WhiteCoat

Insecticide Poisoning From Aluminum Phosphide and Phosphine

June 19th, 2014

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There was a sad story about a woman who died from insecticide poisoning inside her home after family member sprayed agricultural insecticide inside the house earlier in the day. While the story was sad, the back story was quite interesting to me.

The poisoning was from aluminum phosphide. When exposed to atmospheric moisture or stomach acid, aluminum phosphate converts to aluminum hydroxide (which is used to treat excess stomach acid) and phosphine gas – which is highly toxic. Phosphine gas typically smells like rotting fish or garlic. Phosphine is explosive and is heavier than air, so it tends to collect in low-lying poorly ventilated areas such as basements. Toxicity usually develops a few hours after exposure and affects the cardiac and vascular tissues, causing hypotension, congestive heart failure and electrocardiographic abnormalities.

Diagnosis of aluminum phosphate poisoning is difficult to make and usually depends on history of exposure due to the nonspecific symptoms. Confirmatory testing involves putting silver nitrate paper over the patient’s mouth or over a heated beaker of the patient’s stomach contents. If positive for exposure, the paper turns black. There’s no antidote for the poisoning, so treatment is supportive, although oils reportedly inhibit phosphine release and there have been case reports of using coconut oil in treatment of aluminum phosphide poisoning. Potassium permanganate (1:10,000) via gastric lavage will also oxidize phosphine to nontoxic phosphate.
Phosphine can be absorbed through the skin, so removing the patient to fresh air and decontamination with water is important.

Although management will probably be in combination with a poison control center, you may just look like a rockstar if you diagnose aluminum phosphide poisoning in a patient in cardiovascular collapse … who smells like rotten fish … and who just happens to have an ant infestation at home.

Also remember that if you smell phosphine on a patient, you could be poisoned, too.
Again, think decontamination and negative pressure ventilation.

Healthcare Update Satellite — 06-17-2014

June 17th, 2014

Read more healthcare-related news from around the web on my other blog at DrWhitecoat.com

Oklahoma University Medical Center joins the growing ranks of hospitals that are requiring patients to pay a fee of $200 to be treated for non-emergency complaints. That amounts to an estimated 40% of OU’s emergency department visits. If patients do not want to pay for non-emergent care, they will be referred to nearby urgent care clinics.
This “triage out” protocol will eventually become a standard throughout US emergency departments. Count on it.

Emergency physician writes about how she almost diagnosed Lou Gehrig’s Disease in the emergency department, then learned that the real diagnosis wasn’t quite so ominous.

Holy Cross Hospital puts bowl of Percocet tablets in waiting room. Wait times suddenly decrease to record lows and there hasn’t been a complaint about the ED in months.

Florida emergency physician put on probation, nearly loses license, and has to pay $5000 fine after relying on reports of physician assistant’s assessment of a patient’s finger injury rather than evaluating the patient and making the diagnosis himself. The patient returned the following day and required a finger amputation.
Keep in mind that you may not be covered by your malpractice insurance policy when an injury results from your supervision of other health professionals. Your agreement to supervise could be construed as a contractual agreement or as an administrative duty instead of the practice of medicine – for which malpractice insurance covers you.

Our overuse of antibiotics over the years has caused a crisis of antibiotic resistance. The Telegraph warns us that the golden age of medicine has come to an end.
“Antibiotics are no longer effective. The drugs that have transformed life and longevity and saved countless millions since penicillin was discovered by Sir Alexander Fleming in 1928 now saturate every corner of our environment. We stuff them into ourselves and our animals; we spray them on crops, dump them in rivers, and even – as emerged at a meeting of science ministers from the G8 last year – paint them on the hulls of boats to keep off barnacles. As a result an invisible army of super-resistant bacteria has evolved, one that is increasingly claiming lives – currently more than 25,000 a year in Europe alone.”

Is Vermont State neglecting patients in need of emergency psychiatric care? Currently, only four hospitals in the entire state are capable of providing the highest level of psychiatric care.

As we lose the battle against bacteria in one area, we may have found a weapon to help us win the war. Scientists find protein that will dissolve bacterial biofilm – a substance that some bacteria create in order to protect themselves from the effects of antibiotics. Think of it as if we found a weapon that penetrated the shields on Klingon warships.

Child rushed to emergency department after allegedly drinking nicotine from e-cigarette cartridge. The cartridges are childproof and there is nothing in the article stating that the child actually ingested the liquid, but we should probably just ban nicotine to keep our children safe.

Neat story about a Florida emergency physician and CPR instructor who passed out and died … for 20 minutes … until CPR brought him back to life. Talks about “the light” and how lucky he is to be alive.

More patients in Oregon emergency department – about 600 more per month – after Obamacare took effect.
Most of those patients were “losing access to doctors who’ve cut-back on the number of Medicaid patients because reimbursements don’t cover their costs.” For example, “the Vancouver Clinic announced recently it will no longer accept new Medicaid patients.”
Wait. People with insurance are having problems with access to care? This can’t be. They told us that emergency department visits would decrease. The title of the legislation is the Affordable CARE Act. How can this be happening?

14.5 Million Reasons Physicians Practice Defensive Medicine

June 16th, 2014

Fetal Tracing

Cleveland’s MetroHealth Medical Center and a staff physician were recently found liable for a $14.5 million medical malpractice verdict in what is commonly termed a “bad baby” case.

The case as described in the article involved 36 year old Stephanie Stewart who was pregnant with her second child. She went to MetroHealth several times for premature labor when the child was 22-23 weeks gestational age (a full term infant is 40 weeks) and was admitted twice, with labor being stopped using medication and bedrest. There were apparently discussions about her requiring a C-section since her first child was delivered by C-section.
Six days after being discharged from her second hospital admission, she returned for evaluation after her water broke. At that time, she reportedly asked physicians to give her an immediate C-section to deliver her 24 week old baby, but they do not do so. The attending physician arrived later that afternoon and she again requested a C-section, but the attending doctor noted that the baby appeared “healthy” on the monitor. Three and a half hours later, the baby showed signs of distress. Doctors performed an emergency C-section, but the child was unfortunately born with a brain hemorrhage, cerebral palsy, cognitive delays, visual impairments, and “other issues that will require lifelong care.”

The doctor and hospital were sued and after a trial, according to the plaintiff’s attorney, the “jury determined there was medical negligence and Stewart was not informed that there was a significant risk of a brain hemorrhage if a baby goes into fetal distress … [in addition, the mother] was not given any options, and her request for a Caesarian was not granted.”

What would have prevented all of the patient’s medical injuries and what the hospital and physicians should have done, according to the attorney, is to have kept the mother in the hospital after her third admission for three months until she delivered a healthy baby, or alternatively, the doctors should have performed a Caesarian section on the mother when she requested it.

Comments to the article alleged that this “malpractice” isn’t an isolated incident.

However, when you look at the allegations in the case within context, you have to wonder.

20% of premature infants suffer from bleeding in the brain.
In infants born between 22 and 25 weeks of gestation, 73% either die or have some type of neurodevelopmental impairment and 61% die or have “profound impairment.” The risks of adverse outcomes are decreased by increasing gestational age (i.e. allowing the baby to remain in the uterus longer), in addition to administering steroids.
A 2000 study showed that “survival at 23 weeks’ gestation ranges from 2 to 35%, at 24 weeks’ gestation 17 to 62% and at 25 weeks’ gestation 35 to 72%.” Those survival rates have probably improved over the past 14 years, but the data show that even an extra week of keeping a developing fetus inside the uterus has a significant effect on the child’s survival. 

Now a woman who is 24 weeks pregnant – at which time, if delivered, her fetus has a 38% to 83% chance of dying – comes to the hospital and demands to have a C-section.
If the doctors perform the C-section without a proper reason for doing so, more likely than not, the child is going to die. Then the mother will allege that the doctors should never have performed the C-section and will sue the doctors and hospital for performing the C-section. In addition, the state will go after them for causing patient harm without following medical protocols.
If the doctors don’t perform the C-section, the patient has a 60% chance of having some type of neurodevelopmental impairment and a 20% chance of bleeding in the brain. If the child is born with any of those problems that are likely to occur in any premature infant, it creates the appealing plaintiff lawyer argument that if the doctors just listened to the mother’s requests for a C-section none of this would have ever happened. After all, how dumb can the doctors be if a mother knows more about premature pregnancy than they do?

The rule that the plaintiff attorney apparently thinks all physicians should follow is that doctors should always perform all testing or treatment that patients request, even if that testing or treatment is potentially harmful or medically unfounded.

Unless the mother was skilled in evaluating premature labor, the judge should never have let the jury hear that the mother demanded a Caesarian section. Had a C-section been performed and a bad outcome occurred, the fact that the mother demanded the procedure be performed wouldn’t be admissible.
If the defense attorney did not move to have that highly inflammatory testimony excluded, the defense attorney likely committed legal malpractice.

In either case, this scenario reinforces the notion that doctors should fear the bad outcome. Regardless of what actions we take, if a bad outcome occurs, someone will find something that should have been done differently.

Until we address no-win situations involving multimillion dollar liability such as this, defensive medicine, overtesting, and overtreatment will never go away.

BMI Measurements Inaccurate But Still A Government Gold Standard

June 14th, 2014

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Everyone needs to read this NY Times article and then think about how inane the concept has become.

The Body Mass Index or “BMI” is used as a measure of a person’s body weight. If your BMI is between 18.5 and 25, you’re normal. More than 25 and you’re overweight. More than 30 and you’re obese. The measurement is based on a person’s weight and height, but it was originally created in the 1800s to measure human growth – not as a measure of a person’s ideal body weight or health. More recent studies show that people considered “overweight” using the BMI measurement are healthier than those who are at the lower end of the “normal” measurement. One study shows that likelihood of death increases with a BMI of less than 23. BMI doesn’t account for the distribution of body fat (abdominal fat is less healthy), BMI falsely classifies muscular individuals as “obese”, and even the CDC has recommended that doctors not use BMI as a diagnostic tool.
Yet what is one of the things our government requires that doctors calculate on every patient’s chart in order to meet “meaningful use” criteria?
You guessed it.
A BMI measurement.

This is what happens when inmates run the asylum.

The reason that we are being required to measure BMI isn’t because a patient’s BMI has any meaningful clinical use … it’s that the BMI can be measured. If it can be measured, it can be tracked. If it can be tracked, then people (essentially health care providers) can be manipulated and penalized if some arbitrary number on a meaningless scale isn’t reached.

Think about it. If we tried to find other substitutes for “health”, they would be difficult to calculate. How many calories does a patient eat? How much alcohol does a patient drink in a day or week? How much exercise does a patient get each day or week? There’s no standard way to objectively quantify or objectively measure any of those criteria.

Instead the government sticks with something easy to measure – even though it has no bearing on a patient’s health. With a little propaganda, the government can make all the patients who don’t know any better think that BMI really is a useful measure of health. Then, if the BMI isn’t calculated and put on the patient’s chart, it gives the government a means to reduce or deny payments to the healthcare providers.

Calculating a BMI and asserting that it is a representation of health is like measuring the number of clouds in the sky at 3PM each day and claiming that a higher number of clouds is an accurate representation of good government.

The scary thing is that another industry has been making similar assertions for years and certain village idiots just continue to believe the misinformation.

Patient satisfaction scores have long been asserted to be a surrogate measure for healthcare quality. Of course, those assertions are made by corporations which receive hundreds of millions of dollars each year from hospitals so that they can compare one hospital to another … on a statistically invalid and entirely misapplied metric. Studies prove that higher satisfaction is associated with higher healthcare costs and almost double the amount of patient deaths. Recall the story about the Texas neurosurgeon who maimed and killed patients yet who had great Healthgrades.com scores (which were suddenly removed by the Healthgrades staff when the story broke). Healthgrades knows its data are inaccurate, but persists in collecting and disseminating inaccurate and potentially dangerous information.
Junior high statistics classes teach twelve year olds that inadequate sample sizes automatically prevent you from making valid conclusions from the results. Want a real life example? Open up a pack of skittles, take out 5 pieces of candy, note the proportion of colors, and then see if those proportions match the proportions of colors left inside the pack.

Despite the woefully inadequate sample sizes and scientific evidence showing that these measures have no bearing on patient outcomes, the same government that relies upon BMI measurements as a representation of health is going to rely upon patient satisfaction scores as a measure of healthcare quality … and will reimburse hospitals less for care when they have lower satisfaction scores. Hospital administrators and hospital governing boards swallow this obviously inaccurate and misleading information like high school kids sucking beer through a beer bong — all in the name of profits with little regard to the adverse effects on patient health.

It is refreshing to see that hospitals are starting to be held accountable for these decisions. It is easy to prove administrative negligence and hospital board liability when bad faith actions harm patients so that hospitals can earn more money.

After all … the sun is shining. That means that BMI measurements and payment for satisfaction are bad government policies that no one should follow.

I’m a scientist. I know these things.

The Effectiveness of Advertising

June 11th, 2014

A cute little 6 year old boy was brought from home. He had autism and didn’t communicate much.

His mother stated that he would occasionally just stop eating and drinking. Then he would get dehydrated. Then he’d get constipated. Then it would be a big problem to attempt to get him un-constipated. He had to be hospitalized for dehydration a couple of times and he had to be manually disimpacted once. The mom estimated that he had gotten significantly dehydrated 4-5 times in the past few years. So the patient’s pediatrician sent him to the emergency department to get some IV fluids in order to attempt to avoid the progression of events.

I examined the boy and he did seem behind on his fluids. He hadn’t urinated since he had woken that morning and his mucous membranes were tacky.

I asked him “Won’t you drink some juice for me?”
He said “Dehydrated. Need fluids.”
OK. Interesting vocabulary for a six year old.
“I know you need fluids. Could you drink some fluids to make you feel better?”
“No. Dehydrated. Need fluids.”
The nurse brought him some juice. He turned his head away and got upset when it was offered to him.
“Dehydrated. Need fluids.”
“We’ll have to stick you with a needle to give you fluids if you won’t drink.”
“Dehydrated. Need fluids.”
His mom interjected. “He’s really good about IVs.”

Difficult situation. On one hand, the kid did seem dehydrated. But the source of his dehydration seemed entirely psychogenic. It was almost as if he wanted an IV. On the other hand, if he did have some underlying desire to get IV fluids, would giving him IV fluids just encourage him to stop eating and drinking on a more regular basis?
Then you weigh the upsides and the downsides.
Potential Upsides: IV fluids seemed to be what the primary care physician, the mother, and the patient wanted. Little harm. Hopefully a quick disposition after receiving the fluids.
Potential Downsides: Probably overkill. Would be the first point of contention if the kid kept refusing oral fluids and required hospitalization. There’s no guarantee that the kid would start drinking again after he was “tanked up.” Probably would result in unmet expectations if wasn’t done, which would likely result in complaints to the administration and possibly negative Press Ganey scores.
As an aside, this situation perfectly demonstrates the perverse notion of HCAHPS and patient satisfaction ratings. If you don’t give the patient a desired treatment that is of questionable medical benefit, you get bad reviews from the patient and the government or hospital penalizes you. If you do give the patient a desired treatment that is of questionable medical benefit, you get accused of providing “unnecessary care” and the government or hospital penalizes you. You’re put in a no-win situation where you’re guilty of some misconduct regardless of what path you choose. But that’s another story.

In the end, the potential downsides won out. The kid got an IV.

So they sat there watching TV as he got a few fluid boluses. The patient sat there intently watching the shows and even more intently watching the commercials.
“He LOVES watching TV commercials,” his mom said.
He finally urinated which was my cue that his tank was full.
The mom asked if I was planning on doing any blood tests.
“Not really. They aren’t likely to change our treatment course. Besides, kids are pretty resilient.”
Then the patient chimed in. “High cholesterol. See your doctor.”
“Wow. You did see your doctor today,” I quipped.
“High cholesterol. See your doctor.”
So I asked him “What would your doctor give you for high cholesterol?”
Without missing a beat, he said “CRESTOR!”
I looked at the mom. She shrugged and smiled.
“Well, it’s time for you to go home and drink some Gatorade.”
His eyes opened wide “Yeahhhh. The THIRST Quencher.”
“Yeahhhh,” I echoed.

Now why didn’t I think of that before we started the IV?

———————–

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.

Healthcare Update Satellite — 06-10-2014

June 10th, 2014

See more health-related stories from around the web on my other blog at DrWhitecoat.com.

The doctor will call you now …
Rural health clinics increasingly turning to telemedicine. The story gives an example of a South Dakota clinic physician who used a video feed to get advice on how to insert a chest tube – while a patient was in the room with a hemothorax.

Want to see some of the trick questions that plaintiff attorneys will throw at you during a malpractice trial and see some good responses to those questions? Good examples in this article from Colorado’s Cortez Journal.

Even though your state may have approved medical marijuana, don’t forget that marijuana is still banned by federal law.
DEA cracking down on Massachusetts physicians associated with medical marijuana dispensaries.

Kind of ballsy approach to managing uncomplicated appendicitis in kids. Researchers find that children 7 to 17 years old with pain less than 48 hours, WBC count < 18k, appendix < 1.1 cm on CT or ultrasound, and no evidence of abscess or fecalith can be effectively managed with antibiotics instead of surgery.
I’d be interested in information about relapse rate. If a child has a propensity toward developing “medically managed” appendicitis, it better to just have the appendix removed than to have the patient risk relapses requiring repeat hospital visits for IV antibiotics and CT scans/ultrasounds?

Do you prescribe steroids to patients with acute low back pain? This study found no benefit in doing so. However, note that the study population was limited to patients with a “bending or twisting injury.” Patients were excluded if they had suspected nonmusculoskeletal etiology, direct trauma, motor deficits, or local occupational medicine program visits.
I’m still giving steroids for exacerbations of chronic pain and for radiculopathy.

Potential patients gone wild … Colorado man shot in emergency department parking lot after “confronting” police with a knife.
Lesson #1: Don’t run around in a parking lot wielding a knife
Lesson #2: Don’t use a knife to threaten a man with a gun

Speaking about guns … you know how the incidence of gun-related deaths is increasing over the years? Well it isn’t. A Pew Research study (.pdf link) shows that firearm homicides dropped by 50% and non-fatal firearm crime has dropped 75% between 1993 and 2010. 56% of people think that gun crimes have gone up in the past 20 years.
Wonder why accurate facts like this aren’t being publicized in the evening news?

Woman lays dead in a Paris emergency department for six hours before someone checks on her and realizes that she is cold. Unidentified French official is matter of fact about the death. “People die every day in the emergency room.”

Fortunately, marijuana is a harmless drug … NY Times reporter writes about how she laid in a “hallucinatory state” for eight hours and thought that she had died after eating a pot candy bar in Colorado.

More ideas from people who know little about the effects of the policies they create. Prohibiting people using food stamps from purchasing sugar-sweetened beverages “expected to” improve nutrition and drive down diabetes. And these authors just assume that everyone uses their food stamps legitimately.
I’m not going to pay for the entire study, but I’d wager that they don’t consider how often people misuse food stamps. Therefore the authors are putting invalid data into their calculations. It is not uncommon for people to act as “straw purchasers” of grocery items. I’ve had people offer to do it with me on more than one occasion. You have cash, they’ll purchase all your groceries if you give them half of the total cost in cash. Grocery stores will also purchase food for half of its retail value. I recall reading one article about how bottles of soda were used as a currency of sorts by people in a rural community with people filling up pickup truck beds with cases of soda and bartering the cases for money, cigarettes, and other items – but couldn’t find the article on a web search.
Who cares, though? The authors are now published in a reputable magazine. Their conclusions must be valid.

Chicago files lawsuit against world’s largest narcotics manufacturers accusing the drugmakers of concealing the health risks associated with taking pain medications.
Next up: Suing alcohol companies on behalf of alcoholics and suing fast food restaurants on behalf of overweight people.
Here’s hoping that the drug companies file a counterclaim against the City of Chicago.

Michael Kirsch, MD Redux

June 9th, 2014

For the past 30 minutes, my cell phone has buzzed repeatedly, urging me not to climb out of this rabbit hole. “Come back,” it beckons, “we’re not finished yet.”

When KevinMD deleted my first comment about Dr. Kirsch, I decided to keep further comments on my own blogs so they don’t mysteriously disappear again. Now I’ve learned that I’ve been demoted: Instead of my comments on KevinMD posting immediately, I must receive prior approval before my comments can be viewed by anyone else on Kevin’s blog. All because I pull aside the curtain so people could see the real “insider.”

KevinMD Moderation

Next will be the stocks. Then an outright ban on my creative postings.

So, as with the previous post, I’ve copied Dr. Kirsch’s comments here and will comment below.

[phone buzzes yet again]  OK, I’m typing as fast as I can …

Dr. Kirsch writes:

I have read the comments to my post on this blog and elsewhere. Regrettably, some have resorted to vituperative language and demonization, rather than to engage in civil discourse and debate. If I have made factual errors regarding the reimbursement of ED physicians, then I am prepared to stand down from these comments. The fact that one commenter above who was particularly critical of me wrote, “the hospital loves it when I order tests”, suggests that there do exist economic incentives. I am not prepared to retreat, however, from my belief that over-diagnosis and over-treatment are embedded in American medical culture. This is an undeniable fact. If some commenters wish to opine that their specialty is somehow not part of this reality, then they are free to do so. I think they have a tough case, but they are free to make it. Regarding my own specialty, I have written more than once under my own name, and expressed elsewhere, that my specialty and me personally are part of the problem. A fair minded reader of my own blog would already know this.

To write and circulate throughout the internet that I am an ‘ER basher’ may have some red meat appeal, but it is false and defamatory. I write in my post that “If I were an ER physician I would behave similarly facing the same pressures that they do”. I continue for several sentences offering a sympathetic view of emergency medicine physicians. Not quite my definition of a ‘basher’.
Regarding my NY colleague’s assertion that gastroenterologists are not qualified to evaluate acute abdominal pain, I believe that the other physician readers will agree that this claim has no basis. In my experience, we are the specialists who are first responders to acute abdominal pain.

Responding to the claim that emergency room physicians do not admit patients, this needs some context. While ED doctors may not sign the admission order, they have often advised patients and later the admitting doctors that the patient needs admission. How many times have emergency physicians called primary care physicians or consultants telling us, “this guy needs to come in”? This is a proper exercise of their role, in my view. It is somewhat disingenuous to claim that “Emergency physicians don’t admit patients”, which may be only technically true.
Finally, personal attacks only demean the attacker and provide little opportunity for a dialogue that could offer all participants the chance for a civil airing of divergent views. We can do better than this and we should.

Dr. Whitecoat responds:

My father was a lawyer. One of the points he always used to make about his opponents is that when they complained that he was being mean, or uncivil, or offensive, or otherwise just plain hurt the opponent’s feelings, it really meant that the opponent had no counterargument to his position and was simply trying to gain sympathy with the judge or jury. He never used the word “vituperative,” though. That may have been because I was in third grade when he told me these things, but that’s another story.

So Dr. Kirsch has labeled people responding to his initial post (and I’m sure I fall in that subset of people) as being vituperative, demonizing, uncivil, and engaging in personal attacks. Yes, I was being vituperative in one sense of the definition. According to Merriam-Webster’s dictionary, vituperative means “uttering or given to censure :  containing or characterized by verbal abuse.” If you don’t want to be censured, then don’t make vituperative-worthy statements. And if you’re “offended” or consider it “abusive” that I repeatedly mention that you’re an “insider” with “insider’s knowledge” as I eviscerate all of your misstatements, then, after drying the tears from your eyes with the Kleenex for extra sensitive skin, perhaps in the future you’ll consider researching and providing evidence for your assertions rather than making inaccurate statements of fact to policymakers – many of whom lack the knowledge and insight to see through your self-aggrandizement.

[my phone buzzes yet again] I’m WORKING here. Have patience.

I also get accused of the tort of defamation for calling Dr. Kirsch an “ER basher”. First of all, it is an emergency DEPARTMENT.

[another buzz from the phone]

As I was saying, it is an emergency DEPARTMENT, not an “ER.” Since you seem to be stuck on the title of the cancelled TV show from last decade, let me explain. Back in the early days, there was a “room” in the hospital where all the consultants used to take their patients when they had emergencies. The emergency “room”. These days, hospitals have whole departments with lots of separate “rooms” where lots of emergency physicians treat really sick patients. See the difference? It would be like me calling an endoscopy suite an endoscopy closet.

Back on point. Let’s look up the definition of “bash” at Merriam-Webster’s site. To be a “basher”, one must either “strike with a crushing or smashing blow” or “hurl harsh verbal abuse at.” Now asserting

[phone buzzes again. I am now putting it on "airplane mode"]

Asserting that emergency physicians perform “unnecessary” medical care, while as an “insider” knowing that billing for unnecessary medical care is by definition health care FRAUD seems pretty harsh to me. Asserting that we are somehow incompetent in our trade because “there is a significant percentage of ER patients who should be sent home and are sent upstairs instead” seems pretty harsh to me. And to assert that our morals are so low that we would conspire with hospitals that “encourage” us to inappropriately admit patients to make more money sounds more defamatory than your hurt feelings after I labeled you as an “emergency department basher.”

Remember this little post over at ACP Hospitalist and how I called you out on it back then, too? Same tune, different day. You try to make yourself appear as a better clinician, a smarter physician, and as a more cost-efficient steward of resources by second guessing the emergency physicians after you have completed your negative workup. What you either think no one will pick up on or what you’re too dense to realize, though, is that by the time you have come to your conclusion that the patient never should have been admitted, you also have much more information upon which to base your “insider” opinion. Hindsight is always 20/20.

So to end the comments about butt hurt and defamation, recall that truth is an absolute bar to defamation. You don’t like the label, then stop acting the part. And for Pete’s sake stop whining about it. You’re a grown man.

So let’s get to some of your other comments.

“I am not prepared to retreat, however, from my belief that over-diagnosis and over-treatment are embedded in American medical culture. This is an undeniable fact.”

First, this isn’t what you said in your post. You bash the emergency department because “They are in a culture of overtreatment and overtesting.” Now you’re trying to walk it back to say you really meant that “all of us are to blame.” Oh, and for the added emphasis, your statement is “undeniable,” too. I asked you before and you didn’t respond. Give me a list of testing that should never be performed and of some treatments that should never be offered. You’re the “insider,” share some of that information with us “outsiders.” You know why you won’t do it? Because your statement isn’t “undeniable.” In fact, when you try to prospectively examine emergency department evaluation and treatment, it’s highly deniable. There are low yield tests and high yield tests. Whether those tests are ordered depends on a physician’s medical judgment. And you certainly aren’t the yardstick by which an emergency physician’s judgment should be measured.

“I continue for several sentences offering a sympathetic view of emergency medicine physicians.”

Is that kind of like a husband who beats his wife telling her that he really loves her before he winds up for another punch? Just because you feign sympathy doesn’t mean that you get a free pass to backstab emergency medicine throughout the rest of your post. Nice try, though.

“In my experience, [gastroenterologists] are the specialists who are first responders to acute abdominal pain.”

This statement exemplifies what is wrong with you, your insights, and your “inside information.”
YOU HAVE NO EMERGENCY DEPARTMENT “EXPERIENCE.” You’re making yourself the laughing stock of the medical community when you make statements like this. Many emergency physicians have already responded that they rarely if ever call a gastroenterologist for evaluation of abdominal pain. I can add my own experiences to that list. I can’t remember ever calling a gastroenterologist to evaluate a patient with undifferentiated abdominal pain. I’m betting that if someone interviewed the emergency physicians in your hospital’s “ER,” they would say the same thing. But you babble on in your blissful ignorance holding your asserted truths to be self-evident, “inarguable,” and “undeniable.” Enough already.

Finally, your whole argument about whether or not emergency physicians truly “admit” patients is a non-argument. You agree that it is “technically true,” but then you seem to state that it really isn’t true because we advise another doctor that “this guy needs to come in”? What is your point? Another physician is still admitting the patient. Are you going to change your criticisms to attack the true admitting physicians who “unnecessarily” waste all of our precious health care dollars?

I’ll end this response with a Twitter picture that just happened to pop up on my Twitter feed a day or two ago. With hat-tips to @CardioNP for re-tweeting it and to @pkedrosky for initially tweeting it.

I’ve spent a couple of hours responding to something that shouldn’t have even needed a response. Hopefully this ends both this debate and any of Dr. Kirsch’s future uninformed posts about “emergency rooms”.

BouonGKCIAAjl5V

 

Michael Kirsch, MD – An Emergency Physician Basher Without A Clue

June 7th, 2014

The nice thing about the internet, about having a blog, and about having a Twitter account is that even us peons have the ability to combat censorship.

Here’s a good example.

Self-described “insider” and “whistleblower” Michael Kirsch, MD, who blogs at “MD Whistleblower,” has a penchant for bashing emergency physicians even though his commentary shows that his “inside knowledge” is full of misinformation. You can be the judge of Dr. Kirsch’s veracity, but my opinion is that he is unethically spewing his inside misinformation as fact.

So I called him out on it.

KevinMD re-posted a blog post that Dr. Kirsch made about emergency physicians. Dr. Kirsch’s post initially asked “Are Emergency Rooms Admitting Too Many Patients?” I responded with a longwinded comment. My comment dripped with snark as I pointed out multiple errors in Dr. Kirsch’s assertions and multiple bits of misinformation he asserted were “fact.” I spent about an hour writing it because I thought it was important to show everyone who reads the post how Dr. Kirsch was being unethical as he tried to aggrandize his “inside knowledge” of a specialty he didn’t even practice. Within a few hours, my comment had twelve “upvotes.”

This morning, I woke to an e-mail from a reader telling me that my comment had been deleted from Kevin MD’s blog.

When I went to check, I saw the following:

Kevin MD comment deleted
So I wrote to Kevin and asked him who deleted the comment.

Kevin responded

Kevin MD response
I wrote Kevin back and asked him what the threshold number of flags was and who determined it. He didn’t reply.

I performed a search of Disqus for the term “flag” and found no mention of how to automatically delete comments based upon “flags”. The only action that Disqus appears to allow for “flagging” is to notify the moderator (i.e. Kevin) that a comment “requires moderator attention.” I also checked my own moderator dashboard for Disqus and wasn’t able to find an “automatic deletion” feature. If someone can point me to that feature, I’ll update this post.

It’s Kevin’s blog, so he is free to choose what comments stay and go.

So now I’m pissed. This Dr. Kirsch, the “Whistleblower” with “insider knowledge” is free to create a post basically accusing emergency physicians of widespread fraud, but when he gets butt hurt because someone points out all of the deficiencies in his “insider knowledge”, the comment mysteriously disappears.

Below, dear readers, you will find Dr. Kirsch’s post and my response, preserved for all eternity on the internet. Dr. Kirsch, Kevin MD, Disqus, and anyone else who is butthurt by my comments have no ability to delete them. I’m cross-posting it on my other blog and pushing it out on Twitter just to be safe. See Streisand Effect.
I fortunately copied an initial version of part of my comment onto a text file, so I didn’t lose the whole thing, but I had to re-write a lot of the comment from memory. Since the comment is version 2.0 and since someone was apparently offended that I would dare call out a “whistleblower”, I added more to the response.

Please do me a favor and pass this post around.

———————————————————————————-

Dr. Kirsch’s initial post:

Are Emergency Rooms Admitting Too Many Patients?

Every player in the medical arena has found itself challenged by conflicts where one’s self-interest competes can skew what should be pure advice.   This issue is not restricted to the medical universe.  Every one of us has to navigate through similar circumstances throughout the journey of life.  If an attorney, for example, is paid by the hour, then there is an incentive for the legal task to take longer than it might if the client were paying a flat fee.

The fee-for-service (FFS) payment system that had been the standard reimbursement model in medicine has been challenged and is being dismantled because of obvious conflicts that were present.  (This is not the only reason that FFS is under attack, but it is the principal reason offered by FFS antagonists.)  Physicians who were paid for each procedure they performed , performed more procedures.   This has been well documented.  Of course many other professions and trades still operate under a FFS system, but they are left unmolested.   Consider dentists, auto mechanics and plumbers and contractors.

FFS is not inherently evil.  But, it depends upon a high level of personal integrity which, admittedly, is not always present.   In my own life, I often hope and pray that the individual who is offering me goods or services is thinking of my interests exclusively.  Am I living in fantasy land?

The Rand Corporation released a study in May 2013 that demonstrated that emergency rooms accounted for about 50% of hospital admissions during the study period from 2003-2009.  When I have posted on emergency medicine in the past, it has stimulated a high volume of responses, some good, some bad and some ugly.

I think it is inarguable that emergency room (ER) care wastes health care dollars by performing unnecessary medical care.  As a gastroenterologist, I affirm that the threshold for obtaining a CT scan of the abdomen in the ER is much lower than it should be.   And, so it is with other radiology tests, labs, cardiac testing, etc.

I understand why this is happening.  If I were an ER physician, I would behave similarly facing the same pressures that they do.  They face huge legal risks.   They are in a culture of overtreatment and overtesting because they feel more than other physicians that they cannot miss anything.  They argue that they have only one chance to get it right, unlike internists and others who can see their patients again in a follow-up visit.  If an ER physician holds back on a CT scan of the abdomen on a patient who has a stomach ache, and directs the patient to see his doctor in 48 hours, what is the ER physician’s legal exposure if the patient skips this appointment and ends up having appendicitis?

Keep in mind that we should expect that ERs to have higher hospitalization rates of their patients, since their patients are much more likely to be acutely ill.

But even accounting for the sick patients in the ER, I think there is a significant percentage of ER patients who should be sent home and are sent upstairs instead. This would be an easy study to perform.  Compare the intensity of testing between the emergency room and a primary care office with regard to common medical conditions.  I would wager handsomely that the ER testing intensity and admission rate would be several fold higher than compared to doctors’ offices.  Want to challenge me on this point?

Even though I understand why ER docs do what they do, it is a bleeding point in the health care system that needs a tourniquet.

It is clear that ER physicians are incentivized to admit their patients to the hospital.  Of course, they might be “encouraged” to do this by their hospitals who stand to gain financially when the house is full.  Leaving the financial conflict aside, when an ER physician admits a patient, he is completely free of the risk of sending a patient home who may have a serious medical issue. I am not referring here to patients who clearly should be admitted, but to the large group of patients who most likely have a benign medical complaint, but the ER physician advises hospitalization “just to be on the safe side.” These same patients if seen in their own doctors’ offices would never be sent to the hospital to be admitted.

Where’s the foul here?  Here are some of the side effects of unnecessary hospitalizations.

  • wastes gazillions of dollars
  • loss of productivity by confining folks who should be working
  • departure from sound medical practice which diminished the profession
  • emotional costs to the individuals and their families
  • unnecessary exposure to the risks of hospital life

How can this runaway train be brought under control?   First, let’s try a little tort reform.   Second, pay a flat rate for an ER visit.  Under this model, if the ER physician orders an MRI on a patient with a back strain, the hospital swallows the cost.  Finally, when hospitals are penalized financially for hospitalizing folks who should have been sent home, we will witness the miracle of a runaway train performing a U-turn on the tracks.

While the Rand Corporation’s results are not earth shaking on its face, my intuition, insider’s knowledge and a tincture of cynicism all converge on the conclusion that for too many patients the ER has become a portal of entry in the hospital.  Is the greater good served if the ER is a revolving door or barricade?

Dr. Whitecoat’s Response:
What is it with people who have little or no knowledge of emergency medicine thinking that they have the insight to comment on what factors influence emergency medical care? You assert you have “insider knowledge”? Sounds more like a case of advanced megalomania to me.

First, you make a bunch of assertions without any basis.
“Inarguable” that the emergency department performs unnecessary medical care? OK, doc. Tell me what tests that ED physicians regularly perform that are “unnecessary.” I’m sure that you have tomes of instances of inappropriate care just waiting to be published on your blog. Educate all of us.

You “think” that there are more patients who are admitted who should instead be sent home? What’s the basis for your “thought”? I’m guessing that you don’t admit patients personally. You’re a consultant. You have no basis for making that statement. On the outside chance that you do practice primary care medicine, here’s an idea if you’re inundated with “inappropriate” admits. Drag your whining buttocks to the emergency department and evaluate the patient yourself. Then YOU write the discharge orders. In twenty years, I’ve seen exactly two doctors ever do that.
Another point that you can add to your “insider knowledge”: Emergency physicians don’t admit patients, the hospitalists and primary care docs do. Emergency docs don’t have admitting privileges. So if you’re so concerned with all of the “inappropriate” admissions, realize that it is the primary care docs authorizing them. Point the blame where it belongs. Oooooh. Stop the presses. Emergency physicians and hospitalists are conspiring to defraud the government by making inappropriate hospital admissions. Wait. You wouldn’t make a statement like that because if you pissed off your primary care docs and hospitalists, they wouldn’t refer patients to you. Funny how economic incentives influence your own desire to “whistleblow” “insider information,” isn’t it? Or was it that you were just too obtuse to realize this obvious “insider” fact?

In your little study about intensity of service and admission rates, make sure that you exclude all of the patients sent to the ED from their doctors’ offices with specific instructions to have the testing performed and also make sure that all of the patients who have been to their doctors offices several times with the same problem and who get no evaluation at all get treated as one “low testing” visit, not multiple “low testing” visits. Oh, and since pretty much every patient coming to the emergency department is a “new” patient to the emergency physician, make sure that your study only includes workups that primary care physicians perform on “new” patients to their practices. Not really fair to compare workups that emergency physicians perform on patients that primary care physicians have known for 20 years, now is it? When you’ve compiled your data, you can then compare how many lives that emergency physicians save with their “inappropriate” testing and “inappropriate” admissions … all for about 2% of the health dollars spent in this country.

Your next bit of misinformation states that “It is clear that ER physicians are incentivized to admit their patients to the hospital.” Another clue for you, Dr. Insider: Emergency physicians are paid by intensity of service, not by hospital admissions. If the medical decisionmaking is high and the workup is extensive, we are paid the same whether or not a patient is admitted. So what is our “incentive”?
Oh, wait. You explain that emergency physicians “might be ‘encouraged’ to [inappropriately admit patients] by their hospitals who stand to gain financially when the house is full.” Wow. With your “insider knowledge” you have uncovered yet another conspiracy. Emergency physicians “MIGHT” be colluding with hospital administrators to inappropriately “fill the house.” A little flaw with that theory, though: When the hospitals are full and there are boarders in the emergency department, the throughput slows and we see fewer patients, which actually decreases the hospital’s profits.

You, oh mighty insider, suggest that “when hospitals are penalized financially for hospitalizing folks who should have been sent home, we will witness the miracle of a runaway train performing a U-turn on the tracks.” Look up “RAC audits“. Then look up the “two midnight rule.” Both of these processes cause hospitals to lose significant amounts of money for “inappropriate” admissions. If you know about these processes and just chose not to mention them in your diatribe against emergency physicians, you are being intentionally misleading. If you didn’t know about them, then you are a buffoon for calling yourself an “insider”. How has the “runaway train” slowed? You don’t know because you don’t even know the processes in place or the right questions to ask.

I’ll end with a couple of responses to your criticism that we “ER physicians” advise admitting patients “who most likely have a benign medical complaint” just so that the patients can “be on the safe side.” First of all, we go by criteria and sometimes a gestalt after we actually examine the patient. If you don’t agree with our assessment, then come in and see the patient yourself before the admission, rather than backstabbing us after all the testing is normal because the patient never should have been admitted to begin with. Second, since when is looking out for the safety of our patients a bad thing? I can rattle off story after story about patients who I admitted “just to be on the safe side” who avoided a bad outcome because they were admitted. Yes, many go home with normal workups. Just like most of your endocsopies are normal exams but no one faults you for performing them. If you’re going to criticize me for being a patient advocate, then I’m guilty as charged.

I suggest that you stick to commenting about your own specialty and stop demeaning yourself by creating these uninformed linkbait posts about emergency physicians.

With all of your “insider knowledge,” have you ever written about how often gastroenterologists perform inappropriate endoscopies, there Dr. Whistleblower? When I did my internal medicine training, the GI fellows used to call it “scoping for dollars.” Care to comment?

I didn’t think so.

P.S. It’s an emergency DEPARTMENT, not an “emergency room.” And we’re emergency physicians, not “ER physicians.”  Using 1990s vernacular does nothing to support your esteemed position as an “insider.”

Healthcare Update Satellite – 06-04-2014

June 4th, 2014

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

Car crashes into VA Hospital emergency department in Boston. Elderly driver taken to emergency department … then put on a secret waiting list and will be seen within 2 weeks … if he’s lucky.

What happens when someone calls an ambulance in South L.A.? Same thing that happens in most other places in the country. The stories are the same, only the faces change.
Patient evaluated by EMS for dizziness, hard time breathing, chest pain. Paramedics arrive within 4 minutes. Symptoms resolve. Likely a panic attack. Patient wants ride to hospital anyway. Sits in the hospital with paramedics for up to 3 hours waiting for a bed to open up.
“In many cases people who live in low-to-middle-income neighborhoods like those served by Martin Luther King Jr. Community Hospital choose to take ambulance rides even when deemed unnecessary, all with the public picking up the tab.”
When ambulances are transporting patients with fevers instead of strokes, however, these varying states of crisis weaken the entire system. “They’re not going to a clinic and pay; they’re going to go wherever they can go the fastest, and they use ambulances to get there.”
“The number of people using EMS as a taxi is, not only way to high, it’s alarming,” said Weiss who sees the effects of this first hand as he works in Emergency Departments at various facilities around Los Angeles each day. “We’re using precious resources for a process that isn’t valid.”

Florida Supreme Court decision to invalidate medical malpractice caps may have a ripple effect throughout the nation. Five of seven justices held that there was no malpractice crisis and that the caps don’t hold medical costs down. Of course, when the caps were created, the legislature held differently, but who cares about that.
And if the justices think that there is no malpractice crisis, then why don’t they also rule that the state must provide malpractice insurance to all Florida physicians? Shouldn’t be much of an expense since there isn’t a crisis, right?
Don’t practice medicine in Florida.

Study from Detroit’s Henry Ford Hospital presented at SAEM’s annual meeting shows that 77% of emergency department “super users” have some type of addiction disorder and half were seeking narcotic pain medications. And they still get satisfaction surveys.

Another hospital emergency department closing. Latest victim is Long Island College Hospital in Brooklyn. It is losing about $13 million per month. May get converted into condos. Housing apparently pays better than medical care.

Half of all medical school deans say that their students aren’t competent to treat patients with disabilities. Enlightening article describes how our ignorance about patients with disabilities affects our ability to provide emergency department care. We need to do a better job at this.

ProPublica report shows that even though Medicare is able to export its data for the public to review, Medicare officials are still too dumb to actually look at the data themselves. Average “Level 5″ visit billing by physicians is about 4% of patient volume. 1800 health professionals across the country bill that level in 90% of their patients … yet Medicare keeps paying them. Idiots.
Medicare is just as guilty for paying these providers as the providers are for submitting the bills.

“I am so pleased that justice was served.” Now give me my 30%.
- Quote from Florida malpractice attorney after winning $7.5 million medical malpractice case against a doctor who failed to evaluate and treat a conduction disorder of a 13-year-old girl’s heart.
Couldn’t find out more about the case during a web search, but did find another recent $7.5 million malpractice judgment in Alabama after patient brought to Brookwood Medical Center and admitted for back pain, then developed incontinence and paralysis of the legs. The patient had developed cauda equina syndrome and wasn’t treated quickly enough. But remember … imaging in patient with back pain (which is the only way to diagnose cauda equina syndrome) is considered “unnecessary” testing according the Choosing Wisely campaign.

Connecticut woman wins $12 million in medical malpractice case after surgeon punctures her colon during routine hernia surgery. Doctors didn’t realize the complication until after patient developed abdominal infection and went into septic shock.
I’m betting that one reason for the large verdict was because defendants started pointing fingers at each other. Surgeon alleges that it was the resident who punctured the colon. Resident denies it. Hospital says it shouldn’t be responsible for the resident’s actions. Patient says she didn’t know a resident would be operating on her.

CPAP machines soon to become an “uncovered benefit” for our country’s veterans. Veteran’s sleep apnea claims have increased by 150% in the past 5 years with total costs more than $1 billion per year. 90% of patients with the disease are rated at 50% disabled, enabling them to receive monthly payments of $822 in addition to their pensions.
But the winds of change are a-blowing. A military budget expert is now on record saying “sleep apnea is not a combat injury, especially if it’s caused by obesity.”

Sasquatch Music Festival overloads local emergency department every year, increasing its volume six- to seven-fold. Them’s the breaks.
I used to work at a trauma center near an outdoor concert ampitheater like this. Same thing used to happen to us. ED and ambulance services were constantly busy with people passed out from unknown drug cocktails or who had drank too much. We would plan our schedules around which bands were playing. Jimmy Buffet and OzzFest used to be the worst. The ampitheater owners were at least somewhat cool about it, though. Every summer, the owners would show up with dozens of free tickets to each concert for the people in the ED who weren’t stuck working.
Or maybe that was a secret plan to have more emergency medical personnel available on scene ….

Pardon me while I pick my jaw up off of the ground. Poll states that there are MORE emergency department visits due to Obamacare? That can’t be. They told us that there would be LESS emergency department utilization once people had insurance.

Diagnosis by Retrospectoscope

May 29th, 2014

The patient was crying and shaking her hands when she rolled through the doors on the ambulance stretcher. She had been sitting at work and developed severe chest pain. There was also a little shortness of breath thrown in because she felt as if someone was sitting on her chest. She said she had been upset over something that happened at work and was “stressed out.” The pain was right in the middle of her chest and felt a fullness in her neck. She was starting to get tingling in her fingers and thought that shaking her hands would help. Paramedics gave her aspirin and nitroglycerin which she said may have helped her chest feel better.
The nurse gave the paramedics a stink eye. “Come on, now. She’s 27 years old. She ain’t having a heart attack.”
Even though she wasn’t having a heart attack, the nurse still ordered an EKG. Doesn’t it figure. Something didn’t look quite right. Little bit of ST elevation in Lead I and aVL. May just meet criteria for MI. Also a little elevation in V1 through V3. Not the tombstones you typically see. Just a hint of elevation. And there’s some T wave inversion in the inferior leads as well. Since she’s 27, there’s obviously no old EKG for comparison.
“That’s concerning. She has some EKG changes that may be ischemic.”
The nurse was quick to counter. “Yeah, right. She needs some Ativan, not a cardiologist.”
“Well, you can give her some aspirin, some morphine, and a milligram of Ativan also. If nitroglycerin helped in the ambulance, give her another dose of that as well.”

EKG

Decision time. I’m moonlighting at a rural hospital and there’s no cardiologist available. Do I treat her like an 80 year old diabetic and fly her to the medical center 60 miles away? Or do I treat her for her anxiety and watch her? She technically meets the criteria for an MI, which puts you in a no-win situation. If you send her to the referral hospital and her pain goes away, everyone thinks you’re an idiot. If you keep her at your facility, on the outside chance there’s something serious that you didn’t act upon, you get tarred and feathered by everyone who looks at the case.

After receiving some morphine and Ativan, she’s a little out of it, but is still crying and having pain that she rates as a 4 on a 1-10 scale. I call the Metro General referral center and ask to speak to the cardiologist.
“There’s a 27 year old young lady with typical sounding chest pain and EKG changes that look ischemic. Can I fax you the EKGs to look at?”
“Family history? Smoker? Drug use? Other medical problems?”
“Nope. Nope. Nope. Nope. Can I fax you the EKG?”
“Hey, you’re there seeing the patient. I’m not. If you believe that the patient is having an acute MI, just send her here. What I say about the EKG doesn’t matter.” Actively avoiding looking at the EKG. In other words, “If I look at the EKG and say it looks like a 27 year old is having a heart attack, then I look bad. If I rely on your interpretation, then you get left holding the bag.”
Labs have come back and of course they’re all normal. Not even a little bump in the cardiac enzymes. Normal d-dimer as well. Chest x-ray looks fine. She is still crying in pain.
“Okay, let’s call the helicopter,” I told the nurse . “Grab some heparin and Plavix. We’re going to treat her as if she is having a heart attack.”
“Holy sh*t. Are you kidding me? She’s 27 years old.”
“Hey. Cardiac disease doesn’t discriminate. Let’s get this show on the road.”

I walked back into the room to talk to the patient. She was crying and talking on her cell phone.
“Your EKG looks like you may be having a heart attack. We’re going to have to send you to Metro General by helicopter.”
She stopped crying immediately.
“Holy sh*t. Are you kidding me?” I wanted to say “No, I’m serious as a heart attack” but cheap blog humor didn’t seem appropriate at that point. I explained to her what was going to happen and had her sign the necessary paperwork.
I went back into the office and completed her medical records which took about another 10 minutes.
I went back into the room, the patient’s mother was standing there. She looked at me and said “Can I ask you what is going on?”
“Sure. You probably heard the unexpected news. Your daughter has changes on her EKG that make it appear she is having a heart attack .”
“Hole-lee sh*t .”
I’m getting kind of sick of hearing that phrase by now.

About 20 minutes later, the helicopter crew was walking through the door. The nurse began giving them report. The patient was still having chest pain, so we repeated her EKG. It hadn’t changed from her initial presentation. The helicopter nurse gave me a quizzical look out of the corner of his eye. I gave the same quizzical look back at him.
Now I’m getting ticked off. Just be quiet and take your damn notes. You’re getting paid regardless of whether or not I know how to read an EKG.
They loaded patient on their stretcher and wheeled her back to the elevator leading to the helicopter pad on the roof.
As I heard the helicopter blades start spinning, I started to wonder whether or not I had documented the chart well enough to survive the inquisition by retrospectoscope that would be occurring the following day. We met all of our “quality” indicators including aspirin at time of arrival and EKG within 10 minutes. But how many people would still be sitting around the conference room table the next day asking what I was thinking?

Oh well, that part of the job. Everyone’s a genius once the diagnosis is known.

Just to rub it in, during my next shift, the nurse mentioned that she had seen the patient in the grocery store two days after we transferred her.

Such is the life of a pit doc, I guess.

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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.

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