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Author Archives: WhiteCoat

Voices Carry

Wisecracking doc that I work with recently had a little surprise.  He was walking down the hallway and saw a nurse escorting a mother and her overweight young daughter into a room. Daughter was holding her right eye.  When the patient’s registration was completed, he signed up for the patient, took a swig of coffee, and said “OK, looks like it’s time to go see what’s wrong with Honey Boo Boo‘s eye.”  A couple of the nurses chuckled and he had a smirk on his face as he walked into the room and pulled the curtain. Only the patient and her mother could see his face after that, but his smirk probably faded pretty quickly. The first words out of the mother’s mouth were a stern “Honey Boo Boo, huh?” Oops.  Isn’t it just like a bullshitter to be quick on his feet, though? There was a hesitation and then he began laughing. “Awwww. I’m sorry. I didn’t mean anything bad by saying that. I call EVERYONE that.”  There was another uncomfortable silence and then he doubled down on his faux pas.  “OK, Honey, let’s see if we can get your eye feeling better. What happened?” In the ensuing banter back and forth, it seemed as if the mother’s irritation had waned. Then the moron starts in again. He pokes his head out from the curtain and asks the nurse “Ummm Chelsea, Honey, could you pleeeease grab me some tetracaine eye drops?” Chelsea would have none of it. She promptly gave him a stink eye.  He mouthed the word “Pleeeeease” and put his hands together as if he was praying.  The stink eye remained.  He then mouth the word “Starbucks” and expanded his hands to make a “large” gesture. Of course, he knew Chelsea’s weakness. Mocha latte frappucino deluxe.  She raised an eyebrow. And held up two fingers. He scowled. It was then her turn to smirk as she took a big breath acting as if she was about to say something he didn’t want to hear. He quickly re-thought his predicament. He grimaced momentarily and mouthed the words “OK OK.” “Sure thing, doc, right away.”  By the time they were done, everyone was laughing back and forth in the room. A handful of lollipops and an IOU for two Starbucks later and the crisis was averted.  “Jeez. Does my voice carry that much?” he asked. A chorous of responses from across the department responded “Yeeessss.”  “I hope bald Donald Trump from earlier today had a hearing impediment ….”  ———————– 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 DrWhiteCoat.com, please e-mail me.  

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Hurry Home

  First of all, I’m having blog withdrawals. Seriously. I wish I could make a living writing a blog. It would be my dream job to write blog posts and troll the internet. Maybe some day. So a quick story before I go to bed for another long day tomorrow. At one of the hospitals where I moonlight, many nursing homes refer patients to the emergency department for routine medical care. Stuff like “patient has a rash for a week” or “patient is agitated.” Normally, it doesn’t bother me too much, but one specific nursing home not only sends its patients in for routine medical issues, but it refuses to take the patient back unless we do the testing that their nurses want. If a patient with a history of agitation gets sent in for agitation but arrives calm, we can’t just send them back on the same ambulance. We have to do tests … special “agitation” tests … to rule out excess agitation levels, apparently. Rashes have to have skin scrapings sent. Patients found on the floor must have head and neck CTs. Haven’t had a positive one yet, but try sending a patient back without one and the ambulance will be sent back to the ED. I tried fighting it a couple of times. They’d send the patient back. I’d do another exam while the patient was on the ambulance stretcher, take vital signs, then send the patient back again. Then there would be the call from their medical director to our department chair. Bad doctor. How dare we practice proper medical care? Patient returns by ambulance for third time. Just do the friggin tests, OK? So when patients come with orders … er, um … requests … from this nursing home’s staff, regardless of how stupid the orders er, um requests are, we put the orders in to save time and to save administrative hassles. Harry was the unfortunate soul who was drafted one Sunday morning. It seemed that the nursing home staff felt it was odd that Harry hadn’t had a bowel movement in two days. He probably had an obstruction. Needs an acute abdominal series and some labs. I called BS. Harry had normal bowel sounds, no palpable masses, and no impaction on his rectal exam (sorry about having to do that on an early Sunday morning, Harry). Besides, it’s entirely normal for someone not to have a bowel movement for two days. We called the nursing home and told them Harry was coming back. Nope. Need labs and an abdominal series. Bastards. Needless to say, the labs and the abdominal series were [gasp] normal. So I asked Harry “Would you like me to give you something to help you move your bowels?” Harry replied “Sure, doc. Always nice to have a good BM every day.” We called the ambulance and made arrangements for transfer back to the nursing home … after being forced to fax them the lab and x-ray results. So I’m curious. Would it have been mean for us to give Harry lactulose and Milk of Magnesia as the paramedics were loading him onto the stretcher to take him back to the nursing home?

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Eeew-perman

One of many ambulance transfers included a 80-ish year old nursing home patient who was sent by the night staff at the nursing home because they were too busy he had mental status changes. When the patient arrived, he seemed OK to me. Awake, alert, smiling. Held a relatively normal conversation. Watching the news on television. He even grabbed the remote and muted the sound when I came into the room. Unfortunately when a patient gets sent from the nursing home with a complaint like this, you’re forced to prove that a problem doesn’t exist. Woe is the doctor who sends a normal patient back to the nursing home without performing testing to prove that the patient really is normal. Then the nursing home administrator calls the hospital administrator and the patient gets sent back to the emergency department for the desperately needed testing. When – and ONLY when – the testing is normal will a patient be accepted back to the nursing home. It’s a stupid game, but one that we’re forced to play. The sooner the normal testing gets done, the sooner the taxi with the big spinning lights can come back to bring the patient back to the nursing home. So we order the standard nursing home lab panel. CBC, chemistries, urinalysis, and drug levels of any medications the patient may be taking. If the patient has dementia, then add a mandatory CT scan of the brain. You see, we can’t really tell if a demented patient has mental status changes, but if the demented patient DID have mental status changes, those mental status changes COULD be due to an acute stroke affecting only the personality centers in the brain. Hey – it happened once, you can’t be too careful. So the lab tech came in to draw the patient’s blood and the nurse gave the patient a urinal for a urine sample. About an hour goes by and the labs are [gasp] normal, but the lab still hasn’t received a urine sample. So I walk back into the room to see if the patient could give us just a little bit of urine in the urinal. Sur-prise! Anyone have some popcorn? “Ummm. Mr. Clinton … why are you drinking your urine out of the urinal?” [giggles, then whispers] “It gives me secret powers.” At that point, I didn’t know whether to puke or to take a sip. “You haven’t been taking your Zyprexa, have you?” “Oh, no. I take it … some-times.” Then he gave me a sheepish wink. Good enough for me. His urinalysis was normal and he levitated got a ride back to the nursing home. Take that, night nurses. ———————– 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 DrWhiteCoat.com, please e-mail me.

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Texas Lawsuit Damage Caps Must Cause Cancer

Never put it past a plaintiff’s attorney to twist an argument to the benefit of other plaintiff attorneys. The last post I wrote was about (former) neurosurgeon Christopher Duntsch, who was recently convicted of a first degree felony related to his medically negligent treatment of an elderly patient’s back pain. There were extenuating circumstances in this case. Dr. Duntsch had established a pattern of egregious medical mistakes. When patients developed complications after surgery, Dr. Duntsch also had apparently tried to cover up his mistakes instead of seeking help. Then there was an e-mail that Dr. Duntsch purportedly sent to a friend in which Dr. Duntsch referred to himself as a “stone cold killer.” Earlier this week, Dr. Duntsch was sentenced to life in prison for his actions. Dr. Duntsch’s case is an outlier. In general, I have a lot of concerns about charging physicians criminally for the medical care they provide. In the past, I’ve discussed how increasing liability for medical malpractice and “suing our way to better health care” just doesn’t work. Increasing the risk of practicing medicine has a few effects. First of all, it decreases availability of medical care. Physicians who don’t like risk will leave risky specialties or will leave risky states. Here’s an article about how a Florida (which is a high-risk state for medical practice) legislator was whining because there was a physician shortage. Think about it. Suppose that several of the houses in your neighborhood were purchased by families who stay up late at night using drugs, who have shootouts in the streets, and who try to get kids in the neighborhood to join gangs. How would you respond to that increased risk to your family? Second, increasing risk in medicine will increase the practice of defensive medicine. Physicians who are risk adverse will engage in more testing and more referrals, which may minimally improve outcomes but at a tremendous cost to patients and to the medical system. There are other effects of increasing liability for physicians such as eroding the physician-patient relationship, increasing physician burnout, and increasing insurance costs, but I’m getting off on a tangent. If you accept the premise that increasing civil liability for medical mistakes has an adverse effect on availability and cost of medical care, can you imagine what a chilling effect that criminal prosecution for medical mistakes would have on the practice of medicine in this country? Enter attorney Christopher Hamilton, Esq. from Standly Hamilton LLC in Dallas. Mr. Hamilton told reporters for ABC News that Texas’ cap on some lawsuit damages may cause more criminal prosecutions of physicians in Texas in the future. Mr. Hamilton also asserted that if it weren’t for Texas’ malpractice caps, hospitals would have caught on to Dr. Duntsch’s egregious medical practices and would have “kicked out a doctor like this much sooner.” He continues by stating that “A lot of times, hospitals only find out about poor outcomes when a lawsuit is brought.” Finally, Mr. Hamilton goes on record as stating that the Duntsch case is “a circumstance where the civil system was not able to weed out a bad apple because of the damage caps.” Let me see if I get this straight … Caps on pain and suffering may increase criminal prosecution of physicians for malpractice. Caps on pain and suffering prevent lawyers from “weeding out” poor physicians. Filing a lawsuit alerts hospitals to the fact that a physician’s practice may have caused poor outcomes But … even though hospitals may be alerted to a physician’s poor practice patterns by a lawsuit being filed, damage caps render hospitals powerless to take action against the physicians. Makes ...

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Press Ganey and HealthGrades.com Are Medicine’s Fake News

Whether you agree with the Trump administration assertions about “fake news” or not, the term has gained legs and has at least put the American public on notice that you can’t trust everything that you read in the media or on the internet. Fake News Definition As the term “fake news” has become more commonplace, it remains loosely defined, often being used as a blanket pejorative against information that counters the interests of those using the term. This article from the Daily Caller describing how journalists are declaring war on fake news without knowing how to define it conjures ideas of the old Keystone Cops movies. I’m going define “fake news” as information that is reported as fact but is without foundation, is demonstrably false, or is presented in a manner that is intended to deceive the reader. To differentiate “fake news” from opinion pieces, we sometimes need to look at the actual or apparent intent of the report, since arguments may be intended to sway opinion, but shouldn’t necessarily be considered “fake news” if they are well-reasoned and supported by evidence. In some instances my definition may fall short, but then again, “fake news” may be one of those terms that is difficult to define but that “everyone knows it when they see it.” Compare that “recognition” definition with concepts such as “justice”, “due process,” and “pornography” which even courts have had some difficulty consistently defining. The internet realm of “fake news” includes such things as “clickbait” and sponsored posts. While I would initially fall for links to posts with phrases such as “this will make your jaw drop” or “you wouldn’t believe”, seldom was I incredulous or left with my mouth agape. Yet the clicks that those links created benefited the publisher by improving site stats and advertising revenue. Similarly, sponsored posts may seem like they’re intended solely for the information and benefit of the readers, but may also be created for compensation at the request of another interested party. These types of “fake news” are more difficult to detect, but the federal government was so concerned about the issue that the Federal Trade Commission created rules requiring disclosure of any sponsorship in posts endorsing a product. Applying Fake News to Healthcare Reports The event that prompted this post and bumped others that I was working on was the news story about former prominent Texas neurosurgeon Christopher Duntsch. I wrote about the story several years ago over at EPMonthly.com. My prior post was, in turn, prompted by an excellent article in the Texas Observer by Saul Elbein. The gist of Saul Elbein’s article was that Dr. Duntsch had multiple egregious medical misadventures while operating on patients and that those misadventures caused multiple serious patient injuries and one patient death. Dr. Duntsch would bounce from hospital to hospital after he started feeling heat from his malpractice, so it took some of the hospitals a while to figure out the problems. However, the Texas Medical Board was reportedly notified of these misadventures on multiple occasions by multiple physicians from multiple different hospitals, but Dr. Duntsch reportedly kept maiming patients in surgery while the Board “investigated” for more than a year before suspending his license. See Order of Temporary Suspension from the Texas Medical Board here (.pdf file). The recent articles on Dr. Duntsch provide some closure. He was tried criminally for his botched surgeries – an extremely difficult allegation to prove. However, after only four hours of deliberation, a jury convicted Dr. Duntsch of the first degree felony of “harming an elderly person” with regard to the care of one of his patients. Dr. Duntsch now faces life in prison. See more information on the trial in the ...

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Healthcare Update — 02-10-2017

So I hadn’t planned to continue doing Healthcare Updates, but there are always so many interesting healthcare-related articles that I can’t stay away. To wit … For women, it’s the birth control pill. For men, it may soon be a shot to the nuts. Literally. Researchers showed that an injection of Vasalgel into the vas deferens (the pathway leading out of the testicles) could temporarily block the flow of sperm and effectively sterilize monkeys. Other studies in rabbits showed that the gel eventually “flushed out,” returning flow of sperm. Learn more about Vasalgel here. If you aren’t adventurous enough to inject some slime into your working parts, there’s also an app for that … maybe. A mobile app called Natural Cycles was recently granted approval to be used as a contraceptive in the European Union. It works by tracking temperatures and then predicting when women ovulate. The app will recommend against having sex on days 6 through 16 of a woman’s cycle. That’s all fine and dandy, but to me, there are too many variables involved in fertility. These “fertility awareness” methods of contraception are notoriously unreliable. As in up to 24% of women will end up pregnant at the end of 1 year by using them. Wondering if the app will give refunds for that. If your smartphone can’t keep you from getting pregnant, it may at least be able to tell you if you smell bad. New Japanese gadget called KunKun links to your smart phone and detects multiple different chemicals that are often associated with bad smells. At an estimated price of $300, I don’t know that I’d purchase this for personal use, but it would be an interesting attraction outside of a bar at the end of the evening – as long as no one puked on it. One of my many pet-peeves: Overmedicating our children. There is waaay too much medication for ADHD and ADD being prescribed to young children. The problem is that the diagnosis of ADHD includes activities that are common in most children – doesn’t pay attention, doesn’t listen, fails to finish chores, often loses things, fidgets in seat, often “on the go” …. these activities seem to be the rule, not the exception. This article recommends that we Stop Drugging Our Kids and explores some of the reasons parents may want their kids to take stimulant medications. Helping kids excel in school and perhaps a lack of parenting skills fit in there somewhere maybe? Money quote: “we are putting kids on drugs for behaving in age appropriate ways.” Absolutely true and it needs to stop. The graphic accompanying the article artfully demonstrates one of the issues our society is facing. Fascinating article about how grip strength is a predictor of overall health … and how grip strength is rapidly declining in this country: Raising the American Weakling. One researcher, an occupational therapist, noted that the grip strength in her patients was far from the norms established in the 1980s. The article cites many other studies showing that, for example, that grip strength was a stronger predictor of all-cause and cardiovascular mortality than systolic blood pressure. Another interesting point in the article was that a top NHL scouting prospect wasn’t able to perform a single pull-up during a fitness test. On the other hand (no pun intended), a different researcher noted that womens’ grip strength is worse than men, yet women live longer than men. I’m a fan of exercising, so I tend to agree with the study sentiments – even if grip strength is an imperfect indicator of overall strength/health. Another fascinating article about how some doctors in Wake ...

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