    Here is a thought-provoking one:

    Cash for kidneys as organ donors set to get wage from government
    [Brisbane Courier Mail - Australia]

    — Living donors will be offered cash grants up to $3,600
    — Donors must have a job and employers will distribute payments over six weeks
    — Paid leave scheme will be offered for living donors offering kidneys and parts of their liver

    It might be interesting to hear others’ thoughts on this.

  11. Marnie says:

    As for the 1st dr mentioned, I have had the unfortunate experience of being his patient – as well as my family.

    He dx my grandpa with “european flu” – he had cancer and died 3 mos later.

    Another family member was prescribed 120 mg methadone and 10 mg xanax daily (!!) for their chronic pain after accident. Eventually he abruptly left his practice with no referrals and left this person in an extreme situation. No doctor wanted to work with them (can’t blame them, but hey, this is a serious situation). You can’t just go cold turkey on meds like this.

    I could go on and on. I don’t believe it’s fair to hold doctors to an impossible standard. But this doctor, he shouldn’t have been practicing at all.

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