April 23rd, 2013
More HealthCare Updates from around the web are at my new digs at www.drwhitecoat.com.
Diagnostic errors account for most paid claims in medical malpractice cases. Errors in diagnosis were the most common type of claim and also amounted to the highest proportion of total payments. The total inflation-adjusted amount of diagnosis-related payouts was $38.8 billion over 25 years.
Remember, these statistics represent just the payouts. On average, two of three medical malpractice lawsuits end in no payment to the plaintiff.
And we still wonder why doctors do so many “unnecessary” diagnostic tests?
Missing bamblance. University of Virginia is on the lookout for a stolen ambulance after the driver left the ambulance unlocked with the engine running.
Another missing bamblance. This one was from University of Alabama Birmingham ED ramp. The ambulance company executive said that it “wasn’t clear how or why someone took the vehicle.”
How – The driver obviously left the keys in it.
I agree with him on the “why” part.
Ex-boyfriend kidnaps patient from hospital room. Waited until she was called back to the treatment area from the waiting room, then stuck a gun in her ribs and made her leave.
I can’t make this stuff up.
Another application of federal EMTALA law. Everyone coming to the emergency department must be evaluated and treated – even if they just bombed the Boston Marathon.
Cases like this come up every once in a while and it is very difficult for the emergency department staff to set aside their feelings.
Another story on the topic here
Surgical complications good for a hospital’s bottom line. With insured patients, hospitals made an extra $39,000 per patient who had post-surgical complications. Medicare patients with post surgical complications earned the hospital about $1750 more. Hospitals lost money on Medicaid and private pay patients with post-op complications.
Don’t believe people who try to draw the conclusion that “errors” and “complications” are the same thing – they aren’t.
Posted in Healthcare Update | 2 Comments »
April 17th, 2013
Interesting issue brought to my attention by a reader in South Carolina.
One of the hospitals in South Carolina wanted to post a sign in its emergency department waiting room stating the following:
Prescribing Pain Medication in the Emergency Department
Our Emergency Department staff understands that pain relief is important when one is hurt or needs emergency care. However, providing pain relief is often a complex issue, especially when pain is a chronic or recurrent process. Mistakes or misuses of pain medication can cause serious health problems and even death. Our Emergency Department will only provide pain relief options that are safe and appropriate.
• The primary role of the Emergency Medicine provider is to look for and treat an emergency medical condition. We will use our best medical judgment when treating pain, following all legal and ethical guidelines.
• You may be asked about a history of pain medication use, misuse, or substance abuse before prescribing any pain medication.
• We may ask you to show a photo ID, such as a driver’s license, when you check into the Emergency Department or receive a prescription for pain medications. We may also research the statewide prescription data base regarding your prescription drug use.
• We may only provide enough pain medication to last until you can contact your doctor. We will prescribe pain medications with a lower risk of addiction and/or overdose when possible.
For your safety, we do not:
– Give pain medication shots for sudden increases in chronic pain, or aggravation of chronic pain syndromes.
– Refill lost or stolen prescriptions for medications. You must obtain refill prescriptions from your primary care provider or pain clinician.
– Prescribe missed methadone doses, or provide prescription refills for chronic pain management.
– Prescribe long-acting pain medications, such as OxyContin, MSContin, fentanyl patches, or methadone for chronic, non-cancer pain.
– Prescribe pain medications if you already receive pain medication from another doctor or emergency department.
The Centers for Medicare and Medicaid Services (CMS) had a different take.
EMTALA requires that every patient seeking care in the emergency department receive a “screening exam” and then receive “stabilizing treatment” of any emergency medical condition. In other words, if you are having a heart attack, the emergency department is required to stabilize you regardless of your ability to pay. If you have a runny nose or other non-emergency condition, the emergency department still has to examine you, but then doesn’t have to treat you. In either case, the hospital isn’t allowed to discourage you from seeking care.
CMS therefore wrote a letter to the South Carolina Hospital Association [.pdf file] and advised it that hospitals displaying such a sign would likely “unduly coerce [patients with legitimate medical needs] to leave the ED before receiving an appropriate medical screening exam.” Therefore, CMS considered such signs as potentially constituting an EMTALA violation.
I disagree with a lot of things about EMTALA. It is an unfunded mandate. Its reach has progressed far beyond the initial intent of the statute. But unless and until we repeal it, we are stuck with it.
I’m interested in your opinion, though.
Should a sign like the one above be considered an EMTALA violation?
Is it any different than hospitals that advertise their wait times? After all, a patient with an emergency medical condition may see the advertised wait time as being too long and might not go to a hospital because of it.
Vote below and leave a comment.
 Loading ...
Posted in EMTALA | 27 Comments »
April 15th, 2013
See more HealthCare Updates from around the web at my new digs at www.drwhitecoat.com.
More of a free market approach to medical care. Australian private hospitals noting a large uptick in emergency department patients as patients opt to pay for emergency services rather than wait for care at the public hospitals. Some emergency departments are recruiting highly regarded specialists to further increase patient demand for services.
Another article about Australian medical care. Patient goes to hospital complaining of the “worst headache of his life.” In many cases, that translates into doctor speak for “order a head CT scan to rule out bleeding”. The patient had a head CT nine days before going to the emergency department which showed the presence of an aneurysm. He was discharged from the emergency department and died the next day.
More arrests for oxycodone prescriptions. In this case, a physician wrote prescriptions for more than 500,000 pills over 2 years. The prescriptions were filled in New Jersey – even though they were written in New York. Other allegations surfaced as well.
The investigation was sparked by an overdose death where a prescription bottle bearing the doctor’s name was found at the scene.
More Unaffordable Care Act follies. Smoking is considered a “pre-existing condition” under the Act and smokers therefore can’t be charged higher rates than non-smokers for insurance. Which means that non-smokers will be charged even more to cover the cost of treating smokers.
I’m getting the impression that the government wants the insurance industry to fail.
Get your healthcare now while you still have insurance, folks.
“Sounds good my man, seeya soon, ill tw …” The University of Northern Colorado student sending this text message never got to finish it. He was driving while texting, drifted into oncoming traffic, jerked the steering wheel, and rolled his car. He died from the resulting injuries.
His parents published pictures of his phone with the message hoping that they can keep others from texting and driving. I hope that every parent prints this article and discusses it with their children.
Posted in Healthcare Update | 3 Comments »
April 12th, 2013
 So much to rant about today.
The girls are doing a dance competition this weekend. I’m trapped in my own little version of Dance Moms. Aaaaauuuuuggghhh. Somebody help me. One daughter complains because she’s in the back of one dance the whole time. Another daughter is upset because people are mad at her because she’s in front during one of her dances. Glitter is all over our fricking kitchen and it doesn’t come up with wet wipes, either. We have to purchase hair extensions with curls for $25 for the girls, and we have to make SURE to purchase the color that most closely matches the girl’s hair. We can’t just curl the girls’ hair because judges can apparently tell the difference between real curled hair and fake curled hair and that makes a difference on how they grade the performance. Sounds like a Joint Commission inspection.
I just keep thinking that they couldn’t pay me enough to participate in a reality show based on this crap.
Junior WhiteCoat is ramping up lacrosse season. He’s loving it. Playing in a huge tournament at Notre Dame next weekend. Junior was also one of the main characters in a movie that won first place and multiple other awards at an indie film festival last week. He’s now getting requests for auditions with some bigger movies. Hear that, Adam Sandler? Pick him and your movie could grace the pages of WhiteCoat’s Call Room.
On the doggie chew list for the past week include a Jenga block, a decorative pillow from the couch, a garbage can in the office, the leg from a “Monster High” doll (since when did it become cool for young girls to go from modeling themselves after Barbies to modeling themselves after zombie high school kids, anyway?), and the middle of her doggie bed. The last one is most interesting. You see, she’s chewed half of the inside out of her own bed and now she no longer wants to sleep on the bed. So when it gets dark out, she runs upstairs to the bedroom and lays on the other dog’s bed before he gets there. That means that the innocent dog is stuck sleeping on a disaster of a dog bed that he had no part in creating. After the first couple of times that happened, I started moving the doggie garbage disposal off the good bed and letting our other dog lay on his bed. By the morning, though, there was more foam filling sitting on the floor, Chewmeister was laying on the good bed, and our other dog was laying on the floor. I’m getting to the point that I’m going to start making little Chewy sleep in a cage … on her own frigged up bed.
Then I thought to myself … those beds are a lot like, say California and Texas right about now. Read the rest of this entry »
Posted in Random Thoughts | 11 Comments »
April 11th, 2013
![Skull Medical book [morguefile.com]](http://www.epmonthly.com/whitecoat/wp-content/uploads/2013/04/Skull-Medical-book-morguefile.com_.jpg) A young lady comes to the emergency department and wants to be evaluated for a … somewhat nonurgent … problem.
Chief complaint: “I’ve lost 50 lbs in the past month.” She felt a little weak as well, but she had just lost too much weight. No other symptoms.
The patient weighed 132 pounds. Her skin wasn’t sagging. Her jeans didn’t appear to be new and they seemed to fit pretty well. Nothing about her seemed abnormal on exam. But she insisted that she weighed 180 pounds just a month earlier.
No old records in the computer.
I asked her if she could show me a recent picture of herself on her iPhone. She briefly stopped texting to check, but she couldn’t find any.
I asked her to show me her drivers license. Nope. Didn’t have that, either.
I was quickly developing an opinion that this was a snipe hunt.
Snipe hunts like this are an example of another conundrum that many physicians face.
We are often expected to prove a negative.
Clinically, I can say that the patient did not appear to have lost 50 lbs in the past month. I can even say that it is unlikely [although not impossible - don't comment with all your weight loss feats] that any patient could lose 50 pounds in a month.
But what if …?
What if the patient had cancer that caused some type of weight loss and I didn’t evaluate her for it? What if the patient had a bad outcome from a metabolic problem that I didn’t screen for?
What if, as a result of weight loss, the patient had developed an severe electrolyte abnormality or other blood abnormalities?
Retrospectively, if the patient suffered a bad outcome, it would be easy to allege that weight loss is an obvious symptom of [insert bad outcome here] and that Dr. WhiteCoat was careless because he didn’t evaluate the patient for this problem.
I suppose that the same issue holds true for a febrile child. If a three year old with a runny nose had a fever of 102 at home, but looks fine and is afebrile in the emergency department, he’ll probably get a pass on the workup. But if an afebrile 27 day old infant reportedly had a fever of 102 at home, get the lumbar puncture tray ready.
A physician must have a certain degree of risk tolerance in choosing whether or not to do testing to evaluate an odd complaint, but where should we draw the line between “necessary” and “unnecessary” workups?
And in case you were wondering, yes, I did labs and a chest x-ray on the incredible shrinking woman. She was anemic. Her hemoglobin was 10.5. Not enough to hospitalize her, but enough to recommend that she follow up with the on-call physician for a more thorough weight loss/anemia evaluation.
I’m going to be eating my words if she comes back next month weighing 80 pounds.
Posted in Patient Encounters, Policy | No Comments »
April 10th, 2013
 Second time in a week.
The first episode, the patient from the assisted living facility came in with sharp anterior chest pain. She said that she was sleeping and woke up with sudden onset of pain. When she opened her eyes, her roommate was standing over her with a crazed look in her eye. Sticking out of her right breast was a ball point pen. Fortunately, the injury was to adipose tissue only and didn’t require any surgical intervention.
On her most recent visit, the same patient returned after waking to her roommate’s friend beating her with a cane. She tried to fend off her attacker and fell to the floor where the friend repeatedly pounded her in the stomach with said cane. She had a lip laceration and multiple bruises to her abdomen.
I feel so bad for this patient because she’s doing nothing wrong and getting beaten in her sleep. It’s not like a loan shark is trying to collect on a debt or anything like that.
Definitely time to find a new roommate.
Or a new facility.
———————–
This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.
Posted in Patient Encounters | 8 Comments »
April 8th, 2013
Columbus, OH paper compares hospital wait times from 15 different hospitals throughout central Ohio. Metrics include minutes until diagnostic evaluation, minutes until pain medication, minutes until admission decision, and minutes from admission to room placement. I just wonder how accurate the metrics are. It isn’t like self-reported data like this can’t be manipulated.
Evanston Northwestern Hospital in Chicago suburbs also making news because of its wait times – nearly twice the national average.
The problem with providing patients with insurance: When the insurer cuts payments, what happens if providers won’t take your insurance? Government cuts payments to providers so that it costs more for cancer clinics to provide chemotherapy to some Medicare patients than the government reimburses. To stay afloat, some cancer clinics have now begun turning away Medicare patients needing cancer infusions. Now patients go to hospitals where the charges for cancer treatment are higher and the waits for treatment will likely be longer.
But we’re going to be insured! And we can keep our doctors, too!
Patients gone wild. Two brothers in Lebanon “attack” an emergency department, smashing windows and insulting the doctors and nurses on duty. In other words … a normal day in a typical American emergency department. And their Press Ganey scores probably stink for that day, too.
What a great story. Six year old Long Island kid treated in emergency department raises $275 with a fundraiser and uses the money to buy coloring books for other emergency department children.
Remember how CMS promised to give incentive payments for “meaningful use” of electronic medical records? Not so fast. Rules changing. Now it is doing random audits of 5-10% of all applicants to see whether they should actually get their bonus payments. Self-reporting isn’t good enough any more.
Wouldn’t it be interesting to see what would happen if all providers went back to paper records?
Canadian paramedics visiting patients with “non-urgent” issues to keep them out of emergency departments. The only question I have is who determines whether the issues are “non-urgent”?
A second interesting Medical Economics article. What are the tech trends that will affect how doctors practice medicine in the future? Interesting to consider. Remote patient monitoring. Personal health records with biometric security. Cool stuff.
More than 25% of Oklahoma patients enrolled in Medicaid. Of those, about a quarter used the emergency department a total of 528,000 times at a cost of $170 million. Oklahoma is now trying to determine how to deal with the high utilizers – those who use the ED more than 15 times every 3 months.
Speaking about Oklahoma … Oklahoma Dentistry Board officials are deciding whether to pursue criminal charges against a dentist. Officials found rusty instruments, “potentially contaminated drug vials” and “improper use of a machine designed to sterilize tools” in the dentist’s office.
The Oklahoma Dentistry Board accused the dentist of re-inserting needles in drug vials after their initial use and using the same drug vials on multiple patients. This happens often in medicine. The dentistry board also stated that a sterilization machine hadn’t undergone monthly testing in six years. Concerning, but when the Board officials tested the machine was it not properly sterilizing equipment? They did test the machine, right? Were the rusty instruments used on patients? Where was the rust located – on the handles or on the surfaces that come into contact with patients?
In addition, the dentist allegedly allowed dental assistants to administer IV sedation when only dentists are allowed to perform such acts.
For each charge, the dentist could face up to four years in prison and a $10,000 fine.
Are the alleged actions above worth throwing someone in jail for 8 years over?
Rhode Island emergency department reportedly one of few in country to have an MRI available in the department. Wonder how MRI use at this hospital compares to national averages.
Remember … fast care, quality care, free care – pick any two. Patient upset because she was treated quickly in a freestanding emergency department, but her bill was too high and included a $1,500 “facility fee” typically used by hospitals. Some of those costs to go complying with governmental regulations.
One British Columbia hospital emergency department is in a “state of emergency” due to understaffing and high patient volumes.
Emergency department personnel don’t routinely ask suicidal patients about availability of firearms in the home. Will patients admit to having guns and if so, will intervention make any difference in suicide rates?
Woman with double uterus told not to have any more children due to possibility of dying from complications. Goes for abortion and learns several days later that the abortion was unsuccessful. Instead of going for repeat procedure, keeps pregnancy. Now, after delivering healthy 6 pound girl, woman sues abortion clinic for the pain, suffering, and emotional distress of having undergone an improperly performed abortion.
Posted in Healthcare Update | 2 Comments »
April 4th, 2013
A patient was sent to the emergency department to have an ultrasound of her uterus performed.
She had been having abnormal bleeding which coincided with about the time her period was due – only it was a little heavier and lasted a little longer than usual. She decided the best course of action would be to make an emergency appointment with the gynecologist. She was seen the day before she was sent to the ED and the gynecologist performed an ultrasound in his office … which was normal.
The patient called the gynecologist the following day and said that the bleeding was still there, so the gynecologist told her to go to the emergency department for another ultrasound and some blood testing.
The patient arrived stating “I’m here for my ultrasound. Dr. Speculum sent me.” Since patients need orders for testing to be performed, the patient was given the choice of waiting to be seen in the ED or of getting a prescription from her doctor for the exam. She chose the former.
After examining her, we performed a pregnancy test which was negative and a CBC which was normal. So I told the patient she was likely just having a heavy period and that she could follow up with her gynecologist as an outpatient.
The patient demanded an ultrasound. After all, Dr. Speculum sent her to the ED specifically to have an ultrasound done.
So I called Dr. Speculum.
“Hey, it’s WhiteCoat here. Your patient is here with metrorrhagia and I’m trying to discharge her, but she insists that you want her pelvic ultrasound repeated.”
“Yeah. Can you do it?”
“Well what are we doing it to look for?”
“Fibroids”
“OK, well if she does have fibroids, are you going to admit her? Her hemoglobin is fine.”
“Noooooo. Discharge her after the ultrasound.”
“So then why … nevermind. If all you’re looking for is fibroids, weren’t you able to see that she didn’t have any fibroids on the ultrasound you did on her in the office yesterday?”
He must have really wanted that ultrasound by his response.
“Naaaaaaah. The ultrasounds I do in my office aren’t accurate.”
Allrightey, then.
The repeat ultrasound was still normal. I guess he was more accurate than he gave himself credit for.
Wonder if she’ll be referred back to the ED tomorrow for repeat pregnancy testing.
———————–
This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.
Posted in Patient Encounters, Random Thoughts | 6 Comments »
April 3rd, 2013
By an Anonymous Emergency Physician
Hi. I’m Anon. I’m a 44 year old emergency physician. And I’m an addict.
My addiction came to light when my Press Ganey scores plummeted after I started to stand up to the chronic pain and frequent ER patients.
The fact that I have an addiction was reaffirmed when I went to my state’s Prescription Drug Abuse Summit. When I saw so many professionals from varying fields (medicine, law enforcement, pharmacy, education, etc…) assembled, I realized my problem: I’m addicted to prescribing pain medications.
As with any addiction, the first step in treatment requires acknowledgement of the problem.
I thought back to how my addiction began.
Coming out of medical school, there is a certain power that comes on the first day of residency. You suddenly have the power of the pen. You can write prescriptions for low blood pressure, high blood pressure, low blood sugar, high blood sugar, too many bowel movements, not enough bowel movements. The list goes on and on. But one of the largest ways in which we can help patients is by treating their pain. Controlled substances. Yes, the new physician quickly learns that the pen wields an awesome power and an awesome responsibility. This feeling fades quickly in the face of an 80+ hour work week.
Fast forward 5-10 years. You are seeing 10-12 patients at the same time, all the chest trauma goes across town, and you have a waiting room that is 20 patients deep, and you already know the medical history of ten patients waiting to be seen on the tracking board. Hospital administrators pressure you to make sure that all nonemergent patients are treated and released within 90 minutes. All admits must be up to the floors within 240 minutes … if only the medicine consultant would get down and actually see the patient.
It’s not uncommon to see 40 or more patients in a shift. I make it a point to look up the prescription/controlled substance database our state has. This has been an absolute lifesaver to me and to several patients I have confronted.
The problem is that it takes time:
- 2 minutes to look up the patient and print off the list
- Another minute to count up the number of prescriptions (it does take time to count to 50 or even 72 – my personal best record for one year)
- Another 3-5 minutes to go to the room and confront a patient who has an issue
- Then a few more minutes to sit down and document the conversation.
So I have 10 minutes to evaluate a patient, create notes in an arcane electronic medical record, and discharge the patient. Yet all of that time can be taken up by doing what is right with drug seeking patients. I cherish the ability to “catch” someone who is diverting drugs, to be able to sit down with them and have that “aha” moment. I have even had a few patients come back and thank me for confronting them. But my worth is partially measured by the number of patients I see per hour. My worth is also partially measured by my patient satisfaction scores. It’s not all possible.
Why do I and so many other physicians have this addiction? NOT providing the prescription is very hard. It takes time to do the research on the patient. Confronting the patient with a problem is emotionally draining. Doing it 5-10 times in one shift is not only a reality, it is downright crippling. It sucks out last bit of energy out of your soul. Rather than confronting patients and arguing, it’s far easier to write a prescription for narcotics and move on to the next patient. This is the mindset of thousands of physicians. Healthcare is different than it was 5-10 years ago.
As soon as I started saying “no” to drug-seeking patients, it was as if I had been liberated. I still have lapses and give out prescriptions to a patient against my better judgement. And I occasionally get burned. I am human and some days I just don’t have the energy to argue and fight with drug seeking patients. As time passes, however, saying “no” gets easier.
Physicians need to start saying “no” once in a while. Take the time to review a patient’s medication history. Don’t be the doctor who prescribes the patient’s 300th Norco tablet of the week. Saying “no” just once a day can be liberating. Try it just once a day for a month. Then twice a day. It gets easier. At first, I actually felt guilty when I wrote for Ultram instead of Vicodin. It has become easier with time.
Physicians can’t fight this addiction alone, though. We need the backing of hospital administrators. Hospital administrators must listen to physicians and see how much of a toll the prescription drug abuse epidemic is taking on patients, the healthcare system, physicians, and the bottom line. How many $500 ER visits will a hospital be willing to write off when they learn the patient just wants 20 Vicodin? Hospitals must stand behind and support physicians who are willing to stand up to drug-seeking patients. Perhaps patient satisfaction scores will take a hit. So be it. Administrators need to take a step back and see the big picture on this one.
Maybe administrators need to be held legally liable for patient overdose deaths when they haven’t created a policy for dealing with medication prescriptions. Sometimes getting sued is the only thing that makes administrators wake up.
So, I’m out of the closet. I am a recovering “controlled substance prescribing addict.”
It feels good to be free of that burden.
Well … most of the time at least.
Posted in Guest Posts | 2 Comments »
April 3rd, 2013
A nursing home patient is brought by ambulance with a cough. Nursing home staff believe the patient may have aspirated lunch 30 minutes ago. The patient’s workup is normal except for his EKG which is shown below (you can click on it for a much larger/printable version).
What’s the diagnosis? What needs to be done with the patient? Does it make any difference whether this was a new finding or an old finding?
I’ll provide the answer in the comments section in a couple of days.
Posted in What's the Diagnosis? | 14 Comments »
|
|
