“I tried to think of a witty comment to this story … but I was stumped.” So begins the comments section to the story about a Washington man who was rushed to the emergency department after cutting off his arm with a homemade guillotine. While the story is sad, many of the comments are amusing … in a morbid kind of way.
A picture of the actual guillotine is here.
Then there’s this article about whether the patient may have Body Integrity Identity Disorder. A related story describes a man who wanted to cut his arm off with a table saw but who lost his … nerve.
Aaaaugh. Make it stop.
 Archive for the ‘News Commentary’ CategoryMan Cuts Arm Off with GuillotineFriday, October 28th, 2011Worst States For Medical Malpractice RiskFriday, October 28th, 2011I just read an article in American Medical News about medical malpractice insurance costs. Included in the article was a small graphic about how much internists pay for medical malpractice insurance. Internists in Dade County, Florida paid medical malpractice insurance premiums that were 1400% higher than internists in the state of Minnesota. Illinois internists in Chicago paid more than 12 times as much in malpractice insurance premiums as their Minnesota counterparts. In other words, internists in select Florida and Illinois counties pay more for malpractice insurance in one month than internists in the state of Minnesota pay for an entire year. There are similar premium disparities for general surgeons and obstetricians, with Long Island, NY and Las Vegas NV also consistently being on the list for high malpractice premiums Does that mean that the Florida and Illinois physicians were 1200% to 1400% more negligent than doctors in Minnesota? Doubtful. It just means that Miami, FL; Chicago, IL; Las Vegas, NV; and Long Island, NY are places where insurance companies have determined that it is much more risky to practice medicine. When doctors search for the best states in which to practice medicine, they should consider the medical malpractice environment when making that decision. Given these statistics, doctors should not practice in Miami, Chicago, Las Vegas, or Long Island if they want to reduce their medical malpractice risk. Yet Florida lawmakers reach out to news stations and claim that the state “desperately needs more doctors.” Suing your way to better health care doesn’t work very well, does it, Senator Nelson?
Dr. NurseThursday, October 27th, 2011I really don’t like it when people call me “doctor.” The only time that I ever refer to myself as “Dr. WhiteCoat” is when I first enter a room and introduce myself to a patient. That way they know that I’m not some schmuck off of the street who wandered into the wrong room. Patients came to the emergency department to be evaluated by a doctor and, like it or not, I’m that guy. Personally, it annoys me to no end when people correct others and demand to be called “Doctor”. Enough rambling. In the NY Times a couple of weeks ago, there was an article about nurses who want to be called “doctor.” Actually, the nurses in the article earned the title. They have doctorates in nursing or other PhD degrees. Is it good public policy to allow a non-physician to use the title “doctor” in a medical setting without having a medical degree? Personally, I don’t care what people want to call themselves. If your ego is that fragile, call yourself Grand Exalted Supreme Poobah Doctor Nightingale for all I care. Introduce yourself that way at dinner parties. Command people to address you that way. Knock yourself out. When someone introduces themselves as “doctor” in a medical setting, it evokes a specific and consistent response from just about any patient: The person in front of me is a physician. Whether the patient thinks the “doctor” is intelligent or a quack depends upon multiple other issues, but the presumption is that “doctors” have gone through a lot of medical training and are capable of independently evaluating, diagnosing, and treating the medical condition for which the patient is seeking care. In my view, calling oneself “doctor” when one is not a physician is misleading. Think about it. What if you bought a “hybrid” car, then opened up the hood to find a regular engine with a “hybrid” soybean growing in a crevice. Hey, it is a hybrid, isn’t it ? Or what if you bought a “Big Mac” and unwrapped a sandwich with two buns and a piece of cheese that was made by some guy named “Big Mac”? States tend to frown upon nurses and physicians assistants referring to themselves as “doctor” as well. Many state Medical Practice Acts, Nursing Practice Acts, and Physician Assistant Practice Acts prohibit non-physicians from leading a patient to believe that they are capable of independently providing medical care. There have also been lawsuits against physician assistants who have not disclosed their credentials. Maybe the increasing number of non-physicians who refer to themselves as “doctor” will create a “caveat emptor” environment where consumers will inquire about the credentials of a health care provider before seeking care. I see that as a good thing. Given the current medical practice environment where providers are attempting to cut costs by employing non-physicians, I don’t think it is appropriate for non-physicians to refer to themselves in a medical setting as “doctor,” even if they have earned some other doctorate degree. If non-physicians want to demand that others call them “Doctor” at dinner parties, go through the explanation about how they are not a physician but have completed a doctorate in some other course of study, garner the eye rolls that go along with the explanation, and then deal with the whispers about how he or she is not a “real” doctor, hey … be my guest. What do you think? Time To Join The Debate Team?Sunday, October 9th, 2011
This past Friday, I saw six patients who had assorted injuries from football games. Six. Two of them had concussions, which goes along with a recent study published by the CDC showing that concussions are on the rise. See articles here, here, and here. CDC report is here. There is a lot of debate on how to manage sports-related concussions. The American Academy of Neurology essentially recommends discontinuing participation in the sport until symptoms resolve and appropriate evaluation … by a neurologist (or other physician with “proper training”) … prior to being cleared for participation. The Consensus statement on concussion in sport (2008) recommends physical and cognitive rest until symptoms resolve and then a graded return to activity prior to medical clearance. There is also an excellent but dated (1999) article in American Family Physician containing a summary of the then-current treatment recommendations for concussion. Several recommendations included discontinuing participation in the sport if several concussions occurred. Anyone symptomatic when I see them gets taken out of sports and gym until cleared by their physician. I also had another “oops” from Dragon Naturally Speaking related to the football injuries which was almost finalized in the medical record … I dictated “… followed by hitting head on another player’s football helmet.” Dragon spat out ” … swallowed getting hand in another player’s foot vomit.” Haven’t seen foot vomit in a while, but I know I wouldn’t want to be getting my hand in it. Pennsylvania Medicaid’s Cost “Savings”Wednesday, September 21st, 2011While scanning the news this morning, I laughed out loud at Pennsylvania’s newest proposal to cut Medicaid costs. According to this Kaiser Health News report, Pennsylvania plans to pay Medicaid recipients up to $200 to visit “higher quality and lower cost hospitals and doctors.” Gary D. Alexander, the Pennsylvania secretary of public welfare, compared the idea to a shared cost savings. “If the state saves $1,000 on a medical procedure we may give the beneficiary $100 or $200 as a reward.” Does anyone see a problem with this approach? Let me lay it out for Mr. Alexander, just in case someone who reads my column has his e-mail address. In some of the inner-city emergency departments where I have worked, there used to be a policy that patients would be given subway tokens … or bus fare … or cab vouchers at the conclusion of their ED visit. The theory was that hospitals didn’t want patients loitering in the emergency department waiting rooms after their visits trying to find a ride home. The policy was also viewed as creating good public opinion since the hospitals were making sure that patients had a way home if they came by ambulance and had no other means of transport. Ambulance transport to the hospital is provided at no cost to the patients. Ambulance transport home must be paid with credit card. Once the general public got wind of the cab voucher policy, guess what happened. Patient volumes increased. Ambulance transports increased. Wait times went up. People waited hours for free medical care so that they could then get their free subway token … or bus fare … or cab vouchers at the end of their visit. The policies were quickly discontinued. If Pennsylvania begins paying people to go to “better” hospitals, the cab voucher fiasco will occur in Pennsylvania, only on a much grander scale. Once Pennsylvania Medicaid recipients learn that they will be paid to go to a certain hospital for medical care, those hospitals will be deluged with patients. To those receiving public medical assistance, the medical care is free, the medical testing is free, and the medical procedures are free. Now, with a monetary incentive to have a procedure done at a given facility, what do you expect will happen? Patients get $200 if they get a cardiac catheterization at one hospital versus another? Twelve year olds will go to those emergency departments complaining of crushing chest pain. Patients get $50 if they go to one emergency department that provides “higher quality”? There will be lines out the door. Medicaid will end up footing the bill for an increase in medical care because it has incentivized the patient population to seek out that care. Brilliant. Just brilliant. Mr. Alexander even went to a meeting of “300 health insurance executives” in Washington and pitched his plan. I’m sure he got a little round of golf claps for his innovative approach to reducing health care costs. This is what happens when people who make policies have no practical experience in the industry in which they are making the policies. Mr. Alexander was a political science major in college and has a law degree. You want to decrease utilization? Pay Medicaid patients that same $200 at the end of a year only if their medical resource utilization (ED visits/prescriptions/whatever other variable you want to control) is below the average utilization for other Medicaid recipients for that year. Kids get $50 per year. Send out letters to those who didn’t get the money telling them why they didn’t get their “incentive payment”. That policy will pay for itself within the first two years. But what do I know? I’m just a dumb ER doc without a political science degree. Walgreens Blows ItThursday, September 8th, 2011Scanning the news this morning and found a story that really bothered me. Walgreens fired one of its Benton Harbor, Michigan pharmacists. No big news there. However, the reason the pharmacist was fired was more of a story. Walgreens fired the pharmacist for thwarting a robbery. Video posted on the mlive.com site shows two hooded thugs running into the store with guns. They took one or two employees hostage and, when they saw the pharmacist behind the counter, one jumped over the counter to presumably take the pharmacist hostage, too. The robber tried to shoot, but his gun jammed. That’s when pharmacist Jeremy Hoven whipped out his own handgun and shot back. The robbers ran away with their tails between their legs. Walgreens has now terminated Hoven’s employment because Hoven violated Walgreen’s “non-escalation” policy. Exactly how much more “escalated” can things get after someone tries to shoot you dead at your job? It’s not like Hoven detonated a bomb or anything. Walgreens management is dead wrong on this move. I understand the reasoning behind not wanting to encourage shootouts in the store, but the right of employees to take steps to avoid being found amongst a group of employees in a storage room with bullet holes in the head trumps that reasoning every time. It’s almost as if the policy is saying “come rob us, our employees won’t shoot back!” Multiple commenters to the article said that they will take their business elsewhere. If Walgreens doesn’t rectify this situation quickly, I’ll likely add my name to that list. More Florida Medical FolliesSaturday, September 3rd, 2011Yet another reason to stay away from Florida if you are a physician. The inspectors and health care agencies down there leave quite a bit to be desired. The Florida Agency for Healthcare Administration cited an emergency department’s staff for failing to give “adequate care” to 13 week pregnant patient before she had miscarriage of twins. The timeline of events for the patient was outlined in this article.
The inspectors stated that the physician failed to monitor blood sugar levels, failed to respond to the patient’s bleeding and pain, and failed to intervene to stop her labor. In eight of ten other cases that inspectors reviewed, the hospital was cited for failing to document the amount of the patient’s blood loss, failing to record vital signs, and failing to record other case information. We need more information about the other cases, but even without extra information, I’m still calling out the inspector and the Florida Agency for Healthcare Administration. Many of these citations are uninformed and inappropriate. #1 No discussion documented about whether to continue or discontinue the patient’s insulin pump. #2 The emergency physician “failed to initiate any immediate response to the ultrasound report, the patient’s continued labor pains and the profuse bleeding.” #3 The patient was not informed of the risks and benefits of performing the pelvic exam and did not give informed consent. #4 After the patient passed one fetus, “the doctor took no steps to stop labor or maintain the second pregnancy.” This has to be the nadir of medical misinformation. Most pre-med college students know that a fetus is not viable until roughly 24 weeks of gestation. If a woman is having labor with a gestation less than 20 weeks, it is called a miscarriage. There is no treatment to save the pregnancy. A 13 week fetus is never, and will never be, viable outside of the uterus — unless the patient is a lion or some other member of the animal kingdom with a short gestation. To illustrate the problems in lay terms, imagine being arrested for failing to drive the correct speed. You aren’t told what the correct speed is, you just have to pay a fine because you weren’t driving the correct speed. You have to apologize and promise to drive the correct speed in the future in order to keep your driver’s license. I hope that everyone realizes the significant effect that “investigations” such as this have on the access to medical care in the communities. Doctors are publicly accused of inappropriate medical care. Oh and throw in some unjustified lawsuits as well. You know that if a governmental agency states that doctors “didn’t do anything” to stop a patient’s 13 week old miscarriage, however uneducated and inappropriate the statement may be, the patient is going to believe that she was wronged and will find a malpractice attorney to file a suit against the physician. Don’t take this post as me advocating for less oversight of medical practice in the states. I fully believe that there needs to be oversight of medical care and that dangerous physicians need to either improve or have action taken against their licenses. Investigations need to be based in sound medical practice, though. The issue I have here is that the investigator in this case made multiple vague unsubstantiated and medically inappropriate opinions about several providers’ care and those opinions were taken as fact when instead they should have been recognized largely as calumny. Based on the investigator’s calumny, the hospital was cited and the medical practitioners were publicly chastised. I’d bet that there was action taken against the providers at work as well. By the way, if someone can get me a copy of this inspector’s actual report, I’d love to post it for further discussion. Yep, between the “three strikes” rule, the criminalization of medicine, the high medical malpractice premiums, and the quality of the state inspections, doctors would be plum crazy to practice medicine in Florida right now. Sorry, Senator Bill Nelson, things like this are going to drive doctors away from a state that “desperately needs more doctors.” Have fun rearranging the deck chairs on your Titanic, though.
Hurricane Safety, Part DeuxSaturday, August 27th, 2011
Any of you self-righteous attorneys from New Orleans want to post a comment prospectively telling all the hospitals everything that they need to do in order to avoid being sued for an “inadequate response” to this natural disaster? Any experts in disaster preparedness want to chime in? Anyone? Bueller? [crickets] Yeah. Didn’t think so. Yet when some patient gets a fleck of dust in their eye from the 120 mile an hour winds after the storm has passed, based on the recent $25 million settlement from Katrina lawsuits, I’m betting that the attorneys will be falling over each other to file lawsuits to retrospectively tell everyone what the hospital did wrong in preventing said speck of dust to become airborne and lodge in the patient’s cornea, though. God forbid that a hospital’s backup generator breaks down. Just sign a check. While I’m at it … Any person living east of the Mississippi River is hereby put on notice that a hurricane is coming. You need to take adequate measures to protect yourself from any potential injury or death from the hurricane. This may include moving yourself out of any hospital within 300 miles of the hurricane and relocating yourself in a hospital west of the Mississippi River. Is that enough to prevent people from suing? We’re From The Government, We’re Here To Help …Thursday, August 18th, 2011The clock is ticking for Parkland Memorial Hospital in Dallas. Last week, Parkland was cited by the Centers for Medicare & Medicaid Services for several “serious threats” to patient safety. As a result, the hospital is now in jeopardy of losing its ability to participate in the Medicare program unless it submits “correction plans” to CMS by August 20, 2011. According to a CMS spokesperson, two violations relating to infection control and emergency care issues were “so serious that they triggered ‘immediate jeopardy’” for the hospital. In fact, the reasons for the citation were so heinous that CMS won’t even disclose them to the public until Parkland submits plans on how to fix those super secret problems. That’s the subject of another WTF discussion, but we’ll save that one for later. The event triggering the CMS investigation involved a schizophrenic psychiatric patient with a heart condition who died while in the emergency department. The report states that the technicians who subdued the man did not have “effective training” and that the patient was not closely monitored before his death. According to the article and an interview Parkland’s Chief Medical Officer, Parkland was cited for several reasons. Based on what I can gather from the article, two of the hospital’s citations were for: Think about how grave these dangers are. When a patient is more than 20 weeks pregnant and has abdominal contractions, what happens when she comes to the emergency department? She gets put in a wheelchair and brought directly to the obstetrical department for further evaluation. So by virtue of their presenting complaint, some pregnant women are immediately sent to a different department for medical screening. This process is apparently acceptable for CMS because it happens everywhere in the country. Suppose the same 20 week pregnant patient has a hangnail instead of being in possible labor. Now, instead of moving the patient to obstetrics for pregnancy evaluation, Parkland was moving the patient to its urgent care department for further medical evaluation. Both “moves” are made based upon a patient’s presenting symptoms. However, when a patient with one presenting complaint is sent to one area of the hospital for further evaluation, it is entirely acceptable while sending the same patient to a different part of the hospital for a different presenting complaint constitutes a “serious violation” and a “threat to patient safety” that must be stopped immediately. Makes perfect sense to me. Then there’s the “let’s have a sterile universe” violation of epic proportions. Do I think that medical providers need to wash their hands more frequently? Of course. I’m sure that CMS has more infection control violations in its own offices than Parkland has in its hospital. You CMS wonks sterilize your computer keyboards much? Door handles? How about your telephones (when you answer them, of course)? And what is CMS’s official position on presidential candidates shaking hands during election campaigns? I don’ t see the candidates washing their hands between shakes. Nope. Nary even a squirt of alcohol sanitizer. Those germ infested malevolents are engaging in a serious and immediate risk to the health of every prospective voter at these rallies! They’re like giant bumblebees pollinating the population with deadly germs! GACK! Call off the elections! Unless CMS is holding back on some other huge bombshell about Parkland’s practices, labeling the above triage policy and infection control violations as “serious and immediate threats to patient safety” is alarmist, capricious, and just plain wrong. And we wonder why health care in this country is in such a wonderful state of affairs right now … |
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Addressing Transgender Patients
Wednesday, December 14th, 2011I read this story about how transgender patients are upset because they are addressed incorrectly when they seek medical care. Because of this, some people are demanding sensitivity training for medical personnel and are alleging that “transphobia” must be occurring.
“Transphobia”?
Sorry, but I think that the whole transgender rights thing is going a little far when transgender people are offended because medical staff need to appropriately identify them before they receive medical care.
The article states that
Yeah. Good advice. Knowing that a man has ovaries would have no impact on my differential diagnosis of abdominal pain. None at all.
If a woman was taken for prostate surgery because medical staff didn’t want “offend” her by asking her whether or not the “MALE” designation on her ID bracelet was incorrect, you know these same people alleging “transphobia” would be demanding that all the providers’ licenses get revoked.
Don’t want to be embarrassed? Go to the hospital desk ahead of time and explain the situation or call the hospital ahead of time and discuss it with the administrator. Don’t get upset because someone is trying to properly identify you, then scream discrimination when none exists. Make it easy on us and we’ll usually try to make it easy on you.
If you act unreasonably, you’re probably going to end up offended, but it won’t be because of your current or desired gender.
Posted in Medical Topics, News Commentary | 32 Comments »