WhiteCoat

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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Please don’t forget to add comments in the comment section!

CMS One Way Data Transparency

January 23rd, 2014

1-23-2014 8-42-19 PMAccording to an article on the CMS Blog, in 60 days the government plans to begin disclosing information regarding payments it has made to individual physicians. In order to receive the information, there has to be a FOIA request and each request will be evaluated on a “case by case basis” which means it is unlikely that they plan to just give their entire payment database over to the first person who makes an inquiry. However, the CMS blog states that the government is planning to publicly disseminate aggregate information regarding payment information.

The AMA, all of the State Medical Societies, and a few dozen specialty societies all oppose the idea (.pdf file), alleging that privacy rights of the physicians would be violated, that releasing raw data would result in “inaccurate and misleading information,” and that releasing information such as a physician’s National Provider Identifier would subject the physicians to identity fraud.
On the other hand, watchdog groups such as the “Council for Affordable Health Coverage” believe that all of the data regarding physician payments should be on a publicly accessible database rather than being disseminated on a case-by-case basis.

CMS responded to the medical establishment’s concerns by stating that before releasing individual data, it will consider the “importance of protecting physicians’ privacy and ensuring the accuracy of any data released as well as appropriate protections to limit potential misuse of the information.”

To me, this should be a no-brainer. If any entity does business with the government – not just physicians – disclosure of what services are being performed and what payments are being made should be a right to every citizen.  Remember that whole bit about establishing a constitution on behalf of “We the People”? Remember Abraham Lincoln’s dream of a government of the people, by the people, and for the people? People are the government. If We the People are paying for services through taxes then there is always an overwhelming public interest in seeing how much We the People are paying. If those providing services to the government don’t like it, then do business somewhere else.

With very few exceptions, We the People should be able to see a full and detailed accounting of all government income and expenditures – not just aggregate physician payments.

That’s where CMS’ whole “we’re disclosing physician payments to prevent fraud and abuse” argument falls apart.

Payments to individual doctors are going to be disclosed. Also, any payments or “transfers of value” physicians receive from pharmaceutical companies or medical device manufacturers is also on a government database.

What isn’t going to be disclosed?

  • It isn’t clear whether CMS will release payments to physicians per individual procedure or per individual office visit. My guess is that it won’t. So you won’t know whether your doctor works 4 hours a day twice a week or 12 hours a day for seven days a week to get the payments that CMS is disclosing. You won’t know the overhead in the doctor’s office or the amount of the payments on the doctor’s student loans or the thousands of dollars each month that the doctor pays in malpractice premiums. CMS won’t tell you to divide their “payment” by at least one third to account for taxes that the doctor pays. CMS will just provide you with a number so that everyone can shake their heads at how unfair it is that medical providers are being paid so much
  • It also isn’t clear whether CMS will break down payments to hospitals by specific ICD-9 or CPT codes. To be fair, CMS has published aggregate data for payments to hospitals for the top 100 DRGs, but those payments are several years out of date, in the aggregate, and only involve “average covered charges” and “average total payments” but do not itemize what CMS pays the hospitals for specific services. The aggregate payments include intangible variables such as “teaching,  disproportionate share, capital, and outlier payments” so it is impossible to compare “apples with apples” using the data.
  • And CMS definitely won’t divulge information about patients. The Federal Register Notice (.pdf file) signed by CMS administrator Marilyn Tavenner and approved by Kathleen Sebelius, the Secretary of the Department of Health and Human Services specifically states that “in all cases, we are committed to protecting the privacy of Medicare beneficiaries.” Those superusers and drug seekers who run up the health care tab on the public dime are protected from scrutiny.

On one hand, CMS alleges that it wants to create transparency to avoid fraud, but on the other hand it releases only select data.

Where is the data on how often CMS has denied payments to physicians or to healthcare organizations for services that were provided?
Where is the data showing why those payments were denied?
Where is the data showing how often the denials were reversed and how much extra time that CMS was able to avoid paying for legitimate services by inappropriately denying payments?
Where is the data on the average length of a phone call it takes to contact CMS regarding an inappropriate denial?
The fact is that we don’t get the “transparency” when we look back at CMS.
It’s a one-way mirror.

If we’re really interested in combating fraud, why can’t we get FOIA requests for aggregate payments made on behalf of patients? We don’t need to know what the payments are for and public agencies delivering social security or welfare benefits are not covered by HIPAA privacy rules, so don’t even go there.
Shouldn’t it be my right to see how much of my tax dollars are being paid to the guy on disability down the road with the souped-up Escalade who goes on vacation more than I do and who is out on the golf course all day? Or is it that fraud only of “public interest” when it is committed by medical providers?

CMS is taking this approach for one reason – to vilify medical providers.

With 37% unemployment in this country, medical providers are an easy target. Publish data that inflame a large proportion of the population, allege that medical providers are being “greedy” for not accepting pay cuts, then use that negative public opinion as a means to justify cutting payments and creating even more laws and regulations that make the practice of medicine even less appealing. When you’ve driven enough providers out of health care so that there isn’t sufficient access to all the aging baby boomers and newly-minted Medicaid patients, you can blame that on the medical providers, too. How dare we not provide care to our fellow citizens.

I’m all for transparency, but there needs to be global transparency, not a bunch of smoke and mirrors labeled as “transparency” and used as a means to an end.
You want to publish the data? Publish all of the data.

Come to think of it, maybe we can create public databases of all the payments and perks to all government officials. How much in “transfer of value” has Kathleen Sebelius received since she entered office? Business trips? Meals? Office supplies? Travel?

Betcha those numbers would put payments provided to most medical providers to shame.

Name That Rhythm

January 22nd, 2014

I’m posting this here today because I really don’t know the answer to the question and I wanted to get some opinions from the couple of you who still read this blog.

A patient in his 70′s comes in by ambulance with a complaint of dizziness. As part of his workup, we get an EKG which is noted below. I wasn’t able to figure out the rhythm. A cardiologist came down to the ED to evaluate the patient and wasn’t able to tell me what the rhythm was, either. He only stated that it “isn’t malignant” and it “isn’t what’s causing the patient’s dizziness.”

There is a P wave before every other QRS. The PR interval appears to be constant on those beats.
The R to R intervals appear to alternate and are regularly irregular.
The QRS morphology is narrow and seems to be constant, so it doesn’t appear to be bigeminy.
I guessed that it was a Mobitz II. The cardiologist said “no way.”

Your opinions? If you want to get a better look at the EKG, you can click on the picture. Also, a link to a .pdf copy of the EKG is here.

Undetermined Rhythm EKG

Healthcare Update Satellite — 01-19-2014

January 20th, 2014

Hospital administrators may be sabotaging their own satisfaction scores by boarding patients in the emergency department.
New study in Journal of Emergency Medicine shows that 6 out of 7 patients prefer inpatient boarding to boarding in the emergency department because inpatient hallways are deemed safer, more confidential, more comfortable, quieter, more private, and as having higher staff availability.

Interesting article in Medium about how physician inventors have created new products out of necessity – and why some products are more likely to go to market than others.

I have a funny feeling that this will be the most clicked-on article this week. Porn star’s health is reportedly in jeopardy from her O-cup breast implants. She can’t perform activities like getting dressed and alleges that the implants diminish her blood flow to her body and may cause blood clots. Doctors recommended double mastectomies, but the patient refuses, saying that it would ruin her career.

Usually we get those little baby roaches. This thing must have been huge. Australian man has inch-long cockroach pulled from his ear. When he first developed pain in his ear and figured out that it was a roach, he tried using a vacuum to get the critter out of there. When that didn’t work, he went to the emergency department and the doctors removed the roach with tweezers.
What should you do to keep cockroaches out of your ears? You can sleep with cotton in your ears or use earplugs. Once they’re in there, they usually can’t get out – either because of the wax in the ear or the tight fit of the ear canal (I’ve heard that roaches can’t crawl backwards, and with the angle of their legs, that makes sense, but I’ve never seen that confirmed by an entomologist). To get them out, first they have to be killed, then usually you have to use alligator forceps to grab them.

Midterm ads blasting Democrats by name for supporting Obamacare.
Vote them out. Then repeal the law just like they repealed prohibition.

Plaintiff allowed to proceed with her malpractice case against orthopedist who diagnosed her with lymphedema when patient develops a blood clot a year later and requires an amputation. Orthopedist recommended that she follow up with neurologist for numbness in her foot rather than a vascular specialist for her lymphedema.
The patient had symptoms for a year, didn’t seek further care, and it is the orthopedist’s fault?

University of Iowa fires employee for parking in the emergency department patient parking lot. The sign in the lot said that violators could be fined or towed. Administrative law judge rules that the firing was justified anyway – “she received a benefit intended for employer patients.”

California having lots of success enrolling patients in Obamacare … by enrolling patients in the emergency departments. Many of those patients are enrolled into Medicaid which will only strain the insurers and states even further.

Should doctors be Googling their patients? The article author, who is a physician, thinks not – it may cause the doctors to have inappropriate preconceived notions about patients. I think that if the information is available, the doctors should have the option to review it. It isn’t like patients don’t Google doctors and get misleading statistics from hack sites like Healthgrades.com.

Get your flu shot. Influenza is widespread throughout the US right now.

Don’t get your flu shot. It could cause you to develop narcolepsy.

Have chronic pelvic pain? The good news is that a doctor has developed a device that may cure it. The bad news is that men have to insert a hammer-shaped probe up their rectums in order for it to work.
Hat tip to Instapundit.

Exciting research by scientists at Cornell. By coating leukocytes with special proteins, they were able to form “unnatural killer cells” that would find and kill cancer cells floating in the circulation. You need an advanced degree to understand the paper, but if they can get the process to work reliably on humans, it will be a huge breakthrough for cancer treatment.

Abusing the system? Patient gets airlifted from Galapagos Islands by an Ecuadorian navy helicopter and then takes jet to US in order to receive treatment for a kidney stone.
If your name is Jeff Bezos and you’re paying the tab, you can get whatever treatment you want.

Australian emergency departments trying to cope with inappropriate emergency department use are considering charging patients a co-payment. Detractors argue that patients will avoid accessing care that they need if they have to pay for it.
They’ll probably avoid accessing care that they don’t need as well …

Healthcare Update Satellite — 01-07-2014

January 7th, 2014

In Great Britain, the emergency departments are having problems with “superusers” as well. According to a survey of about 60% of the hospital trusts and boards in the UK, almost 12,000 people used the emergency department an average of once a month in 2012 while 150 patients used the emergency department an average of about once a week. At least a couple of patients averaged visits more than 4 times per week for the entire year.
The biggest problem according to the people being interviewed is that the care in emergency departments is more convenient than waiting for an appointment with a GP.

This article alleges that half of all British patients going to the emergency department don’t need treatment, a third only need medical advice, and 13% don’t even need medical advice.
British doctors are now trying to get patients to ante up £10 for using the ED, which one physician says would probably “cut the attendances by half.”
Those against the proposal argue that “you’re never going to get any money out of those drunks, while there is a real risk that patients who need help will not bother because they can’t afford it.”
So what’s the right answer?

Chain of Florida hospitals belonging to Health Management Associates is under investigation for allegedly providing emergency physicians with kickbacks to perform unnecessary testing and inappropriate hospital admissions. Hospital administrators allegedly told emergency physicians that 75% of all Medicare patients should be admitted.

Pennsylvania jury awards $55 million to a patient who was born with cerebral palsy after getting stuck during a vaginal delivery. Lawyers state “If they’d delivered him by C-section, he would have been fine.”

Patients gone wild is back. Texas woman jailed after punching emergency department nurse when nurse told woman to go sit in the waiting room. Woman stated that she “didn’t appreciate” the nurse’s attitude. Now woman faces 2-10 years in the Greybar Motel and a $10,000 fine.

Make it stop. The show, I mean. Latest episode of Sex Sent Me to the ER reportedly involved woman who couldn’t stop having her orgasm after 3 hours.
You can even see part of the episode acted out on a video at the link.
I heard that the ED staff got her orgasm to stop by showing her a picture of Eliot Spitzer. Is that correct?

Answer the questions on medical board applications accurately. Idaho doctor gets publicly reprimanded by Idaho State Medical Board and must pay $500 fine plus $400 Board costs after failing to list a medical malpractice lawsuit on her board renewal application.

Hawaiian prison inmate suffering severe scrotal pain and swelling that made his scrotum appear the “size of a very large grapefruit” sues state and wins almost $1 million when he requires scrotal amputation due to infection. The prison physician reportedly gave him inappropriate antibiotics and the wrong dosage. The judge disagreed that state physicians should be immune from liability.
Since this ruling is the first case of its kind to get to the Appellate level, will medical care in Hawaiian prisons now get better, get worse, or stay the same?

Nice summary article on what to do if your tooth is knocked out. Summary: The best place for the tooth is back in the socket. If you can’t get it back in the socket, put it in some warm water or milk. DON’T scrub the tooth – doing so will damage the periodontal ligament and make it less likely that the tooth will stay reimplanted. Get to a dentist or an emergency department as soon as possible.

Unconventional Sign Language

December 31st, 2013

Shaka Brah Gesture_raised_fist_with_thumb_and_pinky_liftedThe patient coming through the door was having trouble breathing. No doubt. You could hear the hiss of the nebulizer as the cart whisked by the nurse’s station into a room.

Most people knew the patient from prior emergency department visits.
Bad asthma
Steroid dependent
Several previous intubations
Last ED visit a couple of months ago

Unfortunately, being in the middle of doing a central line on a septic octagenarian with a systolic blood pressure less than her age makes it difficult to go evaluate a new patient.
I asked the nurse to go get me one of the PAs.
“Do me a favor,” I said to the PA, “Go take a peek at the new patient and see how she’s doing.”

After a minute, the PA came back and said “Everything looks pretty good. She’s trying to get comfortable on the cart right now. Her lungs have a few wheezes but are pretty clear. Her saturation is 100%. She even gave me the ‘Chaka Brah‘ sign.”

Good. Now I can finish getting this line in place.

A few minutes later, there was a commotion from down the hall.
“We need a doctor in Room 3 NOW!”
Room 3? That’s the asthma patient’s room. I looked at the PA. She looked back at me with horror.
“Just hold the dressing on this line until I come back and sew it in place, OK? Thanks.”

In Room 3, the asthma patient was diaphoretic and was moving very little air. She was tripoding. She gave me one look and did the “Chaka Brah” sign at me, too — pretending like her fingers were like an endotracheal tube and repeatedly poking her thumb at her lips through her nebulizer mask.
Then she started slapping the side of the bed and shaking her head.

Dammit.
We need to move fast.

“We’ve got you. We’ve got you. We’ll have the tube in in a couple of minutes. Just hang on.”
The patient spun her index finger in quick circles.
I know. I’m hurrying. Fortunately the paramedics had a line. Oxygen.
Crash cart. Ketamine. Sux. Tube in. Start the propofol.
Lung sounds bilateral but diminished. She’s not moving a lot of air. That’s why her wheezes were so faint.
Steroids and in-line nebs.
Sats good.
“Relax, kiddo. You’ll be better with the medications. We’ll keep a close eye on you.”

[Exhale]

Back to the octagenarian to do some quick suturing and some quick didactics in asthma, respiratory distress … and how to interpret unconventional sign language.

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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 — 12-30-2013

December 30th, 2013

More updates on my other blog at DrWhiteCoat.com

North Las Vegas VA Hospital emergency department repeatedly “disrespected and mistreated” a 78 year old diabetic volunteer with more than 5,000 hours of service at local VA facilities. A few weeks after two visits for a colon problem, the patient died in a hospice. When the patient’s friend went to get video of the events from the emergency department, the footage had been erased.

What types of things do Australian emergency departments see on Christmas? Stonefish stings, jet ski accidents, inhaled foreign bodies … not that different from the US, although I had no idea what a stonefish was until I looked it up. Kind of reminds me of my sister.

Back in the US, some emergency physicians are noting “desperate” behavior during the holidays from patients looking to cope with loneliness – manifesting itself in excess drug and alcohol use, excessive sleep, and angry moods.
Other physicians see this behavior every day.

And back to Australia again … Now Press Ganey is “global,” ranking emergency departments in Australia.
Seems like the hospital in the article cut waiting times by doing a lot of things we already do in the US. One thing we aren’t doing, though is seeing patients in order of arrival instead of triaging patients first. Little uneasy with that concept.
“Yes, Mr. Dwyer, you do seem to be having a heart attack, but there was a family of four patients registered ahead of you in the emergency department who have all had runny noses and coughs for the past month and who haven’t had time to get into their family physician.”

Oooh. Can’t wait to see this show. [eyeroll] Sex Sent Me to the ER.
Let’s see. I’ll run down the entire season in one sentence: injuries from doing it where you shouldn’t be doing it, foreign bodies where they shouldn’t be, torn female parts, broken male parts, beatdowns after getting caught with someone else’s partner, and diseases. That about covers everything.
Aaaaand I wasn’t too far off. I found this article from the NY Post discussing other cases in this week’s episode. Stroke “mid-shag,” broken penis, painful orgasm, injuries, more injuries.

Want some sex-related medical news stories?
Florida patient has penile implant placed, then sues surgeon and anesthesiologist when he develops post operative infection requiring amputation of his penis, alleging that “doctors should have known that he was not a good candidate for the procedure because of his diabetes and high blood pressure.”
Beware the bad outcome.

Texas man sues manufacturer of a sexual enhancement supplement after man buys supplement at gas station en route to a hotel for a tryst with is “paramour.” During his episode of carnal knowledge, the man states he suddenly had severe penile pain and that his penis then allegedly began spraying blood over the sheets, wall, and mirror like some broken fire extinguisher. He then went to an emergency department where doctors allegedly had to deglove his member (i.e. pull off the skin like removing a glove from the fingers) in order to repair it.
The plaintiff’s treating physician definitively linked the sexual enhancement supplement to the man’s injuries. I’m sure that rough sex had nothing to do with it.
So keep this in mind, dear readers: Taking roadside erection aids may cause your penis to spontaneously snap in two. A treating physician and a plaintiff’s attorney have vouched that it can happen.

Get your flu shots while they’re still around. Latest round of media reports showing that “killer” flu is back in circulation cause increased demand for immunizations. Most of the confirmed cases of influenza are the dreaded H1N1 “swine flu.”
The CDC Influenza Map shows that most of the US has either regional or widespread influenza activity.

Or, if you’re not inclined to have a flu shot, you can just be fired instead. At Pennsylvania’s Horizon Healthcare Services (a group owned by Lancaster General Health, Reading Health System, PinnacleHealth System and Penn State Hershey) a pregnant nurse refused the flu shot for fear of inducing another miscarriage, offers to wear mask instead. Hospital system fires her anyway.

Emergency department in Wigan Infirmary in the UK increasing police presence during the holidays after more than 200 assaults have been reported by staff members increases from 98 last year to 106 this year. That’s twice per week where the staff is actually reporting the violence.

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