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1209717_19610439The focus of this web site is medicine. In this blog, you’ll read about patient stories. The situations have been changed to be HIPAA compliant. You’ll also read a lot about health care policy. I may throw in posts about life lessons, computers, and will even throw in family stories once in a while. If you’re looking for articles about politics, sports, or celebrities, you’re in the wrong place – unless the topics have some relationship to medicine.
If you want to add a guest post or to cross-post something from your blog, or if you have a patient story you want me to write about, e-mail me. See more information in the “About Me” page.

What’s The Diagnosis 22

Child Skin Lesion

A six year old child is brought to the emergency department by an aunt and a Child Protective Services worker. He was sent home from school by the teacher who said that the child appeared to have marks from being hit over the shoulder by a whip. The school principal called Child Protective Services. The child says he wasn’t hit by a whip but can’t say what, if anything, did happen. The lesion is dry, rough, and non-tender. It does not appear to be a bruise. No drainage. No fever. No URI symptoms. No other lesions anywhere else on the body. The child is up to date on immunizations. What’s the diagnosis and what’s the treatment? Answer posted below in a few days. . . . . . . . . .      

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Healthcare Update — 07-28-2014

Patients with “insurance” wonder why they can’t find access to medical care? Here’s a good example of why: Wisconsin pays a pittance to those who care for its Medicaid patients. As in 71% lower for office visits than private insurance payment rates, 76% to 78% lower for hospital care than private insurance rates, and 91% lower for emergency care than private insurance rates. According to the article: One result of Medicaid’s low payment rates for physicians is a shortage of primary care clinics in low-income neighborhoods in Milwaukee. That contributes to many people seeking care in high-cost hospital emergency departments. Wheaton Franciscan-St. Joseph estimates that roughly half of the patients in its emergency department — the busiest in the state — could be treated elsewhere. Letter to the editor about the article from an emergency physician notes that the abysmal payment rates make it difficult to recruit and maintain emergency physicians in Wisconsin. Oregon hospital notes “record breaking” increases in emergency department visits after Obamacare implemented. Average daily patient volumes in the 60s increased to the mid-70s with some spikes up to 100 patients per day. Wait times also increasing. BMJ investigation shows that drug manufacturer Boehringer Ingelheim reportedly hid data from regulators regarding safety of Pradaxa [dabigatran]. Some Life Pro Tips from Reddit contributors on how to speak to people who have hearing impairment. Not scientific, but I’ve found that I tend to speak slower and enunciate each word when a patient initially says that he or she cannot hear me. After going back and forth once or twice, I’m usually able to speak in a normal or near-normal voice. Any ENT experts care to chime in? Slowly, of course. And for all you young whippersnappers out there, here are two related sitcom videos related to auditory issues from Monty Python and Taxi. More on the $190 million Johns Hopkins settlement after gynecologist found to have taken secret pictures of up to 8000 patients. Hopkins joined an insurance collective with other universities such as Yale, Cornell, Columbia, and the University of Rochester. Now money will be coming out of the pockets of several institutions that had nothing to do with the Hopkins incidents. Recently-published CDC study based on 2012 data shows that children covered by Medicaid use the emergency departments at a rate nearly double that of patients with private insurance. Pregnant California woman in labor is unable to cross street to get into hospital for 30 minutes because President Obama’s motorcade was passing through at the time. Pakistani town organizes protest of 100 people calling for a doctor to be arrested when patient under doctor’s care dies of stroke. Protestors laid patient’s body in road in front of the clinic and initially refuse to leave. Philadelphia psychiatrist pulls out gun and shoots armed patient who had just shot his case worker. Police admit that the doctor’s actions stopped the patient from going on a rampage and killing others, but police are also “investigating” why the doctor had a gun at work since “bringing guns to work is against the rules at the hospital.” Those “no gun” zones work so well. Obviously the patient in the incident was playing close attention to the rules. And Chicago is a shining example of how properly implemented gun-free zones save lives. You know all those fitness wristbands and fitness apps for your phone? They’re a gold mine for advertisers and identity thieves. Almost 75% of the apps studied sent data to third parties; nearly half shared personal information with advertisers — all without the user’s knowledge. Another analysis found that the top ...

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A Medical Malpractice Attorney Tells It Like It Is

Gavel Pic

By Birdstrike MD Below is conversation between an Emergency Physician and a medical malpractice attorney. It was originally posted on Student Doctor Network by an anonymous poster that goes by the handle “TrumpetDoc.” It has been reprinted and edited with permission of the original author. If you have any thoughts or experience regarding medical malpractice, from either the plaintiff or defendant side, I’m sure you’ll find it quite interesting. ……………………………………………… Recently I [TrumpetDoc] had a discussion with a local medical malpractice plaintiffs’ attorney at a social gathering. Since I have been hearing often from my former group’s lead MD/JD and influential leaders in Emergency Medicine, that increased medical testing never protected anybody, I asked his thoughts on the subject. His comment was, “That’s Bull—t! When there is a bad case or outcome, and I see an upstream doc that had the chance to make the diagnosis with a test or procedure, I smile every time. I can get an expert from any specialty to debunk a doc’s thought that his/her exam and thoughts are good enough these days. And if we go to trial, I have a pretty set script here. To the effect of ‘so Doctor, you just didn’t care enough about my client to order this test?’ Or ‘so my client was just a statistic, just a percentage to you?’… [Juries] love that stuff!” He went on to explain that the medical malpractice environment will be getting worse for us doctors and he was extremely bullish on the med-mal business in the coming years. He continued on, “You guys are being hung out to dry. So are hospitals. There is already starting to be a contraction on spending and ‘costs.’ This is just awesome for me. There will be a lot of bad discharges, refused admits, procedure delays, diagnoses delays, all in the name of ‘costs.’ Your societies and hospitals are masking this as evidence based practice, etc. But I can get a jury to see that very differently. A lot of physicians will be paying out before long, as will hospitals…Testing is what makes diagnoses, saves people.” I rebutted by explaining that malpractice cases are best prevented and defended not by practicing “defensive medicine” but by documenting in the chart our thought process, differential diagnosis and rationale, using the concepts of clinical acumen, experience, and evidence and that our own experts could and would defend our actions. He responded with, “But that is in your world; people live in mine… juries live in mine,” with a smug smile and chest tapping. I had to restrain myself. He continued on, “If a patient is in the ER and wants to be admitted…you better just pray nothing happens in a reasonable time frame after if you discharge them against their wishes.” I asked about defensive medicine protecting from us suits and he said, “To a point, it does. Will you get sued? Sure. Will I be less inclined to take a case that had a complete workup? Yup. If you appear to me like you cared and did everything you could, you certainly more protected.” To him that equals ordering tests such as labs, CTs, and MRIs in the ED and admitting patients to avoid risk. He went on to say, “Nurses will hang you. EHRs [Electronic Health Records] are awesome! And nurses chart everything they freaking think of while in the ER with a patient. They are there to cover their butt, and often it is very helpful to me. It is so common that there are discrepancies in the medical record, and now they are so easy to find.” Regarding Choosing Wisely, he said, “This will ...

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Medical School in the Big City, Vol. II: A Month in the Morgue

Skull pic

  By Birdstrike M.D.   “So, I grabbed up my suitcase, and took off down the road When I got there she was layin’ on a coolin’ board” – Son House, Death Letter Blues   Fourth year of medical school is great.  Finally, I get some elective time.  Last month was great: Dermatology, ahh…….Sleep, rest, low stress and drug rep lunches: Yum.  I can still smell the delicious smoked ribs the rep brought for lunch, just last week.  I’m already hungry as I drive to start my second elective month in a row.  This month is going to be even more relaxed.  The patients might have >gasp!< pimples and rashes like last month, but this time they probably won’t even move!  After getting worked to death on 6 straight months with hospital call, this is the break I need. I walk into the building and as I get close to the bottom of the stairs, I smell something.  Is that ribs, again?  Wow, drug rep food already?  It’s only 9 in the morning.  That’s weird?  Oh, well.  I guess life really is good on these elective months, when you’re not getting called at 2 a.m. for a patient who might be dying.  I look at the clock.  Shoot, I’m a few minutes late.  I open the door. A group of students and residents are standing around a table that is covered by a sheet.  The smell of barbequed ribs hits my nose stronger.  A bearded man on the other side of the table, waves to me to come over.  That must be Dr. Black.  I creep toward the others around the table as Dr. Black pulls the sheet off of the table.  The overwhelming smell of smoke chokes my nose and as I see what is lurking under the sheet, I feel my stomach drop and my head get dizzy.  There laying on the table is a charcoal-black human body, burned to a crisp, arms drawn up to the face in a fetal position.  A few of the others turn away.  I hear a gasp, and a few deep breaths as we look at each other.  Oh my god, that smell!  I feel like vomiting.  It’s the smell of barbequed ribs, alright.  Human ribs.  Welcome to Forensic Pathology, I think to myself. “One thing we always do with burn victims is to x-ray them.  Does anyone know why?” asks Dr. Black. “To identify them by dental records,” chirps Gunner Boy with the bow tie. “No, although we do that occasionally,” says Dr. Black.  “It’s to see if there is any lead in them.” “Huh,” Gunner Boy seems puzzled.  “This person died in a fire.” “Are so sure?  Why might such person have lead in them?” asks Dr. Black. Now it’s my turn.  “It’s because they’ll shoot them full of lead, then light the house on fire to try to cover up the evidence,” I blurt out. “Yes sir,” nods Doctor Black. Betsy, the mousy-haired girl that was in my Anatomy group looks at me disturbed, as if to ask, “How’d you know that?” “Welcome to Big City Morgue, Betsy,” I shoot back. I look down at the burnt corpse and despite the whole body being as black as a charcoal briquette, for some reason there’s a patch of skin on the right arm that’s completely unburned.  It’s a tattoo that says, “Mom, I love you forever.  R.I.P.”  Below that is another tattoo that says, “Straight to Hell.”  How unbelievably ironic, I think to myself. We move to the next table.  Dr.  Black pulls back the sheet.  It’s an 18 year ...

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Healthcare Update — 07-18-2014

More patients gone wild. Texas woman gets trip to the hoosegow after running a red light and colliding with another vehicle, then attacking the emergency department nurse who was trying to help her. Adding pelvic exercises to a workout may help men as much as it helps women. Kegel exercises for men *may* improve incontinence and erectile dysfunction, and one company actually created a little weight lifting system that fits over the male genitalia. Gives new meaning to the phrase “pump you up.” Not to be outdone, you can also see this article on weight training with a women’s genitalia using a jade egg. Who wouldn’t want a pelvic floor like a trampoline? Then again, just reading the article makes me think about getting one of these things for Mrs. WhiteCoat. Hat tip to Instapundit for the link North Carolina patient with chronic pain experiences an increase in pain for 2-3 weeks then waits until 3PM on a Friday afternoon to seek medical care in the emergency department rather than seeing their primary care physician in the prior 14-21 days. Given two pain shots and a prescription for pain medications but wife is still upset because he “was not adequately treated for his episode of pain,” so she writes letter to the editor of the newspaper. Speaking about chronic pain … Salix gets approval for its new drug Relistor for treatment of chronic pain in non-cancer patients. Initially approved for opioid induced constipation and is an isomer of the drug naltrexone which is used to treat alcohol dependence and occasionally used to treat opioid dependence. California’s Grant Union High School in the midst of a tuberculosis outbreak. 116 of 450 students and staff have latent TB while 5 students developed active TB including one who spread the disease to some family members. New Jersey’s University Hospital cuts emergency department beds and opens “observation unit” to ease emergency department overcrowding. Kind of interesting how state hospitals work that numbers game. Will be interesting to see how much crowding increases in both the ED and the observation unit. Naval Hospital Bremerton closing its emergency department and ICU and opening an urgent care facility April 15, 2014 article in Huffington Post by Alexander Kjerulf titled “Top 5 Reasons Why ‘The Customer Is Always Right’ Is Wrong.” Companies that exhibit this attitude create unhappy employees: “You can’t treat your employees like serfs. You have to value them … If they think that you won’t support them when a customer is out of line, even the smallest problem can cause resentment.” The “customer is always right” sentiment also creates perverse incentives where “abusive people get better treatment and conditions than nice people.” When companies enforce this culture, employees feel less valued, feel as if they have no right to respect, and gradually learn to provide “fake” good service where the courtesy is “on the surface only.” One expert noted that “when you put the employees first, they put the customers first.” The article ends by noting The fact is that some customers are just plain wrong, that businesses are better of without them, and that managers siding with unreasonable customers over employees is a very bad idea, that results in worse customer service. FDA trying to regulate tweets. Maybe it should spend more time reviewing the safety profile of drugs so that it doesn’t recall medications for safety concerns after it has approved them for 30+ years … not that something like that would ever happen. Twice. Or more. Oh, and by the way. Stare at my avatar for 30 seconds 3-4 times per day. ...

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What is an Aneurysm?

Aneurysm

The kids took out a hose to wash our cars. We have several hoses, but the kids like the cheap nylon hose for most of the jobs around the house because it is light and easy to move around. They used the cheap nylon hose to fill up a bucket with some soap and water, got some sponges, and had a lot of fun cleaning the cars. Then they put a spray nozzle on the hose to rinse the cars off. That’s when my daughter came into the house dripping wet to give me some bad news. “Dad … there’s something wrong with the hose.” I went outside and the hose was in bad shape. “The hose has an aneurysm. Not going to last much longer.” “What’s an ann-you-rism?” My youngest daughter asked. Light bulb! What a perfect idea for a blog post! I went to get my camera. At this point, you’re probably asking yourself what a garden hose has to do with a discussion of aneurysms on a medical blog. The simple answer is that the basic principles remain the same whether we’re talking about an abdominal aortic aneurysm, a brain aneurysm, a hose aneurysm, or even a balloon. In medicine, an aneurysm occurs when there is a weakness in the walls of a blood vessel. As the weakness worsens, the walls of the blood vessel  around the weakness begin to balloon out. As the walls balloon out, they get weaker. The cycle continues until eventually the wall breaks. Think of a balloon. When you first start blowing up the balloon, it is usually a lot more difficult to get the first breath of air inside. After that, it gets easier and easier to blow more air into the balloon until you reach the limits of the tensile strength in the balloon walls and … POP. Aneurysms almost always occur under pressure, so they almost exclusively occur in arteries. Venous aneurysms can occur, but are rare. This makes sense. Go back to the balloon analogy. If you don’t blow to put pressure inside the balloon, it won’t get bigger. Now think of the hose analogy. My kids didn’t notice the swelling in the hose initially because they didn’t have the spray nozzle on the hose and the water ran freely out of the end – therefore no pressure built up inside the hose. Once the spray nozzle was in place, the water had nowhere to drain, causing pressure to build up inside the hose and making the aneurysm bulge. Think about the human body. Higher blood pressure puts more pressure on aneurysm walls. Therefore, it’s a good idea to keep your blood pressure down with aneurysms. Blood vessels have many layers. Because arteries are under higher pressure than veins, arteries have more layers of reinforcement. See the picture above which was originally posted on Wikipedia. Note how there are more layers in the artery and how the smooth muscle layers are thicker than in the veins? Just like layers of clothing in the winter help to keep in warmth, layers in blood vessel walls help to maintain the blood vessel’s strength. There are two basic types of aneurysms. Fusiform aneurysms are similar to what happens when you partially inflate a “twisty balloon”. Fusiform aneurysms involve the entire diameter of the blood vessel. Berry or saccular aneurysms involve a bulge in the side of a blood vessel or can also occur where a blood vessel divides (often in the brain). Our hose had a berry aneurysm. Now here’s the cool part of the hose analogy (click on the pictures to enlarge). Note the yellow nylon coating ...

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Treatment Denied

Staple remover

“I’d like to have someone take out these staples,” said the well-dressed woman who came to the registration window. “OK,” said the registration clerk, “we’ll get you registered and we’ll get you right back to a room.” “Perhaps you didn’t understand,” the woman stated as her voice went up a few decibels, “I want someone to take these staples out now and I’m not going to register to have it done.” The registration desk is on the other side of the wall from the fast track nurse’s station. There was a lull in the action, so I was leaning against the wall talking with a couple of nurses when we heard the woman raise her voice. Everyone stopped talking, looked at each other, and furrowed their brows. One of the nurses went up to the registration area to perform some reconnaissance while pretending to use the copy machine. She came back with a sour look on her face. “It’s Rhonda Jones. Her family owns several restaurants in the area. They’ve got a lot of money and they like trying to push people around.” The registration clerk was already getting flustered. “I’ll have to call my supervisor. Just a minute, ma’am.” “Is Dr. Koop down here today? Maybe you can just call Dr. Koop instead.” Dr. Koop was the head of the medical staff and well-known in the community. Very high-profile doc, but he was a cardiologist and didn’t work in the emergency department. “Just a moment, ma’am. Ummm … Dr. Koop isn’t on call tonight.” Now to put things in perspective, I don’t have any problems doing minor things to help patients. There’s a policy that all patients seen in the emergency department must have a chart made. On one hand, medicine is a business. I get that. On the other hand, morally, I have a hard time justifying a several hundred dollar charge to a patient for doing something that takes two minutes. I’ve gone out to the waiting room or into the triage room and pulled sutures, adjusted a splint that was too tight, and checked people’s blood pressure for them – without registering them to be seen. To me, it’s just the right thing to do and I think it improves the hospital’s reputation with the patients. By this time the woman had raised her voice to the point that people in the waiting room stopped talking to see what was happening. “You call Dr. Koop NOW and tell him that Rhonda Jones is here,” she said firmly. I walked out to the registration desk. “Is there a problem?” “I need to have these staples removed.” “Why are you raising your voice with the registration clerk?” “She wants me to register so that I get another hospital bill and I’m not registering to have it done.” “Unfortunately, the hospital policy is that anyone receiving treatment must be registered to be seen.” “Then you need to call Dr. Koop. He’ll come and remove the staples.” “Again, we don’t call doctors when they’re not on call, and I’ve never seen a doctor come in from home to remove staples, so even if we did call Dr. Koop, I doubt that he’d come to the hospital tonight.” “He’s a family friend of ours. He’d come.” “Have you tried calling him?” [Awkward pause. . . .]  Uh oh. “What is your NAME, doctor?” And so it went from this woman attacking the registration clerk to her attacking me, then calling the administrator on call and telling her I was being rude, then saying the CEO of the hospital would be getting a ...

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Healthcare Update — 07-08-2014

HC Update 8

Here’s an easy way to get published … and try to dispel an “urban legend” at the same time. The “Q**** Study.” Researchers went to the emergency department with random envelopes containing the word “Quiet,” “Busy,” or no statement at all. One envelope was opened each shift and the staff repeatedly said the word and then posted the paper in the department for the remainder of the shift. At the end of the study, the researchers found no difference in the number of patient visits regardless of what word was said at the beginning of the shift. I think the study was flawed. They didn’t measure patient acuity or stress levels during the study periods. Just because there are the same number of patients doesn’t mean that it isn’t less “quiet.” And you could probably cut the tension with a knife when people went around the department saying “quiet” at the beginning of the shift. Ohio hospital planning to cease inpatient services at the end of the year and focus on outpatient procedures. EMS chief calls the closure a “game changer” for patients if they will have to be transported to hospitals that are farther away. Interesting story on how the government is trying to sell Obamacare to the masses … including presidential cameos in return for advertising and attempting to get Obamacare placed into the scripts of TV shows and movies. Hat tip to Instapundit Cyberhacking of medical health records “only a matter of time” according to internet security experts. The full profile in your medical records can be worth up to $500 on the black market. “Have you noticed the proliferation of attorney advertisements on television encouraging, advising, goading anyone — with a bruised pinky toe nail to mesothelioma — to sue someone?” Letter to the editor of Connecticut newspaper alleges “greedy human nature” is behind a majority of medical malpractice lawsuits. Michigan Court rules that patient can’t sue doctor for telling her not to use birth control after patient tells doctor that her fallopian tubes were blocked. Patient argued that the advice was “grossly negligent” when she later had a child and sued for “wrongful conception.” Why courts even allow a claim of wrongful conception is beyond me. If you’re that burdened by your child, then give him or her up for adoption. Louisiana hospital sued for woman’s death from sepsis seven days after she had surgery from a cerebral aneurysm repair. Theory is that nausea then emesis of foul smelling fluids and blood six days later should have clued the medical providers into the diagnosis. Unnecessary testing? Johns Hopkins study shows that by eliminating CPK testing in patients being ruled out for myocardial infarct, they were able to reduce the number of tests by 66% with a decrease in charges of more than $1.25 million over the first year. The number of acute coronary syndrome diagnoses rose by 0.3% during the first year. I’m not paying $40 to purchase the article, but I would like to see how many times MIs were missed or had diagnosis delayed during this timeframe and would also like to see follow up on whether there were any lawsuits based on care during the study period. Saving $1.25 million only to pay out more than that in a couple of missed MI cases – especially if they occurred during a study to save money – may not be so cost effective. US veteran collapses while eating in a VA Hospital cafeteria. Instead of wheeling the patient to the emergency department which was about a four minute walk, VA staff members called ...

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