WhiteCoat

Healthcare Update Satellite — 02-24-2014

February 24th, 2014

More medical posts from around the web over on my other blog at DrWhiteCoat.com

Another Pennsylvania hospital closes its obstetrics department, citing clinical and financial viability of the department with only one obstetrician on staff. Interesting point in the article is that in 14 years, more than 40 obstetrics units have closed in Pennsylvania. One site lists about 240 hospitals in the state total. Why all the closures? How does that affect care provided to the pregnant patients?
The article notes that the emergency department is trained to handle emergency births, but if a baby is breach or needs emergent delivery, the outcome is likely not going to be good. Emergency physicians can’t do emergency Caesarian sections and we don’t specialize in high-risk maternity care.

Paramedics frustrated at having to provide care to patients for hours in parking lot at University Hospital Limerick before being able to move patients onto a bed inside the hospital. During that time, the paramedics are unavailable to make other runs to other hospitals.

More and more Kentucky patients dying from heroin overdoses, but benzodiazepines still cause most emergency department visits for overdoses in Kentucky. According to the CDC, the number of patients using heroin nationwide has increased by 80% between 2007 and 2012 and much of that increase is attributed to a clampdown on pain medication prescriptions.

Interesting arguments for NOT treating a child’s fever. Fevers won’t fry a child’s brain. That whole egg on a frying pan comparison only works for drugs. The magnitude of fever is not related to seizure risk. I always believed that high fevers made additional febrile seizures more likely, but was unable to find any literature to support that belief. Fevers may help your body fight infection better. And lowering a fever increases transmissibility of influenza.

More of the Obamacare Chronicles.
Patients who are happy to have “insurance” then overcome with shock when they can’t find a doctor who takes their insurance. “Covered California” leaves many Californians “uncovered” for medical care and the doctor directories that it posts on its web sites are often inaccurate. Consumer fraud, anyone?
Remember my prior post about how doctors would be vilified for refusing to participate in low-paying insurance plans? This article is just one of what I’m sure will be many more to come.
Another article on the same topic is here.
And another.
Receiving healthcare insurance doesn’t guarantee you medical care any more than receiving automobile insurance guarantees you a car.
And California is getting close to Florida as one of the states in which doctors should NEVER consider practicing medicine.

Topeka, Kansas VA Hospital is converting its emergency department into an urgent care clinic. As a result, the hospital no longer has to take ambulance runs. Hospital cites staffing shortages. Kansas Senator Jerry Moran alleges that the VA’s failure to hire appropriate staffing is “causing a … backlog of our nation’s heroes who are not receiving the heath care they need.”

Do doctors need to lie to patients? Is it ethical to tell a patient that everything will be alright when the doctor knows that is not the case?

Another example of selective government “transparency.” Feds want to release payment numbers to physicians for providing medical care, but refused to disclose how much money grocery stores were earning from government food stamps. Government attorneys argued that the data was privileged and exempted from the Freedom of Information Act. The 8th Circuit Court of Appeals shot down that argument.

Just Checking

February 22nd, 2014

CT BB NoseIn one of the hospitals where I work, when we order certain tests in the computer, we have to write the indications for the test on the order sheet. I suppose this isn’t a bad idea in some cases. For example, if an ultrasound might be better than a CT scan to look for the suspected diagnosis, writing the indication may help to provide the most useful test.

The problem that has popped up recently is that the typewritten indications have now turned into a full scale interrogation by the radiology techs. What symptoms is the patient having? For how long? What is the patient’s medical history? What medications?
Apparently this all has to be written on the order form for some patient safety protocols.

I’m even getting regular calls to ask if I “really want the test” and then ask why I am ordering the test – even though the indication for the test is written on the order.
Just double checking, of course.
It isn’t uncommon for two techs to ask me if I really want a test in some cases.

The director of the radiology department approves of all the questioning. After all, it improves patient safety. I’m not sure how repeated questioning improves patient care and I haven’t been persuaded to change or cancel any of the tests I have ordered, but I am now beginning to see how the pre-authorization process would dissuade some doctors from ordering certain tests. Some doctors just get tired of dealing with the hassles involved in ordering the tests.
I’m not one of those doctors, though.

Initially, I planned to just start typing “yes I really want the test” in the order comments. Then, my better judgment got the best of me. A statement like that probably wouldn’t look too good if the charts were sent to outside hospitals or other third parties.

Although the actions of the techs are frustrating, they are just doing the job assigned to them by their boss. Not really fair to give them a hard time.

How would you address the situation? Is it even worth complaining about? Let me know what you think.

Problem Found

February 17th, 2014

Stuffed Cat

An 8 year old girl was brought in for a psychiatric evaluation.

The child’s mother had a laundry list of abnormal behavior in which the child was engaging. The child allegedly scratched the eyes out of all her dolls – except her stuffed cat, of course. The patient breaks glass on the bathroom floor so no one can use the bathroom. She also screams incessantly. Oh, and today she threatened to burn down the house.

According to the patient’s mother, she was suffering from post-traumatic stress disorder after being beaten by her stepfather as an infant. Then, a couple of years ago, her pet kitten was found dead on the road. Ever since that time, the girl acts out and carries around a stuffed cat with her wherever she goes. And sometimes she carries a blanket, too.
All of this has to be discussed out in the hallway so that the patient doesn’t overhear these conversations and become more upset.

The child hadn’t said a word since she arrived in the emergency department. she just watched TV in the room as she clutched her stuffed kitten. She was still dressed in her coat and gloves as she went to sit on the bed.

“You’re going to have to take off your coat and sweatshirt so we can examine you,” the nurse told her.

The mother interjected “Yeah, well that will probably just get her sexually aroused, but what-ever.”

At that moment, the staff realized that the source of the patient’s psychiatric issues was likely neither the girl’s reported neonatal beatings nor her deceased cat.

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This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

Healthcare Update Satellite — 02-13-2014

February 13th, 2014

More medical news from around the web on my other blog at DrWhiteCoat.com.

No more “putting it on my account.” Due to cuts in payments from Medicare and Medicaid and expenses for treating uninsured patients, Hutchinson Hospital in Kansas will require payment for emergency department services, radiology, and outpatient surgery services before services are rendered.
Emergency department patients will still get screened, but apparently won’t receive non-emergency treatment if a partial payment isn’t made.
Florida Hospital Memorial Medical Center has implemented the same type of system – along with several other hospitals in the area. Hat tip to Scott (@Bnet_bobcast) for the link.
While many people think that emergency departments have to provide patients with medical care, that misconception is only partially true. Federal EMTALA laws only require hospitals to provide care for “emergency” conditions, so chronic back pain, colds, toothaches, and rashes are unlikely to qualify. Many hospitals provide the care anyway, wanting to avoid accusations in the news of “refusing care,” but those winds are changing.
Look for prepayment of nonurgent medical care in the emergency department to become a widespread policy as the Unaffordable Insurance Act ratchets down payments to medical providers. You’ll have insurance, but fewer and fewer doctors will be willing to provide you with care.
Then look for the government to pass more unfunded mandates requiring medical providers to provide care free of charge. Wait. That would never happen … would it?

One of the wildest things I have heard of in a while. Gang busts into Brazilian emergency department and robs patients waiting in the waiting room. Taking “patients gone wild” to a whole new level. Another story about the incident here.

Six ways to avoid “unintentional” Medicare fraud. Usually fraud requires “intent”, but not when dealing with providing medical care to patients on the government’s dime.
The best way to avoid unintentional Medicare fraud is to stop accepting Medicare patients.

Another entry in the “that’s why they call it dope” chronicles. Brainiac in UK went home to visit his mother from college, got high on mephedrone, cut off his woo hoo, and then stabbed his mum.
I was disappointed to see that there wasn’t a comment section to the article.

Canadian “Robin Hood” doctor has license suspended for six months after exaggerating patient’s food allergies so patients could get extra diet allowances from the government – to the tune of $1.8 million over 4 years. In the process, Dr. Roland Wong made $60 per form he completed and earned $718,000 in 2008 alone. Hat tip to Mark for the story.

Study in NEJM shows promise in using an implantable upper airway stimulation device to help control sleep apnea. The abstract doesn’t describe the device, but a small picture on the site makes it appear that the device is similar to a pacemaker and has an electrode implanted under the jaw.

New study in Pediatrics: What’s better for treating children with asthma – oral prednisone/prednisolone or IM dexamethasone?

Hospitals in Ireland so busy and stressful that nurses are checking themselves in to be seen in the emergency department.

Irish patient dies of heart attack while waiting in a “dangerously overcrowded and understaffed” emergency department. Consultants warn that “The risk of our next untimely death remains high while the emergency department overcrowding continues.”
And this is the type of system that we want in the United States?

Not a medical post per se, but may become a bigger issue in the future. A Virginia Court of Appeals held that the rating site Yelp! was required to disclose the identity of “reviewers” who left bad reviews about a carpet cleaning business. The business alleged that the reviewers were not his customers and the court held that there was no “free speech” right to make false statements.
Will the same logic apply to those who anonymously rate physicians and hospitals using Press Ganey? It should.

What’s the Diagnosis #18

February 11th, 2014

An elderly patient with hypertension, hypothyroidism, and dementia is sent from the nursing home by ambulance for evaluation of a rash to her scalp. The patient’s nurse had noted the rash that afternoon while putting the beret in the patient’s hair and is sure that the rash wasn’t there two days ago when she last cared for the patient.

Scalp Rash BeforeThe patient was reportedly sleeping more than usual the day prior to her transport. The nursing director at the nursing home was concerned that the patient had developed shingles to her scalp.

A picture of the patient’s rash is to the right (unfortunately, not the best clarity).  What’s the diagnosis and what is the treatment for this condition?

Scroll down for the answer.

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Answer: Acute Lipstick Misapplication

Scalp Rash AfterThe “rash” happened to be the same color as the patient’s lipstick. There were initially two spots. Both were removed with an alcohol wipe.
Treatment: Discharge with close follow up.

Wait … not so fast.
Upon learning of the patient’s imminent return, the nursing director from the nursing home called back the emergency department and stated that no one had addressed why the patient had slept more than usual. After all, the patient reportedly slept past breakfast the day prior to her transport.
There was a bit of a discussion between the nursing director and the emergency department nurse which then escalated to a discussion between the nursing director from the nursing home and the nursing director from the hospital. Eventually, the patient had several lab tests performed in the emergency department to rule out anemia, electrolyte abnormalities, and hypothyroidism as a cause of the patient’s acute transient hypersomnolence.
When the labs all came back normal (except a mildly low sodium), the patient’s doctor had to be contacted in order to tell the nursing director from both facilities that it was permissible to send the patient back to the nursing home.
The nursing home then had its transport van come to pick up the patient.

Wait … not so fast.
The transport van was not available. It only runs between 8AM and 2PM. It was 4:30 PM.
So an ambulance had to be called to transport the patient back to the nursing home at a cost of roughly $400 plus $37.50 per mile.

The final result was an awful expensive bit of lipstick

Discharge instructions nearly included an order to set the patient’s alarm clock for 15 minutes prior to breakfast each day, but the emergency physician decided that there were enough phone calls made to hospital administrators regarding this patient for the day.

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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.

Open Mic Weekend

February 9th, 2014

theatre curtainIt’s been a year since I last did this and I’ve had a couple of people send me questions about medical issues. Interest has varied in previous Open Mics, so we’ll see how this one turns out.

Like Reddit, you can “Ask Me Anything” in the comments section and I’ll give you the best non-binding informational answer I can give you.  I’ll be back Tuesday to answer questions and any of the other readers who want to chime in are welcome to do so.

The only rules are that there are no personal attacks and that the comments/questions have to be medically-related.

Let the show begin …

Healthcare Update Satellite — 02-06-2014

February 6th, 2014

More medical news from around the web over at my other blog at DrWhiteCoat.com

Holy feces, Batman! How bad of a marriage do you have to be in for your wife to inject “fecal matter” into your IV line while you’re recovering from a heart procedure in the hospital? Whacked out wifey is a former nurse who will now enjoy an extended stay in Arizona’s Maricopa County jail. Thanks to PJ for the link!

Pennsylvania jury awards a $32 million judgment against two nurses who failed to notify an obstetrician about a change in the fetal heart rate for 13 minutes during the mother’s labor. Child later born with cerebral palsy. Hospital, doctor, and a third nurse were all found not liable for the injuries.

The “Affordable” “Care” Act is keeping costs down alright … by refusing care to sick children. A 2 year old with a neck mass being evaluated for cancer, a child with a chronic severe medical condition, an infant with a skull abnormality – all denied care in Washington.

Patients aged 55 and over in Washington State who sign up for Medicaid aren’t getting “free” care. After their death, the state comes after all the assets in their estates, seeking reimbursement for all the medical expenses it has provided.

Texas patient high on methamphetamines convicted of assault on emergency service personnel and faces up to 10 years in prison in sentencing hearing next month. Lola Thompson reportedly headbutted a family member trying to drop her off at the hospital, breaking his nose, then attacked an emergency department nurse, punching her in the face five times. Thompson required three times the normal dose of sedation to calm her down.

Nurse in Canadian emergency department tells anorexic patient with “mental problems” to “go get some supper and come back.” Patient reportedly felt like cutting herself and wanted to “speak to somebody,” but apparently had no other emergency medical issues. Abuse of the emergency department, uncaring staff, neither, or both?

As Ecuador plans to change its malpractice code to establish a 3-5 year prison term for health professionals who cause death by “unnecessary, dangerous and illegitimate actions,” 150 doctors have resigned. Ecuadorian President Rafael Correa says he has more than 700 doctors from other countries who would be willing to practice in Ecuador if the current physicians leave. Wonder if the foreign docs know about the new malpractice law …

Portland, Oregon emergency physician Dr. Jamie Schlueter is one of the team docs for the US athletes in Russia. Excited to go and “hopes no one needs me” – a comment that, for some reason, pisses off one of the readers.

Feds investigating president of American Academy of Pain Medicine after several of his patients die from medication overdoses. One patient notes that his wife went to the physician’s clinic, was initially seen by the physician and then her care was transitioned to a nurse practitioner with “no oversight.” In 14 months, the patient’s medication dose had increased more than sixfold.

Interesting side note is that deaths from drug overdoses in women increased fivefold between 1999 and 2010. In 2010, more than 15,000 women died from drug overdoses and nearly 1 million women visited the emergency department for drug abuse or misuse.

Even more interesting side note is that the fivefold increase in drug overdose deaths in women seemed to start shortly after the Joint Commission declared pain as a “fifth vital sign” and made pain management a “standard.
Has anyone ever considered that the Joint Commission edicts may be responsible for increasing patient deaths?

Should we be doing pelvic exams in the emergency department? In 94% of patients, the results of the exam had no effect on the clinical plan. Good discussion in the comments at ALiEM.

Guaranteed Referral

February 4th, 2014

EarEmergency physicians are generally a good group of people. Most of the time we will go out of our way to try to help you. Sometimes, things just won’t work out, though.

For example, if you bring your child in with a bead stuck in her ear and the first words out of your mouth when the doctor walks in the room are “If my daughter so much as WHIMPERS when you’re trying to get this bead out, I will SUE you!”

Suddenly, the doctor might not feel so comfortable with his or her ENT skills.

Sure, the doctor will examine your daughter to make sure she doesn’t have an emergency medical condition. But then when there is no longer an “emergency,” the law doesn’t force us to risk a lawsuit by digging around in your child’s ear.

In that case, you might get referred to the only ENT in about a 40 mile radius … who doesn’t take your “insurance” … who requires a $200 deposit at the time of the appointment for people whose insurance he doesn’t accept … and whose appointments are probably booked up for the next couple of weeks.

And there’s a pretty good chance that if you make the same threats to him, he’ll just flat out refuse to see you.

In that case you could always call your lawyer to see if he could help you.

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This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

Healthcare Update Satellite – 01-30-2014

January 30th, 2014

More medical news from around the web over on my other blog at DrWhitecoat.com

St. Barnabas Hospital in Bronx, NY registers a patient in emergency department to be seen for a rash. Told to go sit in the emergency department. Was called several times over the loudspeaker but didn’t answer. Found “stiff, cold, and blue” 8 hours later.
An unnamed hospital employee told news that the man died because there is “not enough staff to take care of the number of patients we see each day.”
Comment sections of both articles about the story have created a crowd of people with torches and pitchforks relating their own ED horror stories and demanding to know how hospital staff could be so stupid not to know that rashes could be deadly.

Virginia emergency department closed four hours due to … bedbugs. I’m guessing that they aren’t just in the ED, but that’s another story.

Repeal and replace. Republicans offer framework for a health care plan to replace ObamaCare. Will it work? I wonder if telling everyone “you have to pass it to find out what’s in it” would suffice.

Go to one San Jose, CA hospital emergency department without insurance and you’ll get someone offering to sign you up for ObamaCare while you’re sitting in the waiting room.

Doctors Medical Center, the largest emergency department in California’s West County with more than 41,000 visits per year at risk of closing – due to lack of funding.
Doctors Medical Center handles 79% of the region’s hospital admissions, 62% of the region’s ambulance traffic and 59% of the region’s emergency room care, yet 75% of the patients have government “insurance” – which is being cut – and another 11% of patients have no insurance at all. Only 12% have private insurance with who knows how high of deductibles.
“Hospitals are facing $23 billion in government payment cuts through 2020, so independent safety net hospitals that don’t have the large number of private payers face a huge challenge.”
Who’s left to pick up the tab? Taxpayers. The county has already passed two prior property tax increases to help keep the hospital open and is considering a third in November.

And then we wonder why patients with insurance are charged $89,000 for going to the emergency department with a snake bite. Different state, private hospital, same issue.

In Sweden where the government is trying to “guarantee patient care,” patients are purchasing health care insurance so that they can get timely care. Even then, the waits are longer than we would be accustomed to in the United States. “It’s quicker to get a colleague back to work if you have an operation in two weeks’ time rather than having to wait for a year.”
Remember the Engineer’s Triangle: Fast Care, Cheap Care, Quality Care – Pick any Two.

Hospital orderly finds patient’s purse in emergency department and turns it over to a hospital security guard. Security guard then rifles through purse, takes patient’s debit card, leaves work, goes down the street to a fried chicken joint, and withdraws $1,400 – all while patient was still in the emergency department.
When security guard gets back to hospital and sees patient speaking with police officer, he tries to give money back to the patient.
Now the security guard is under arrest and the bail is $5,000. No, he didn’t put down a $1,400 deposit.

Obese preschoolers are four times as likely to become obese teenagers.
Dr. Wikipedia beating out Dr. Google for health care searches. Wikipedia is reportedly the leading source of health care information for both patients AND physicians.
My guess is that the reason for Wikipedia’s dominance has something to do with Wikipedia entries appearing at the top of the search results when someone seeks out a topic.

Don’t go parking in the emergency department patient’s lot if you work at the University of Iowa. They’ll fire you quicker than their clerks take insurance information. News just broke of a third employee fired for the offense (and denied unemployment benefits). Husband and wife employees were fired for the same thing a couple of months ago.

Thrombolytic Use in Ischemic Stroke

January 26th, 2014

Brain CTUse of thrombolytic therapy in ischemic stroke is a perennial hot topic. Chances are that you will have as many people swearing AT the idea as you have swearing BY the idea of using thrombolytics for acute strokes. That fact alone should demonstrate that there is no “standard of care” for thrombolytic use in ischemic strokes.
If reasonable board certified doctors can’t agree that the risk of tPA outweighs the benefit of using tPA, how can there be a “standard” for using it?

I could go through the data and discuss the pros and cons of each trial studying thrombolytic use, but Dr. David Newman has done a far better job than I could ever hope to do and his analysis of thrombolytic therapy in acute ischemic stroke is published on TheNNT.com. In summary, of the available studies on thrombolytics up to March 2013, Dr. Newman found …
Two studies showed a marginal benefit in using thrombolytics
Four studies showed a demonstrable harm in using thrombolytics
Six studies showed no benefit from using thrombolytics

Back in 2011, EP Monthly asked for opinions on thrombolytic use for acute ischemic stroke in its now-defunct Standard of Care project, but those important data were never published or made available to the people who voted.

The debate over tPA use came to a head last year when ACEP representatives met with experts in the field of ischemic stroke, including representatives from ACEP and AAN and developed a policy which was then reviewed by representatives from the Society for Academic Emergency Medicine, the Emergency Nurses Association, the American College of Physicians, the Neurocritical Care Society, the American Academy of Family Physicians, the National Stroke Association, and the American Stroke Association.
The final “evidence based” policy advocated “offering” tPA to acute ischemic stroke when certain criteria were met (.pdf file).  This recommendation was given a “Level A” status, meaning that it constituted

Generally accepted principles for patient management that reflect a high degree of clinical certainty (ie, based on strength of evidence Class I or overwhelming evidence from strength of evidence Class II studies that directly address all of the issues).

Needless to say, there was a lot of discussion after these “evidence based” “guidelines” were published.

Some people questioned whether this “evidence based” policy would create worse patient outcomes. Others were concerned that the guidelines, even though they contained a disclaimer, could create legal liability when not followed. Still others wondered whether this clinical policy was even helpful in determining a course of action since there was no “consensus” statement, only an “evidence based” policy.

Then the British Medical Journal advocated using a healthy “skepticism” in reviewing the data since almost all of the study authors had either direct or indirect ties to companies that manufactured thrombolytics:

for one of the guidelines recommending alteplase, seven of eight panel members had ties with industry: three had direct relationships with companies that market alteplase, while four had links with an educational foundation wholly funded by industry, whose president and founder was an outspoken advocate for alteplase on acute stroke. The remaining author had resigned from the panel six years earlier

Even more troubling is that several of those authors allegedly did not disclose their ties to the manufacturers in the publication of the clinical guidelines (which, if true, would constitute an ethical violation). See table below – taken from this article.

Thrombolytic Author Conflicts of Interest and Disclosures

EM Literature of Note Blog weighed in on the issue, stating:

Whichever side of the expand/limit tPA in acute stroke debate you fall upon, the issues of sponsorship bias, one-sided panelists on a still-controversial practice, and lack of open peer review for the ACEP/AAN guidelines ought to be unacceptable.

Ten months later, ACEP just might be listening to some of the criticism. There is now a form on the ACEP web site where, for the next 60 days, ACEP members can comment on the thrombolytics in acute stroke policy and provide “supporting evidence” for their comments. These comments will then reportedly be presented to the ACEP Board.

http://www.acep.org/commentform/IVtPA-Stroke/

I encourage interested parties to go to the site and add their comments.

Unfortunately, we don’t know whether the comments will also be available for public view. That’s the reason for this post.

I’m asking two favors from the readers who have an opinion on this topic.

First, vote in the poll below. It will provide data that will hopefully be available for web searches far into the future.
Second, if you have an opinion or additional “justification” that you plan to enter on the ACEP site, please also enter it into the comment section below. In that way, the comments – both pro and con – will be available for public review and discussion.

When answering the poll, keep in mind that the “standard of care” is what a reasonable physician would do under the same or similar circumstances. As noted on the defunct Standard of Care site, the standard of care is NOT “what the Best Practice would be, (arguably the top 5%); or what YOU would do (the top 25%); or or even what MOST physicians would do (the top 50%).”

The standard of care is the tipping point between “negligent” and “non-negligent” behavior. In essence, the question as asking whether a doctor has violated the standard of care and is therefore negligent and liable for damages if he or she does not administer tPA to an acute ischemic stroke victim.

Administering Thrombolytics for Acute Ischemic Stroke

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