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Author Archives: WhiteCoat

It’s ALIVE

There was a lull in the patients at 2:15 AM. Conversation turned from splinting and IV drips to baby names and childrearing as two of our nurses are currently pregnant. The aroma of freshly-brewed coffee filled the air. Then the next patient registered. A girl in her early 20s. She sheepishly came up to the registration window and said “there’s something crawling inside of me.” Yes, we thought it, too. “OK, ma’am. When was your last menstrual period?” “I think it may have been a month ago … or maybe two months.” “Did you check to make sure you’re not pregnant?” “Yes, a home pregnancy test was negative about three weeks ago.” “How long has this been going on for?” “About 3 weeks.” Yes, we thought it, too. “If this has been going on for three weeks, why did you wait until 2AM today to decide to come to the emergency department?” “Well … it was worse.” “At 2:00 AM tonight?” “Yeah. Usually it feels like a chipmunk running around inside there. It will scamper around a little bit, then it will stop. Then it will scamper around a little bit more, then stop. I was trying to get my mom to feel it tonight and it wasn’t moving, but then it felt like it had hiccups or something. I couldn’t sleep.” One of the pregnant nurses and I gave each other quizzical looks out of the corners of our eyes. Then the secretary came in and handed us the results for the normal urinalysis and the negative pregnancy test. The pregnant nurse and I gave each other another quizzical look out of the corners of our eyes. “No other problems? No diarrhea? No discharge? No pain?” “No. Nothing. Just something moving. I really need to know what it is.” The patient was rather thin. Her exam was normal. Since she was so thin, it was easy to feel that there were no masses in her stomach. Nothing. “Wait! There. Do you feel it? Feel it hiccuping right there?” She grabbed my hand and held it firmly to the middle of her stomach. “You mean that regular pulsing down deep?” “Yeah! THAT! What is it?!?” “Tell me something, can you feel the same pulsing in your neck?” At that point, the pregnant nurse standing behind me blurted out “Thank GOD! I thought I was crazy! Every time my baby moves, I feel a pulsing in my neck, too. I had no idea what it was and was too embarrassed to ask. So what is it?” “She’s not pregnant, remember?” Then both of them in unison ask “So what’s causing the pulsing?” “Her pulse maybe? Here, check your wrist and see if the pulsing is going at the same rate as the movement in your stomach.” It was. “The biggest blood vessel in your body runs right down the middle where you are feeling the movement. You’re supposed to be able to feel pulsations there.” We all got a good chuckle. After the patient went home, we all sat around the nursing station telling baby stories. While she was talking, one of the nurses started rhythmically contracting her stomach … about 60 times per minute. Everyone else joined in unison shortly thereafter. The pregnant nurse turned red. “Hey, it’s my first baby. Cut me some slack.” Everyone just kept talking and rhythmically contracting. “I’m wrapping up his poopy diapers and mailing them to all of you.” “As long as you don’t bring him in for hiccups, I’ll be fine,” I said. “You’re going to be the first one for a poop bomb, WhiteCoat.” ...

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Healthcare Update — 11-14-2013

See more updates over at my other blog at EPMonthly.com Jury finds cardiologist and hospital liable for performing unnecessary cardiac stenting in patient. Patient wanted $50 million in damages, jury can’t agree on damage award. Judge throws out case against cardiologist during jury deliberations leaving hospital as only defendant. Veteran’s hospitals paying out record amounts in settlements and court judgments for medical malpractice claims. Some of the claims include – a 20-year Marine Corps veteran paralyzed after a routine tooth extraction – an Air Force veteran who died after a surgeon burned a hole in his heart with a laser – an Army veteran who died after doctors repeatedly failed to diagnose and treat a cancerous growth that was present on the patient’s chest x-rays for more than three years – another veteran who bled to death after being left in a room after a liver biopsy and never re-evaluated The payments for VA negligence come from the Treasury budget … meaning from our pockets. One State rep notes “We focus so much on sending our soldiers to war. But when they’re coming back, we don’t have the same focus on taking care of them.” Another article in the Dayton Daily News gives more details about several of the cases. Association or causation? After drug companies voluntarily withdrew many pediatric cold medications and recommended against using others until patients reach 4 years of age, the percentage of ED visits for adverse events from such medications decreased from 4% to 2.5%. Dr. Melvyn Flye arrested for perjury when he made untrue statements as an expert witness at trial. How often do you see that happen? Actually, I think it should happen more. Arrest incidentally occurred in July, but the article just came across my newsfeed this week. Patients gone wild. Patient upset because emergency physician won’t refill his Norco prescription leaves hospital emergency department and stabs emergency department greeter in the neck on his way out the door. The greeter is in serious condition. Godspeed to her. The patient is in the Greybar Motel. Hope he doesn’t even get Tylenol. Another article on the incident courtesy of Scott DuCharme – thanks! Popular Science calls this a “rare new bacterium.” Tersicoccus phoenicis is found in NASA “cleanrooms” and is resistant to chemical cleaning, ultraviolet rays, and other sterilization procedures. Interesting questions develop in my mind. First, I doubt that the bacterium is “new,” but suspect that it is just that no one has ever looked for or found it yet. Perhaps “newly discovered” would be a better term. Second, if chemicals and sterilization don’t kill it, then what does? If the only thing absent from clean rooms is bacteria, then likely the growth of other bacteria somehow hold the growth of this bacterium in check. Hat tip to Instapundit for the link. Will the Unaffordable Insurance Act (if you were wondering, I refuse to call it the “Affordable Care Act” because it isn’t “affordable” and it doesn’t provide medical “care”) provide more reimbursement for emergency department patients? If Medicaid payments stay the same (which they won’t), then this study suggests that receipts for previously uninsured patients will increase by 17-39%. Great save. Orlando emergency physicians perform needle cricothyrotomy on an infant with a pacifier tightly lodged in his throat. Patient went to surgery and an ENT surgeon had to remove the pacifier in pieces. Why don’t newspapers ever publish the names of the doctors that do great things like this? Seems like almost all of the publicity is for malpractice and other allegations of badness. Alicia Gallegos, former medical legal reporter extraordinaire for the ...

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Memorable Patients

In my medical career, there have been a handful of patients that I remember well. Like frames on a storyboard, when I think back upon the tens of thousands of patients I have treated, these patients always seem to come to mind. Perhaps as a precursor of things to come, I even wrote stories about some of them early in my career when I saw them. I remember the first time that I drew blood on an elderly patient and how it seemed like her room was a prison cell. I’m sure she passed away a long time ago, but I can still remember looking into her eyes and wondering what this poor woman had been through in her life. I remember one of the first surgeries that I was asked to scrub in on during my Ob/Gyn rotation. They called it a “TOP”. I was excited to be a part of it. Then I learned that “TOP” stood for “Termination of Pregnancy.” I remember feeling uneasy as the resident showed me how to use the currette. I remember almost passing out when I looked through the speculum and saw a tiny white hand laying across the red surface of the patient’s cervix. I remember almost vomiting as a resident as a nurse told me that an intoxicated patient with dizziness just needed to “sleep it off” … right before he vomited a liter of blood all over her and over the curtain a couple of feet behind her. And of course there was the lollipop lady. I wrote a post about her already. Recently another patient was added to the storyboard of my medical career. I’m not sure if there was anything so memorable about her, but perhaps it was her blase demeanor in the face of a rather messy problem. Well … you can decide. The patient was in her mid- to late-60s, was well spoken, pleasant, and well-kempt. She had changed into a gown and her clothes lay neatly folded on the chair across the room. Her problem was a regulation of her bowels. First, she had diarrhea for a couple of days. She took some Imodium and Pepto Bismol and the diarrhea stopped. But then she had no bowel movement for two days. That was to be expected since after diarrhea stops it often takes the body a day or two to create more stool. The patient became concerned after having no bowel movement on the second day and she took a laxative, thinking that she may have a bowel obstruction. Then she had black colored diarrhea. Her stool was hemoccult negative, meaning the black color was likely from the bismuth in the Pepto Bismol. Bismuth combines with small amounts of sulfur in your GI tract and can turn your tongue and your stool black. Examining her closer showed that there was dried black crust all of the way down the inside of both her legs. She had passed enough diarrhea that her buttocks had become inflamed and it hurt when she sat down, so she preferred to lay on her side. She got a liter of fluid, we got a CBC, chemistries, and a stool sample just to make sure there wasn’t an infectious etiology for her symptoms and that she didn’t have a metabolic acidosis. Everything was normal. Then the strangeness began. I went back into the room to see how the patient was feeling. I could hear the lid on the infectious waste container slamming shut as I entered the room. Then I got hit head-on by a foul smell. I pulled the curtain ...

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Healthcare Update 11-04-2013

See more medical news from around the web on my other blog at EP Monthly.com Like a Nazi article touting the benefits of gas chambers. Press Ganey CMO Thomas Lee writes article about current “surge” in “patient experience” published in Health Affairs. Dr. Lee’s definition of “professionalism” that he and his organization apparently expect us to latch onto includes willingness of physicians to work together to “meet[] patients’ needs,” not wasting resources, and being very concerned about data on your performance – even if that data is statistically insignificant and wholly inappropriate to use. So if we don’t “meet a patient’s needs” for large doses of narcotics and if we perform testing that we believe is clinically appropriate but which is then retrospectively deemed to be a “waste of resources” and then we don’t bow down to Press Ganey’s little red, yellow, and green boxes, then according to Dr. Lee, we must now be labeled as “unprofessional.” Another out of touch “physician” who is writing surreptitious articles for his employer. How low will Press Ganey go to make a buck? Meh. Just a flesh wound … or maybe not. Chinese man walks into emergency department with fruit knife sticking out of his head. Occurred when some kind of a “game” got out of hand. Knife actually penetrated his skull and required three hours of surgery to repair. Then the doctors sent him home with the knife. I can just hear him when he gets home and starts playing the “game” again: THIS time I go first! The White House has a brigade of Twitter attack drones just waiting to use your tax dollars for their salaries while they blast anyone who portrays the government and/or the Unaffordable Insurance Act in an unflattering light … for example an elderly survivor of metastatic gallbladder cancer who is now unable to keep her insurance plan because of Obamacare regulations. Some commenters called White House staffer Dan Pfeiffer (@pfeiffer44) a “douchebag” for attacking the patient. I think that’s being degrading to women’s hygiene products. Is that ACEP newsbyte about emergency medicine accounting for only 2% of all healthcare spending really true? Politifact says that it is … mostly. Politifact did cite a 2013 study showing that the cost of emergency care was between 5% and 10% of the total amount of healthcare spending. “Zero tolerance” in some UK hospitals after multiple “high profile” attacks on emergency department staff. Consultants note that emergency department staff deal with violence on a daily basis, yet the only measures they take to curb the violence is to make sure cameras are in place so they can catch the perpetrators after the act. When hospitals refuse to provide adequate security for their employees and are aware of the high potential for violence, perhaps the hospital administrators should be civilly and criminally liable for any injuries sustained by their employees. Michigan House Bill No 4354 (.pdf) would make it much more difficult to sue physicians or hospitals for EMTALA-related care. Requires proof by “BY CLEAR AND CONVINCING EVIDENCE THAT THE LICENSED HEALTH CARE PROFESSIONAL’S ACTIONS CONSTITUTED GROSS NEGLIGENCE.” This is a very high legal hurdle. Article notes that “the liability in such medical situations has many specialists declining to be on call.” A study performed by the Michigan College of Emergency Physicians showed that states such as Georgia and Texas that enacted similar reforms had an increase in physicians. Apparently the concept that we can’t “sue our way to better health care” is beginning to take hold. Notice how all the attorneys in the comment section argue against the legislation. Head of Veterans Affairs writes a letter to US Representative ...

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Otitis Externa and the Ear Wick

This is the first in a series of posts to explain some common medical problems to patients in a hopefully easy-to-understand manner. Otitis Externa Otitis externa (or “swimmer’s ear”) is an inflammation of the outer portion of the ear canal. It is different from a middle ear infection (“otitis media” or the typical “ear infection” that typically afflicts children) because otitis externa affects only the ear canal (see the red area in the picture below) while otitis media is a collection of pus behind the eardrum (see the yellow area in the picture below) that does not affect the ear canal. Patients with otitis externa often have significant pain in the outer ear and may have swelling and/or drainage from their ear canal. One of the easiest ways to tell whether a patient has swimmer’s ear is the “tragal tug” — pulling outward on the cartilage of the ear (like your mother used to do when she was mad at you). Pulling on the ear will cause traction on the skin within the ear canal. When the skin inside of the ear canal is inflamed and is stretched, it will hurt. Therefore, patients with swimmer’s ear will usually have significant pain when their ears are pulled. The pain from inner ear infections usually doesn’t get much worse with the tragal tug — unless otitis externa is also present. Mild cases of otitis externa can sometimes be treated by putting Burow’s Solution into the ear canal a few times a day. When a patient is diagnosed with otitis externa, drops containing antibiotics and steroids are often prescribed. It is a good idea to check the ear drum for signs of perforation before putting medications into the ear. If some medications get into the inner ear (the yellow area above), they can cause dizziness, ringing in the ears or even hearing loss. For example, Cortisporin Otic and other aminoglycosides have the potential to damage the vestibula with prolonged use. Quinolone/steroid combinations are less likely to cause such damage. The Ear Wick If you put drops into the ear canal and then stand upright, then the drops all collect on the bottom of the ear canal. Eventually, they either get absorbed or they drain out of the ear canal. Additionally, if the ear canal is swollen shut or nearly swollen shut, the medications may not get to the affected areas in the ear. An ear wick solves both problems. An ear wick is a piece of sponge (or sometimes a piece of cotton) that is inserted into the ear canal. Topical medications are then put onto the ear wick and then capillary action pulls the medication further into the ear canal. The wick helps to keep the medications in the ear and helps to hold the medication along all surfaces of the ear canal. As the ear heals, the wick usually falls out on its own. If not, a medical professional can easily remove it.    

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The “Unnecessary” Test

Here’s a real case submitted by a reader. A two year old child is brought into the department by her father, her mother, her grandmother, and her greatgrandmother. All were very concerned. The child was walking on a curb using her dad’s hand for support when she lost her balance and fell. Her dad didn’t catch her quickly enough and the child struck the side of her head. The mother said she saw the child’s head “bounce off the concrete”. Both mother and child cried immediately after the accident. After about 10 minutes, they put the child into the car. She went to sleep immediately. The mother tried shaking her leg, but she wouldn’t wake up. The father then stopped the car and they took her from the car seat and shook her. She still didn’t wake up. They called grandmother who called great grandmother. All agreed to meet at the emergency department. When she got to the emergency department, she was alert. In fact, she was running around the room opening drawers and pressing buttons. Both parents had to restrain her just so she could be examined. Even then, she wouldn’t sit still. A thorough exam of her head showed absolutely no signs of injury. She did say “ouch” when the back of her head was palpated, though. Normal pupils. Normal TMs. Normal neck. No Battle Sign. No other evidence of inury. No vomiting. In other words, she met all of the criteria for a “low-risk” head injury (.pdf) except for the parents’ history of this prolonged unresponsive state. Three generations of family members want a CT scan of the brain. The explanation of injury doesn’t match the physical findings and you believe in your heart that the parent’s story of a 15 minute episode of unresponsiveness is inaccurate. You also know that there’s no way that the child will sit still for a CT scan. That means that you’ll have to do conscious sedation (including all the extra paperwork required by the Joint Commission) and observe the child for a couple of hours after the CT has been performed. If you do the test and it’s normal, then you will be accused of performing defensive medicine, the nurses will be pissed at you for the rest of the shift, your productivity will tank, you’ll get an e-mail from your department chair about all the complaints from patients for the long waits, you’ll get bad Press Ganey scores from the upset patients, and you may get a letter from hospital administration for “overutilization” of resources. If you don’t do the test, the family will be upset with you, will accuse you of providing poor medical care, and will give you bad Press Ganey scores (and you’re on the CEOs hit list for the two bad scores you had last quarter). Oh, and if you don’t do the test and the kid has a bleed, you’ll be sued, the chart will show that everyone in the family thought the CT should be done and you were just too dumb to perform it, and the State Medical Board will likely bring a licensure action against you … which could result in you not being able to practice medicine any longer. What do you do? [yop_poll id=”3″] ———————– 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. I’m making full blog posts ...

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