WhiteCoat

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.

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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.

Healthcare Update Satellite — 05-21-2014

May 21st, 2014

See more healthcare related stories from around the web at my other blog: DrWhiteCoat.com

19 year old Baltimore teen dies in hospital after involved in altercation where 5 security guards were unable to control him, police were called to hospital and used Taser on patient, then left once he had been subdued. Now State’s Attorney is looking into matter.

$25 million lawsuit filed against Las Vegas hospital when pregnant woman enters, has several symptoms and risk factors for tuberculosis on mandated screenings, but hospital does not evaluate or treat her for tuberculosis. She is then allowed to hold her newborn twins in the nursery without wearing a mask. All three patients ultimately die from tuberculosis.
Also of note is that there was a tuberculosis outbreak in the hospital at the time with at least 20 hospital employees contracting the disease.

Feds consider whether to spend billions of extra Medicare dollars to screen former smokers for lung cancer. Doing so could cut a high-risk patient’s chances of dying from cancer by 20%.
I remember someone in a position of leadership once saying that if we can save one life, it’s worth it. Therefore, spending this extra money should be a no-brainer.

At Queen Elizabeth II Hospital in Great Britain, you can only have emergencies between 8 AM and 12 midnight. The emergency department is closed between 12 AM and 8 AM due to staff shortages. To be fair, it seems as if most patients have already gotten the memo on this issue. Severe cases are already referred to Lister Hospital which is 20 minutes away and the QE2 emergency department only sees 5-10 patients per night.

VA Medical Center in Cheyenne, Wyoming busted for “gaming the appointments system” to make it look as if patients are being seen within 14 days of an appointment request when they really weren’t. I’m sure the VA is alleging that this is an isolated incident.
Or maybe not
And if you want a good laugh, watch Jon Stewart’s discussion of the whole debacle.
His summary:”Somehow, we as a country were able to ship 300,000 troops halfway across the world in just a few months to fight a war that cost us $2 trillion.” But it takes veterans hurt in that war longer than that to receive “needed medical care or reimbursement, all while we profess undying love for their service.”
All animals are equal, but some animals are more equal than others.

VA Chief Eric Shinseki grilled about issues in medical care in the Veteran’s system. To his credit, he did put three VA employees on leave after discovering that they may have contributed to the deaths of 40 patients. Of course if that happened in the public sector, the employees would be arrested and charged with murder by now.
All animals are equal, but some animals are more equal than others.

About a third of Australian patients waiting longer than 20 minutes in ambulances once they arrive at hospitals. In some hospitals, more than half of patients wait longer than 20 minutes.
Hopefully they’re not baking their statistics like the governments in some other countries do …

Doctor gets romantically involved with a patient who then commits suicide. Doctor removes medications and suicide note when he finds patient dead in her apartment. Pled guilty to obstruction of justice charge for removing evidence and now is being sued for medical malpractice and wrongful death.

I like this concept. Let’s expand it. If you’re unhappy with a hospital stay or an emergency department visit, do you have to pay? Heck no. If you don’t get perfect medical care, you should demand a refund. Where do these hospitals get off charging us for imperfect care?
If we’re not happy with our state or federal government, we shouldn’t have to pay taxes.
If we’re not getting good gas mileage, we should get a refund on our automobiles.
And if our bosses aren’t happy with our work, they shouldn’t have to pay us.
Others aren’t happy with the way that people on government assistance are utilizing their assistance, they get cut off.
Heck, if everyone just acts pissed at everyone else, everything could be free.

Is non-celiac gluten sensitivity all in your head? Study shows that the effects of having gluten in one’s diet may be due to FODMAPs and not duet just to gluten. Although the sample size is small, it’s an interesting concept. A diet low in FODMAPs has been shown to decrease the amount of gas and, in some cases, the symptoms of irritable bowel syndrome.

This study will give the antivax crowd fits and nightmares. Patients with terminal multiple myeloma injected with enough toxic waste — er, um — measles vaccine to inoculate 10 MILLION people. They didn’t die. They didn’t get sudden onset autism. They didn’t even get Guillian Barre Syndrome.
They got better.
One patient remained relatively disease free at 9 months, the other developed worsening disease after 6 months.
I know. I know. It must be that small doses of toxic waste — er, um — vaccines, are lethal while large doses are curative.

Issues with large medical malpractice judgments in India where the author compared them to the Code of Hammurabi in 2030 BC:
“If the doctor has treated a gentleman with a lancet of bronze and has caused the gentleman to die or has opened an abscess of the eye for a gentleman with a bronze lancet and has caused the loss of the gentleman’s eye, one shall cut off his hands”
Wonder how maiming the healers affected the provision of medical care.

Healthcare Update Satellite — 05-13-2014

May 13th, 2014

Interesting story on how an Indiana hospital discovered the first case of MERS in this country. Patient came in with influenza like symptoms and was placed in negative pressure room immediately. By the time he was admitted to the floor and was interviewed by an ID specialist, everyone coming into contact with him was required to wear full gowns, gloves, and eye protection. MERS was suspected based on his travel history – he was a US resident working in a health care facility in Saudi Arabia.

Don’t ride in a car with pregnant drivers. During a woman’s second trimester, her odds of being in an accident that is bad enough to send her to the emergency department increases by 42%. By the third trimester, the risk is gone.

Obamacare health insurance tax could cost 286,000 Americans their jobs and result in $33 billion in decreased retail sales.
Well of course the right-wingnuts are going to say that. What do you expect?
Wait. The article was written in the official blog of the US Chamber of Commerce? Nevermind. Carry on.

Nice summary article about a physician’s duty to a suicidal patient. Dispels some myths and offers good basic advice. For example, HIPAA doesn’t prevent doctors from disclosing a patient’s psychiatric information if the patient is in imminent risk of self-harm.

Obamacare “MAY” boost hospital emergency department profits. Then again, when you consider that a vast majority of newly “insured” patients under Obamacare have what the article admits are “money-losing Medicaid” patients, that the hospital will have to spend more money to staff the departments to treat the “money-losing” patients, and that the hospital will have to pay more in insurance and consumables to lose this money, Obamacare also “MAY” put more hospitals out of business.
Oh, and I “MAY” have found missing flight 370 in the Sahara Desert.

Since Obamacare was implemented, emergency department visits for the Tenet Healthcare system haven’t seen any decrease in patients. In fact, the number of patients they are seeing in the ED is going up … as their profits go down

OK, I still can’t imagine how this show stays on the air. But this story just has to be repeated. Woman ends up in a hospital emergency department after putting pop rocks in her hoo hah before having sex with her paramour.
All I can do is shake my head and think about all the perfectly good politically incorrect jokes that are going to go unsaid right now.

Why would Americans travel to one of the most dangerous towns in Mexico? To get dental care. The dentist is an American who commutes to Mexico each day and offers care for about 30% of what it would cost in the US. She has low overhead and she has no malpractice insurance, so her costs are less — and she passes those savings on to her patients while still earning a good living.

Doctor and US Vet warns other veterans that their lives are in danger from the care being provided at VA Hospitals.
The medical chief of staff is Dr. Darren Geering. He is a physician but it appears he had no function for protecting the VA patients from this egregious action causing the death of at least 40 patients who were on a “secret waiting list” from which these patients died, waiting for any kind of medical care.

A couple of tangentially medically-related articles.

Jail starts doing body scans on inmates entering the facility. Finds dark object on scan of one perp’s lower abdomen. Turns out that he had a cell phone inside his rectum. The comment section to this article is a riot … must have had crappy reception … taking butt dialing to a whole new level … ring tone set to “”pbthpbthpbth”.

Survey shows that 1 in 9 people want an android child like the kid in the movie “A.I.” and that 20% of people would have sex with an “android.” One of the comments to the article downplayed the results, noting that 20% of the population would probably have sex with a baked chicken.
Now I can’t decide whether I’m hungry or want to watch some crappy Steven Spielberg movie.

 

Healthcare Update Satellite — 05-07-2014

May 7th, 2014

They’ve got “insurance” but they still can’t find anyone to provide them with dental care. In Oregon, dental problems are the second most common emergency department discharge diagnosis in patients 20 to 40 years of age and have a 25% repeat visit rate, costing the State more than $8 million annually — just in hospital costs. Problem is that Obamacare’s coverage doesn’t include adult dental care. Even if patients have Medicaid coverage, the reimbursements are so low that dentists won’t treat patients with that type of “insurance.” But don’t worry, everyone, 7.1 million more people now have health “insurance.” Full report can be found here (.pdf)

Belfast emergency department has 100 patients in its waiting room with one patient reportedly waiting 11 hours just to be evaluated. Strain on resources indeed …

New Jersey Supreme Court throws out a malpractice case against an emergency physician who failed to report suspected child abuse when child brought in for ingesting cologne. Child was discharged to parents who later abused the child. Placed in foster care and foster parents sued physician for failing to report suspected abuse as required by New Jersey statutes. The Appellate Court agreed with the parents. Fortunately, the Supreme Court had some common sense and noted that upholding such a decision, every accidental ingestion case presenting at a hospital’s emergency department give rise to a mandatory child abuse reporting obligation. New Jersey medical providers dodged a bullet with that case.

San Francisco General Hospital in the midst of a “culture of chaos” because hospital is failing to provide enough staff to care for the patients. Because the emergency department is short 23 nursing positions, the remaining nurses are often doing clerical and other work instead of caring for patients.
And I’m sure some member of the clipboard brigade will cite one of the remaining nurses for failing to make sure that patients were screened for domestic violence, tuberculosis, wearing seat belts, substance abuse, and guns in the house. Oh, and making sure that there are safety caps on all medication bottles, too.
Decreased staffing in the food services department has decreased quality of meals and resulted in long waits for patients to get meals because no one is available to deliver meals to patient rooms.
Another example of getting what you pay for in health care.

Patient wins $1.9 million judgment in malpractice case where Massachusetts oncologist diagnoses him with non-Hodgkin’s lymphoma then order several rounds of chemotherapy and a stem cell transplant. The patient never had lymphoma, but instead had an “immunodeficiency” that mimicked cancer.
Doctor claims his treatment was based on a pathology report. Pathologist found not negligent.

How often should you shower? Daily showering may not be as healthy as you’d think. Frequent showering may wash away the natural body oils that protect the skin from drying out and from bacteria. Then again, I imagine that most active people would rather sacrifice a little health to avoid smelling like a used tube sock.

Megan McArdle writes about the “ugly spike” in healthcare spending. Is the spike due to the effects of Obamacare or is it that there was a transient slowdown in spending related to the recession – which is now resolving … or neither … or both?

With healthcare reform and increasing “insurance” coverage comes more emergency department use. Happened in Massachusetts with RomneyCare and it is already happening in the US with Obamacare – regardless of what statistics you see.

Elderly patient sent to nursing home. Lives there three weeks before dying. Jury awards $90 million verdict against nursing home, agreeing with plaintiff’s attorneys that patient’s death was due to inadequate staffing in the nursing home and failure to provide patient with food and water.
Now verdict is under review by the West Virginia Supreme Court to determine whether medical malpractice caps apply to the verdict, which would reduce the award to $500,000 for non-economic (pain and suffering) damages. I wonder if the administrators were named in the suit.

Acute Incarceritis Revisited

April 29th, 2014

Monopoly Get Out Of Jail FreeIt has happened a few times recently. Just had another case of acute incarceritis.

A man was brought in by police after drinking a little too much and then beating the heck out of his girlfriend.

Police were called to the scene and the man was arrested for domestic battery.

While riding handcuffed in the back of the police car, it happened.

Loud wailing. His bad back just gave out on him again.

A state trooper brought him to the emergency department.

“I’ve got a bunch of slipped disks in my back and the pain is about a 15 out of 10 right now.”
His back looked fine and he had a normal neurologic exam.
When his back pain didn’t seem to make the impression he desired, he added “and I’ve got diverticulosis so bad that the surgeon wanted to take out my entire colon – but I wouldn’t let him.”A rectal exam showed good tone, normal sensation to the area, and no blood or mucous.
“And my blood pressure isn’t very well controlled, so it’s making my head hurt.”
“Your blood pressure is 137/66.”
“Well it shoots up unexpectedly and I haven’t been taking my medications. I almost hit 300 one time, you know.”
“Fortunately, it’s normal now.”
“And my chest is killing me. My heart is beating out of my chest.”
“The workup is still pending, but your EKG looks fine.
“Oh, and I have a bum knee. That’s bugging me too. I can barely walk.”
“You looked like you were walking pretty well when you came into the emergency department.”
“And what about this rash?”
“Wait a minute. You mean to tell me that just after you were picked up by police for beating up your girlfriend, you simultaneously developed the worst back pain, chest pain, knee pain, and abdominal pain you’ve ever had in your life – in addition to palpitations, high blood pressure, and a rash?”

At that point the state trooper interrupted.
“Doc, he was just going to spend the night in jail here, but as long as you tell me he’s not going to die on me in the car, my captain said that I can take him to South Metro State Prison where they have a medical ward.”
The patient quickly changed his mind. “I’m OK. The pain’s better.”
The trooper responded back “Naaaah. Can’t be too careful. You’re going to South Metro.”
“But I’m feeling better now! What the f***?!?”
At that point you could tell that the patient was trying to decide whether to come up with more symptoms in a last ditch effort to get admitted or whether he would plead some more so that he wouldn’t have to go to South Metro.

I walked out of the room.

As he was being discharged, and being led out the back doors in handcuffs, it sounded like the patient was taking the latter approach.

“I was just anxious, OK? Can’t a guy get anxious?”

The trooper just walked behind him with a grin.
“Just because you play the get out of jail free card, it doesn’t mean that you’re going home.”
And the patient just had to be thinking “now you tell me ….”

Monopoly Community Chest Go To Jail

———————–

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 04-24-2014

April 24th, 2014

Kudos to staff at Blessing Hospital in Quincy, IL for its excellent management of a rollover bus accident with 27 kids. You all do us proud!

Stock up on your Norco pills now, folks. This study shows there’s no difference in pain relief when compared with codeine, and when the DEA changes hydrocodone to a Schedule II drug, the supplies will dry up quickly.

Mammography may be diagnosing too many cancers. The idea is that some of the tiny cancers found on mammography would never progress or threaten a patient’s life. Overdiagnosis and overtreatment is expensive and potentially dangerous. So the question becomes: Why are radiologists overcharging patients and insurance companies for reading these unnecessary exams and why are surgeons performing these unnecessary surgeries?
Hey ACR – kind of sucks when your own dumbass logic is used against you, doesn’t it?

Catholic Health Initiatives settles lawsuits relating to unnecessary heart stenting procedures performed by Dr. Mark Midei. Total payouts will be $37 million, with each patient receiving payment of at least $134,000.

Patient with potential measles left sitting with other patients at Rhode Island Hospital. Rhode Island Department of Health descends upon hospital and demands immediate action to prevent “potential harm to the public.” Hospital now must re-educate and re-train staff regarding “care and treatment, including emergency room assignments and required precautions, for patients presenting with contagious or potentially contagious conditions.” The patient presented with “flu like symptoms with fever (which is a symptom of the flu).” Given that every snot nose is a potentially contagious condition, there are going to be a lot of cases of “potential harm to the public” regardless of what training takes place.
All because some brainiac decided not to get immunized.
And the patient didn’t even have measles. Sheesh.

California malpractice cap could be raised from $250,000 to $1.1 million during November ballot vote.
Notice now: If you practice in California, get licensed in other states and start working on hospital privileges. California has officially become runner up to Florida for states in which you don’t want to practice medicine.

Florida Supreme Court rejects medical malpractice caps.

Kansas also planning to raise the limits on non-economic damages – from $250,000 to $350,000.

Pennsylvania considering increasing the standard for malpractice in emergency settings from simple negligence to gross negligence and increasing the standard of proof to “clear and convincing” as opposed to a preponderance of the evidence.
Cue plaintiff attorney wailing and gnashing of teeth in … 3 … 2 … 1 …

You have your robot’s lawyer call my robot’s lawyer and we’ll just see about that. How do human laws apply to robots performing surgeries?

Cleveland Clinic neurosurgeon wins $7.7 million malpractice judgment against Cleveland Clinic. The neurosurgeon was using a saw during surgery when a bone chip flew into his eye. During surgery to repair the damage, the Cleveland Clinic ophthalmologist damaged the neurosurgeon’s iris, making it impossible for him to ever practice neurosurgery again.
The big question in the comments section was whether the neurosurgeon was wearing protective glasses.

California family files malpractice suit after elderly family member declared dead of heart attack, placed in morgue, but allegedly was still alive. Morticians who received her body several days later found her face down in the body bag with broken nose and disfiguring cuts and bruises to her face.
Video about the incident here.

Healthcare Update Satellite — 04-16-2014

April 16th, 2014

Ouch. Tree trimmer using chainsaw mistakes his neck for a branch and shows up in the ED with the chainsaw embedded into his neck and shoulder. Trauma surgeons removed the saw and the patient is expected to make a full recovery.

You think eating all of that nasty salad and tofu is doing you any good? Think again. Vegetarians may have lower Body Mass Index, but they’re twice as likely to have allergies and they are 50% more likely to have heart attacks and cancer. The silver lining is that vegetarians also have a higher socioeconomic status. Does that mean that meat costs too much or that eating vegetables will make you rich?

It is both scary and disappointing that this story is even in the news at this point in civilization. Measles is spreading rapidly across New York City’s Lower East Side. Health officials are urging people to get vaccinated since unvaccinated patients who are exposed to the virus have a 90% chance of getting the disease and up to 33% of infected patients can suffer some type of complication such as pneumonia or encephalitis … which is why civil and potentially criminal liability should attach to those who refuse to vaccinate themselves or their children.

A Canadian hospital emergency department so overwhelmed that an elderly patient allegedly develops bedsores while waiting five days for a hospital bed after being admitted. As horrible as it sounds, it is unlikely that five days laying in a bed would cause bedsores “full of pus” and “almost down to the bone”. Those had to be there before the patient arrived.
But a wait of 5 days for a general medical hospital bed is still pathetic.
More hospital closures and more ED patients in the US every year. Is this a look into the future of US healthcare?

California’s Palm Drive Hospital goes bankrupt and plans to close its doors. Board members base the decision on falling Medicare/Medi-Cal reimbursements, competition from other hospitals, significant loss of patients and the general costs of health care. Community members “pleaded with the board to reject the proposal to close the emergency room.”
Unfortunately, many people are learning the hard way that health care insurance and timely health care access are two very different things. Create a hostile environment to services and you won’t have those services any more.

Louisiana’s Governor Bobby Jindal is shooting for a big fat “F” on the next ACEP report card. Louisiana got a D in the latest ACEP report card due to high rates of uninsured and lack of access to primary care. Now Governor Jindal is proposing a flat-rate triage fee for emergency departments that is “significantly less than the cost of providing care.” Look for such a plan to increase the number of “triage out” patients in the emergency department.

Arizona patient gives multiple names to emergency department staff in attempt to obtain pain medications. Now 27 year old Emily Ingerick … or is it Deborah Peel … or is it Jim Dwyer? Whatever her name is, she’s spending the night in the Greybar Motel … sans pain medications.

FedEx employee is exposed to nontoxic food additive powder at home, but develops breathing problems and vomiting. Goes to Methodist University Hospital emergency department where hazmat crews unnecessarily shut down hospital emergency department for three hours to decontaminate it from a substance that was “not hazardous in any way.”
What a waste of time and taxpayer money.

Is Chicago the gun death capital of the US? Last weekend four people were killed and 37 people were wounded in Chicago gun violence … which makes no sense at all because Chicago has such strict gun laws.

Good news and bad news. If you’re looking for a new job and have a scienctifically-oriented mind, going into medical laboratory science may be something to look into. At least according to this article, there is a desparate need for lab techs in Northeastern Louisiana, and one of the people interviewed for the article notes that there is a shortage of lab techs nationwide.
The bad news is that if the University of Louisiana can’t find more students to fill its spots, the program may disappear, which would have a negative impact on health care in the area – including emergency departments that depend on quick turnaround for lab tests.

Why isn’t this show off the air yet? Sex sent me to the ER turns to “sexism” sent me to the ER when doctor passively watches patient get beaten by wife in the ED after patient thrown out of third story window by prostitute when he tries to write her a check.

Income Comparisons – Teacher vs. Physician

April 15th, 2014

Who makes more money over the course of their career – a high school teacher or a doctor?

Doctors are obviously paid more.
However, when you also consider that doctors work 1.5 times more each week than other Americans, that doctors spend an average of 42,000 to 50,000 hours (20-24 years of full time work equivalents) just to become a doctor, and that doctors pay almost $700,000 for their educational debts, the net hourly wage of doctors versus high school teachers shows that, on average, teachers earn about 3 cents per hour more than doctors over the course of their careers.

And these calculations don’t even consider the licensing fees, licensing exam fees, DEA fees, malpractice insurance premiums, continuing medical education fees, hospital staff dues, costs of running an office … and also assumes that the doctor doesn’t get hit with a multimillion lawsuit judgment.

[Also see this related post: http://www.er-doctor.com/doctor_income.html]

Teacher Salary vs. Doctor Salary

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