Archive for the ‘News Commentary’ Category
Thursday, March 7th, 2013
Nevada Senator Tick Segerblom proposes bill that would allow patients addicted to prescription drugs to sue doctors for prescribing the addictive medications and manufacturers for creating the medications.
Patients can already sue doctors for prescribing medications if they can prove that writing the prescriptions violated the standard of care and that they have suffered damages as a result. But Tick wants to take the concept a step further. If the patient sues a doctor and wins, the patient should receive payment for rehabilitation, possible punitive damages, and attorney’s fees.
It doesn’t matter that “addiction” can be either physical or psychologic and that there is no reliable way to determine when addiction occurs. Tick’s bill doesn’t define addiction. It also doesn’t matter that people can get addicted to pretty much anything … alcohol, illegal drugs, porn, gambling, even collecting Cabbage Patch Kids. Tick’s bill only cares about those evil doctors. Beware internet service providers, you could be next on the list if your subscribers get addicted to the internet.
But Tick has good reasons for proposing his bill. Since people lived without drugs before, Pharmacologist Tick doesn’t believe that drugs are the only way to treat pain now. That’s true. Patients in cancer pain could always try incantations and faith healing instead of popping pills. Or patients in pain could bust out some whiskey and a bunch of bullets to bite on … after they take anger management classes so they can purchase the bullets. Oops. That’s Florida. Sorry. Wrong state. Double oops. Alcohol could be addictive. Bad example.
Besides, since children are allegedly taught from an early age to do whatever the doctor says, Neuropsychologist Tick says no one has the free choice whether or not to take addictive pain medicines.
It’s not so much that, at least according to his Twitter feed, Tick seems just all … well … tickled … about seeing his proposal published in newspapers. The scary thing is that people like Tick Segerblom are elected to public office and may be able to regulate our lives.
More comments at Overlawyered.com
Thursday, March 7th, 2013
I’m in shock about the case where a nurse refused to give CPR to 87 year old Lorraine Bayless in a California senior living facility – a housing setup akin to an apartment complex.
Ms. Bayless fell unconscious in the dining room of a senior living facility. Facility members called 911. Ms. Bayless wasn’t breathing and the 911 operator recommended that the facility member perform CPR. The person at the facility would not perform CPR.
It took EMTs about 7 minutes to arrive on scene. Ms. Bayless later died from a “massive stroke.”
The 7 minute call can be heard HERE in its entirety.
A couple of other things made known in the case were that the senior living community did not have any trained medical staff. Remember – the facility was similar to an apartment house. In addition, Ms. Bayless had made known her intentions to “die naturally…without any kind of life-prolonging intervention.” According to the family, Ms. Bayless knew that there were no medical staff when she decided to live at the facility.
So why am I in shock?
Look at all the whacked out opinions that are being generated from this case.
Some people demand criminal charges be filed against the people who wouldn’t help.
One person recommends “Depraved Indifference Homicide”
Another person notes that if a law says that “you cannot deliberately withhold medical care from a dying person” then ignorance of the law is no excuse for failing to act – applying that hypothetical to this case, of course.
Bakersfield California police are looking into whether there was anything criminal and the county Aging and Adult Services Department is determining whether “elder abuse” may have taken place because of the incident.
The thing is that if criminal charges were appropriate, then everyone in the dining room of the senior living facility who saw Ms. Bayless collapse would have to be thrown in jail. No one helped her. Let’s just charge everybody with a crime.
California can’t pay its bills as it is, so it is unlikely that they will criminally charge a group of elderly patients requiring nursing care and then be required to provide continuing medical care to them. Maybe they’ll all get electronic monitoring bracelets and weekly visits via the wheelchair van to a parole officer, instead.
Then the “experts” across the news stations pile on.
Virginia Commonwealth professor of geriatrics Dr. Peter Boling stated that without advance directives, patients “wind up sometimes in a very painful and trying situation.” This quote seems to acknowledge that patients may receive unwanted CPR if there is any question about a patient’s wishes.
CBS legal analyst Jack Ford calls the actions “morally reprehensible” but also notes that our society has become much too litigious.
Ah, but what about California’s Good Samaritan statute? It exempts people who provide emergency care from liability for civil damages, but it also contains exceptions. Providers have to act in “good faith”. It doesn’t apply to those who are grossly negligent. And it doesn’t apply if the provider is being compensated. Employees of the senior living facility are, by definition, being compensated. So a plaintiff’s attorney may have the ability to circumvent the protections afforded in the Good Samaritan statute just through the “compensation” angle.
Other people argued that the 911 operator took all liability for the actions of the nurse. How does such a promise, which is essentially a verbal contract, absolve the nurse from liability when the nurse is the one performing the actions? If a lawsuit was filed, the nurse would still be named regardless of the 911 operator’s promises.
Then there’s the question of a DNR order. According to the Bakersfield Fire Department there wasn’t such an order on hand when paramedics arrived. Not that people carry DNR orders around with them in their pockets or anything. After all, this was a dining room in an apartment complex, not an ICU bed. But even if that was the case, does there have to be a readily producible advance directive available to prevent unwanted care?
A sweet old lady entered a senior living facility knowing that there were no trained medical staff and not wanting any life-prolonging treatment.
Now a firestorm has come down on the living facility for abiding by the patient’s wishes and pundits all over the internet are basically demanding that we perform medical procedures on patients who don’t want them. Don’t agree? It’s off to jail with you. You’re a criminal.
Ms. Bayless’ family issued a statement saying in part
We regret that this private and most personal time has been escalated by the media. Caregivers, nurses and other medical professionals have very difficult waters to tread in the legal and medical landscape of our country today.
About the only thing potentially criminal about this case was the unauthorized dissemination of Ms. Bayless’ private health information to the media.
Are state and local authorities investigating that?
Saturday, January 26th, 2013
One of the posts in my Twitter feed was a re-tweet of something asserted by Dr. Art Kellermann (@ArtKellermannMD). Dr. Kellermann is a distinguished physician. He is the Director and VP of Rand Health. At one point he was a professor at Emory University, but apparently does not practice emergency medicine any more.
Dr. Kellermann’s tweet said the following:
Dr. Kellermann’s tweet references an editorial article that he wrote in the Annals of Emergency Medicine titled “Waiting Room Medicine: Has It Really Come to This? The article was from 2010, so I’m not sure what prompted him to tweet about it in 2013, but nevertheless, the article at least seemed pertinent … until I read it.
The assertion in Dr. Kellermann’s tweet was a quote from his article and was reportedly supported by a 2001 brochure created by the UK Department of Health (.pdf file). The context of Dr. Kellermann’s assertion in the article he wrote is as follows:
The ED is more than a clinical setting; it is a “room with a view” of the best and worst of modern health care. In the United Kingdom, a crowded ED is considered a telltale sign of a poorly managed hospital. If that perspective ever takes hold on this side of the Atlantic, things will change. Until then, it is up to us.
Things will change if our perspective changes. Until then, change is up to us.
What a feel-good nonsensical assertion of nothingness.
Tuesday, December 18th, 2012
By Birdstrike M.D.
Since the massacre of innocent school children and those that gave their lives educating and trying to protect them this past Friday at Newtown Connecticut’s Sandy Hook Elementary School, I’ve struggled to make sense of this calamity as much as much as anyone. As a Physician who has worked to save the lives of sick and injured children, and as a father of children the same age as those massacred in cold blood, I have searched for answers to the questions, “Why?” “How do we make sure this never happens again?” and “How do I know this won’t happen to my family?” along with everyone else. As I’ve read, seen and listened to various explanations and solutions, some better than others, most have rung very hollow. The arguments and blame fly back and forth, “We need to ban guns,” “We need more guns,” “We need more outpatient mental health treatment,” “We need to re-institutionalize the mentally ill,” and so on. The more I listen, the less I am convinced that anyone I’ve heard, from the checkout clerk at my local grocery store, to the President of the United States has any real solution to prevent this from happening again, or even make such happenings less frequent.
As I dropped my daughter off at school today, and let her get out of the car and walk away from me and out of my sight, I realized that to a certain extent, this was and always has been an act of faith of sorts. As I’ve thought more and more about this horrible incident, the questions keep coming, but without answers. I have no good answers to the above questions. In a nearly post-spiritual world where technology can do practically everything but find answers to the truly important questions in life, I realize there is a word that does perfectly describe this incident, and consolidates all the pain, hurt, chaos, insanity, confusion, murder, blood and tears. All religion, preaching, atheism, agnosticism and separation of church-and-state arguments aside, the only word I can find that offers any sort of explanation, summary or satisfying consolidation of what we saw last Friday is…..evil.
If anyone doubts the existence of true evil, you’ve seen it. That is the most disturbing and frightening thing about the incident at Newtown’s Sandy Hook Elementary School. Despite all the good in this world and all the good we may try to achieve with varying levels of success as physicians trying to heal sick and injured children, or trying to protect our own children, we share this world with a certain element of pure unadulterated evil. Despite all of our necessary efforts to prevent, protect against and deter it, when someone chooses to truly commit an act of pure evil, they can. When one does so, there is very little any of us can do about it but hurt, mourn the lost, support the living and move forward with acts of good hoping time will offer at the very least, some solace and clarity. My deepest condolences go out to the victims of this incident, their families and all of those touched in any way.
Monday, December 3rd, 2012
We were away for the weekend, but in a restaurant, I caught glimpses of this segment on 60 Minutes called “The Cost of Admission.” Couldn’t hear the conversations in the restaurant, but luckily CBS posted the entire report online. If you didn’t see it, you really need to watch the video and/or read the transcript.
In summary, 60 Minutes spent a year investigating irregularities in hospital admissions. Administrators at Health Management Associates and at EMCARE (one of the national emergency medicine contract groups) were accused of putting pressure on emergency physicians to admit at least 20% of patients that came to hospital emergency departments. For Medicare patients, the “benchmark” for admissions at one hospital was allegedly 50%. The 60 Minutes expose also included spreadsheets showing comparisons of different physicians’ admission practices and text from e-mails saying such things as “I have been told to replace you if your numbers do not improve.”
HMA held a conference call disputing the allegations and stating that they “take all allegations regarding compliance very seriously.” HMA allegedly had outside experts review the data (not the medical records?) and the experts determined that “the data simply do not support the allegations.”
Now HMA is being investigated by the US Department of Justice for Medicare fraud. I predict that HMA will make a large settlement with the government to drop all charges (without admitting wrongdoing, of course) and that things will return to business as usual shortly thereafter.
With things like this, I can’t really blame patients for thinking that medical care is “all about the Benjamins.”
Patient satisfaction metrics are creating quite similar incentives with physicians. How long will it be before people wake up and see how much fraud that the satisfaction scores are causing?
Thursday, October 25th, 2012
It seems as if some members of the American Academy of Pediatrics have determined that emergency physicians aren’t performing enough useless tests on teenage girls.
According to a study presented at this year’s AAP conference, only 19 percent of the 77 million girls between ages 14 and 21 that were examined in emergency departments between 2000 and 2009 received pregnancy testing. Subgroup analysis showed that only 42% of those patients complaining of abdominal pain received pregnancy testing and only 28% of those patients exposed to radiation that could cause birth defects received a pregnancy test.
In an American Academy of Pediatrics news release, the researchers, including study author Dr. Monika Goyal, found it “particularly concerning” that rates of pregnancy testing were low even among females with potential reproductive health complaints or with exposure to “potentially teratogenic” radiation (i.e. may cause birth defects) such as chest x-rays or CT scans.
First, note how Dr. Goyal and company mention nothing about the indications for performing pregnancy testing in the emergency department. In other words, they’re bashing emergency physicians for failing to order a test when they haven’t even described when the test should be ordered.
I’m sure that Dr. Goyal’s study didn’t look at repeat visits or specific patient histories. If they’re reporting on 77 million patient visits, they must be using aggregate data. Another problem with the study is that aggregate data doesn’t take into account all of the instances in which a pregnancy test may not be indicated in a female teen.
If the patient had a negative pregnancy test in the doctor’s office two days prior to her current visit, another pregnancy test probably isn’t warranted. If a patient who is known to be pregnant is also having abdominal pain, a pregnancy test is probably a waste of time and money. Patients with epigastric pain or “heartburn” probably don’t need pregnancy tests. Should we get pregnancy tests on every patient with classic UTI symptoms? I don’t.
It’s pretty ridiculous to call the lack of pregnancy testing “particularly concerning” without saying what the “concerns” were. Did the researchers find any cases of bad outcomes due to lack of pregnancy testing in the 77 million cases that they reviewed? I’m sure there will be a few, but then a thorough researcher would then analyze thoses cases to determine whether the bad outcome was due to a failure to perform a pregnancy test. This study did nothing of the sort.
I was also surprised by the specious logic that patients having a chest x-ray performed should have pregnancy testing performed because chest x-rays “may” cause birth defects. The amount of radiation in a chest x-ray is equivalent to the amount of background atmospheric radiation people experience just being alive for 10 days. It is also equivalent to the amount of radiation that someone taking two roundtrip flights from Washington DC to Los Angeles would absorb. Read more about it on Wikipedia if you’re interested. Calling for more pregnancy testing because chest x-rays may be “teratogenic” is like demanding that all women take a pregnancy test before taking a cross-country flight on an airplane because the increased radiation exposure in the upper atmosphere may be just as “teratogenic.”
Whoops. Better not give the TSA any ideas.
Another practical issue is that lead aprons block x-ray radiation. Often x-ray techs and/or doctors will just have a potentially pregnant patient put a lead apron over her abdomen while an x-ray is performed rather than obtaining a pregnancy test. Of course such actions would be “particularly concerning” because no pregnancy test was done.
In the AAP news release, the study’s author stated that the “findings underscore the need to develop quality improvement interventions to increase pregnancy testing in adolescent girls in the emergency department, especially among those with higher risk of pregnancy complications.”
Translation: This study has failed to show that failure to perform pregnancy testing has any relation to quality of care or that it has caused harm to even one patient.
Conclusion: This study was a complete waste of time and money.
Friday, September 14th, 2012
Interesting statistics from a September 2012 Modern Healthcare magazine survey regarding the number of contracts held by major emergency medicine contract management groups and the rate of growth in their contracts from 2010 to 2011.
Firm / Percent Change in contracts 2010 to 2011 / Contracts in 2011
EmCare / +8.9% / 428
TeamHealth / +11.4% / 322
Schumacher Group / +11.0% / 181
ECI Healthcare Partners / +10.5% / 105
CEP America / +11.1% / 80
Emergency Medicine Physicians / +1.6% / 62
ApolloMD / +23.4% / 58
Premier Medical Associates / -5.1% / 37
Emergency Medical Associates / +33.3% / 28
Emergency Service Partners / +4.5% / 23
Hat tip to Applied Knowledge, LLC
Tuesday, August 21st, 2012
This story is making the rounds on the internet recently.
A plastic surgeon is being sued by California State because she charges patients fees in excess of what insurance pays for her services. California’s lawsuit alleges that the doctor poses a “substantial, irreparable, and unjustified threat to the financial livelihood” of her patients.
In addition, the California Medical Board is attempting to revoke her medical license because she is allegedly engaging in “unprofessional conduct” by requiring patients visiting emergency rooms to sign agreements to pay her costs if their insurance companies didn’t.
I’m not going to try to justify the fees that the doctor charges. More than $12,000 to repair a fingertip is a lot of money.
However, with one caveat, I think that the actions taken by the state and the medical board are way out of line.
Suing a doctor and trying to revoke her license because she wants to get paid the asking price for her services? If people don’t want to pay her price, then don’t use her. Go see another “professional.”
You go to work at a new job where you agreed that you would be paid $50/hour. You work 40 hours, and expect to get a check for $2,000 at the end of the week. As you leave work Friday, your boss gives you a check for $200.
“Sorry,” he says, “if you don’t like it, you’ll have to go take it up with the company CEO. That’s all I’m paying you for your work.” The company CEO tells you “we pay other workers $5/hour, therefore we can pay you that much, also.”
You try to sue to get your money, but a court says it is against the law for you to demand to be fully reimbursed for your work because the corporation that reimburses your boss pays $5/hour, therefore it is legally entitled to pay you that same amount. Since you’ve already completed the work, you try to sue the company for your back wages. Then the state files a lawsuit against you because you filed a lawsuit against your employer.
Or imagine going into a lawyer’s office, agreeing to pay the lawyer his fee, receiving the services, then sending the lawyer a check for 10% of the total fee as payment in full. You’d be back in court so fast it would make your head swim.
That is the position this doctor is being put in. She performed the work at the patients’ request, the patients signed a form stating that they would pay her full price for her services, then, when she tried to collect the money from the patient after performing her services, the state stepped in and said that the doctor must agree to the amount a third party wanted to pay her.
The caveat in this whole mess is that the patients should know what they could end up paying the plastic surgeon before she renders her services. If that occurs, the patients get to decide whether or not the costs are worth the perceived benefits. If the patients agree to such costs, then they should be held responsible for paying the agreed-upon price.
The patients refused to have the emergency physician repair their wounds and demanded that they be treated by a “professional”. Now they’re accepting the “professional’s” services without planning on paying her the price that she asked?
Wonder why there are so many specialists who aren’t providing care to emergency department patients?
I also wonder whether specialists would be considered “unprofessional” if they required retainer fees before providing services. Would the state take action against them then? Lawyers do it all the time. No money, no representation.
Looks like a lot of patients are going to be stuck with us all of us sub-”professional” emergency docs for their emergency department treatment in California.
I wonder if this whole “we’ll pay you what WE think is fair” line of reasoning would work when the doctor went to pay her California state taxes …
Tuesday, July 31st, 2012
The Greater New York Hospital Association guidelines Jim Dwyer cited in his Rory Staunton articles about physicians who “missed obvious signs” of sepsis were hidden in his article.
Fortunately, Alissa D’Amelio who is the Senior Project Manager for Regulatory and Professional Affairs at the GNYHA was kind enough to forward me a copy of the guidelines.
The disclaimer at the bottom of the guidelines that was partially hidden in Mr. Dwyer’s article stated in full:
GNYHA and UHF hereby disclaim all warranties, express or implied, as to the accuracy of any of the information contained herein, or its fitness for any particular use or purpose. These materials are intended to provide you with information and resources that may assist your organization and should not be used as a substitute for clinical or medical judgment.
In addition, Ms. D’Amelio also specifically stated in her e-mail
Also, please note that the STOP Sepsis Collaborative is a quality improvement initiative that focuses on the adult population, which is the target population for this template tool.
Jim Dwyer did not return e-mails for comment on these issues. And he still hasn’t given me the names of the editors who approved his story for publication, either.
Sunday, July 22nd, 2012
This is probably a record length post for me, but I thought it was important to respond to Mr. Dwyer’s comments to a post written on this blog regarding the article he wrote that appears in the NY Times.
I had planned to leave my comments after his, but they became too long and involved and I also wanted to paste a couple of pictures from Mr. Dwyer’s article, so I instead decided to answer his criticisms in a post.
If any of you were wondering, I was not the anonymous physician who authored the previous post on Mr. Dwyer’s article. I spent most of my afternoon creating this response because Mr. Dwyer’s original article was somewhat frustrating to me, but I found his justifications and explanations for what was contained in his article to be misleading.
See additional commentary about Mr. Dwyer’s articles here and here.
Dear Mr. Dwyer,
When re-reading your article, I absolutely agree with Rory’s wish that no other child – and no other family for that matter – should have to go through what Rory went through. He sounded like a great kid and he obviously had a close family and a bright future. As you also mentioned, Rory’s uncle was a friend of yours, so I can imagine that this incident affected you more than most other investigations you have performed. This topic hit home for me as well. My daughter nearly died from an invasive pneumococcal infection when she was younger. She was hospitalized for a week in a university medical center on triple antibiotics. Very scary times and we thank God that things turned out well.
So let’s go through your article and responses you made to the criticism about your article so that we can determine how to prevent kids from dying from sepsis due to invasive organisms.
JIM DWYER COMMENT:
1. You say that the stop sepsis campaign is for tracking severe sepsis. That misstates both the nature of the campaign and my citation of it in the article. The campaign’s goal is to aggressively identify sepsis and begin treatment within an hour. (The tracking of cases you cite is secondary.) To begin the process of identification, the initiative created a triage screening tool which gives a list of 8 signs and calls for additional investigation if a patient has three of them. As I wrote, Rory Staunton had two when he came into the ER. He had three when he was leaving. (BTW — his heart rate over a period of two hours ranged from 131 to 143. That’s in the article, too.) In the distribution literature with the screening tool, there is no distinction between pediatric and adult patients. Whether or not you think the values are relevant to a 12 year old, 5’9″, 169 lb boy, Rory was assessed for possible sepsis in triage.
Let’s look at the sepsis criteria according to the checklist that you posted. Then let’s apply them to children.
1. Pulse greater than 90. In children up to 2 years of age, a pulse rate less than 90 is considered too slow. In other words, ALL children up to 2 years of age should have a pulse rate greater than 90.
2. Respiratory rate greater than 20. In children up to 5 years of age, a respiratory rate less than 20 is considered too slow. In other words, ALL children up to 5 years of age should have a respiratory rate greater than 20.
So now in children who have entirely normal vital signs for their age, right away you have two of the three “danger signs” your article repeatedly emphasizes.
Add a temperature of 100.5 degrees which is essentially not a temperature at all.
Let’s give the child a runny nose which causes us to suspect a viral URI – the suspicion of an “infection” required by the criteria.
This two year old child, running around the room and laughing with his parents, with essentially normal vital signs for age, now has 4 of the criteria on the screening tool you cite.
According to the premise of your article, we must rigidly follow the criteria on the “screening tool,” which means that on every such child, doctors should get a mandatory serum lactate level, order immediate IV antibiotics, and hospitalize the patient. Heck, we should probably throw in a central line and urinary catheter as well to monitor central venous pressure and input/output.
Can you even begin to imagine all of the unnecessary added expense and adverse reactions from the antibiotics/invasive monitoring that would occur if every medical center in the country adopted Jim Dwyer’s rules of pediatric management? Every influenza season, there would be no hospital beds available for months as hospitals were forced to overtreat healthy well-appearing children while delays for care of other emergent patients precipitously increased.
The problem with your article, and something that you conveniently hid from your readers, was the disclaimer at the bottom of your so colorfully highlighted checklist
Doesn’t the disclaimer at the bottom of the checklist say something to the effect that it “should not be used as a substitute for clinical judgment”? Can’t really see the whole sentence because your placement of Rory’s labs just happens to obscure the rest of the wording. But I’ve read enough checklists and disclaimers to know that the disclaimer most likely states that the checklist should not be substituted for a physician’s clinical judgment.
Well, here, let me highlight the area I’m talking about. You can click on the image to get a bigger view if you want:
Yet, despite the checklist specifically telling you NOT to do so, that’s exactly what you did, isn’t it, Mr. Dwyer? You published an article asserting that regardless of the clinical judgment of a physician who has many years of training in medicine and who is described in your article as being “hyper-conscientious”, this protocol must be rigidly followed. You misused this guideline in order to inappropriately attack the qualifications of physicians you never met and to whom you never even spoke.
You state that the guideline and its literature made “no distinction between pediatric and adult patients,” yet you didn’t even know enough or didn’t care enough to ask what patient populations the guidelines were created for.
You keep asserting that Rory was the size of an adult. Fine. I agree. But he was still 12 years old. Unless you have evidence that the criteria have been validated in children – even adult-sized children - don’t assert that the criteria are valid in children. You know darn well that if the situation was different, the medical treatment involved medications not approved in “children,” and Rory died after receiving the medications, you’d be the first one writing about “warnings ignored” in giving the medication. 20/20 hindsight is just crystal clear.
See a more balanced article about the same topic at ABC News.