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Author Archives: WhiteCoat

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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A False Alarm

Cup of Coffee

There aren’t too many times that the staff gets the giggles when a patient’s monitor shows ventricular tachycardia. Normally, there is a flurry of activity while everyone wheels a code cart into a patient’s room ready to deliver lifesaving shocks. So when the new nurse was halfway through her second day working in the ED, she couldn’t believe how calm the staff was when the cardiac monitor began alarming in Room 8. Room 8 was Clarence. He had dementia and was a transfer from the nursing home for mental status change. When Clarence arrived by ambulance, he seemed just like the same old Clarence they’d seen dozens of times in the ED before. Toothless smile. Southern drawl to his speech. Always wanted coffee – cream no sugar. A lot of times staff would try to avoid putting Clarence on a cardiac monitor because the monitor would often give false alarms when they were attached to him. But the paramedics stated that Clarence had some PVCs on the way to the emergency department, so the triage nurse dutifully attached EKG leads to Clarence’s chest. About 20 minutes later, Clarence’s monitor showed ventricular tachycardia. “BLEEP BLEEP BLEEP BLEEP BLEEEP” went the alarms. One nurse and the secretary looked at each other, smiled, and shook their heads. The new nurse looked quizically about the department, obviously wondering why no one was running to bring the crash cart into Clarence’s room. The charge nurse started to get up from her chair, then sat back down and continued charting. “Mary, can you go and check on Room 8 for me?” “Um … sure,” said the new nurse as she walked briskly into Clarence’s room. Thirty seconds later, Mary came back to the nursing station with a stunned look and a red face. “Everything OK in there?” asked the charge nurse. “Well … yes,” she said as she regained her composure. “It seems that the only thing going fast in that room was Clarence’s hand under the sheets.” “Welcome to the team. You’ll get to know these patients as well as we do in no time. As for Clarence, I’ll take care of him. A nice cup of coffee — cream, no sugar — usually breaks his ‘ventricular tachycardia’ fairly quickly.” “But did he have a pulse?” asked one of the doctors. Mary smirked. “I’m kind of a … new … nurse. Maybe you could help me check that?” The doc smirked. “See, you’re going to fit in here just fine.” ———————– 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 Dr.WhiteCoat.com, please e-mail me.

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Sites to Download Free Pictures

Antique Camera

Getty Images has earned a reputation as a copyright troll for demanding hundreds to thousands of dollars in licensing fees and penalties from bloggers and other web sites that use a Getty photo without a license. Getty uses a search engine that scours all of the pictures on the internet looking for copyright infringers, then sends off demand letters to anyone flagged in its system. At least one law firm has fought back, suing Getty to get a court declaration that Getty’s tactics should not apply to thumbnail images.  The article contains a copy of the lawsuit if you happen to get a letter from Getty and want to sue them. Most people won’t have the desire to fight one of the demand letters and will instead just pay Getty Images what one person labeled as an “extortion fee” to settle the case. I completely acknowledge and agree that photographers deserve to be compensated for their work. But copyright laws make exceptions for use of copyrighted materials (including pictures). For example, if I created the changes at the right to parody of Getty’s iStock licensing model where it costs $45 (three “credits” costing $15 each) to download one picture, the transformative changes I made to Getty’s logo would fall under the “parody” exception of copyright law. In addition, under US Copyright law, words and short phrases such as names, titles, and slogans and typeface are not subject to copyright. Even if you choose to pay Getty’s outrageous licensing fees, you’ll need an attorney to decipher Getty’s license. For example, as some of the 16 restrictions on use of its images, Getty states that licensees may not … 5. incorporate the Content in any product that results in a re-distribution or re-use of the Content (such as electronic greeting card web sites, web templates and the like) or is otherwise made available in a manner such that a person can extract or access or reproduce the Content as an electronic file. *** 12. use or display the Content in an electronic format that enables it to be downloaded or shared in any peer-to-peer or similar file sharing arrangement; Since anyone can right-click and download an image from a blog post, by including a Getty image in your blog, you are violating Getty’s terms of service. As part of the license, Getty demands that … You agree to indemnify, defend and hold iStock, its affiliates, its Content providers and their respective directors, officers, employees, shareholders, partners and agents (collectively, the “iStock Parties”) harmless from and against any and all claims, liability, losses, damages, costs and expenses (including reasonable legal fees on a solicitor and client basis) incurred by any iStock Party as a result of or in connection with any breach or alleged breach by you or anyone acting on your behalf of any of the terms of this Agreement. In other words, if Getty alleges that you have breached any of the terms of its license agreement, you give Getty permission to sue you for damages and you agree to pay all of the damages plus pay for all of Getty’s attorneys’ fees. Finally, Getty requires you to acknowledge that YOU HAVE READ THIS AGREEMENT, UNDERSTAND IT, AND HAD AN OPPORTUNITY TO SEEK INDEPENDENT LEGAL ADVICE PRIOR TO AGREEING TO IT That’s an awful lot of risk and expense to go through just to put a picture on a blog, isn’t it? Violate their restrictive and confusing licensing agreement and Getty can sue you and make you pay the fees of the lawyers that are suing you. Since Getty has already demonstrated its penchant for filing lawsuits ...

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Healthcare Update — 10-21-2014

More healthcare related news from around the web on my other blog at EP Monthly Let’s call the first part of this post the Ebola Chronicles Treating one Ebola patient would wipe out the ICU in an average-sized hospital and may even bankrupt some smaller facilities. Most states won’t even allow disposal of waste from Ebola patients. Then there’s the Ebola patient in the US you didn’t know about. Doctor infected with Ebola while working for the WHO in Sierra Leone was treated in Emory Hospital’s biocontainment unit for the past 6 weeks. Now is “well on his way to a full recovery.” Baylor Medical Center in Texas requires that patients knock on glass door and answer Ebola screening questions before being allowed in emergency department. Clipboard idiot walking alongside Dallas Ebola patient Amber Vinson and directing people in hazmat suits grabs hazmat trash bag and discards it, then boards the flight — with no hazmat gear. Were he and his clipboard quarantined after touching waste from the Ebola patient? Of course not. The only conclusion we can make from this scenario is that clipboards must prevent Ebola. Vomiting is now an actionable offense. California’s Southwestern College evacuates and institutes quarantine after student who flew on same airplane as Amber Vinson gets sick and vomits in class But vomiting and dying … not so much. Patient on Nigeria flight to JFK vomits and dies. Officials give corpse a “cursory” exam, declare he does not have Ebola, then whisk him from the airplane. Nothing to see here, folks. Move along. Move along. Don’t look now … actress Tori Spelling quarantined in hospital with symptoms of Ebola. Well, she did have a fever and an “uncontrollable” cough, but she was hospitalized for bronchitis. That reminds me. I have symptoms of Ebola, too. My muscles are sore … after I worked out yesterday. Just wait until flu season hits. And finally, the lawyers are already figuring out ways to profit from Ebola, suggesting that hospitals may have liability if they miss a diagnosis of Ebola. Now back to regular news … Buying insurance on the Obamacare exchange? Last year’s enrollment period began October 1. This year, you can enroll and find out how much your rates have increased … on November 15, 2014 … after the elections. This strategic timing can only mean that rates are set to skyrocket. If they were trending downward, the elected officials who voted to pass Obamacare would be using that fact in their campaigns. Want to see the names of the numbskulls who voted for this abominable law? Roll call of Senators who voted for Obamacare (a party line vote by Democrats) Roll call of House members who voted for Obamacare (pretty much a party line vote by Democrats as well) Did I mention that elections are a couple of weeks away and that many of these people want to be re-elected? More on the microbiome. Stress and shock may really cause a heart attack – by affecting the bacteria present in arterial walls. The stress hormones released during sudden stress may cause the bacterial biofilm over the arterial walls to dissolve, causing placques within the walls to rupture. In the future, managing bacteria within an arterial plaque (carotid arteries typically have Pseudomonas growing inside) may be just as important as managing a patient’s cholesterol. What happens to all the kids who are sent from schools to the emergency department for psychiatric evaluations? In 92.2% of cases, they’re sent home, and in half of those cases they aren’t even given psychiatric follow up. The study notes that only ...

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Healthcare Update — 10-13-2014

HC Update 6

See more medical news from around the web at my other blog at EP Monthly. _________________ NEW SITE SPONSOR! Need to renew your BLS, ACLS, or PALS certificate? You can get your certificate the SAME DAY by taking an online course and passing the online test at Pacific Medical Training. By clicking on THIS LINK, you’ll also get a 15% discount on the course fees. That’s a $25 savings for your ACLS recertification! _________________ Straight out of Men in Black. UC Davis researchers have discovered that they can erase certain memories in mice by using flashes of light. China is cracking down on pharmaceutical price fixing. Some company executives received prison sentences of between 2 and 4 years for their actions – although unfortunately those prison sentences were suspended. Government department heads are also being investigated since they are responsible for and must be punished for law violations committed by their subordinates. Even the cats were amazed. 18 year old woman who had habit of chewing on her hair goes to doctor with abdominal pain and malnourishment. Rushed to surgery where a 9 pound hairball was removed. Yes, you read that correctly. A nine pound hairball. Like she had a baby Cousin Itt inside of her. The Limits of Friendship. How many friends can an average person realistically have in their social circle? Based on human brain size … about …. Oh go on and read the article. The discussion is pretty interesting. Baylor University Medical Center reportedly at risk of losing all federal funding if it doesn’t submit an acceptable action plan regarding psychiatric patient elopement. CMS inspectors recently found six cases in which psychiatric patients walked away from the hospital’s emergency department before treatment concluded and determined that those “elopements” put patients in “immediate jeopardy” of their health and safety. The Netherlands has a slightly different way to treat patients with severe psychiatric problems: Euthanization. The rate of death by lethal injection for patients with severe psychiatric problems tripled from 14 cases in 2012 to 42 cases in 2013. Counting “terminal sedation,” euthanasia accounts for one in eight deaths in the Netherlands. But at least the patients in the Netherlands have insurance – just like us. No more curly fries for me for a while. Woman puts potato in her vagina after being assured by her mother that doing so would be a fail-safe contraceptive method. Turns out mom was right. Guys tend to run the other way when they see roots growing out of your hoo hah. Fortunately, doctors were able to remove the budding spud without surgery. And if anyone makes any Mr. Potatohead jokes, I’m going to be sick. I just know it. The hormones from birth control pills found in sewage found to cause feminization of of male minnows. This caused the number of minnows in the Ontario waterways to decrease to 1% of the usual population. As a result, the number of lake trout decreased – lake trout are the minnow’s main predator. Also as a result, the number of insects in the area began increasing – insects are the minnow’s main source of food. When estrogen was removed from the water supplies, all of the changes reversed. Wait a minute. Obamacare requires that birth control pills be provided at no cost. That must mean that the government wants less fish and more insects in our country. What effect has the Affordable Care Act had on employment in the US? Mostly negative, according to this paper from the Mercatus Center at George Mason University. It creates financial incentives for employees to work less. Part ...

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