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Author Archives: WhiteCoat

The $500 Emergency Popsicle

Popsicles

Natalie Fuelner created a well-written article in the Bangor Daily News describing some of the tribulations many new parents go through with young children. One weekend, her toddler fell face first onto a metal patio table. Immediately, the toddler’s face is full of blood. The dad panicked. Natalie was a “trembling mess” on the inside. Their physician neighbor wasn’t available to look at the child. They didn’t want to wait two and a half hours at the urgent care center. They were both still panicking, so they went to the emergency department where they were evaluated immediately by an emergency nurse and then 10 minutes later by an emergency physician. The emergency physician evaluated the child, determined that putting stitches into the laceration on the child’s lip would be more traumatizing than letting the laceration close on its own, then gave the child a popsicle. Wait? That’s it? Suddenly their panic was gone. Then they felt embarrassment. A couple of weeks later they received a $514 bill for the services and Ms. Fuelner quipped “That was one pricey popsicle.” One innuendo from the article seems to be along the lines of a comic I once saw from Bob Vojtko. An elderly woman was pointing her finger at a doctor saying “I spent $4 in cab fare to get here, so you better find something wrong with me.” Another underlying theme in the article is that many people don’t realize the costs of providing medical care in this country. I absolutely agree that $500 is a lot of money. And based on Ms. Fuelner’s perceptions, some people may think that she got “ripped off” for the services she received. Unfortunately, in the world of $20 copays and government-mandated free birth control pills, there seems to be a pervasive belief that medical care should cost less than an appointment at a hairstylist and should definitely cost less than the newest iPhone. See a prior article on this topic from Birdstrike here. As many communities are finding, the less you pay for medical care, the less medical care you have available. A few examples are here, here, here, and here, but an internet search will undoubtedly reveal many more articles about hospitals or departments that have closed because of insufficient funding. Let’s look at what Ms. Fuelner got for her $500 … She got the convenience of immediate access to a large business providing services to the public that is open every minute of every day. That business has millions of dollars of overhead costs every year that it must pay just so that it can keep its doors open. She got immediate access to expertise from a nurse who spent tens of thousands of dollars to go through years of post graduate training and who gave up her weekend so that she could be there to care for sick and injured patients. She also got immediate access to a physician who spent hundreds of thousands of dollars and went through even more post graduate training, and who also gave up his weekend so that he could be there to help sick and injured patients. Those are just the two medical professionals who cared for her child. I’m sure there were many more available in the department. I could go on and on about all of the hard-working personnel in the hospital whose services are available and who contribute behind the scenes to many patient visits – radiology, lab, surgical personnel, registration clerks, billing department, housekeeping, maintenance, cafeteria, security, IT, and many others – even administration, but hopefully you get the point. The hospital also has advanced diagnostic equipment costing millions of ...

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Healthcare Update – 06-09-2015

HC Update 12

Check out other news from around the web on my other blog at EPMonthly.com Super glue mistaken for sexual lubricant, patients brought in by ambulance – stuck together by their genitals. Or maybe not. Turns out Scott Paulson, a reporter from Examiner.com, was punked by a GomerBlog-like headline. Newswatch 28.com reported the original story, along with other stories about a woman who has been pregnant for two years and how the FDA has approved tranquilizer darts for use in children. He did verify the story on RoastRoom.com, which was surrounded by ads about disturbing photos, gut yeast, and a baby born without a nose. Mr. Paulson’s article turns up as a 404 error now, but the Google Cache from his article is here. A screen capture is here. I know I’ve linked to some questionable articles in these Updates over the years, but this whole episode just struck me as funny. By the way, did you know that a woman was banned from KFC for breastfeeding her 48 year old son? It’s true. It was reported on Newswatch 28.com. In 2001, Portugal decriminalized use of all drugs. What effect did this move have on drug deaths? The latest statistics released from the European Monitoring Centre for Drugs and Drug Addiction show that Portugal has the second lowest rate of drug overdose deaths in all of the European Union. Don’t know whether we can equate correlation with causation, but the numbers are still pretty impressive. Dammit. To think that I just got done making a fresh pot of placenta soup. Despite what you hear on television and despite what other animal species do, there is no convincing evidence that eating a placenta after birth will prevent pain, prevent postpartum depression, boost milk production, or provide any other health benefits. I could be really gross right now, but I’ll just leave it at that. What do patients want from their insurance programs? A survey by … America’s Health Insurance Plans … says that patients don’t value choices and would accept narrow networks. In addition patient’s reportedly don’t care whether their physician is in network as only 26% said they would leave a network if their doctor stopped participating in it. The thing is that the “Vice President for Medical Transformation” at Highmark said that insurance companies are more than willing to kick doctors out of networks if the doctors don’t “change” by holding down costs. So the doctors in network may be more likely to take the cheapest course of action in treating a patient’s complaint. Fast care, cheap care, quality care. Pick any two. Cost effective use of DNA analysis – to catch the Chili’s worker who hawked a loogie in your drink. It only took three months for the results to come back, though.The next step toward curbing medication abuse. Hospitals in Wyoming now forming committees of administrators and doctors to create lists of medication abusers. If a patient’s name is flagged in the system, the hospital will send out certified letter to the patient stating that they will not be prescribed painkillers for anything other than a dire emergency. One New Mexico hospital that took this approach cut down its number of emergency department visits by 5% and saved $500,000 in one year. Of course then patients will complain about the emergency physicians who refuse to prescribe the pain medications. This study will be cited liberally in accusing emergency physicians of being the source of opiate addiction. A study in Annals of Emergency Medicine shows that patients who have never used opioids in the past and who receive their first ...

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Schadenfreude: Florida Leads The US In Primary Care Physician Shortages

US MAP NO FLORIDA

I can’t help my feelings of schadenfreude when I happened to see a graph at the Kaiser Family Foundation noting that Florida has the largest shortage of primary care physicians in the United States. Only 42% of Florida’s overall need for primary care physicians has been met. Runner up California was a distant second. Why do I continue to get satisfaction from Florida’s troubles? It goes to show that states reap what they sow when they create policies to attack medical providers. When Florida’s Senator Bill Nelson whines that Florida “desperately needs more doctors“, maybe he should discuss with Governor Rick Scott why Florida has chosen to implement so many unfriendly policies toward physicians. I’ve been keeping a separate page with some of the reasons why physicians should avoid going to Florida to practice medicine. Here are a few reasons: Florida voters changed the Florida Constitution so that if a physician loses three malpractice cases, the physician’s license is automatically revoked. Florida used to cap non-economic damages in malpractice cases. Not any more. Florida’s Supreme Court recently struck them down (.pdf file). News article from the Tampa Bay Times here. Florida voters also created a Constitutional Amendment that makes peer-review documents related to adverse events discoverable in lawsuits. Florida is perennially on the list of Judicial Hellholes. When medical providers begin searching for the best places and worst places to practice medicine, Florida definitely is one of the worst. Don’t practice medicine in Florida.

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Healthcare Update — 05-27-2015

HC Update 16

Patient in Ontario Canada’s Guelph General Hospital emergency department has “interaction” with two police officers, both officers whip out their guns and shoot the patient dead. No further information available. Kentucky newspaper reminds everyone that stroke is an emergency and requires immediate care. Anyone having signs of a stroke should immediately contact Dr. Louis Caplan at Beth Israel Deaconess Medical Center. Don’t waste your time in “dangerous” emergency departments. I wasn’t being serious about contacting Louis Caplan. If you have signs of a stroke, go to your nearest emergency department. We’ll get you the help you need regardless of what some ivory tower neurologists think. Maryland patient in “horrible pain” calls ambulance. As paramedics “rushed her away,” her husband tucked her purse under her arm. She had her purse in her clutches until she reportedly had a “cardiac arrest” and went unconscious in the emergency department. She woke up the next day on a ventilator and the $1,100 that was in her purse was gone. I sympathize with the woman for losing her money, but something just doesn’t smell right about this story. Crystal meth is bad. In fact my uncle knows a guy whose cousin was on meth, gouged his eyes out, and ate his eyeballs like little hors doeuvres. Unfortunately, this story, told by an Australian member of parliament, was not able to be verified. That didn’t keep news agencies from picking up the story and running with it. Anything for the clicks. Nearly a year after the VA scandal was made public and what’s happened to the people responsible for the fraud? One person was fired, a few others were “disciplined” with paid leave and transfers. In addition, the number of patients waiting longer than 90 days to receive medical care has nearly doubled. This is the system we’re hoping to implement on a widespread basis? Here we go again with the antibiotics for appendicitis debate. According to several small studies in Europe, antibiotics can cure about 70% of patients with acute appendicitis. This article also states that most people who develop a ruptured appendix do so before they get to the hospital. And – because American sailors who were on submarines for six month stints did well when given antibiotics for appendicitis, obviously antibiotics should be a good treatment. The problem with this logic is that submarines didn’t have CT scanners to prove that patients actually had appendicitis. This just means that everyone who had a belly ache got antibiotics. We don’t know if any of the sailors actually had an inflamed appendix. In addition, even if antibiotics did cure appendicitis, who’s going to want to run to the hospital for repeat ED visits and CT scans every time they get lower abdominal pain? Remove the inflamed appendix and be done with it. Rise of the machines. iControl-RP is a machine that monitors brain wave activity, pulse ox and vital signs during surgery and adjusts the dose of anesthetic accordingly. A professor once told me that anesthesia is a boring specialty … about 95% of the time. The other 5% it is life or death. Not sure how a machine would respond in one of the 5% situations. Despite this, the machine’s co-developer is “convinced the machine can do better than human anesthesiologists.” Wonder how its intubation skills are … Pedialyte is advertising itself as a cure for hangovers. Probably because kids won’t drink it. Take a sip some day and you’ll see why. The stuff tastes horrible. The company touts the increased sodium and potassium concentrations in Pedialyte versus Gatorade as the reason it reportedly ...

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Body Blow

Punch

A patient came in semi-conscious with low blood pressure. She was known to paramedics for her history of opiate abuse. In the past, the patient had been treated several times for adverse effects from excessive doses of prescription pain medications. The nurses were having trouble trying to start an IV and there were no good veins visible, so I grabbed an IV, put a tourniquet around the patient’s arm, and slapped the back of the patient’s hand several times to get the veins to stand out. It worked. I was able to get an IV in on the first stick and the patient received some Narcan which immediately woke her up and brought her blood pressure back to normal. Then she demanded to see a hospital administrator. “That doctor hit me.” “Wait. Whoa. What??” “He hit me in my arm, then he hit me in the side of my head.” “Ma’am, I slapped the back of your hand so I could start an IV, but no one was near the head of your bed.” “No … You. HIT. Me.” Another patient was in the room next to hers waiting to have a laceration sutured. The curtain had been pulled back so that everyone could access the patient’s bed and the patient had watched the entire event. “You’re lying. He didn’t touch you.” The patient said. “You mind your business,” said the resuscitated patient. “I WANT to talk to an administrator.” So the administrator came to the emergency department and took statements from everyone. He promised the patient that he would follow up on the matter and he left the room without even talking to me. A little while later, I went and sewed up the laceration on the other patient’s face. “You’ll be able to resume your modeling career in no time,” I said with a smile. “Sorry you had to wait.” “Hey. At least you didn’t hit me,” he said with a wink. “Yeah, well you haven’t been discharged yet,” I joked back. Shortly after we had discharged the patient, the overdose patient rang her call light and demanded to see an administrator again. The administrator came back to the emergency department and spoke to the patient. A nurse overheard him promising to follow up on both matters. But what happened? No one had been in her room between then and the first complaint. Turns out that the patient told the administrator that I had also threatened to hit another patient. I’m wondering if the administrator can investigate someone being run over by a truck after they leave hospital property …

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This Is All YOUR Fault

Jackpot

When a patient comes to the emergency department at 3:30 in the morning with an injury that was sustained while moving furniture just prior to arrival, it raises my eyebrows a little. When the first two sentences out of the patient’s mouth to the triage nurse are “I need something for pain – it’s 10 out of 10″ and “Also, I’m allergic to Toradol, tramadol, codeine, morphine, and I can’t take NSAIDs because I have an ulcer” then it raises my eyebrows even more. The injury wasn’t a 10 out of 10 injury. The patient was reportedly moving a couch while wearing flip flops. She caught her foot and hit the outer part of her great toe on the edge of the couch. In the process, she ripped the callus off the side of her great toe, leaving a raw area about an inch in diameter and a scrape to her instep. This injury caused her to have 10 of 10 pain. As the nurse started to clean her wound, the patient howled. Literally. “Aren’t you going to give me anything for this pain?” “How about we start with some Tylenol.” “Tylenol?!?!” “You’re allergic to all of these other medications and your wound certainly doesn’t look bad enough for something like Norco. So I think we’ll start with some Tylenol.” She looked at her boyfriend who had accompanied her to the emergency department. “You know, it’s FAKERS like you who make it so that people in legitimate pain like me don’t get proper pain medicine.” He had a shocked look on his face. I didn’t know the boyfriend, but I kind of agreed with the patient’s sentiments. Drug seeking patients do tend to ruin things for patients who really are in pain. This woman appeared to be overacting from the pain she was having from her injury, but who knows? It wasn’t too busy in the ED at the time, so I went and looked the patient up on the state controlled substances database. Surprisingly, the patient only had 88 prescriptions for controlled substances from 18 different prescribers in the past 12 months. Only four prescriptions for Norco in the past 10 days. I went back in the room and handed her the printout from the state database. She scowled at her boyfriend. “This is all YOUR fault.” Then she got up and stomped out of the emergency department before the nurse had a chance to bandage her wound or to provide her with Tylenol for her 10 out of 10 pain. Funny how information can have such a dramatic effect on relieving pain.  

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Louis Caplan, Maureen Dowd, and Lack of Professional Ethics

Head Sculpture

With the flurry of Twitter posts about Maureen Dowd’s article “Stroke of Fate” in the New York Times, it almost seems as if the subject is already stale. Maureen Dowd is the Pulitzer prize-winning op-ed columnist for the New York Times who tells a compelling story about a young patient who suffered from a stroke. The patient was a healthy triathlete and she initially attributed the symptoms of her stroke to a migraine headache. Ms. Dowd’s article also touched upon the frustration and fear that patients feel after the diagnosis of a stroke which was an important part of the article. However, somewhere in the middle of the article, Ms. Dowd does a journalistic faceplant that probably had Joseph Pulitzer doing a few backflips in his grave. Ms. Dowd accompanied the subject of her story – her niece – to Boston in order to be evaluated by a national stroke expert. There they met 78-year-old Dr. Louis Caplan, a Harvard professor of neurology. Dr. Caplan made several inflammatory quotes regarding emergency departments which Ms. Dowd was only too happy to publish. She doesn’t appear to have fact checked the statements, she doesn’t appear to have asked the professor for the basis behind his statements, nor does she appear to have asked other experts in the field for their comments on the topic. Of course, Ms. Dowd may argue that her failure to check her sources was an innocent mistake or that was part of her journalistic expression, but in either case, she was irresponsible and unethical. She used one of the largest forums in the United States to provide misinformation about emergency medical care. As I read through Dr. Caplan’s quotes and the comments to the article, I can’t help but wonder whether or not Ms. Dowd’s actions were intentional. It doesn’t take much insight to realize that comments from a medical “expert” who denigrated another medical specialty would result in an avalanche of clicks to the New York Times web site. The problem is, Ms. Dowd, your article generated interest not because it was good journalism, but rather because it was hack reporting. You could have used your niece’s misfortune to provide information to your readers about the signs and symptoms of vertebral artery dissection, the treatment, and the outcomes. Instead you threw your integrity out the window to create just another piece of clickbait. Shame on you. It isn’t just Ms. Dowd who failed at the New York Times. The New York Times editors failed. Again. Ms. Dowd’s article is eerily similar to a sepsis article written by Jim Dwyer in the New York Times several years ago. Mr. Dwyer told the story of his nephew, Rory Staunton, who, in the midst of influenza season, went to the emergency department with fever and vomiting. Rory received treatment in the emergency department, his symptoms improved, and he was discharged, but he later died from sepsis. Mr. Dwyer went on a crusade against the hospital and the emergency medical providers. In the process, Mr. Dwyer failed to note many of the circumstances regarding Rory’s care, made many inappropriate comments, misapplied sepsis guidelines that were not designed for children, and then tried to hide the fact that those guidelines were not designed for use in children. When called out on his selective reporting of the facts, Mr. Dwyer made excuses such as Rory may have been a child, but he “was the size of an adult.” That episode of drive-by journalism didn’t work so well, either. So the New York Times editors allowed yet another poorly researched and inflammatory article to be published in ...

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Healthcare Update — 12-01-2014

HC Update 1

More health related news from around the web on my other blog at EP Monthly. ___ This site is an AMAZON affiliate. Purchasing products through Amazon by clicking on THIS LINK will support this blog at no cost to you. ___ Arkansas personal injury attorney Michael Smith implies that outpatient clinics should all have “the right kind of life-saving equipment” at hand at all times. He never says what the “right kind of life-saving equipment” should be, but mark his words – if a patient ever suffers a bad outcome in an outpatient clinic, he’ll be sure to find something that the clinic didn’t have that would have prevented the bad outcome. I hate articles like this. On their face, they are appealing. Sure, everyone should have the “right kind of equipment.” That’s like saying that attorneys should always file the “right kind of motions” and use the “right kind of case precedent” in their briefs. But if you ask personal injury attorney Michael Smith exactly what equipment to purchase in order to be compliant with whatever standards he thinks should apply, he’ll suddenly change the subject. I guarantee it. Inappropriate opinion by expert witness surgeon Dr. Michael Drew causes $19.5 million judgment against treating surgeon to be overturned by Pennsylvania Superior Court. Court opinion (.pdf file) notes how Dr. Drew’s opinion on how treating physician breached the standard of care “morphed each time he opined on how [the treating physician] breached it” and how Dr. Michael Drew’s opinion created an “untenable” “no-win” situation for the treating physician. Kudos to Pennsylvania Superior Court Judge Jack Panella for the well-reasoned court opinion. Recent court opinion expands liability for medical providers. A passenger on a Royal Caribbean Cruise fell and hit his head while his ship was docked in Bermuda. The patient was then wheeled back onto the ship where a nurse allegedly didn’t evaluate his head trauma and a doctor didn’t even evaluate him for four hours. After the doctor examined him, he started the patient on a mannitol drip and transferred the patient to a Bermuda hospital for further care. A week later, the patient died from his injuries. Maritime law of the US normally prevents a shipowner from being liable for negligent medical provided by the ship’s crew. However, the US Court of Appeals held that evolution of legal norms, rise of a complex cruise industry, and progression of modern technology have made those prior laws inapplicable (.pdf file). Pertinent quotes from the opinion include “medical negligence triggers the same equitable concerns whether it arises on land or at sea” and “we can discern no sound basis for allowing a special exception for onboard medical negligence.” I’m guessing that there will be a petition to the Supreme Court on this case. Nearly $1 billion in medical malpractice payments from VA hospital coming from federal treasury, not the VA budget … and payouts are occurring at a higher rate than in the private sector. The Veteran’s Administration declined a request for an interview in the article. A vet who had his esophagus punctured gave an interview and stated “If I had it to do all over again, I’d never go to the VA.” New Jersey’s St Lukes Hospital closing its behavioral health unit for cost cutting measures. Police and county prosecutors concerned that closing the unit will increase the burden on law enforcement. After closure, patients requiring inpatient behavioral care will be held in emergency departments until transfer can be arranged to remaining behavioral health centers in New Jersey or Pennsylvania. Ummmm. Yeah. I’m suffering from acute incarceritis and need an evaluation quickly. Utah’s ...

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