Another bamblance theft from the emergency department. If you don’t know why it’s called a bamblance, you need to listen to the video below (strong language alert). This latest ambulance theft occurred at University of Michigan. Many of the commenters to the article suggested that the patient was going to a different emergency department due to the wait times.
How much will you be charged for your emergency department visit. This study in PLOS-ONE gives you a good idea of what you should be charged. Keep in mind, though, that the numbers are “median” values, meaning half of patients got charged more than those numbers and half of patients were charged less than those numbers. The range of charges was ridiculous. For a UTI, the lowest charge was $50 while the highest charge was $73,002. That doesn’t mean some poor patients actually paid $73,000 for a Bactrim prescription, only that insurance was billed that much (which is still a crime).
Wrestling is officially over for the year. I happened to be the “trainer” for junior’s regional wrestling meet. Was busy most of the day. It seems as if the coaches give kids Coumadin before the meets. I haven’t seen so many nosebleeds in a long time … except maybe last year when I was the “trainer” for a wrestling meet. Not only nosebleeds, but there were also head injuries, an eye injury, and a broken arm. Nothing some 3 inch tape and gauze pads can’t handle, though.
During the match, I had a firsthand experience of why the UnAffordable Care Act isn’t going to help as much as many people believe. Again, it boils down to the fact that healthcare insurance doesn’t equal healthcare access.
A dad walked into the meet and from a distance I could tell he was having difficulty breathing. He was stopping every so often while he was walking so that he could lean on the wall or sit down and catch his breath. He made his way over to me and asked for a favor. Could I write him a prescription for ciprofloxacin? He had these same symptoms with pneumonia in the past and that is what his doctor prescribed to clear it up. This dad is a great guy, but he doesn’t live the healthiest lifestyle. He smokes. He’s heavy. He drinks quite a bit. I also knew from previous discussions that he had a history of anemia. There were literally 10 diseases that popped into my head that could have been causing his trouble breathing – besides pneumonia.
“You really have to go to the hospital. You need blood work and a chest x-ray, not a prescription for antibiotics. Besides, even if this is pneumonia, ciprofloxacin probably isn’t going to help. And if the pneumonia is bad enough to be causing you trouble breathing, you’ll need to be admitted anyway. This is serious.”
“I can’t afford it. The doctor’s visit will be $75, the chest x-ray will be $250, and my insurance won’t pay for any of it. I am having trouble paying my bills as it is.”
“But this is your life. I would rather see you have to pay a couple extra bills and be around for your kids.”
“I’ll be okay.”
I kept an eye on him during the meet, and he ended up leaving early.
I even texted him later in the day. He wrote back that he was okay as long as he was laying on the couch. I told them that I could call some people at the hospital to see if we could get him discounted testing performed. He said that he still couldn’t afford it.
I hope I don’t read about him in the obituaries.
It just sickens me that our government provides no-cost “insurance” for poverty-stricken people who earn no money, but many of the working poor get nothing but a mandate. If we’re going to make the system better, why can’t the government provide access to health care for everyone?
As a result of this increased workload, 22% of doctors stated that they had delayed admissions or discharges, 10% stated that they had failed to promptly note/follow up/act on a critical lab value or radiology report, and 7% stated that they had made a treatment or medication error.
In addition, 22% of doctors believed that they had ordered potentially unnecessary testing, 12% believed that the quality of care they provided had worsened, and 5% said that it was possible/likely/or definite that a patient died due to the increased workload.
As more and more doctors become employees of hospitals, I wonder how long it will take before hospital CEOs and administrators start being named in malpractice lawsuits (no malpractice caps on non-physicians, folks) for inadequately staffing the hospitals.
I happened to read an article in the Columbus (Ohio) Dispatch where Ohio coroners are complaining because some doctors, including emergency physicians, are refusing to sign death certificates listing a patient’s cause of death. The coroners are concerned because they are being “burdened” with hundreds of extra cases every year that they must handle. And if other doctors don’t sign off on the cause of death, sometimes it takes two months for them to examine records, wait for test results, and make a final ruling on a patient’s death.
The treating physicians reportedly use the excuses that they haven’t seen the patients in several months or they weren’t there when the person died. Some emergency physicians expressed concern about liability if the wrong cause of death was listed.
The coroners used the article to try to add a guilt trip on doctors who won’t sign a death certificate by stating that the reluctant doctors aren’t inconveniencing the coroner, they’re inconveniencing a family.
Baloney.
If, according to the article, it takes coroners sometimes TWO MONTHS to determine a cause of death, then how can coroners reasonably expect other physicians to determine the cause of death on the spot? How can an emergency physician determine the cause of a patient’s death just by performing CPR on a patient for 20-30 minutes?
As far as death certificates apply to emergency medicine, if a patient comes in and has a heart attack or has a bullet wound through their chest then the cause of death is rather clear and the death certificates shouldn’t be a problem for the coroners to complete. If the cause of death isn’t so clear, then why would the coroners want to rush the completion of the death certificate? Either way you argue the point, it doesn’t make sense. If the amount of time required to complete a death certificate is marginal, then it isn’t as much of a burden as the coroners are making it out to be. If the amount of time required to complete a death certificate is substantial, then is the time spent performing non-patient care tasks really the best use of an emergency physician’s limited time?
In addition, improperly completed death certificates are a problem. In a recent article in American Medical News, one Pennsylvania coroner was quoted as saying that many physicians “don’t realize that what they put down has some real, long-term ramifications.” The article also notes that “filling out certificates inaccurately can have widespread consequences,” although in the latter case, the speaker was referring to underreporting of some diseases to federal agencies. Another vignette in the article noted how a murderer almost went free because the cause of a patient’s death was misclassified by a treating physician. I am aware of another well-publicized case in which a personal friend of mine was involved in a medical malpractice action where a coroner determined that a patient’s cause of death was “murder” without knowing all the facts of the case. Later, the coroner was involved in litigation over that determination and ultimately resigned her position due to this and other similar errors.
Requiring that people other than coroners sign death certificates is just another example of medical mission creep and it needs to stop.
It is the coroner’s job to determine the cause of a person’s death. Stop pushing that job off on other people.
Interesting dilemma. A patient in Washington DC called an ambulance at 1:26 AM when he was having trouble breathing. Just so happens that it was New Years Eve and about 25% of the entire DC firefighting force had called off sick that day. An ambulance arrived 30 minutes later and the patient arrived at the hospital exactly one hour after the initial call for help. Unfortunately, the patient’s condition was poor and he later died. There is now a news article about how the family thinks the $780 bill for the ambulance is “appalling and hurtful.” A petition was posted on Change.org to get the DC Fire and EMS Department to drop the bill and 166,000 people have signed it, many stating that the family should sue the Department for damages.
Yet the bill went to the patient’s insurance company and a copy of the bill was sent to the patient’s family – clearly stating that insurance was being billed, so the family isn’t paying for the transport.
Should we not pay for less than desired outcomes? If so, should the lack of payment extend to all aspects of payments? Job performance? Government benefits?
So I had a problem with a patient and family recently and I’m looking for solutions from everyone who reads this blog.
An elderly patient who lives at home with his wife, his son, and his son’s family was brought by the ambulance to the emergency department for “not feeling well.”
As I attempted to get more of a history about the patient’s symptoms, the discussions angered the family.
“When you say that you don’t feel well, what do you mean?”
“I’m sick! That’s why I came here so you could tell me what’s wrong.”
“But I don’t understand what you mean when you say that you’re ‘sick.’ Do you mean that you’re nauseous or you’re having pain or you’re feeling weak?”
“No, none of that.”
The daughter in law then stood up next to the bed and firmly said that he “just doesn’t look right.”
That didn’t help me much, so I said “I’ve never seen him before, so I don’t know where to begin in finding out what is wrong. What about him doesn’t look right to you?”
She threw her arms up in the air and rolled her eyes. “What do you want me to say? He doesn’t look right.”
No, I didn’t grab his head, turn it to the right and say “There … problem solved.” I just stopped asking about his symptoms.
“OK, well how long has he not been looking right for?”
“Oh, it’s been a while now ….”
After about 15 minutes, I was able to determine that the patient was sleeping more than usual for anywhere between 3 days and a week, depending on who was answering my questions.
After I left the room, the nurse told me that the whole family was upset with me because I was being “difficult.”
So the questions I have for you all are the following:
1. If you’re in the medical field, and a patient/family provide you with a vague history, do you try to find out more information? If so, what approach do you use?
2. If you’re not in the medical field, how would you suggest that a health care provider respond to you if the information that you are giving them isn’t helping them figure out what may be wrong with you?
I think that these are questions that a lot of people would like to know, so please chime in below.
I hate the movie Pitch Perfect. Actually I like the movie itself, but my kids won’t stop singing the frigging songs. I have heard the songs from that movie in my sleep for months now. The latest thing that my kids have taken to doing is re-enacting the “cup” scene where Anna Kendrick sings You’re Gonna Miss Me When I’m Gone using a cup. Before school in the morning, “you’re gonna miss me when I’m gone.” At night after dinner, it’s a chorus of “you’re gonna miss me when I’m gone.” Without a doubt I am NOT going to miss that damn song when it’s gone. I can’t take it any more. Ditto for Don’t You Forget About Me. My head hurts just thinking about the words.
When I try to go to sleep, then it’s the dogs’ turn. About half of the nights of the week our boxer snores … loudly. Most of the time Mrs. WhiteCoat will call her name and wake her up to stop the snoring. Sometimes, Mrs. WhiteCoat has to throw a slipper at her to wake her up. When that doesn’t work, she’s actually had to tip over the bed a couple of times to get the dog to wake up. Even that didn’t work last night. After being dumped out of bed, the dog woke up, climbed back into bed, and promptly started snoring again. By that time, I was awake and I was tired. So I sat up in bed and yelled like a dog … I barked at the top of my lungs for about five seconds. I think it roughly translated into “wake up and be quiet or I’m going to tie your ears in knots.” Our older dog sat bolt upright in his bed and was looking at me with his head cocked to the side. The boxer was doing a John Belushi imitation (forward to 0:30) spinning back and forth trying to see where the attack was coming from. One of the girls let out a scream from down the hall. I laid back down and then I couldn’t sleep because I was giggling to myself. But the snoring stopped.
Once Mrs. WhiteCoat went to sleep, she had bizarre dreams. In one dream she was trying to get into our oldest daughter’s room, but she couldn’t get the door open. So she broke the door in. It was freezing in the room. Our daughter was sitting on the bed and she could see her breath. “Come on, let’s go,” Mrs. WhiteCoat said. “I can’t move,” our daughter replied. So Mrs. WhiteCoat ran into the room and grabbed her, then headed for the door. The door closed and she opened it. While doing so, she bumped something behind her. She turned around. It was her carrying a laundry basket. Her mirror image dropped the laundry basket, pointed at our daughter, and said … “check her potassium level.” Then she woke up. And no, we didn’t check her potassium level. What are we going to put for the reason … vision in a whacked out dream told me to?
Almost back to normal after surgery. There’s still a bulge there and yes, it is the hernia. Just some postoperative swelling. Have to wait another week before I get back into normal activity. It’s strange not feeling the area pressing up against my pant leg like it used to. And after about six days I no longer feel like I have a weight tied to one of my “boys” … if you know what I mean. Still a little sore walking around, but I’ll get over it soon enough.
I was going to try some walking this week and slowly get back to running on the treadmill, but I can’t do that because Junior WhiteCoat and his friends had to watch some dumb YouTube clips where people were trying to launch themselves off of treadmills. Then they had to try it for themselves and busted the damn treadmill. They bent a roller and they bent the platform and the manufacturer doesn’t make either any longer. Fortunately, I anticipated someone in the house being a victim of dumbassery (Junior was the odds-on favorite) which is why I bought a cheap used treadmill instead of a fancy expensive new one. So said treadmill goes out to the curb this week and I have to look for another used model. Doubt I’ll be able to beat the $150 I paid for the last one, but we’ll see.
So back to the wall thing. I was trying to videotape what I was seeing as I pushed through the insulation. So I had a camera in one hand and a MagLite in the other hand. I used the MagLite to push away the insulation and something flittered in front of the light. I jumped back thinking “Holy second cousin, Batman.” But how could bats be in a wall? Don’t they like to hang? I pushed through the insulation again and a loose piece of insulation pulled off the edge. I found a crawl space behind our closet that I never knew existed. Like 6 or so feet deep, 4-5 feet tall and about 20 feet wide. Damn. It was like a varmint party room in there. On the floor between two rafters were a bunch of chewed up sunflower seeds. Then I stuck my camera in the area and recorded to see if anything was around. Nothing when I reviewed the movie. I put on some protective eyewear and stuck my head inside to look around. Up in the corner of one wall, something had chewed its way through the wall leading to the outside. I stuck a straightened coat hanger in there and went outside to see where the end came out. Couldn’t find it. Then I realized that our house has a brick exterior. More secret passages inside to be discovered.
We called the exterminator, but apparently no one deals with varmints. Only bugs and mice. That’s when hernia surgery stopped me from climbing around further.
The good news is that since I stuck the hanger in the hole, the scratching hasn’t been back, either. So either whatever it is either became pregnant and is hatching spawn to create a habitrail through the walls of our house or it got scared and moved on to another house. I’ve already decided that I’m going to open up the wall and put flypaper and mouse traps all over the place. So I don’t think that the mysterious scratch is of a flying variety. My guess is on a squirrel. We’ll find out next week, I suppose. Maybe I’ll even post a couple of pictures.
When you work in an urban hospital, sometimes it’s difficult not to become jaded.
There are certain neighborhoods that generate a disproportionate number of patients for some emergency departments. Meth is rampant. Marriage pretty much nonexistent. More bars than there are restaurants. Domestic abuse frequent, but prosecutions rare. Police know people more by their street names than by their real names.
South Heights was one of those neighborhoods.
The emergency department frequently treats South Heights kids who are neglected by their parents. I’ve seen young South Heights kids with seizures from cocaine. Now seizing kids get drug screened as part of their workup. I’ve seen more than one young South Heights kid with a lighter burn. I’ve given a lollipop to a 2 year old South Heights kid and watched the mother take the lollipop out of the kid’s mouth when she thought no one was looking, chew on the lollipop until there was nothing left, then slap the kid for crying. Many parents from South Heights can recite the names of the family court judges from memory and quite a few have had their children taken away. Social service workers know many South Heights kids personally. Based on the history of the area, many people tend to look at the kids from South Heights with pity and look at parents from South Heights with contempt.
The next patient on the board was “finger laceration.” As I walked toward the room, the nurse mentioned “they’re from South Heights.” I was already thinking about whether I’d get attacked if I had to call Child Protective Services.
The patient was a cute little girl about 5 years old. Thin stature, great smile, polite. She was holding her arm out on the table and a gauze pad with a slowly enlarging spot of blood covered her hand. Her mom was weathered. Most of her teeth were missing. Her clothes looked like they hadn’t been washed in a while. A reusable shopping bag with newspapers, empty beer cans, and a pair of headphones sat on the chair next to her.
“So what happened to your finger?” I asked the little girl.
“I cut it with a scissor.”
The mom explained that the patient was told to wait to open a bag of cookies, but didn’t do so. Instead, she grabbed a pair of scissors from the drawer and forgot to take her finger out of the way when she cut. The result was a fairly deep laceration to the outer part of the index finger.
I went through the described mechanism in my head for a second. Scissors in one hand, holding a bag with other hand, cut to opposite index finger. OK. Injuries seem to fit the explanation.
Then I went about describing what I was going to do next.
“I’m going to put some medicine into your finger to make it stop hurting. Then we have to clean it out to get rid of all the germs. Then I’ll fix it up for you. The medicine to make it stop hurting burns a little bit. Once the burn is gone, it won’t hurt any more. OK?”
The little girl looked from me to her mother and her eyes began to tear up.
She cried and whimpered, but she held completely still while I injected lidocaine into her finger. Her mom leaned over next to her, gently cupped her head and wiped away her tears.
After the wound was clean, I got everything ready to fix the wound. But the patient was a little hesitant because the lidocaine injection had hurt. Despite me showing her how her finger was numb, she cried and didn’t want me to touch her hand.
Then mom came up with an idea.
She ruffled through her shopping bag and pulled out an old iPod. She started playing a country song on the iPod.
“Do you know what this song is?” mom asked.
“My ‘I love you’ song,” the little girl said back.
While I worked fixing the little girl’s finger, I watched as her mom caressed her daughter’s face and as they softly sang the words of the “I love you” song back and forth to each other.
I finished the last suture about 15 seconds before the song ended. The little girl didn’t move a bit until the end of the song. Then she used her uninjured arm to hug her mom around the neck and tell her one more time “I love you, mommy.”
As I wrapped up the little girl’s finger, I thought how difficult it can sometimes be not to form premature impressions about people.
And as the young patient blew me a kiss with her bandaged hand while being carried out the door by her mother, I thought how desperately South Heights needs a few more moms like this one.
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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.
As a follow up to the article about wait times in upstate New York emergency departments, the CEO of one hospital provides a great response … and reiterates that health care insurance doesn’t equal health care access.
“With a severe primary care shortage and some practices without after hours and/or weekend care, people are forced to seek care that is available … [j]ust around the corner, millions of Americans are about to have health coverage. Where will they seek care if we have not expanded access to primary care? In the emergency room.”
Government regulations never seem to get less onerous, do they? HIPAA regulations change again. Now doctors can be held liable if their business associates cause patient privacy breaches, penalties increase, and privacy notices have to be modified.
For some reason, I seem to read about events like this on a regular basis. Another car crashes into hospital emergency department. This schmoe wasn’t seeking medical care, he was intoxicated and trying to get away from police.
My first night shift in a stretch of 7 was almost over. It was 6:15 a.m. and I had to keep moving otherwise the minute I would stop, my eyelids would drop like two ton shades and I’d fall asleep. That never makes for a good drive home after a night shift.
“Got time to see one more?” asked Jenny the nurse.
“Do I have choice? The door-to-doctor time storm-troopers would have it no other way,” I grunted back, eye lids drifting closed.
“Febrile seizure,” it said.
Good, this should be quick and easy, I think to myself. We’ll give some Tylenol, reassess in 30 minutes and this baby will be happy, smiling and bouncing off the walls. That way I can get out of here at 7 a.m. and be home in bed with my eye blinders on drifting towards sweet REM sleep at 7:20 a.m. My sanity depends on it. 15 feet away, I head towards the room. Looking into room 4, I expect to see the usual post-febrile seizure toddler, sitting up in bed, recovered, awake and well appearing. First I see the child’s mother, well put together, attractive, smiling and relaxed. I cross the threshold to the room, look down on the hospital stretcher and I see a child, about 1-year-old, still seizing. Still seizing? I think to myself. This isn’t right.
“Jenny, get in here! We’ve got a seizing baby,” I say. I look down at the child, who is pale, head turned to the right, with the left arm twitching violently. “Call respiratory! Jenny, you get the IV, I’m going to start bagging. Someone get the Broselow tape and some Ativan. Let’s stop this seizure. Get some diastat, too. We may need it. As I bag the child, Jenny quickly gets an IV in. We give a dose of Ativan and the baby stops seizing quickly. The O2 sat is 97%, the baby is breathing spontaneously and I stop bagging. I put an O2 mask on the baby. I feel the brachial and femoral pulses. They are bounding.
Considering the baby has normal vitals, I turn to Mom hoping to get some history while hoping the baby will quickly awaken from the post-ictal slumber. “Mom, hi, I’m Doctor Bird, tell me what happened please.”
She looks at me and smiles. Her lips spread apart and reveal a soul-sucking brown smile. Why is she smiling? Her baby just got done seizing? Why isn’t she panicked? I look towards Jenny the nurse whose face is beet red and stressed like mine, after a 12 hour night. I shoot a glance at the clock and it’s well after shift change now. I’m fried. I haven’t slept in over 24 hours. I look back at Mom and I realize she’s the calmest one in the room. There’s something really, really wrong here. In the corner of the room is a man sitting on a chair that I hadn’t noticed before. He’s smiling. I look at him. “Hey doc! How’s it goin’? Havin’ a good night?” he asks with a smile and a laugh as he slaps his knee. Having a good night? I’m having a horrible night, I think to myself, and I’ve got a seizing baby on the stretcher in front of me. It doesn’t seem to be cramping his style too much, however. I feel the energy drain right out of my chest. At that moment I know exactly what the diagnosis is, and I feel like I might puke my guts out.
“Charge nurse? Please escort them to the family consult room. Thank you. Suzy, call the chopper, now. Jenny, let’s get this baby tubed. Tell CT to clear the table, we’ll need a scan in 2 minutes. Call PICU at —– —— Medical Center. We’re flying this one out! Call Social Services and the Police, too.”
Once intubated, stabilized and after another dose of Ativan we shoot over to CT. I watch the image slices appear on the computer monitor one by one. My stomach turns over. I see just what I feared: massive bilateral subdural hematomas (bleeding around the brain.) There are skull fractures. There is a brain that looks obliterated.
The helicopter crew arrives and prepares the toddler for transport. As they wheel out the door with our tiny toddler in tow, Jenny the nurse, the respiratory therapist, Suzy the unit clerk, Bob the charge nurse and I all just look at each other. Nobody says a word. What is there to say? We all know as much as we need to know. Off we go, out the ED doors headed home, exhausted as the sun comes up after a very long night shift.
A few days went by. We all tried to work through the next few shifts pretending like nothing big had happened. It’s “just a job,” right? A few muttered comments here or there but most everyone tried to work past it. In a case like this, despite knowing you did all you could do, it’s hard not to feel like somehow you failed, since at the end of it, a child remains brain-damaged or worse. I tried to forget about the case and move on, but I had to get some follow-up. In a rare slow moment, during a shift a few days later I asked, “Suzy, why don’t you call down to the PICU at —– —— Medical Center. Let’s see how the baby from the other night is doing. I’m sure we could all use some good news right now.” I was hoping that my worst suspicions would be proven wrong, and my cynicism would lose out to wishful thinking. I sat down to check the internet for the weather while I waited. Already up on the screen, was the local news site. The headline said:
“Shaken Baby Dies: Mom and Boyfriend Charged with Murder”
“You know what Suzy? Hang up the phone. We don’t need to call. I’m sure everything turned out just fine. You all did a great job with that baby,” I said. I headed to see the next patient, chief complaint: “Itchy nose.”
“Hello, Mrs. Jones, I’m Dr. Bird, how can I help you today?”
This author does not divulge protected patient information or information from real life court cases. Any post that appears to resemble a real patient or trial can only be by coincidence. This author does not post, has not posted and will not post factual identifying information about real patients. To the extent that any post is based on the real life experiences of the author, names, dates, ages, sexes, locations, diagnoses, and all other factual information are routinely changed to the extent that it should be considered fictional. Any opinions expressed here are of the author alone and not those of epmontly, WhiteCoat, my employer or any of the hospitals with which I am affiliated.
