Archive for the ‘Health’ Category

Antibiotics For The Flu

Thursday, February 26th, 2009

Reading through a patient’s old records and came across the following entry:


Holy Deep Chill, Batman … taking antibiotics for the flu just might turn you into … into … Mr. Freeze.


Then you might get elected governor of a state and … well … I’ll let you all have fun in the comments section with the conclusions you can draw.

By the way, antibiotics don’t work for viruses … including the influenza virus.

Emergency Care – Where’s The Line?

Wednesday, February 25th, 2009

rat-under-yellow-lines-in-streetThe University of Chicago case is getting a lot of press and is polarizing the people on either side of the argument about Dontae Adams’ care.

Read about it at one of my previous posts, at ShadowFax’s place, over at Kevin’s blog, or at Scalpel’s blog. The Chicago Tribune is getting a lot of play out of the controversy. It has published several articles already and just put up another one last night.

Just by the sheer number of people writing about the topic, you should be able to tell that the outcome of this topic is going to help define how medical care will be provided in the future.

On one side of this issue is Dontae Adams and his mother.

Dontae happened to be in the wrong place at the wrong time. He was bitten in the mouth by a pit bull and had a large cut on his lip. It is obvious that he needed medical care. Dontae’s mother took him to the emergency department at the University of Chicago where she alleges that they began asking her about their insurance soon after they arrived. Dontae’s mom works and he has medical coverage through the Illinois Medicare program.

Stop here for a minute.

If you read through the comment boards at the Chicago Tribune web site, they are rife with people who criticize indigent/uninsured patients who may or may not be citizens of this country for “clogging up the emergency department” by going there for “routine” care. It’s easy to look down on someone is viewed as “abusing the system.”
So let me ask you this: Suppose you lost your job tomorrow and had no insurance. Suppose you had to take a minimum wage job at WalMart to keep food on the table for your kids and you weren’t eligible for health insurance. What would you do for medical care?
If you called a random doctor’s office and told them you needed an appointment for “routine” care and could only pay a small amount of cash, what are the chances that you’d get seen that same day? What are the chances that you’d be seen at all? Our family has good insurance, my daughter needs to see a specialist, and the earliest appointment is 4 months away.
Let’s say you’re living on a fixed income and want to pay for your doctor’s visits in cash. How can you afford to spend well over a hundred dollars for a single doctor’s office visit?
Ah, but there are free clinics all over the place, right? In the rural hospital where I moonlight, the closest free clinic is about 40 miles away and has very strict criteria on who it will treat at no cost. Cook County, IL, where the University of Chicago is located, is in the midst of a budget crunch and has closed down many free clinics. See articles HERE, HERE, and HERE.

There’s also an issue of whether or not the care some people seek in the emergency department is “necessary.” Clearly, much of the care that emergency physicians provide is not “emergent.” But I can say that because I have had eight years of medical training plus all the continuing medical education each year. Going to the emergency department to get an excuse for missing work, or trying to get a three day government-paid babysitter for grandma so you can leave on a trip is one thing, but in general, we have to give the benefit of the doubt to the patients.

Back to Dontae.

According to federal EMTALA laws, patients must receive a medical screening examination when they present to an emergency department seeking care. If an emergency medical condition is found, the condition must be stabilized or the patient must be transferred. If no emergency medical condition exists, the hospital’s duty under EMTALA ends.

From what I’ve read in the newspapers, according to EMTALA, Dontae’s injury was not an “emergency medical condition,” so the University of Chicago did not have a legal duty to treat Dontae once the emergency physicians determined that no emergency medical condition existed.

Now let’s look at things from the other side of the coin: Outside of federal EMTALA laws, what services should hospitals and physicians be “required” to provide?

Some believe that medical providers should be on the hook for everything. Expand EMTALA laws to require that patients receive everything they ask for. We need to provide for all of a patient’s needs. Whether it’s cardiac stents, kidney dialysis, Vicodin prescriptions, Lasik surgery, hair plugs, or a sex change operation, all medical care should be free to everyone. Sound silly? That’s the way our system is headed. If you think that some things should be free, but others should not, then you’re engaging in the same thought process that the University of Chicago used when it discharged Dontae Adams. Where ever you draw the line between free and not free, someone who would have to pay is going to criticize you for your decision.

That “free care” medical system is akin to expecting government to provide services with no one paying income taxes, expecting cities to provide services without anyone paying property taxes, expecting newspapers to run all of your advertisements for free (and to be delivered for free, too), or expecting professional medical societies to stay solvent without charging membership fees.

If we head down the free-for-all route in medicine, then why have insurance? If hospitals are required to provide all services to everyone regardless of the ability to pay, there’s no need to have any insurance. Hospitals can’t refuse care and all we have to do is show up at the front door to have access to the latest and greatest medical technology.

That’s a great idea, except for one problem: Who’s paying for it?

Medical care isn’t cheap. Government reimbursements for medical care are shrinking or nonexistent. New York pays a whopping $17.50 to physicians who provide lifesaving care to patients in the emergency department. California’s whole medical system is in shambles. Very few patients can afford huge medical bills. That leaves the physicians and hospitals holding the bag.

A “provide everything” approach becomes a system where hospitals and doctors are essentially paying for patients to come and receive medical care. That type of system is unsustainable. Providers have gone and will continue to go bankrupt. In addition, the more we lessen the incentive to go into medicine, the less physicians we will have. Who will want to spend twelve years of their life for medical education and take out several hundred thousand dollars in loans just so that they can provide unreimbursed care to anyone that demands it?

Do an internet search about hospital closings. Here’s a list of 50 hospitals that have closed in Illinois since 1980. Here’s another example of a hospital closure this month in Queens, NY. Is the University of Medicine and Dentistry in New Jersey next?

Where do we draw the line between care that must be provided and care that doesn’t have to be provided?

The line is already there. We just have to stop trying to redefine it.

The more we try to force medical providers to provide comprehensive free care for everyone, the closer we get to a system in which fewer and fewer patients have access to any care.

Where’s the Injury?

Saturday, February 14th, 2009

A new version of Throckmorton’s?


Bad Dog

Wednesday, February 11th, 2009

A very nice young lady came to be evaluated after being sexually assaulted.

The history as she described it was that she had just come out of the shower, was drying herself off, and had bent over when she was attacked from behind. She was knocked to the floor and rolled around to get free from the attacker, but she was held down on the ground and the attacker had sex with her. She had a couple of scratches on her back and side which occurred during the event.

There were other issues involved that I won’t discuss. As it stands, the patient was pretty embarrassed and upset about the whole situation.

She was able to make a positive ID on her attacker, though.

It was her boyfriend’s great dane.

Not the boyfriend. The boyfriend’s dog.

No we didn’t do a rape kit.

No we didn’t do a pregnancy test.

After discharging the patient, we did have a dilemma about who to call – the police or animal control.

We ended up calling both.

Just thought I’d throw this one out there to warn everone to be careful out there.

The Wait of Death

Monday, February 9th, 2009

intensive care unit monitorWhile searching for more information about the alleged death in the University of Chicago emergency department waiting room, I came across this article at the Huffington Post regarding an emergency patient in Japan who died after sustaining head and back injuries in a motorcycle accident.

When paramedics on the scene called hospitals to accept transport, 14 hospitals refused to accept the patient because they did not have the proper specialists. By the time the paramedics found a hospital to accept the patient, the patient had gone into shock from blood loss and later died.

The article notes that it is common for hospitals in Japan to be on the equivalent of “bypass” in the US, with more than 14,000 emergency patients being rejected by at least three Japanese hospitals in 2007 before getting treatment. In one case, a woman in her 70s with a breathing problem was rejected 49 times by Tokyo hospitals.

For all of you that think a situation like this could never happen in the US, consider this: In the US, under EMTALA laws, every patient is guaranteed a screening exam and stabilizing treatment to the best of an emergency department’s ability (unless coming by ambulance and the closest emergency department is on bypass – in which case you generally get diverted to another facility). If you are in a smaller ED and need specialty care that the hospital does not provide, you’re at the mercy of the specialty hospitals and the transport services.

I’ve had psychiatric patients in need of transfer rejected by seven different psychiatric hospitals. The time that I’ve spent trying to transfer those patients could have been used to treat other patients. I’ve seen many patients whose medical condition has gotten worse while waiting for transport from the rural hospital where I moonlight. I’ve watched patients die in front of me from heart attacks that didn’t respond to thrombolytics while waiting for transport to the tertiary care facility to arrive.

As more and more hospitals close and the services available at community hospitals shrink, I don’t expect things in this country to get better.

I foresee more and more essential services being centralized to large academic centers that will have finite resources. When those resources are overwhelmed by all of the patients being transferred to them, well …

When everything’s an emergency, nothing’s an emergency.

Another ED Waiting Room Death?

Sunday, February 8th, 2009

I spoke to someone who mentioned that they had heard a news report about a patient who was brought to the University of Chicago emergency department by ambulance, who was triaged, and who then later died in the waiting room.

Looked for the story on the internet, but wasn’t able to find anything.

Anyone have any other information?

Osteoporosis and Compression Fractures

Saturday, February 7th, 2009

osteoporosis-compression-fracture-kyphoplastyHad a patient come in with back pain and obtained an interesting x-ray of the lumbar spine showing what osteoporosis can do to one’s bones.

The more dense the bones, the “whiter” they appear on x-ray. These bones are fairly thin. The lower two vertebrae in the x-ray are a fairly normal height.

At the red arrow is a vertebrae that has been “crushed” – a compression fracture. Imagine taking your fist and just pushing down on the edge of a cereal box until it collapses. That’s what happened to the bone.

At the green arrow is the result of a kyphoplasty – which involves injecting a bone filler material into the bone to expand it. Kyphoplasties have mixed results as can be seen in this x-ray – the height of the vertebrae hasn’t increased a whole lot.

The two best ways to keep this from happening to you are to make sure that your diet includes calcium and to perform resistance exercises (lift weights). In more severe cases, your doctor can prescribe a class of drugs called “bisphosphonates” that will make it more difficult for your body to reabsorb the calcium in your bones.

Overcoming Bias

Friday, February 6th, 2009

I had a patient write me about a problem and ask for advice on how to prevent the problem from happening.

The patient has a medical condition – bipolar disorder. The patient has also been to the emergency department a few times and perceives that, once the staff learns that he is bipolar, a bias develops. To quote him,

I’ve seen a hesitation when it comes up while they are taking my history. Perhaps I’m reading too much into it, but it feels like they are mentally recalibrating their general impression of me.

The patient asks whether the bias really exists (“is there a tendency to immediately give
more consideration to a diagnosis of drug abuser or drama queen?”) and, if so, asks for suggestions on what to do to to overcome that bias.

I don’t think that anyone can say they don’t develop some type of bias from a patient’s history. Some instances of bias are worse than others, but they all go back to the healthcare worker’s previous experiences. For example, if a young child is attacked by a dog, that child will have a future fear of other dogs – no matter how friendly the dogs are in the future. Previous experiences have shaped future perceptions.

We have one schizophrenic patient who frequently comes to the emergency department for “antibiotics” to get rid of the “infection” caused by his previous interactions with various tadwry women in his life from years past. He believes that he is unable to get their “secretions” (my word, not his) off of his body. So once a month or so he comes in for his antibiotic shot and he leaves after getting a shot of “norMAL sahLEEN” or the really good stuff – “dihydrogen oxide” – which are “normal saline” or “H2O” respectively. And getting those medications helps him. Really. He’s happier. He thanks us, and he goes on his way.

But my experiences with that patient do give me a bias when I see in someone’s history that they are schizophrenic. I can’t help wondering – are they going to be like “him”? No matter what I do, that’s the bias that I sometimes start with.

When I meet a patient, their actions either refute or confirm any bias that exists. In other words, I may be inclined to think one way, but my mind isn’t set in stone. Be pleasant with me, interact normally, say “thanks, doc” and the bias is gone. Swear at me, pretend that you’re passed out from severe pain, or engage in floor throwing and the bias is substantiated.

I guess the bottom line is that I do believe a bias exists toward certain aspects of a patient’s history. I don’t believe the bias is huge, although with some providers – and depending on the complaint –  I suppose it could be.

How to overcome the bias?
Be nice. Say “please” and “thank you.” You’d be surprised how much someone’s attitude about you will change if they think you appreciate what they are doing for you.
Don’t exaggerate your problems. Most doctors and nurses can tell when you are doing so.
Don’t act like a “drama queen” and in most cases, you won’t be treated like one.
If you have a history of going to the emergency department for pain complaints, be up front about it. You may not get the narcotic prescription to take home, but if you are in pain, most docs will do what they can to get you out of pain as long as you aren’t there every week. If you have been hopping from hospital to hospital and don’t tell the staff about it, most of the time the staff in the ED will call around to other hospitals to check you out. Once you’re caught hospital hopping, at most places you’ll go on The List and it will be harder for you to get your problem treated anywhere.

Hope this helps.

No Health Care

Saturday, January 31st, 2009

Three recent published articles about the health care crisis caught my attention while surfing the internet.

First, in the article “Forget good; any doctor is hard to find,” a mother laments because she has to drive all over the Coachella Valley in California to find a doctor to evaluate her 2 year old child with a cough. After going to four different providers, she finally went to the emergency department and was seen by a PA because “a good doctor is hard to find.”
I sympathize with her, but if you read the article, it wasn’t that she couldn’t find a physician to see her child (although a couple of the clinics she went to didn’t see children under 3 years old). The problem was that the physicians that *were* available didn’t take her insurance and she didn’t want to pay out of pocket. The article did not say what type of insurance she had, but my guess is that the insurance was MediCal. Given the low payments MediCal makes to physicians, fewer and fewer physicians are willing to accept it. This mother’s ordeal just highlights the fact that universal coverage doesn’t mean much if no one takes your insurance. Kind of like having $10,000 worth of Japanese yen in your pocket and trying to buy a hoagie in downtown Pittsburgh with them.

Another article that caught my eye
was from Canada, where protesters were planning a sit-in at a hospital emergency department because the hospital will longer perform emergency surgeries and will instead ship the emergency cases to another hospital across town. If there is no incentive to provide emergency surgeries, then it is difficult to force a hospital to continue performing them. The article also notes that several other hospitals in the area have already stopped performing emergency surgeries – also deciding to ship them to different facilities. As fewer and fewer facilities perform emergency surgeries, more and more emergencies will pile up. At some point it will be a case of “when everything is an emergency, nothing is an emergency.” Think that care will be good?
But at least the care is free … right?

Then finally was the article from Florida’s Gainesville Sun, titled “ER care for kids ‘stinks’“.
Fewer and fewer specialists are willing to take call from the emergency departments and there is difficulty finding emergency specialty care for children. The unfunded federal mandate EMTALA is backfiring. If you’re an “on call specialist”, EMTALA requires you to provide emergency stabilizing treatment for any patient that needs your services – even though many patients needing emergency services will never pay their bill and can sue for millions of dollars if the care they receive is not deemed adequate.
So specialists just stop taking emergency calls. Now emergency physicians treating people with emergencies scramble to find emergency specialist care when in some subspecialties, there is little or no emergency care nearby. Neurosurgery, obstetrics, and psychiatry are just a few of the specialties in very short supply in some states.

In trying to legislate “perfect” and “equal” care for all, now more and more people are finding that there is “no” care for anyone.

2009 Influenza Update

Friday, January 30th, 2009

Think you’ve gotten by this season without getting the flu?

Think again. The worst of this year’s influenza season hasn’t hit yet.

CDC statistics show that between 1983 and 2008, the peak influenza activity is more than twice as likely to occur in February than in any other month.

Most states were starting to see “sporadic” influenza activity in mid-January – the latest data available right now.

Google Flu Trends is showing a slow but steady rise in inquiries. It also shows that January and February are typically the most active months for web searches about influenza year after year.

It’s almost heeeere…

Hope you got your flu shot.

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