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Healthcare Update Satellite — 11-20-2013

Wednesday, November 20th, 2013

How do patients choose their physicians? New survey by the American Osteopathic Association shows that 65% use word of mouth. 50% use their insurance provider directories. 10% use hospital web sites. 9% use consumer review websites such as Yelp. Then 19% who want to gamble with their lives use physician rating sites such as Healthgrades.com. The most important factor in choosing a physician is whether that physician accepts the patient’s insurance plan.

Another example of the difference between “insurance” and “health care.” UnitedHealth cuts thousands of doctors from its networks. You can have the most expensive insurance in the country, but if few doctors accept it as payment or if the company doesn’t have sufficient providers on its network to care for its patients, “health care” will inevitably suffer. One doctor noted that “Fewer practitioners mean longer waits, longer drives, less convenience.” Another oncologist stated that “Patients battling cancer should be focused on their treatment, not on finding another doctor.”

John Edwards will be representing the rights of the disenfranchised once more. I can only wonder if, during all of his “channeling”, his wife tells him what an a-hole he is.

Remember the 2 year old Indonesian kid who was a 2 packs per day chain smoker? Well at 6 years old he’s finally kicked the habit. Now he’s reportedly an overweight junk food addict.

I wonder if there is a study comparing swimmers to non-swimmers … a 1:200 concentration of bleach in water (roughly 2 tsp of bleach per gallon of water), reverses aging of the skin and inflammation from diseases such as eczema. So far, the trials have only been done in mice, but researchers are also looking at whether dilute bleach can improve healing of diabetic ulcers. Stock up on bleach while you can … before it gets labeled as a drug by the FDA and the price goes up to $750/gallon.

Infants often have low body stores of Vitamin K, a vitamin that is needed for blood to clot properly. So infants are usually given a dose of Vitamin K to prevent bleeding. Risks of developing bleeding are 81 times greater in infants that don’t receive the Vitamin K shots.
In Nashville TN, there have been several incidents of intracranial bleeding in infants whose parents have refused to let them receive Vitamin K shots. Of course, the parents initially refused the injections due to fears of their children being exposed to toxins or getting leukemia from the shots, then the parents pled ignorance of the bleeding risks from not receiving the shot after their children had developed brain bleeds.
Jenny McCarthyism is still putting children’s lives at risk.

Police go to residence to investigate a complaint of a pig running around a property. They find an 11 year old boy handcuffed to a porch with a dead chicken tied around his neck. His foster parents? A social services supervisor and an emergency department nurse.

Should the government be prosecuted for creating Healthcare.gov? Andrew Stiles believes so. After all, a commercial venture that is likely mislead consumers violates the Federal Trade Commission Act. The whole premise that people “can keep their healthcare plan” and the “dramatic underestimate[s]” of pricing on the site are just a couple of ways in which consumers have been misled on the site.

Doctor Christine Daniel gets 14 years in prison and a $1.2 million fine for selling snake oil to cancer patients. What she alleged was a herbal concoction to cure cancer was really just a mixture of suntan lotion and beef flavoring. Several patients died when they didn’t seek medical treatment and instead relied on Dr. Daniel’s promises.

Mental health care is in a crisis in Colorado. This report says that mental health patients make up almost half of the emergency department patients at Denver Health every weekend. When you cut funding for psychiatric care by 20% and cut the number of psychiatric beds by 30%, the patients with psychiatric problems don’t just disappear. When they can’t get help, they end up in the emergency department, in jail, or even worse. Could the Columbine or Aurora shootings have been prevented by expanding psychiatric care? Probably not. But one emergency department physician noted that for every “high-profile event that everybody knows about, there’s a hundred that were either near misses … or resulted in violence.”

Healthcare Update Satellite — 11-14-2013

Thursday, November 14th, 2013

See more news from around the web over at my other blog at DrWhitecoat.com

An example of the downside to government-run health care. Patients in Venezuela can’t get proper medical care. 300 cancer patients were just sent home when supply shortages and “overtaxed equipment” made it “impossible … to perform non-emergency surgeries.” 70% of the radiation therapy machines are inoperable. Basic supplies such as needles, syringes, medications, operating room equipment, X-ray film, and blood needed for transfusions are all in short supply. There is no anesthesia for elective surgery. Patients can no longer get organ donations or organ transplants.
The most important point in the article is that Venezuela’s constitution guarantees free universal health care to its citizens. They don’t just get government-mandated health “insurance,” they get free health care … and look what happens.
We need to be very careful about what type of health care system we ask for in this country. The government that has the power to give everything to you also has the power to take everything away from you.

Another example of what can happen with “free” medical care. Don’t have a heart attack after 5PM on weekdays or any time on weekends in Kaslo, British Columbia – the ED is closed. If your body doesn’t pay attention to those hours, you’ll have to travel an hour over mountainous terrain to get to the next closest hospital. Hope there’s no snow.

Interesting study in Annals of Emergency Medicine showing that sending daily text messages to poorly controlled diabetic patients improved medicine compliance (.pdf file). There was no statistical change in the HbA1c, but patients receiving text messages used the EDs less than the control population and patients actually liked receiving the messages. Kudos to the investigators for thinking outside the box.

LA County Medical Center board approves $7.5 million settlement to formerly homeless patient after patient was discharged from labor and delivery department at 39 weeks gestation with abdominal pain without being evaluated by obstetrician. Patient returned 12 hours later with ruptured uterus and child born with severe brain damage.

Idaho man suffers broken ribs after being hit by drunk driver … while playing cards in his living room. But there’s more to the story. The man’s dog went missing after the accident. A town resident found the dog wandering … near the emergency department of the hospital where the patient was taken. Happy and amazing reunion.

Entering the emergency department with atrial fibrillation? You have a 69% chance of being admitted according to this American Journal of Cardiology study.

Patients gone wild. Arizona man arrested for being aggressive with emergency department staff and trying to bite a male employee several times. Must have been a full moon.

Patient at Chicago-area Riveredge psychiatric hospital hangs herself with bedsheet. Hospital cited for putting patient in a room with a 7 foot ceiling and having the wrong type of vent covers which placed the patient in danger of “immediate jeopardy” by making it possible for the patient to hang herself.  Beware the bad outcome.

Another reason not to practice medicine in Florida. Predicted medical malpractice loss ratios in Florida for 2014 are highest in the nation – and more than nine times greater than the predicted loss ratios in states such as Indiana and Minnesota. Pennsylvania comes in second highest on the predicted loss ratio list. Check out the link a the top for other reasons not to practice medicine in Florida.

A pair of settlements paid by Iowa State underscore two important points. First, lumbar punctures are not complication-free. One 69 year old patient received $1.75 million after a lumbar puncture left him paralyzed in his lower extremities. In another non-medical case, a patient was awarded $125,000 for a retaliatory discharge from her job after she filed a workplace violence complaint. If hospital administrators take action against ED staff members for complaining about patient violence, there can be liability for doing so.

Healthcare Update Satellite — 11-04-2013

Monday, November 4th, 2013

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

72 year old Connecticut patient awarded $9.3 million after being hospitalized for UTI, then given overdose of Lovenox. She developed intra-abdominal bleeding and required several surgeries and blood transfusions to correct the problem. She also developed a large abscess at the site of a central line insertion. Attorneys for the patient say that it was “an understatement” to say that the standard of care was violated.

One of the ideas behind providing more patients with “insurance” (not with “health care,” mind you) is that the insured patients will be less likely to use the emergency department. Untrue. When few doctors take the patients’ insurance, often the patients’ only option is to go to the emergency department. In addition, the emergency department is free for Medicaid patients. The Cato Institute’s Michael Cannon was quoted in the article. I’ve argued with Michael Cannon about his opinions in the past, but this time he is right on the mark when he says “Nobody spends (other people’s) money as carefully as they do their own.” In other words, with no skin in the game, patients have no incentive to limit spending.
The policymakers in Washington have no idea about the economics and incentives of this perverse system they are creating.

October 2013 study in Pediatrics shows that 10% of 14-20 year old ED patients at the University of Michigan admit to nonprescription opioid or sedative use.
My jaw dropped when I read that 12% of these kids had been prescribed sedatives but then I realized that it was 12% of the 5% of kids who reported using sedatives … or about 0.6% of the total patient population. That’s still a lot but it’s better than 12%.

InQuickER still allowing patients to schedule appointments in the emergency department and bypass other patients waiting in the waiting room. At some point a smart plaintiff attorney is going to realize that an EMTALA claim against a hospital using this service is a slam dunk.

Our national health care plan sucks so much that doctors are refusing to accept patients with government “insurance.” That, dear readers, is the difference between health “care” and health “insurance”: Health insurance is a false promise of obtaining health care. Virginia Democrat Kathleen Murphy has a solution to the problem, though: Force doctors to accept Medicare and Medicaid patients.
Our government is getting awful comfortable “forcing” the private sector to engage in activities that go against acceptable business practices. Obamacare forces insurance companies to provide policy coverage that makes policies too expensive and that provides services many people neither want nor need. Then Obamacare forces insurance companies to offer policies to people regardless of their pre-existing conditions. But insurance means nothing without being able to provide the health care and that’s a business the government doesn’t want to be involved in. So now politicians are floating trial balloons about forcing doctors to treat patients. Hopefully, this idea gets shot down quickly and forcefully.

Too many nursing home patients being sent to emergency departments? A research letter to the editor of JAMA Internal Medicine shows that the number of visits for preventable causes increased 21% between and that the number of visits for non preventable causes increased 23% from 2001 to 2010. More than half of the “preventable” visits were due to either pneumonia or UTIs.

Saving money by cutting services. New York’s St. Luke’s Cornwall Hospital plans to close its emergency department between 10am and 10pm in order to save more than $1 million per year. Patients needing emergency care will be directed to another hospital 5 miles away.

More on saving money by cutting services. Massachusetts’ North Adams Regional Hospital proposing closure of its psychiatric facility. The hospital is having financial difficulties and reimbursement for care of psychiatric patients is notoriously low. The hospital’s director of finance says that “Unless change happens, [the next hearing] won’t be about closing one unit, it will be about closing all the units.”

Michael Jackson’s former physician Conrad Murray is out of jail, but will he ever be able to practice medicine again?

 

Healthcare Update Satellite 10-28-2013

Monday, October 28th, 2013

Check out more updates on my newly refurbished blog at DrWhiteCoat.com!

Does homelessness affect use of emergency departments and hospitals? Absolutely.
According to this study of 1165 homeless Canadian patients in the American Journal of Public Health, when compared with a control population, homeless patients used the emergency department 8.5 times more often, were hospitalized 4.2 times more often for medical/surgical problems, and were hospitalized 9.2 times more often for psychiatric hospitalizations.
According to this accompanying study, the average ED utilization for homeless patients was 2 visits per year, but 10% of the sample population accounted for more than 60% of all ED visits.

Drug seeking behaviors permeate emergency medicine. Opiate overdoses resulted in more than 100,000 ED visits in 2009. Now more and more patients with Toradol “allergies” are being tracked and put into “non-medical” treatment programs.
In other words, keeping “The List” is becoming standard practice in many emergency departments.

Massachusetts Medical Board gone wild? Bariatric surgeon who has performed more than 6000 weight loss operations in his career and who reportedly has complication rates better than or equal to the national average has his license suspended because he uses open gastric bypass surgery rather than performing laparoscopic procedures and because he allegedly did not recognize and treat post operative complications in four patients quickly enough.
Interesting to note that bariatric surgery death rates range from 1 in 100 patients to 1 in 300 patients, meaning that it would be expected that this physician would have expected death rates of 20 to 60 patients in his career.
Even though four Harvard physicians have written letters supporting his care, the Massachusetts Medical Board declared him an “immediate and serious threat’’ to the public.
Medical board actions are becoming a larger threat to physicians than are malpractice suits and there are a lot fewer protections in place regarding those actions.
Beware.

The hardest medical simulator ever? Surgeon Simulator’s controls are difficult and the gameplay is supposedly clunky, but the game is reportedly quite popular. Anyone tried it?

That will teach those uncaring emergency department staff members … Houston man gets fed up because staff weren’t taking his headache seriously enough, so he jumped into an ambulance in the parking lot and drove away, then crashed ambulance into an overpass.

Street drug MDMA, otherwise known as “Molly,” making inroads with recreational drug users. Some states seeing a 100-fold increase in use, with multiple overdoses and deaths. The number of ED visits related to MDMA increased to 22,498 in 2011.

Police in West Palm Beach, Florida (go figure) arrest emergency department nurse for refusing to draw blood from a suspected drunk driving offender, charge nurse with “obstructing justice.” Federal magistrate rules that such actions violate Fourth Amendment for false arrest. Nurse then sues West Palm Beach sheriff’s department for back pay.

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.

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