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Author Archives: WhiteCoat

Google Glass in the Emergency Department

Google Glass

Google Glass is trying to make inroads into the medical field and there have been several stories about how it is being used in the emergency department. One story begins with how Boston’s Beth Israel Deaconess Medical Center is the first hospital in the world to use the glasses for direct patient care. The benefits are reportedly legion: “Information like the patient’s name, their past medical history, even X-rays can all come up with Google Glass and could be life-saving, especially if a patient can’t communicate or doesn’t know their allergies and medications.” Yawwwwn … er, um … WHOA! The physician who is spearheading the Google Glass program at Beth Israel says that “I can say, ‘Page nurse,’ and say, ‘Nurse, can you get me some more sedation, thanks!’ And it will page them automatically all through voice commands and voice dictation.” That’s great. But there are other products out there that do the same thing. Think Vocera. And in Dr. Horng’s example, the nurse would then page the doctor back and say” “Doctor, I’ll get you some more sedation as soon as you put the order in the computer. Administration doesn’t let us take verbal orders, remember?” Then the doctor would have to walk out of the patient’s room, with Google Glass flashing e-mails and cat videos into his peripheral vision, so that he could enter the sedation order into the computer, then re-page the nurse and tell her that the order has been entered, which she’ll probably already know about and will only serve to piss her off because of the needless interruptions from the doctor playing with his new toy. Either that, or the doctor will sit in front of the patient having the following argument with an inanimate object … OK Glass … OK GLASS! Open patient John Smith chart. No, not that one. Close patient John Smith chart. Open patient John … what’s your middle name, sir? … Open patient John Francis Smith chart. Close patient Francis Smith chart. Open patient JOHN Francis Smith chart. Open orders. No, I don’t want hors d’oeuvres. O-PEN OR-DERS. By now, the patient is either annoyed or laughing. In either case, Google Glass probably cost more time than it saved. No sooner did the pixels dim on the first story than another story pops up about how not only did Google Glass just *work* at Beth Israel Deaconess Medical Center, but how Google Glass SAVED A LIFE! It turns out that the same Dr. Horng was treating a patient with a “severe brain bleed” and that the priority in brain bleed patients is to lower the blood pressure. However … dun dun dun duuuuuhhhhhh … the patient was *allergic* to some unknown blood pressure medication and … dun dun dun duuuuuhhhhhh … the patient was also taking an unknown blood thinner. Dr. Horng was able to find the answers “almost instantly” using Google Glass and “was able to administer the right medications to slow the bleeding and save the man’s life.” I call bullshit. Let’s walk through a typical patient experiencing a “severe brain bleed.” First, the patient doesn’t walk up to the registration window saying “Pardon me, ma’am, but I happen to be having a severe brain bleed – left hemisphere, temporal region.” The patient walks up to the registration window (or is brought in by ambulance) saying “I have a headache.” Perhaps the patient has “weakness.” Or maybe the patient is brought in by ambulance unconscious. But a “severe brain bleed” is a diagnosis made after workup, not a presenting symptom. So even with the help of Google Glass, a ...

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Physician Bodyguards and Government Policies

Surgery

Chinese hospitals recruiting 1500 “guardian angels” to protect doctors from violent patient attacks. Patients who are angry about the Chinese healthcare system, medical expenses, long waiting times, and uncaring doctors have become more violent over the years, with violent attacks occurring every two weeks on average – according to state media – which in reality means that it probably occurs a lot more frequently than twice a month. Now China is starting a campaign to get volunteer students, medical staff and other patients to intervene when patients are upset with physicians. Apparently China views non-physicians as being more expendable when patients become upset and brandish cutlery. At least we have concealed carry laws in the US … for now. Interesting that according to the article, China has created a culture in which “doctors are in crisis” and in which “medical practice in China is a high-risk job.” Now China is vowing to “root out corruption in the healthcare system” – to save all the patients from the evil and corrupt medical providers. In reality, China’s policies have created many of the problems it seeks to “root out”, but state-run media likely won’t put that in print, either. After reading through the article, think about what it happening in the US right now. Doctor rating sites and patient satisfaction take precedence over proper medical care. Patients are forced to purchase government-mandated “insurance” that in many cases doesn’t pay for the cost of care and that many doctors will therefore not accept as payment. Losing money every time that you provide medical care to patients – while paying off student loans, paying office overhead and salaries, paying malpractice insurance premiums, and paying licensure fees – is just not a sustainable business plan. As a result, patients pay a lot of money for government insurance but they often have difficulty finding medical care when they need it. Federal agencies, in order to improve “transparency,” publish a list of how much money the federal government is paying physicians so that it can make physicians look like overpaid whiners when they complain about their workload and the regulatory burdens of a medical practice … but the same federal agencies refuse to publish statistics about patients who abuse the system (“privacy rights” apparently outweigh the public’s right to know about illegal acts) and the same government hides data about maltreatment of patients in its own facilities. “Transparency” indeed. Regulations related to the provision of medical care rise exponentially and educational costs to become a physician steadily increase while payments for medical services steadily decline. The pervasive media message is what a lousy job physicians are doing. Increased malpractice. Unnecessary testing. Missed diagnoses. Malpractice verdict after malpractice verdict. Hundreds of thousands of deaths each year from hospital errors. A well-respected profession is now becoming despised. By systematically making the practice of medicine more difficult and less appealing, the United States is slowly creating a crisis similar to that which China is experiencing now. The more insidious problem is that it takes at least 10 years and sometimes up to 14 years to educate and train a new physician. Cause the best and brightest students to shy away from medicine while older physicians retire or die off and in 5-10 years there will be an even larger crisis that will be impossible to immediately solve. At that point, it may no longer be an issue of which doctor you will choose to treat your medical problems, but instead a question of which doctor will choose to accept you as a patient. Then who will the government and President Obama ...

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We’ve Been Facebooked — Part 2

Thumbs Down

My dislike for certain forms of social media continues. One of the problems with social media in the medical field is the federal privacy act known as HIPAA. HIPAA prevents medical providers from publicly disclosing any “protected health information” about patients without the patients’ permission. We can disclose the information among other medical providers providing care to the patient with few limitations, but we can’t disclose the information to the public. A patient can go to newspapers and say that a doctor committed gross malpractice by misdiagnosing her abdominal pain, but the doctor can’t respond by saying “no, actually we treated your gonorrhea appropriately, you just didn’t follow up and you gave us a fake phone number so we couldn’t contact you to tell you that it was resistant to the medications you received.” HIPAA doesn’t allow providers to disclose medical information to third parties without the patient’s permission … which leads to such difficult situations as below. A patient presents to the emergency department after leaving work for evaluation of “severe” abdominal pain which she was sure was due to a hernia surgery that she had a few months prior. She was laughing and joking in the room, eating Cheetos and watching television. Apparently, the hour or so wait became too long for her. The multiple trauma victims and patients needing mechanical ventilation were much less important than her work note. So, orange fingers and all, she pecks away on her phone and posts on Facebook how crappy the emergency department is because she had to wait. It just so happens that one of her Facebook “friends” works as a nurse on the medical floor. The nurse happened to glance at her phone between patients, notices the Facebook update, and calls to the emergency department to ask what the problem is. Emergency department secretary is frazzled by all of the sick patients and tells the floor nurse it isn’t any of her damn business what is going on in the emergency department and to worry about her own patients instead of checking out Facebook during work hours. That pisses off floor nurse who then calls hospital administration and tells them that the emergency department is slacking off … which prompts a visit from the Director of Nursing. When DON arrives, she reviews the situation and pulls the charge nurse aside and asks if we can see this abdominal pain patient ASAP. Charge nurse (who is awesome) briefly educates DON about the concept of triage and asks DON if she can help register and triage continuing influx of patients. DON says that she has a meeting to attend and leaves. When the more critical patients have been stabilized, we get in to see the patient. Her abdominal pain has essentially resolved. Actually, it resolved shortly after she arrived. But she has had this lump on her surgical scar ever since her surgery, it has been bothering her more than usual lately, and she really wants to know what the lump is. The lump is where they tied the knot for the stitches they put in under your skin. May be the mesh as well. No problems with the surgical site that we can see. You’re welcome to make an appointment with your surgeon if you still have questions. Oh, and by the way, I think I missed my last period. It’s negative. Oh, I’ll also need a work note. Your discharge papers will show when you were discharged.  Have a nice day. So about a half hour after the patient is discharged, the unit secretary suddenly blurts out “Oh … ...

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Healthcare Update – 04-08-2014

HC Update 14

See more healthcare-related news from around the web on my other blog at EPMonthly.com EmCare sues former emergency department medical director for “hundreds of thousands of dollars” for “incompetent and substandard” work. As a result of the physician’s actions, which were not described, the hospital reportedly discontinued its contract with EmCare. What is even more interesting in the article is that EmCare alleged that its losses amounted to “hundreds of thousands of dollars per month” – which is millions of dollars per year just from one hospital system. Why is there this hand print on my butt after I wake up from surgery? Oh, it’s the new dominator/dominatrix surgical technique. Federal investigators accuse a New York orthopedist of insulting anesthetized patients and slapping some patients on the buttocks – sometimes so hard that he left hand prints. Now the hospital faces sanctions for his actions. Interesting that several comments to the news article say that this is a common way that surgeons use to determine whether a patient is under anesthesia. I personally wouldn’t slap a patient’s buttocks, but then what noxious stimuli is appropriate for determining whether a patient is conscious or not? It would be just as easy to write a damaging article about doctors giving patients sternal rubs (which I have done) or pinching a patient (which I have also done). Is this issue dragging us down the rabbit hole of political correctness? Americans hit with sharpest health insurance premiums in years according to Morgan Stanley survey of insurance brokers. This quarter, the average insurance premium increase is 12%. Anyone want to guess why that is? Hint: According to the article, the first word ironically begins with “Affordable”. Welcome to the world’s 20th most populous nation: The country of Medicaid. 72.7 million Americans are on Medicaid, making the number of people on the government program larger than the populations of France, the United Kingdom, and Italy. Add in the 49.4 million patients on Medicare and the resulting 122.1 million people become the 11th most populous “nation” – ahead of Mexico and just behind Japan’s 126 million people. We’re sure to crack the top 10 when the new statistics come out after Obamacare enrollments. With the Unaffordable Insurance Act, you can still see a primary care physician … if you have the right kind of insurance … or you pay cash. When researchers made calls to primary care physicians posing as new patients, 85% of patients with private insurance were able to book appointments. Only 58% of patients with Medicaid got appointments. If you agreed to pay full cash at the time of the visit, 79% got appointments while only 15% got appointments if they couldn’t pay more than $75 at the time of visit. There’s a big difference between “insurance” and “access”. Kings of Leon concert goes viral … literally. Washington State woman contracts measles but treks all over the Seattle area before she becomes symptomatic – including the Pike Place Market and several department stores. Then heads to a Kings of Leon concert. If you’re not vaccinated and have been exposed to the patient (or any of the other unvaccinated individuals who may have caught the disease), you and your family may be in for an unpleasant surprise. People should be free not to vaccinate themselves or their children, but they should not be immune from the legal and financial consequences that occur when they require medical treatment for the diseases they catch and when they spread the diseases to other people. Talk about a downward spiral. Moderate to severe depression increases risk of heart failure ...

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Hospital CEOs Earn Tens of Thousands of Dollars From Patient Satisfaction

Million Dollar Bill

Dan Diamond (@ddiamond) tweeted this slide from a lecture by Harvard’s Ashish K. Jha at this year’s Association for Healthcare Journalist’s Annual Meeting in Denver. The slide shows how CEO incomes are affected by different variables and contains a few interesting tidbits of information. First, hospital CEOs earn around $600,000. Far more than most physicians. Second, hospital CEO salaries are not significantly affected by multiple different, yet seemingly important factors, including “quality” scores, the number of patients who die in their hospitals, the number of readmissions to their hospital, or the amount of charity care they provide. Logically, it would seem that the payment system would want to incentivize hospital administrators to work on those topics: Improve quality scores, decrease hospital deaths, decrease readmissions, increase charity care. But payments systems apparently don’t work that way. Want to know the thing that affects a hospital CEO’s salary the most? Patient Satisfaction. Highly favorable patient satisfaction scores add an average of $51,000 to the income of hospital CEOs. When your CEO threatens your job because your satisfaction scores aren’t high enough, when your CEO relies upon the statistically insignificant data reported by companies like Press Ganey, and when your CEO ignores studies showing that highly satisfied patients are more likely to die and suffer adverse consequences, now you know why your CEO may be making those decisions. Plaintiff attorneys are crazy for not raising this issue in medical malpractice lawsuits. Companies provide invalid statistics to hospital CEOs. Hospital CEOs knowingly rely upon invalid statistics to influence medical care. Tie patient harm to the CEO’s decisions (and motives) and you have another defendant with deep pockets who isn’t subject to a malpractice insurance cap. Oh, and by the way, Press Ganey’s ratings over at Glassdoor – despite the obviously fake positive reviews – is still an abysmal 2.7 out of 5, with only 39% of employees willing to recommend this company to a friend. If doctors had those types of ratings, they would be fired immediately. Why is CEO Patrick Ryan still around?

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Healthcare Update — 03-30-2014

HC Update 11

Didn’t realize how long it’s been. You can see other Updates from the past couple of weeks on my other blog at EP Monthly.com Supplies of liquid nitroglycerin in hospitals are dwindling – not because of medication shortage, but because of packaging issues. Nitroglycerin must be packaged in glass bottles and apparently the only manufacturer, Baxter, is having difficulty finding enough glass bottles to meet demand. Funny. I never remember Coca Cola having such problems. Emergency department visits for dental problems on the rise. Article focuses on New Jersey, but the same problem is occurring everywhere. Oh, and dental care for adults isn’t covered under the Unaffordable Insurance Act. As the CNN article notes, get ready for a “State of Decay.” Study shows that 1 in 25 patients develops a hospital acquired infection. About 721,000 infections were “acquired in hospitals” last year and 75,000 of those patients died, but the study reportedly did not look into whether the infections actually caused the patients’ deaths. I have problems with these statistics. I wasn’t able to find the NHSN criteria they used to determine whether an infection was present before a patient arrived in a hospital or after a patient left a hospital. And if hospitals are such germ-infested dangerous places, why don’t 1 in 25 hospital employees also have these infections? Black Death from Yersinia pestis (“the Plague”) caused the deaths of one third of the European population between 1348 and 1353. For a long time, it was believed that Black Death was spread by rat fleas. New research now says the vector for spread was human to human contact and not rat fleas. Police trying to determine why patient in New York’s Brookdale Hospital beat a nurse unconscious when the nurse tried to remove his catheter. Does it matter what psychiatric diagnosis they come up with? More problems with the cost of emergency department care. Patient upset because emergency department trip after a head injury from a bike accident costs her more than $6000. She had insurance, but it was a high deductible plan, meaning that she had to pay for all the costs out of her pocket. A head CT cost her $4800, calling a doctor in to place the stitches was $460, and the stitches themselves cost $850. The article mentions cost-conscious care … which is fine until something is missed. In this patient’s case, she thought an x-ray should have been done for her head injury instead of a CT scan. Xrays don’t show bleeding, though. Would she still have felt that only an x-ray should have been done if she had bleeding inside her brain and the x-ray missed it? On the other hand, patients can’t be cost conscious about their care if they don’t know the prices. Care and testing performed when a patient has not been advised of the costs in advance should be required to be provided at no cost. More information about how Beth Israel is using Google Glass to enhance medical care in the emergency department. Will be interesting to see a report on their results. You can check in any time you like … but you can never leave. Woman purchases insurance through Obamacare exchange, then gets job and tries to unenroll in her initial plan. Not so easy. She ended up paying premiums on both plans until she could run the gauntlet of unenrollment. Trying to change the message again. Obamacare architect Dr. Ezekiel Emanuel asserts that “you don’t need a doctor for every part of your health care.” If you like your high school sophomore with a 16 ...

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Contaminated Stethoscopes COULD Be Harmless

mrsa_magn_lg

An interesting study is making the rounds in the mainstream media. Instapundit, Scientific American, NBC News, Healthcare Business Tech Blog, MedPage Today, CBS Atlanta, and Consumer Reports have all reported on the study. Unfortunately, the study draws questionable conclusions. A group of scientists at the University of Geneva Hospitals (Switzerland) and affiliated with the World Health Organization recently published a study demonstrating that physicians’ stethoscopes harbor many bacteria. The study was titled “Contamination of Stethoscopes and Physicians’ Hands After a Physical Examination” and was published in this months’ Mayo Clinic Proceedings. First, the researchers note that physician stethoscopes can be contaminated after a physical examination. Agreed. The amount of contamination can be as much as that contained on the palm of the hand (but not the fingertips). OK wonderful. The number of colonies causing the level of contamination is “substantial” after a single physical exam. For fingertips, the average number of colony forming units transferred was 467. For stethoscopes, the average number of colony forming units transferred was 89. Not so sure that is “substantial,” but we’ll go with it. For MRSA carriers, the average number of CFUs transferred was 12 for the fingertips and 7 for the stethoscope. However … no transfer of any MRSA bacteria occurred in 24% of patients and the researchers just discarded the data from those patients for the final analysis. (“Because MRSA was not recovered from the physicians’ dominant hand or the stethoscope after the examination of 12 of 50 patients colonized with MRSA (24%), these patients were excluded from the final analysis”). Averaging in a bunch of data that don’t fit with their conclusions would only dilute their message. Then come the “scientific” conclusions: “By considering that stethoscopes are used repeatedly over the course of a day, come directly into contact with patients’ skin, and may harbor several thousands of bacteria (including MRSA) collected during a previous physical examination, we consider them as potentially significant vectors of transmission. Thus, failing to disinfect stethoscopes could constitute a serious patient safety issue akin to omitting hand hygiene.” Note the hypothetical pseudoscience contained in just these two sentences. Stethoscopes “MAY harbor several thousands of bacteria” – meaning that stethoscopes also “may NOT harbor” several thousands of bacteria and you haven’t proven anything. “WE consider them as potentially significant” – ah, the logical fallacy of an appeal to authority. WE are published in a national journal and are getting national media attention. No one else might consider them as potentially significant, but those who do not agree with US are obviously unqualified to make such decisions. Oh, and by the way, WE still haven’t shown any literature proving this point, so just believe our pseudoscience and move along. “THUS …” – a haughty prelude showing that you are trying to use your unfounded conclusions to get everyone to believe your ultimate point that … “failing to disinfect stethoscopes COULD constitute a serious patient safety issue” – BRILLIANT! Oh, and by the way, the moon COULD be made out of green cheese, the government COULD be putting nanobots in our vaccines, Juan Pablo COULD marry any woman he wanted on the Bachelor, and I COULD win the lottery. Without better research, there is no way to determine whether any of these possibilities is more likely to occur than any other of the possibilities. A scientific statement that something “COULD” occur is close to being meaningless, showing only the absence of an impossibility. The likelihood of that event occurring is anywhere between 0.0000000000000000001% and 100%. There are multiple parallel studies which also make leaps in logic about the possibility ...

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“Illegal” Limits on Emergency Department Use

Sunrise over Frozen Field (Copy)

According to an article in the Miami Herald, Florida is “illegally” limiting Medicaid patients to six emergency department visits per year. Federal officials call such arbitrary limits illegal and says that the limits would not be in a patient’s best interests. CMS intends to withhold a portion of Florida’s Medicaid funding as a result. Another article on ThinkProgress.org comments on how unfair and inappropriate the limits would be, especially since only a “sliver of the poorest Florida residents” are eligible for Medicaid. The total population in Floirda is 19.5 million. The number of Florida residents eligible for Medicaid is 3.3 million. That’s 17% of Florida residents eligible for Medicaid. Add to that another 3.1 million Florida residents who have Medicare benefits (although there is likely some overlap with patients who have both Medicare and Medicaid) and you’re looking at one third of Florida’s population that receive medical care from the government. Some fricking “sliver.” Aside from the misinformation that reporter Sy Mukherjee is perpetuating, the story raised several additional issues with me. First, if acts that are not in a patient’s “best interests” violate the Social Security Act, then how did Obamacare pass muster? Not enough doctors in the system: not in a patient’s best interests. Outlawing established insurance plans: not in a patient’s best interests. Byzantine registration process: not in a patient’s best interests. Inappropriate Healthcare.gov web site security: not in a patient’s best interests. Second, I was surprised by the number of people commenting on the articles who deemed Gov. Rick Scott’s attempts to limit excessive emergency department use as: intended to harm poor people “DEATH PANELS,” a form of fascism a form of criminal Naziism preventing “Medicaid patients from receiving legitimate treatment” There were also multiple ad hominem attacks tossed at Gov. Rick Scott for taking steps to shore up the state’s budget. Want a couple of easy ways to solve this problem? Get rid of the rationing. All it will do is incite people whose services may be rationed. Change must come from within. First, publish the names (pictures?) of the top 50 ED users each month/each quarter/each year in the newspapers and on websites throughout the state. Announce that this list will be published in advance so patients are given fair notice. Don’t have to publish any medical data or the hospitals involved – just publish the number of visits the patient made and the costs involved in providing care for each patient. Post the lists in the waiting rooms of the hospital emergency departments. If the public is paying for the care of these individuals, the public has a right to know who is receiving the public’s money. Sunlight is the best disinfectant. Then, require mandatory co-pays for all emergency department visits … regardless of the medical problem … regardless of the urgency. Other patients don’t get free health care just because they’re having an emergency. Why should we create a privileged class of patients who receive all their medical care at no cost? Everyone should pay something for their medical care. Non-urgent cases still pay a co-pay, receive a screening exam and then must be discharged to a federal health clinic for follow up care. Not enough federal health clinics? That’s not in a patient’s best interests. The federal government is violating the Social Security Act. If the patient doesn’t have money for the co-pay, deduct the costs of the copay from any future forms of government assistance that the patient may obtain each month. Controversial? Sure. Effective? Absolutely. If you don’t agree with me, give me some better ideas on how to ...

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