Archive for the ‘Healthcare Update’ Category

Healthcare Update Satellite – 10-21-2013

Monday, October 21st, 2013

Setting the record straight about EMS myths. Well … really one myth … going to an emergency department by ambulance doesn’t mean you’ll go to the front of the line. The places that I work will frequently have patients who come by ambulance go directly to the waiting room. Other times when it isn’t as busy, the patients would have gone straight to a bed regardless of how they arrived. Calling an ambulance to try to game the system isn’t worth the expense.

One of the things people don’t think about when filing a lawsuit is called “subrogation.” If insurance has paid for care that is related to your lawsuit, they’re going to want to be reimbursed for the money they spent. If the government spent $250,000 on your care and you win a $500,000 malpractice suit, between the costs of suit, the attorney’s fees, and the government subrogation claim, you’re going to come away with very little money.
In this case, a patient is trying to block Oregon from taking $236,000 of her malpractice settlement – an amount that the state claims it paid for her care over 6 months. I’d like to see the itemized bill and receipts for that bill.
And if an insurance company is allowed to prevent a patient from receiving a “windfall” of a malpractice judgment, shouldn’t policyholders be able to prevent insurance companies from receiving a “windfall” of premium payments when the policyholders don’t use the insurance? You lawyers know of any “reverse subrogation” cases?

OK, these pictures are disconcerting. Now I’m going around looking at the size of senior citizens’ ears. How does a person’s appearance change with age? Ten photographic comparisons show that ears and noses get bigger, eyelids droop, and sun exposure kills a complexion. But the ear thing still weirds me out the most.

Dr. Ben Carson claims that Obamacare is “ the worst thing that has happened in this nation since slavery” and that it is “making all of us subservient to the government.”

The government that has the power to give everything to you also has the power to take everything away from you. Food stamp benefits set to be cut before the holidays. Maybe Dr. Carson was right.

Hospitals need to change their business models with the Unaffordable Insurance Act. Hospitals with better clinical outcomes and better patient satisfaction surveys will receive financial incentives under Obamacare.
For those of you who think that better outcomes and higher satisfaction are good measures of quality, be prepared to be transferred somewhere else when you’re a high-risk patient (hospitals won’t want to risk a bad outcome on your care) and remember the studies showing that highly satisfied patients are nearly twice as likely to die from their medical care.

United HealthCare fires “thousands” of doctors in Connecticut who are caring for Medicare Advantage patients. Slick move. United HealthCare took this action right before Medicare enrollment started, so that Medicare patients could enroll in the United HealthCare program and then find that there were a lot less physicians to take care of them. And when patients don’t have access to health care, they can’t utilize as many services … which means that United HealthCare doesn’t have to pay as much money for treatments and doctor’s visits.
United HealthCare stated that it was releasing physicians in order to build a “network of health care providers that we can collaborate with more closely ….”
But at least those seniors have medical insurance.

22 year old patient who was paralyzed after spinal surgery for scoliosis wins $4 million malpractice verdict … against law firm that represented her. According to the accompanying news article, a jury decided that the Virginia law firm of Paulson & Nace committed legal malpractice when they incorrectly filed the first complaint on behalf of their client, then
I find it odd that Paulson & Nace doesn’t have this $4 million malpractice verdict on their “Our Results” page. Must just be a web site programming glitch.
One thing that struck me about this article was the grace and determination with which this young patient is dealing with her disability. Very encouraging.

Why the Unaffordable Insurance Act won’t work.
“Many young people—who are two-thirds of the roughly 40 million uninsured—will prefer to pay the penalty ($96 in the first year) rather than buy coverage, especially since they can always [just purchase coverage] when they fall sick. That’s because Obamacare bans insurance companies from turning away patients with pre-existing condition or charging them rates much above what others pay—the so-called community rating mandate. Over time, this will unleash a downward spiral of adverse selection: Rising premiums will push more healthy people to drop out, leaving the insurance pool sicker, which, in turn, will cause premiums to rise further, which will require more subsidies from an already strained federal fisc—until the whole Rube Goldberg structure collapses.”
When you can jump into the insurance pool only when you’re sick, it kind of defeats the point of having insurance.

What’s wrong with the driver’s seats in Saudi cars? Leading Saudi cleric Sheikh Saleh Al-Loheidan warned that medical studies show that driving cars “automatically affect[s] a woman’s ovaries and … pushes the pelvis upward.” Even worse, children born to women who continuously drive cars “are born with varying degrees of clinical problems.”
Riding in cars apparently has no such detrimental effects, which leads me to believe that the Saudis don’t know how to properly design driver’s seats.
And I can only imagine what the constant driving must do to Saudi men’s woo hoos. The horror!

Oregon law capping civil damages in all cases doesn’t apply to medical malpractice cases, but cap doesn’t apply to prenatal injuries. Recent Oregon Supreme Court ruling states that injuries to a child occurring during delivery are not considered “prenatal” injuries and therefore are not covered by the cap.

When a patient files a medical malpractice case, plaintiff attorneys can talk to the treating physicians without a defense attorney being present. However, defense attorneys are not allowed to talk to the treating physicians without the plaintiff attorney being present. A Florida malpractice reform evened the playing field by allowing both sides to discuss the case with the patient’s physicians. Now a judge has ruled that the Florida malpractice law is invalid because it conflicts with Federal laws.

Study shows that emergency physicians spend 43% of their clinical time entering data in a computer and 28% of their clinical time in direct patient care.
Those numbers pretty closely correlate with the mini study I did about 18 months ago.

The “Ottawa SAH Rule” published in JAMA has 100% sensitivity in determining when patients have a subarachnoid hemorrhage. Wonderful. Every one of patients with age > 40, neck pain, loss of consciousness, onset of pain during exertion, thunderclap headache, and meningeal signs has a subarachnoid hemorrhage. Are we not supposed to scan and LP patients who have fewer than six of those symptoms?
The real issue is that the rule doesn’t do a very good job in saying when people don’t have a subarachnoid hemorrhage … which is the question we need to answer in order to affect our clinical care. Caveats to applying the rule are contained in an editorial to the article by David Newman and Jonathan Edlow.

Georgia lawmakers attempting to overhaul the state medical malpractice system. Proposed system is a “no fault” system similar to worker’s compensation claims. If a medical injury occurs, a patient is compensated. No determination of “medical malpractice” is made. The bill’s proponents believe that under such a system, defensive medicine and subsequent litigation would decrease. If doctors’ names are reported to the National Practitioner Databank, the new law will increase defensive medicine and will increase litigation as doctors do whatever they can to keep claims from being reported.
When both the medical association and the bar association are against the proposed legislation, someone should get the hint that there may be a problem.

Healthcare Update Satellite — 10-09-2013

Wednesday, October 9th, 2013

Government getting pissed because providers are beating it at its own game? When feds started pushing electronic medical records and threatening to penalize patient, a funny thing happened … the amount of money the feds spent on healthcare increased by billions of dollars. Now Kathleen Sebelius and Eric “Fast N Furious” Holder are warning that doctors that copying and pasting patient data between patient medical record entries should not occur because it risks medical errors and overpayments. They promise to “prosecute health care fraud” and will “consider future payment reductions as warranted.”
In other words, if you type or write the same thing over and over again, you’re fine, but if you cut and paste you are a prima facie criminal.
When people with no clue about the inner workings of the health care system attempt to create laws regulating the system, increased costs will result.
Medicare recently implemented a rule requiring that full hospital admissions must be reasonably expected to require a “two midnight” stay in the hospital, requiring physicians to certify the medical necessity of such care, and imposing more costs on patients if they do not stay two midnights. Do they really think that there will be less admits? All that is going to happen (and that is already happening) is more thorough documentation of a patient’s condition and comorbidities – which will increase billing levels further and will increase costs. Oh, and look for an increase in the number of new symptoms requiring extended hospital stays if a patient is stable to go home before the second midnight. What’s that, the patient’s pulse oximeter reading suddenly dropped? Let’s keep the patient on telemetry and do pulmonary function testing tomorrow? Whats that? The patient developed chest pain on the second night? Now they’ll have to be admitted another day for serial cardiac enzymes. Spending will go up not down because of this rule. Mark my words.

Oregon surgeon criminally charged and loses her license after patient dies from reaction to anesthetic in doctor’s office during a cosmetic procedure. Doctor faulted for not having equipment in the office to respond to medical emergencies, for performing a procedure in her office at night without staff support, and for failing to respond appropriately to a patient in distress. When another patient experienced dizziness and tachycardia after a cosmetic procedure, prosecutors alleged that the doctor put the patient at “substantial risk.”
State medical board hearings are becoming as serious as medical malpractice lawsuits.

Fascinating case report in the International Journal of Clinical Medicine. Patient suffers from Auto-Brewery Syndrome, otherwise known as Gut Fermentation Syndrome. 61 year old patient is constantly intoxicated without drinking alcohol – sometimes reaching levels of 400. Overgrowth of a certain fungus in the man’s intestine causes fermentation of excess carbohydrates into alcohol. After treating the patient with antifungals and temporarily putting him on a zero carb diet, then re-colonizing the gut with probiotics, the symptoms resolved.
Even more interesting is that the responsible fungus, Saccharomyces cerevisiae, is used to ferment beer and antibodies against it are markers for inflammatory bowel disease such as Crohn’s Disease and ulcerative colitis.
In addition, a related fungus, Saccharomyces boulardii, has been found effective in reducing symptoms of inflammatory bowel disease, irritable bowel syndrome, Clostridium difficile infections, and traveler’s diarrhea.
We have so much to learn about the microbiome in the gut and its effect on human health.

What happens when emergency physicians are routinely pressured to work overtime in high-stress and increasingly complex work environments? They leave. The UK’s NHS is concerned that there will be a staffing crisis in UK hospitals because fewer doctors are choosing to go into emergency medicine and more experienced doctors are leaving the country to practice elsewhere … which will increase the stress on the remaining physicians … which will cause more of them to leave … which will increase the crisis.
Who suffers? Patients.
But at least the care is free.

Interesting topic on Medscape discussion boards. Should a patient who attempted suicide be resuscitated in the emergency department? Or should the patient’s intent be honored?
Even more interesting is that much of the discussion focused upon liability associated with making the wrong decisions.
Another example of how human behavior is shaped by fear of liability.

Healthcare “superusers” are back in the news. This Kaiser article states that 1% of patients are responsible for 21% of all healthcare spending while 5% of patients are responsible for 50% of all healthcare spending. Reducing costs involves integrating their care.

What happens when relatives ask for information about an unconscious patient in the emergency department? Many times they get the “we can’t tell you anything due to HIPAA laws.” Such an assertion is not necessarily true. Disclosures in such situations are permissible, so staff can choose to do so based on their own discretion. But with increasing penalties for HIPAA violations under the HITECH Act, many practitioners choose not to take the chance. And don’t believe this attorney’s statement that “health care providers are only penalized when they act unreasonably.” Even incidental disclosures are subject to statutory penalties (see the HITECH Act link above) and the complaint of a HIPAA disclosure is easily enough to cause a hospital to terminate a healthcare provider’s job.
An example of what happens when we try to regulate (and or sue) our way to better health care.

According to this article in the American Journal of Emergency Medicine, more than one third of pulmonary emboli have a delayed diagnosis in the emergency department. Factors associated with misdiagnosis in patients admitted to the hospital included chronic pulmonary diseases such as asthma and COPD. Factors associated with misdiagnosis in patients sent home included fever, coughing up blood, and infiltrate on chest x-ray.

Wait times an issue in hospital emergency departments all over the world. Number of admitted patients waiting more than 24 hours to get a bed in Australian hospitals nearly triples in the past year.

An app to notify the emergency department about your symptoms before you arrive? I think this is a total waste of money. It is highly unlikely that there is going to be any ED “preparation” for a patient before the patient arrives. In many cases, the patients will be lucky if there is a bed available. And if forced to answer phone calls, all that will happen is that providers will be taken away from caring for other patients. While I think it may be an idea of limited utility, the docs who created the system and then sold it to Aetna are laughing all the way to the bank.

More on patients gone wild. St. Louis area’s St. Mary’s Hospital has had three attacks on emergency department nurses in two weeks. Two of the cases involved intoxicated patients.

Healthcare Update Satellite — 10-03-2013

Thursday, October 3rd, 2013

Via @mdaware … ever wonder whether you need to prescribe two antibiotics for patients with uncomplicated cellulitis? EM Literature of Note’s Ryan Radecki pulls an article showing that there isn’t much difference in outcome/cure rates between treatment of uncomplicated cellulitis with only cephalexin versus combination treatment with cephalexin and Bactrim.

This is important. And it’s from Fox News, so you know it’s fair and balanced. Be very careful about how you sign up for the Obamacare exchanges. Experts expect that there will be a lot of hacking/phishing attacks using phony web sites to try to get unsuspecting users’ information. Experts suggest not clicking on links in unsolicited e-mails or on social media sites, avoiding downloading any e-mail attachments, and making sure that the sites you visit have “https://” in the address.

The drug that eats the junkies. Called “krokodil,” the drug desomorphine is mixed with adulterants such as gasoline, paint thinner, iodine, or oil and then injected. Reportedly it can get the user hooked in one or two uses and reportedly rots the brain and liver. Not so sure whether it is the drug or the adulterant doing the rotting, but the end results are still nasty.
If you want to see examples of what the drug does to the skin of users, click on this link, but do it on an empty stomach. The site is in Russian and some of the pictures are gross. You’ve been warned.

This link is more for the clipboard patrol and the office-based docs. The Department of Health and Human Services has published model privacy notices which be provided to patients under HIPAA. You can download them here.

We’re from the government and we’re here to help. Karen Sibert notes how the Veteran’s Administration plans to force all advance practice RNs and nurse anesthetists to practice independently – even if they want to work with a physician.
The final draft of the VA Nursing Handbook is here (.pdf file). Check pages 26-27.

Texas emergency department patient lights garbage can on fire, then flees from ED, jumping two barricades then jumping off a 25 foot high helipad and injuring himself … before being brought back to the ED to treat his injuries.

Patients gone wild. Intoxicated Hoboken emergency department patient slaps and punches a paramedic in the face.

More patients gone wild. Pennsylvania man spit on paramedic and tried to bite paramedic in face. Then he kicks and punched hospital staff. Then he threatened physical harm to everyone in the ED. Police didn’t say why the patient was in the hospital, but anyone who threatens to beat up a room full of people has to be intoxicated.

And even more patients gone wild. Where will it end? Shooting outside of Hoppy’s Bar in Ohio spills over into the local ED where the hospital went into “lockdown mode” at 4:30 AM due to the threat of continued violence.
And all I want to do is find out where these people live, drive a police car up to their houses and randomly turn on the lights and sirens for the rest of the morning when they’re trying to sleep.

Another Pennsylvania patient who attacked an emergency nurse last year and who had a long history of run-ins with the law was sentenced to between 27 and 85 months in state prison.

Study in Pediatrics shows that the incidence of ED visits for sports-related head injuries in children has increased by 92% in the past 10 years, but there was no change in the percentage of children being admitted. In addition, the severity of injury for those being admitted decreased significantly during the study period.
Why are more kids being seen in the EDs? I think it is a combination of increased attention on the effects of head injuries on children and policies of the sports leagues.

Ottawa terrier gets picked up and shaken around by German Shepherd. Then runs across field and six lanes of rush hour traffic to get to the local hospital emergency department.
Unfortunately, the dog hadn’t signed up for the Obamacare exchanges, so she had to be transferred to a veterinary hospital for three hours of surgery.

Lawyers complaining because patient emergency department charges are too expensive.
Why don’t you lawyers start with your own house. Charging $600,000 to tweak a proxy statement and create a 1,300 word supplement in order to settle a class action suit? Makes a $10,000 visit to the ED for abdominal pain seem kind of reasonable, doesn’t it?

Medical providers in Ireland changing their practices or retiring early after being sued for medical malpractice and then developing “medical malpractice syndrome.”
Will that qualify medical providers for disability benefits?

Healthcare Update Satellite – 09-25-2013

Wednesday, September 25th, 2013

See more health care news from around the web on my other blog at DrWhiteCoat.com

Man found dead in parking lot of Detroit’s Grand Valley State University had just used the university computers to query Dr. Google on “pain and tightness of the chest and sweating.”
Wonder what happens if the web site he landed on didn’t tell him to call 911?
Maybe Google, Esq.?

North Carolina woman busted for drug trafficking and felony possession of controlled substances after going to multiple physicians and being prescribed 1,286 doses of Xanax and 2,330 doses of oxycodone/hydrocodone between May 2012 and May 2013.

Think closely about those discharges against medical advice. A Canadian study of more than 1.9 million patient records shows that the 90 day mortality rate for patients leaving against medical advice was 2.5 times greater than for all patients combined.
Then again, I did a survey of two patients who left AMA and neither of them died in 90 days, so using Press Ganey statistical methods, the authors of this study must be all wrong.

The first day of Fall was also National Falls Awareness Day. The Executive Director of Elder Care Advocacy in Florida provides a nice letter to the editor listing some easy ways to minimize fall risks in elderly patients … including getting rid of throw rugs, avoiding slippers/sandals/[and flip flops], and placing non-slip mats in bathtubs and showers.

You can’t make this stuff up. Sadly, I’ve heard the same things said by patient before. Montana sheriff starts following a car that is swerving on the road. Pulls car over and finds out the the people were fighting and punching each other. Driver found in possession of oxycodone pill in wallet that he states girlfriend planted there. Girlfriend was confused and told officers that she believed someone was surreptitiously injecting her with drugs. Taken to hospital, then said girlfriend goes into emergency department bathroom and sets bathroom on fire in an attempt to “kill herself from smoke inhalation.”
This sheriff was probably kicking himself for ever pulling this car over.

Assuming that Obamacare is not defunded, if you want to get an idea of what you will have to pay to purchase insurance on the Unaffordable Insurance Act exchanges beginning next month, you can check out this Kaiser Family Foundation subsidy calculator.

In response to costs from the Unaffordable Insurance Act, Trader Joes cuts health care benefits for part-time workers, but will give those workers a $500 check to help defray the costs of finding another health care plan.

California mother taking methadone and other painkillers was charged with murder and child endangerment after her 9 month old child suffered fatal drug overdose from medications in mother’s breast milk. Child “Protective” Services knew about the issue and reportedly warned the mother to stop breast feeding, but the “safety plan” that CPS created reportedly wasn’t reviewed and approved for three months after a social worker created it and the CPS didn’t release the contents of the “safety plan” to the media.

More on antibiotic resistance with a hat tip to Instapundit. As more and more patients opt to have surgeries in ambulatory centers, the CDC is expecting the rate of antibiotic resistant infections in outpatient settings to increase. While “preventable infections” in hospitals have dropped by 20% in the past 4 years, allegedly due to institutional assistance, training and Medicare fines, ambulatory surgical centers are expected not to have the same resources that hospitals have in order to address these “preventable” events.
Unfortunately, the article doesn’t really say too much more about doctors’ offices or even ambulatory surgical centers for that matter.
One of the things that caught my eye, though, was the Medicare Factsheet (.pdf) contained within the article. Remember all of those conditions that were previously known as “Never Events”? They’re not called “never events” any more. They’re now just called “Hospital Acquired Conditions” and Medicare still isn’t paying for them if they happen in the hospitals. No payment for surgical site infections for bariatric surgery or for surgical site infections after certain orthopedic procedures. No payment for DVTs after hip replacement or knee replacement. No payment for vascular catheter-associated infections. Of course, we all saw how hospitals may be gaming the system by classifying a catheter related infection as something else, but that’s beside the point. When the CDC can tell a Senate panel that it is reducing central line associated infections by 44%, it can pat itself on the back — even though an NIH fact sheet has noted that the “number of sepsis cases per year has been on the rise in the United States.” So the CDC can congratulate itself because the reported incidence of bloodstream infections related to central lines has decreased while the overall incidence of bloodstream infections in general continues to climb.
Is that a good thing?
Personally, I think that the statistics are largely a combination of creative medical coding and getting the numbers that you pay for.

Healthcare Update Sattelite Edition – 09-18-2013

Wednesday, September 18th, 2013

Copeptin levels may revolutionize chest pain evaluations in the ED. When standard treatment was compared with early discharge after normal copeptin levels were obtained, there was no significant difference in major adverse cardiac events at 30 days.
Need to review the study data, but this is a promising new test.

Marco Rubio calls federal government’s $8.7 million advertising campaign for Obamacare a “blatant misuse of federal dollars.”

International Longshore and Warehouse Union dumps affiliation with the AFL-CIO, citing support of Obamacare and immigration reform as two reasons for the disaffiilation.

Good thing to keep in mind with start of school – heavy backpacks can cause or can aggravate back problems with children. Ideally, the article states that a backpack should weigh less than 15% of a child’s total body weight.

Kind of amazing ingenuity. When horse bites off one-third of man’s finger, surgeon forms a mold of the missing finger from a pig bladder, attaches it to the patient … and the finger regenerated – bone, nail, and all. Of course, now he has a permanent aversion to bacon, but it is a small price to pay for a new finger.
I started wondering how the surgeon came up with the idea, so I did a little research. The whole pig bladder idea isn’t new. This man grew back a finger with powdered pig bladder after cutting off the tip while working on a model airplane in 2008. This 19 year old war vet grew back 70% of his injured leg muscle using a pig bladder matrix – which saved him from amputation.

Another example of unintended consequences when doctor performance is measured in the inexact science of medicine. When surgeons and hospitals in Massachusetts were labeled as being “outliers” for having excessive death rates after cardiac stenting, they stop treating the patients most likely to die. Can’t get dinged for trying to save a patient who dies if you don’t try to save the patient.
In the study the doctors didn’t come out and say that they stopped treating the sickest patients, but the pre-operative likelihood of patients dying after the procedure dropped by more than 30% after hospitals got the “outlier” label.

cb090613dAPR20130905104555What a bunch of hypocrites. In 2009, Chuck Grassley inserted a provision in Obamacare ending their subsidies and requiring all members of Congress and their staff  to get insurance through the health exchanges – like everyone else. Congress pressured the Office of Personnel Management to change it.
Recently, Senator David Vitter from Louisiana sponsored another bill to end the subsidies and force everyone on Capitol Hill to purchase their insurance through the exchanges. Now Congressional leaders like Harry Reid and Barbara Boxer are attacking him.
A requirement for government employees to obtain their insurance through the health care exchanges like everyone else should be the sine qua non of the Unaffordable Insurance Act.

Lawsuit Abuse Reduction Act of 2013 is moving through Congress. Would change federal rules of civil procedure to REQUIRE courts to impose sanctions on attorneys who file frivolous, unwarranted, or factually unsupported claims or briefs. Under the current Rule, the decision to impose sanctions is discretionary.
It would still be left to the court’s discretion whether a claim has met those criteria, so the Act doesn’t have as much bite as it appears, but it would be a step in the right direction.
Then we can sanction our way to better legal representation. Hey … it works for medicine, right?

Interesting study on estrogen requirements in … men. Lower estrogen levels in men may be associated with increased fat deposition and decreased libido. It may not just be about “low T.”

Computer programmer comes up with app for smartphone that may put a lot of optometrists out of business. Place a small viewer against a smart phone screen, use dials on the viewer to align the red and green lines on the smartphone screen, then the app calculates the strength of the glasses you need.
The article also links to descriptions of other apps that perform EKGs and diagnose children’s ear infections.
I’m personally waiting for an app that sues the other apps when they make a mistake. Where’s the smartphone courthouse, anyway?

Interesting story about the investigation of a mother with Munchausen’s and Munchausen’s by proxy.

CMS creating more of a regulatory morass for patients admitted less than “two midnights.” Hospitals now instructed that patients expected to stay less than two midnights should be classified as observation status (and will therefore pay more money out of pocket). Doctors also must certify that inpatient stays are “medically necessary.”
Remember that if the government is charged for care is determined to be medically unnecessary, fines, penalties, and criminal charges can be filed against the health care providers.

Australian girl left laying on the floor of the emergency department for nine hours because there were no beds available to treat her. Hospital overwhelmed with sicker patients and a line of ambulances was waiting to offload patients at the time.
Does Australia have the same socialized medical system that the US is heading toward?

Canadian doctor with multiple tweets about safety concerns in Canadian emergency department. “Second ER doc at QEH considering resigning due to safety concerns. Doctors outside the ER need to pull their weight.” Emergency physicians being required to round on inpatients.

Healthcare Update Satellite — 09-04-2013

Wednesday, September 4th, 2013

Look for more updates on my other blog at DrWhitecoat.com

American Medical News ceasing publication due to decreasing ad sales. Now focusing on online and e-mail publications.

Too fat to rescue? Some patients weighing more than 350 pounds (and even some weighing more than 250 pounds) are being denied air transport due to their weight. Other services are spending millions of dollars to purchase helicopters that can carry patients up to 650 pounds.
What happens with a 750 pound patient, then?

University of Pennsylvania adding metal detectors to its emergency departments. They reportedly aren’t used in emergencies, though.

Young California girls end up in emergency department, then in burn unit after getting lime juice on their skin and then going out into the sun. All apparently suffered from phytophotodermatitis. They’re healing well, but can’t go out into the sun for 6 months and all have scars to their faces, torsos, and extremities.

I’m not even going to post a link, but I’m having difficulty determining whether it is appropriate for a chain of acute care clinics … in Florida … to be advertising how it will provide “stronger” treatment for painful conditions and “emergency pain relief” for patients who don’t want to wait in emergency departments.

Jesse Jackson Jr will be in jail, but receiving almost $150,000/year in federal pension and disability payments for his mood disorder.

Kid has minor blunt head injury? Observation in the ED significantly lessens the likelihood that a CT of the brain will be performed.

Obamacare is great. That’s why Daniel Werfel, the Principal Deputy IRS Commissioner for Services and Enforcement (and one of the people who will be helping enforce the Unaffordable Insurance Act mandates) wants to exempt himself and his employees from the Obamacare exchanges.

Patient’s gone wild again. California patient goes to the ED for treatment, then once he gets inside begins chasing staff around, punching one staff member in face. Now he’s cooling his heels in the Greybar Motel.

Healthcare Update Sattelite — 08-28-2013

Wednesday, August 28th, 2013

Find more updates on my other blog at DrWhitecoat.com

British National Health Service now gives physical therapists and podiatrists the authority to prescribe medications to patients without physician supervision. Good for them.
I still believe that all drugs aside from antibiotics and perhaps narcotics should be over the counter anyway.

Not only the King of Beers, it’s the King of Emergency Department visits. One third of injury visits to Level 1 trauma centers were alcohol related. Personally, I think that number is low. Of the patients who admitted drinking before their injury, 69% were male and 69% were black. Of the types of alcohol consumed before the injury, Budweiser ranked supreme. Malt liquor was consumed by 46% of patients before their injury while it only accounted for 2.4% of consumption in the general population. (.pdf file)
As a result of this study, the researchers suggested that alcohol content on malt liquors should be clearly labeled and that perhaps the availability of malt liquor should be limited … which just tells me that the researchers really have no clue about real world effects of their recommendations.

Welcome to the Abercrombie and Fitch emergency department, how may I help you? When payments for providing care get cut, some hospitals get creative in making more income. Ohio State University is one of them. Hey – think about the Ronald McDonald Childrens Hospitals. Not sure I disagree with the tactic, although it may tend blur the distinction between medical care and retail which I don’t think is a good thing.
Although personally I would think it was funny if some rich donor from another school purchased the naming rights for a hospital and made it the Michigan Wolverine Trauma Center.

Elevated BMI may not be the best indicator of poor health. In fact, some studies show that an “obese” BMI improves survival under certain conditions. So why do we use it? “Because it’s simple,” says one of the authors of the paper.
Strangely similar to Press Ganey scores, isn’t it?

Using Google Glass to record and live-stream surgery? The Reebok Chair of Orthopedics at Ohio State Wexner Medical Center is doing it. Check out the video.
Had you going for a second with that “Reebok” thing, didn’t I?

Why we need free markets and open pricing. Hospitals charge $787 for IV fluids that cost about $1 per bag. Then hospitals accept $119 as payment in full of bills for more than $2,100.

Illinois emergency department gets a bolus of 79 teenaged patients who were crop-dusted while in a field detasseling corn. What felt like raindrops was really some chemical being dropped on the field next to theirs.
Monsanto apparently owned the field and the patients were being contracted to work in the field. A spokesman for Monsanto, who incidentally has three eyes, seventeen fingers, and involuted genitals, said there was nothing to worry about.
I’m kidding. She only has thirteen fingers.

Are you giving epinephrine to patients with suspected or actual anaphylaxis in your ED? If not, you should be.

Tort reform works. Or, if you’re a plaintiff attorney, tort reform is a sham. Medical malpractice payouts reach an all-time low in 2012.

One final note from the ED community to the ED community. A third year emergency medicine resident at Cook County Hospital in Chicago was recently diagnosed with a rare form of liver cancer. Because it is so rare, there is no standard treatment, so insurance won’t cover any therapy.
If you can spare a few bucks to help or if you can attend a fundraising event, it would be appreciated.

Healthcare Update Satellite — 8-21-2013

Wednesday, August 21st, 2013

Look for more updates on my other blog at DrWhitecoat.com

Judge orders Colorado family to pay $340,000 in legal fees after losing the medical malpractice suit it brought against a hospital.
The family plans to declare bankruptcy. The family’s attorney, Stacy Warden, alleges that the hospital lacked compassion for “going after a family with a severely disabled child.” If attorneys file frivolous cases, perhaps the attorneys should be on the hook, not the families …

West Virginia couple is suing a physician for failing to diagnose an epidural abscess that later rendered the patient with permanent paralysis, in addition to other physical pain and suffering.
The details of the case aren’t provided, so the comments below are not necessarily related to this case.
However, just consider …
Spinal epidural abscesses present as either neck or back pain in 70-100% of cases. Fever and neurologic deficits accompany the pain in only 10-15% of initial presentations.
CT or MRI of the spine is the only way to diagnose this disease process and early diagnosis is important to a good outcome.
But the American Academy of Family Physicians and the Choosing Wisely campaign state that CT or MRI for acute low back pain is “often a waste of money” and probably not needed unless there is “a history of cancer, unexplained weight loss, fever, recent infection, loss of bowel or bladder control, abnormal reflexes, or loss of muscle power or feeling in the legs.” Remember … these symptoms are present in only 15% of patients with spinal epidural abscesses.
Therefore, according to the AAFP and the Choosing Wisely campaign, it should be “unnecessary” to diagnose the 85% of spinal epidural abscesses that present with only acute back pain.
Yeah, that logic didn’t work too well with me, either.

Want a *brief* look into a day in the life of an emergency nurse … since certain other emergency nurses aren’t blogging any more? Here’s a local newspaper’s brief overview.

SAMHSA study (.pdf file) shows that emergency department visits due to nonmedical use of prescription stimulants and caffeine pills increased fourfold between 2005 and 2011.

Another hospital starts collecting payments at the time of a patient’s emergency department discharge. Wonder what happens if patients don’t pay …

Number of emergency department visits from magnetic foreign body ingestions increases fivefold between 2003 and 2011. The government already put buckyballs out of business due to safety concerns. The only logical conclusion is to criminalize the manufacture of any magnet smaller than the size of a child’s mouth. Come on, Joint Commission. You’re dropping the ball here. Our childrens’ safety is in jeopardy.
Next stop: Outlawing credit cards. Those magnetic stripes could KILL a person!

What happens when you pass laws to provide medical insurance to everyone? Emergency department visits increase. Massachusetts Medical Society President notes that when people have medical insurance and they don’t have a primary care physician, they “go to the emergency room.” Same thing can be said when people have medical insurance and their physicians won’t take their medical insurance because it pays less than the cost of care for the patients. Not that that would ever happen …

The rhetoric is getting old already. Your doctor is a worrywort, therfore you may end up getting “unnecessary” tests and paying for lots of expensive tests. But if your doctor misses a diagnosis because he didn’t order the “unnecessary” test, he’s a flaming idiot and should have his license revoked.
Harvard law professor Michelle Mello, who commented on the article, says that mediation in front of a judge would reduce defensive testing because it would reduce the stigma of being accused of malpractice and negligence. Just goes to show you that just because you’re a Harvard professor doesn’t mean that you know what you’re talking about. Doctors still have to report all claims – mediated or not – when applying for hospital privileges or state licensure, and any payments on a physician’s behalf get reported to the National Practitioner Databank – which is queried every time that a physician seeks licensure, insurance, or hospital privileges.
But thanks for spreading the misinformation, professor.

Healthcare Update Satellite – 08-06-2013

Tuesday, August 6th, 2013

Look for more updates at my other blog at Dr.Whitecoat.com

Naked West Virginia patient steals ambulance from emergency department parking lot, goes on joy ride and then crashes into three vehicles – requiring more ambulances to take injured patients to the hospital. Hopefully this time they locked the ambulance doors. And I’m not sure I’d be wanting to sit on the driver’s seat without a plastic cover until after the seat gets washed down.

Use of chest x-rays in asthma patients increasing between 1995 and 2009. According to a 2005 study cited within the post, most xrays in children with asthma are deemed “unnecessary.” I don’t have access to the full article, but if it doesn’t have prospective criteria for what are considered necessary tests in wheezing or dyspneic children, then the results are suspect. Remember, kids don’t come to the emergency department saying “treat my asthma.” Kids come to the emergency department with trouble breathing, with wheezing, and with coughing. If the researchers are saying retrospectively, based on a normal CXR, that the kids had asthma and didn’t need an x-ray, that’s classic hindsight bias.

What’s that? You have an ingrown toenail? Well, you’re getting tested for HIV. Why? Because some study says so. Who’s paying for it? Who cares? The study says there’s a benefit. Out of 9,572 patients offered testing, 40% agreed and they found SIX new HIV cases. But don’t you dare call that an “unnecessary test,” dammit. Tests are only unnecessary when doctors do them for … well …
Oh nevermind. Carry on.

How good are emergency physicians at diagnosing Bell’s Palsy in the emergency department? Greater than 99% accurate by this study. Just hope that your patient isn’t one of the less than one percent who ends up having a brain bleed, stroke, or meningitis instead. Those outcomes are more likely in the elderly, in diabetics, and in blacks, with black race being the largest risk for patients having a diagnosis other than Bell’s Palsy.
Would be interesting to see how many of the misdiagnosed patients developed bad outcomes and sued for failure to diagnose.
Failing to perform testing that would have made the alternative diagnosis is seen as a negligent event while performing testing in the exact same patient when no alternative disease is present is considered “unnecessary,” “greedy,” and “wasteful”.

Study by Safe Kids Worldwide (.pdf file) shows that there were more than 1.3 million visits to the emergency department for sports injuries in 2012. Of those visits, 163,000 were for concussions meaning about one concussion every three minutes. That’s a lot of damaged neurons.

Nothing new in this study. Health Affairs study shows that physicians with higher concern for medical malpractice are more likely to practice ‘defensive medicine” than those with lower concerns for medical malpractice. Scenarios presented to physicians included patients coming to a medical office with chest pain and patients complaining of a headache. Those physicians with higher levels of malpractice concern were more likely to send the chest pain patients to the ED and were more likely to obtain imaging on the headache patients.
And if, using our magical retrospectoscope, we truly believe that patients with those complaints shouldn’t go to the emergency departments and shouldn’t obtain advanced imaging, then we need to change the system to reflect those values. Maybe we make “failure to diagnose” an exception to medical malpractice suits.

Any of you medical professionals want to help your fellow Americans when a disaster hits? Stay away from Missouri. After the devastation from the Joplin, MO tornado, charities sent medical care to the area but weren’t allowed to help because of Missouri laws. State legislatures saw the problem and created legislation that would have permitted licensed health professionals from other states to provide free care in Missouri and would have protected them from medical malpractice. Missouri Governor Jay Nixon vetoed the bill, stating that it was “unnecessary” because Missouri already has a system that encourages volunteers.”
Wonder if all the people in Joplin who needed medical care after the last tornado felt the same way.

Another example of the WhiteCoat Effect. Bert Fish Medical Center in … Florida … puts out creative ad with picture of surf board and shark bite taken out of the top using the caption that it has “emergency care when you need us.” New Smyrna, Florida’s public information officer takes offense at the ad, stating that the ad “doesn’t help us to market the safety of our beaches.” Well, when your beaches have the most shark bites in 2012 in the WORLD according to one study, maybe you should stop throwing chum in the surf, then, lady. Now even more people are going to know how New Smyrna, Florida is the shark bite capitol of the planet and how people could be taking their lives into their stumps … er … um … hands … by setting stump … er … um … foot … on the beach there.

Healthcare Update Satellite 07-29-2013

Monday, July 29th, 2013

Look for more health care stories from around the web at my other blog at DrWhitecoat.com

InQuickER has some competition for violating EMTALA in the “reserve a spot for my emergency department visit” market. Massachusetts hospital using service called “ResERved” and another company called ER Express is also filling this niche … at least until malpractice attorneys realize that EMTALA violations and decisions from hospital administrators to utilize these services aren’t subject to state malpractice caps and also bring in another set of “deep pockets” when patients suffer an injury.

Brazilian man dies when cow falls through roof of his home and lands on him in bed. Family doesn’t blame cow, but rather blames the excessive amount of time that the patient waited to be examined in the hospital.
Now the owner of the cow could be charged with manslaughter.
Those commenting to the article note how red meat isn’t good for you.

Why do low income patients go to the emergency department?
1. More accessibility. If you’re bored some day, get a list of doctors offices in your area, call around and tell them that you have Medicaid and need an appointment as soon as possible. Walk into the emergency department and you get evaluated by a medical professional.
2. Lower out of pocket costs. Primary care physicians sent many patients to multiple specialists – each who required a co-pay. Emergency departments took care of the problems in one visit.
3. Higher quality of care. Well, you know. What can all of us emergency docs say?

Fourteen of the 500 or so NHS hospitals are allegedly to blame for up to 13 thousand excess patient deaths in the past 8 years. Report shows “alarming levels of infections, patients suffering from neglect and appalling blunders such as surgery performed on the wrong parts of bodies.
After the shock headline was disseminated, the author of the report, when asked for comment, responded “Don’t believe everything you read, particularly in some newspapers.”
The cited report was supposed to be published two weeks ago. I found a summary of the allegations here, but I can’t find the report itself anywhere online.

Interesting point to keep in mind regarding testing for pulmonary embolism: The higher the d-dimer level, the more likely that a PE will be present. Those with the highest d-dimer levels had a 45% chance of having PE on chest CT scans.
Should we have a new criteria to presumptively diagnose PE solely by blood testing?

Gynecologist’s assets seized after $5 million malpractice judgment.
Patient develops metastatic ovarian cancer when gynecologist discusses removing ovaries during a hysterectomy, but doesn’t “strongly advise” that they be removed.
Skeptical Scalpel creates a nice summary of the case, Downs v. Trias. The court opinion notes that the patient previously had bilateral mastectomies due to strong family history of breast cancer, that the doctor testified he had limited knowledge of the patient’s ovarian cancer risk, and that plaintiff experts testified that the doctor did not properly inform the patient about her risk of developing cancer.
What message does a verdict and asset seizure like this send to physicians?
Refer cases to multiple specialists for expert opinions on everything. Order more testing so that patients can be fully informed about all the potential risks of any of their medical problems. It is only called “defensive medicine” when the testing is performed and the results are normal. Take proactive steps to protect your assets in the event that any one of the hundreds of medical decisions you make each day turns out to be incorrect and results in harm to a patient.

Two Alabama postal service employees hospitalized after coming into contact with KY Gel that had leaked out of a package. Yeah, that same stuff doctors put on their gloved fingers before performing rectal exams. Oh, the comments running through my mind right now …

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