WhiteCoat

Comic Relief

March 13th, 2013

Courtesy of mednificentcomics.com

Not quite a case medical student’s disease, but close. Have to love it.
The thing is that when I was a medical student, there wasn’t an internet and there definitely wasn’t a Dr. Google. So we were a lot more stressed out because we had to rely on the advice of our professors – who weren’t always that well versed in the diseases.

Medical Student's Disease?

Healthcare Update — 03-11-2013

March 11th, 2013

Doctor treats child born to HIV positive mother with full three-drug regimen of HIV drugs one day after birth instead of one or two drug regimen typically used until an HIV infection can be confirmed. Treatment continued for 18 months, then the patient’s mother stopped bringing the patient to appointments.
The child is now 30 months old, has been off HIV medications for a year, and has no HIV infection according to ultrasensitive testing performed at Johns Hopkins.
Now the doctor’s colleagues are planning a celebration.
Of course, if the child did poorly or had a bad reaction to the medications, the doctor would likely have been arrested, lost her license, and sued for millions.

More warnings about superbugs. MRSA is bad enough, but what happens when the organisms living in all of our intestines become resistant to antibiotics?

Patients gone wild returns. Minnesota goof screams profanities and disrupts medical care. Tied down in four point restraints until police arrive. Will likely be charged with disorderly conduct. Wow. If every patient that did this kind of thing was charged with disorderly conduct and whisked off to jail, our ED volumes would drop by a good percentage.

Electronic medical records are supposed to improve care, right? In this study, alert fatigue caused 30% of VA doctors to miss important alerts. 87% of doctors said that the number of alerts they received was excessive and more than half blamed the design of the EMR for the problem.

Quite possibly better than the lollipop story. Police find loaded gun in woman’s hoo hah during search. Also had crystal meth in her butt crack. And THAT, dear readers, is why they call it “dope.”

You think your wait in the emergency department is long? Try going to LA County Medical Center where the wait averages 12 hours at some points.
In the past, certain people have equated high wait times to a poorly run hospital, but we won’t go there.

Spider bites may be a common complaint when coming to the emergency department, but the complaint often turns out to be a MRSA infection. As the Milwaukee Brewers General Manager discovered, bites from other arachnids may also require an emergency department visit when you try to squish them up in a tissue.

British Columbia emergency physicians describe horror stories in their emergency departments allegedly due to funding issues and overcrowding. Performing CPR on the waiting room floor? Even I haven’t heard of that one before.

Nurse in New York caught stealing medications from nursing home patients.

Not sure how to take the wording in this article. Polish man walks into emergency department with screwdriver sticking two inches into his forehead, article reports that there was no damage to the patient’s brain.

South Carolina inmate grabs an officer’s gun during emergency department visit. Second officer “fires shot to subdue him” – inside the emergency department. Inmate then gets taken back to jail. What happened to the gunshot wound?

Did medical malpractice kill Bruce Springsteen’s saxophonist? Clarence Clemons’ brother, an attorney, pursues malpractice litigation against doctors for Clemons’ stroke.

Could medical malpractice climate in Florida be changing? Bill working its way through Florida House would increase burden of proof on medical malpractice claimants and would limit who can serve as an expert witness. Also protects hospitals from liability for actions of their contracted health providers.
Florida Medical Association attorney notes that Florida’s current malpractice laws are “doing a disservice to our state and are a driving force in a physician’s decision to leave critical-need specialities, retire prematurely and even leave to practice in another state.”

We’re watching you …California wants $10 million in funding to create a prescription-tracking database so that it can find doctors who overprescribe narcotics. Once the system was up and running, doctors and pharmacists would be REQUIRED to check it to look for signs of narcotic abuse. Of course, the definition of “signs of narcotic” abuse is purposely not included. That way the state could just attack at will any physicians who prescribe any narcotics. The database would be paid, in part, by raising physician licensing fees.

Interesting statistic. Top 25% of Medicare beneficiaries account for 85% of total Medicare spending. Prime targets for “death panels,” huh?
Seriously, though the article has several good points about how to improve the medical system, even though it is written by someone with no apparent experience in the medical system.
One point in which I disagree with the author is that “guidelines” should be used both as a shield and as a sword. We all saw what happened when NY Times reporter Jim Dwyer misused guidelines. In general, guidelines are situation specific and failure to follow them to the letter shouldn’t be considered malpractice.

Obese patients eligible for special seating at the 2014 World Cup in Brazil. Just need a medical certificate stating that your body mass index is 30 or more, which apparently qualifies people as being disabled under Brazilian law.

Should Refusing Medical Care Be A Crime?

March 8th, 2013

Doctor threatens to call police on patient if she does not consent to immediate Caesarian section.

The mother was a high-risk pregnancy (due to VBAC), was post-dates and had gestational diabetes. The fetus wasn’t in a good position to facilitate vaginal delivery, and an ultrasound showed the fetus in possible distress.

The patient was sent to Tampa General hospital for immediate C-section, but refused to have the surgery done that day. She wanted the baby delivered on Friday, not Tuesday. So the obstetrician sent her an e-mail which stated, in part

I am deeply concerned that you are contributing to a very high probability that your fetus will die or your child will incur brain damage if born alive. At this time, you must come in for delivery.
I would hate to move to the most extreme option, which is having law enforcement pick you up at your home and bring you in, but you are leaving the providers of USF/TGH no choice

The doctor was promptly contacted by the National Advocates for Pregnant Women, whose New York attorneys advised him (apparently applying their vast knowledge of Florida law to the case) that he was making “legally and ethically unjustifiable” threats and demanded he cease taking further action against the patient. The NAPW even put up a post about the incident on their web site. Hopefully, the attorneys at NAPW have licenses in Florida, otherwise some might consider them to be practicing law in Florida without a license – which I think might be illegal.

Now the patient is having her baby delivered on Friday as she wanted.

When I initially read this article, I was upset with the doctor.

The more I thought about it, though, the fetus has as many rights as the mother does. If the mother was doing things to endanger the life of the fetus the day after it was born, a call to the police would be expected, not ridiculed. States mandate reporting of suspected child abuse and impose liability on providers if suspected abuse is not reported.

In this case, it is questionable whether a failure to deliver a child that is possibly in distress would be considered “child abuse,” but usually if there is a suspicion, a report is mandated.

I side with the doctor on this one. And I probably would have called the state child welfare agency on the woman just to cover myself.

This case will get ugly real quick if there are complications during the pregnancy or if the child isn’t born healthy.

If the baby is stillborn, should the mother be charged with a crime?

Suing Doctors For Patient Addictions

March 7th, 2013

Nevada Senator Tick Segerblom proposes bill that would allow patients addicted to prescription drugs to sue doctors for prescribing the addictive medications and manufacturers for creating the medications.

Patients can already sue doctors for prescribing medications if they can prove that writing the prescriptions violated the standard of care and that they have suffered damages as a result. But Tick wants to take the concept a step further. If the patient sues a doctor and wins, the patient should receive payment for rehabilitation, possible punitive damages, and attorney’s fees.

It doesn’t matter that “addiction” can be either physical or psychologic and that there is no reliable way to determine when addiction occurs. Tick’s bill doesn’t define addiction. It also doesn’t matter that people can get addicted to pretty much anything … alcohol, illegal drugs, porn, gambling, even collecting Cabbage Patch Kids. Tick’s bill only cares about those evil doctors. Beware internet service providers, you could be next on the list if your subscribers get addicted to the internet.

But Tick has good reasons for proposing his bill. Since people lived without drugs before, Pharmacologist Tick doesn’t believe that drugs are the only way to treat pain now. That’s true. Patients in cancer pain could always try incantations and faith healing instead of popping pills. Or patients in pain could bust out some whiskey and a bunch of bullets to bite on … after they take anger management classes so they can purchase the bullets. Oops. That’s Florida. Sorry. Wrong state. Double oops. Alcohol could be addictive. Bad example.
Besides, since children are allegedly taught from an early age to do whatever the doctor says, Neuropsychologist Tick says no one has the free choice whether or not to take addictive pain medicines.

It’s not so much that, at least according to his Twitter feed, Tick seems just all … well … tickled … about seeing his proposal published in newspapers. The scary thing is that people like Tick Segerblom are elected to public office and may be able to regulate our lives.

More comments at Overlawyered.com

The Nurse Who Denied CPR

March 7th, 2013

I’m in shock about the case where a nurse refused to give CPR to 87 year old Lorraine Bayless in a California senior living facility – a housing setup akin to an apartment complex.

Ms. Bayless fell unconscious in the dining room of a senior living facility. Facility members called 911. Ms. Bayless wasn’t breathing and the 911 operator recommended that the facility member perform CPR. The person at the facility would not perform CPR.

It took EMTs about 7 minutes to arrive on scene. Ms. Bayless later died from a “massive stroke.”

The 7 minute call can be heard HERE in its entirety.

A couple of other things made known in the case were that the senior living community did not have any trained medical staff. Remember – the facility was similar to an apartment house. In addition, Ms. Bayless had made known her intentions to “die naturally…without any kind of life-prolonging intervention.” According to the family, Ms. Bayless knew that there were no medical staff when she decided to live at the facility.

So why am I in shock?

Look at all the whacked out opinions that are being generated from this case.

Some people demand criminal charges be filed against the people who wouldn’t help.
One person recommends “Depraved Indifference Homicide
Another person notes that if a law says that “you cannot deliberately withhold medical care from a dying person” then ignorance of the law is no excuse for failing to act – applying that hypothetical to this case, of course.
Bakersfield California police are looking into whether there was anything criminal and the county Aging and Adult Services Department is determining whether “elder abuse” may have taken place because of the incident.
The thing is that if criminal charges were appropriate, then everyone in the dining room of the senior living facility who saw Ms. Bayless collapse would have to be thrown in jail. No one helped her. Let’s just charge everybody with a crime.
California can’t pay its bills as it is, so it is unlikely that they will criminally charge a group of elderly patients requiring nursing care and then be required to provide continuing medical care to them. Maybe they’ll all get electronic monitoring bracelets and weekly visits via the wheelchair van to a parole officer, instead.

Then the “experts” across the news stations pile on.
Virginia Commonwealth professor of geriatrics Dr. Peter Boling stated that without advance directives, patients “wind up sometimes in a very painful and trying situation.” This quote seems to acknowledge that patients may receive unwanted CPR if  there is any question about a patient’s wishes.
CBS legal analyst Jack Ford calls the actions “morally reprehensible” but also notes that our society has become much too litigious.
Ah, but what about California’s Good Samaritan statute? It exempts people who provide emergency care from liability for civil damages, but it also contains exceptions. Providers have to act in “good faith”. It doesn’t apply to those who are grossly negligent. And it doesn’t apply if the provider is being compensated. Employees of the senior living facility are, by definition, being compensated. So a plaintiff’s attorney may have the ability to circumvent the protections afforded in the Good Samaritan statute just through the “compensation” angle.
Other people argued that the 911 operator took all liability for the actions of the nurse. How does such a promise, which is essentially a verbal contract, absolve the nurse from liability when the nurse is the one performing the actions? If a lawsuit was filed, the nurse would still be named regardless of the 911 operator’s promises.

Then there’s the question of a DNR order. According to the Bakersfield Fire Department there wasn’t such an order on hand when paramedics arrived. Not that people carry DNR orders around with them in their pockets or anything. After all, this was a dining room in an apartment complex, not an ICU bed. But even if that was the case, does there have to be a readily producible advance directive available to prevent unwanted care?

A sweet old lady entered a senior living facility knowing that there were no trained medical staff and not wanting any life-prolonging treatment.

Now a firestorm has come down on the living facility for abiding by the patient’s wishes and pundits all over the internet are basically demanding that we perform medical procedures on patients who don’t want them. Don’t agree? It’s off to jail with you. You’re a criminal.

Ms. Bayless’ family issued a statement saying in part

We regret that this private and most personal time has been escalated by the media. Caregivers, nurses and other medical professionals have very difficult waters to tread in the legal and medical landscape of our country today.

About the only thing potentially criminal about this case was the unauthorized dissemination of Ms. Bayless’ private health information to the media.

Are state and local authorities investigating that?

High School Science Class Fail

March 6th, 2013

Daughter WhiteCoat doesn’t have the stomach for her science class.

They were dissecting a sheep heart in her class not too long ago and she was becoming increasingly queasy. Apparently the sheep had been recently slaughtered because she said that there was still blood in the heart. She was more skeeved because the science teacher was manipulating and dissecting the muscle without using gloves.

She went up to the table where the dissection was taking place, but had to leave the class at one point because she thought she was going to throw up. Mrs. WhiteCoat and I? We can watch surgery while eating a plate of spaghetti and meatballs. Or eggs and sausage.

After the class, several “concerned” classmates came up to my daughter. Instead of consoling her, they said “Eeeeewwww. You have heart juice on your sleeve” or “Gross. There’s heart juice on your notebook.”

Heart juice?

Heart juice?

What the hell is heart juice? It’s called “blood” people. You all fricking fail.

I gave her a bottle of disappearing ink and told her to squirt it on those people’s notebooks, saying that they had crab heart juice on their notebooks (yes, horseshoe crab blood is blue and it contributes to modern medicine), but she wouldn’t do it.

Can’t wait for them to start discussing reproductive system. I’m going to have to send the teacher some smelling salts for use on my daughter.

Healthcare Update – 03-04-2013

March 4th, 2013

Drunks caught on security camera beating each other in a Turkish emergency department waiting room. Best part of the video is when one dope pulls off his belt to start hitting people and his pants fall down. Then he waddles about swinging his belt like a little kid with a load in his diapers.

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.

FDA stifling pharmaceutical innovation through excess regulation. You don’t say. Scary that the average time and cost involved in developing a single drug approved by the FDA is 12 years and $1.2 billion.

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).

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Dear Diary

March 3rd, 2013

Lets see. What’s new recently?

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?

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Increased Workload = Increased Medical Errors?

March 1st, 2013

They throw around that lame 98,000 preventable deaths per year statistic, but the survey is still quite telling.

More than one third of 890 hospitalists surveyed stated that their workload exceeded safe levels on at least a weekly basis.

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.

Who Should Sign Death Certificates?

February 28th, 2013

PaperworkI 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.