WhiteCoat

Hemoptysis Pearls

June 26th, 2014

There was a nice article over at Consultant360.com by Drs. Laren Tan and Samuel Louie on hemoptysis pearls. Learned quite a few things.

200 mls of blood (about a cupful) is enough to fill the dead space in the lungs and is therefore generally considered the minimum amount of blood to make the diagnosis of “massive” hemoptysis.

Hemoptysis with chest pain – think pneumonia/pleurisy, PE with pleurisy, pulmonary edema from an MI, or lung cancer

Hemoptysis with dyspnea – think either exacerbation of patient’s underlying medical problem or a precursor to respiratory failure

Hemoptysis with fever – think infection, autoimmune disease, vasculitis, or even PE with lung infarction

Chest xray, CBC, and coags are the initial diagnostic tests. CT scan is indicated for suspected masses, recurrent hemoptysis, or high suspicion of cancer. Although not mentioned in the article, PE evaluation would also be an indication, depending on symptoms and pre-test probability scoring. CT alone has a diagnostic yield of about 67%.

For a differential diagnosis of hemoptysis, remember the mnemonic “BATTLECAMP”

B – Bronchitis
A – Abscess
T – Tumor
T – Tuberculosis
L – Lupus
E – Embolism
C – Coagulopathy
A – Autoimmune (eg, Goodpasture syndrome, systemic lupus erythematosus)
M – Mitral Stenosis
P – Pneumonia

Healthcare Update Satellite — 06-23-2014

June 23rd, 2014

The right to carry a concealed weapon only exists if your doctor says so. Many states are requiring that physicians certify whether patients are competent to carry a concealed weapon. Some states require mandatory reporting of those deemed not competent to carry a concealed weapon. Of course, the natural extension of such laws is that if the doctors make an inappropriate determination, then the doctors can be held liable if the certifiee does something inappropriate with the weapon.
This New England Journal of Medicine article shows that many doctors aren’t comfortable making that determination.
Then again, I’ve heard colleagues threaten that if they’re required to report people, they’re just going to make anonymous certifications that every police officer they see is not capable of carrying a concealed weapon, then forward them to the state using USPS Delivery Confirmation to prove that the reports were received.
We really shouldn’t stop at physician certifications of competency for gun ownership. We should expand the physician certification to encompass other areas in which people could be potentially harmed. For example, physician determination of competency should be required for positions such as judges, CEOs, prosecutors, and anyone who comes into contact with a child. Dammit, we need to protect the children.

We’ll have to re-publish this study again around November, but for now, keep in mind that using hypertonic saline nebulizers to treat bronchiolitis causes less improvement than just using regular saline.

Many people reportedly complaining of headaches after using Google Glass. Harvard optometrist notes that they aren’t really headaches but a “discomfort in the eye muscles” from looking in strange directions.
Wait. That optometrist said nothing of the sort. Those quotes were taken out of context. Only a few people feel the pain. There are no health risks. Now retract your story or we’ll bury you in the search rankings.
Also see my other post discussing problems using Google Glass for medical applications.

Listen up you administrators and hospital board members … plaintiff lawyers are wising up. Children’s Hospital in New Orleans sued for institutional negligence when deadly fungus spreads through NICU on bed linens and kills five children.
By alleging institutional negligence, the lawyers avoid the $500,000 malpractice cap and also extend the statute of limitations.
No medical providers were named in the lawsuit, either.

This is amazing. Drug trial for arthritis causes interesting side effect. Person with alopecia receiving tofacitinib (Xeljanz) in a clinical trial grows full head of hair.
hair
Our government’s failure to control our borders is now having significant repercussions for the health of our nation’s residents. Deadly diseases such as tuberculosis, dengue fever, and Chagas disease coming into country along with all of the illegal immigrants.
Author of the article describes how President Obama is implementing the Cloward Piven strategy to overwhelm the public health system in order to replace it with a national welfare system to end poverty.
Worked well in Venezuela, didn’t it?

57% of all Italians fear being harmed by physicians. 44% disapprove of their national health care system. The European Commission notes that “Much still remains to be done in terms of patients’ rights, safety, and empowerment to report medical malpractice”within the European Union.

Patient taken to Houston’s St. Joseph Medical Center for an “anxiety attack.” Two hours later, the patient was reportedly discharged. The patient didn’t come home for several days. Finally, the patient was found on the hospital’s fourth floor stairwell. Now the patient’s daughter is “convinced someone from the hospital should pay.”
Hat tip to Scott for the link. Thanks!

When an attorney sued a hospital after mother and twin neonates all die from tuberculosis, he held a news conference stating that “There may have been a motivation to find a cause for her condition other than tuberculosis … If the cause was some other infection, they wouldn’t need the state government in there to investigate … a tuberculosis diagnosis invites oversight and opens up a can of worms.”
Now the hospital is suing the attorney for defamation, alleging that the attorney is implying that the hospital engaged in a cover up.
Paging Barbara Streisand …

Why are we providing better healthcare to those who killed thousands of Americans than we do to the veterans who put their lives on the line to protect us?
“The ratio of patients to doctors in Guantanamo prison is 1.5 to 1. For America’s 9 million veterans receiving VA health care and 267,930 VA employees, the ratio is 35 patients to 1 doctor. Additionally, in late 2008, when Obama was president-elect, he and his staff were warned not to trust the wait times reported by VA health care facilities. But instead of fixing the problem, their focus was closing Guantanamo and improving the comfort of detainees. Even though they already lived under some of the best prison conditions ever seen.”

Another fascinating case. Usually necrotizing fasciitis (a.k.a. “flesh eating bacteria”) causes massive tissue damage, often resulting in death or amputation of limbs. In this case, doctors cured necrotizing fasciitis using a wound vac, antibiotics and irrigation of the wound with an ingredient in household cleaners.

Patient’s pseudoseizure causes doctor to have pseudoseizure when asked to give Ativan and Morphine to treat the pseudoseizure. And I just giggle to myself thinking what would happen if a doctor really did develop a pseudoseizure when a patient went into his or her pseudoseizure.

VA tries to hunt down anonymous whistleblowers, demanding that a watchdog group turn over all records it received pertaining to “wait times, access to care, and/or patient scheduling issues” at VA facilities in Phoenix or elsewhere.
First I’d start by “losing” the requests a few times. Then I’d make them fill out all requests in triplicate. Oh wait, did you fax that? I never received it. You’ll have to re-send it. I’ll put you on a waiting list and you’ll get the information as soon as possible.
Oops. Sorry. The hard drive crashed and we lost the e-mails. No back ups, either. Darn.

Assistant Physicians Coming to Missouri

June 22nd, 2014

Lucy VanPelt The Doctor is INMissouri is planning to allow medical school graduates who have not completed residency to treat patients in underserved parts of the state. Bills that would allow medical school graduates to provide medical care have passed the General Assembly and are awaiting Governor Jay Nixon’s signature. The newly-minted physicians would receive “assistant physician” licenses and would be able to treat patients in collaboration with a licensed physician – much in the way a physician assistant does. However, the new graduates will be able to call themselves “doctor” while physician assistants will not.
Now the American Academy of Physician Assistants is up in arms because the arrangement would “jeopardize (physician assistant) practice” and because these insufficiently trained Assistant Physicians might be confused with Physician Assistants. The new doctors will have more schooling than the physician assistants, but will only be required to work with a collaborating physician for one month before they can practice alone.
One other important thing to note in the legislation: The collaborating physician maintains full responsibility for all actions of the assistant physician. In other words, if the assistant physician commits malpractice, the supervising physician takes the fall for it.

Creative licensing such as this will be a boon to states since each of these extra providers will have to pay significant licensing fees to the states each year.
When the assistant physicians can’t fill the void in access to care, next up will be medical students who independently treat patients in remote campsites and who receive a “Assistant Physician Aide” designation.
When still more providers are needed, Missouri can then license college students who have completed 12 hours of Basic Life Support and who have any scouting merit badges, calling them “Pre Assistant Physician Aides.”

Anyone should be able to provide medical care. Parents already do it to their children. Just like people who choose to purchase a Kia rather than a Mercedes, people who want to pay five cents for Lucy’s psychiatric treatment versus far more for a formal Dr. Phil evaluation should be allowed to do so.
Two things can’t be overlooked:

  1. The credentials and training of the person providing the care must be fully disclosed to the recipients of the care
  2. Those providing the care must be subject to the same regulations, responsibilities and penalties of any other provider performing the same actions. Providers shouldn’t be able to escape liability for negligent actions by blaming someone else or by alleging that they are behaving reasonably given their amount of training. If you want to do brain surgery, you’re held to the standards of a brain surgeon, not a pre assistant physician aide.

We need to carefully consider the evolving paradigm of medical care in this country. The Affordable Care Act ostensibly provided Americans with medical insuance. Now that the bill comes due, how should Americans be receiving care? See tomorrow’s post on my other blog at DrWhitecoat.com for more discussion of this topic.

UPDATE JUNE 25, 2014

Additional article on the topic here

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

 

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