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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.

Healthcare Update — 05-27-2015

HC Update 16

Patient in Ontario Canada’s Guelph General Hospital emergency department has “interaction” with two police officers, both officers whip out their guns and shoot the patient dead. No further information available. Kentucky newspaper reminds everyone that stroke is an emergency and requires immediate care. Anyone having signs of a stroke should immediately contact Dr. Louis Caplan at Beth Israel Deaconess Medical Center. Don’t waste your time in “dangerous” emergency departments. I wasn’t being serious about contacting Louis Caplan. If you have signs of a stroke, go to your nearest emergency department. We’ll get you the help you need regardless of what some ivory tower neurologists think. Maryland patient in “horrible pain” calls ambulance. As paramedics “rushed her away,” her husband tucked her purse under her arm. She had her purse in her clutches until she reportedly had a “cardiac arrest” and went unconscious in the emergency department. She woke up the next day on a ventilator and the $1,100 that was in her purse was gone. I sympathize with the woman for losing her money, but something just doesn’t smell right about this story. Crystal meth is bad. In fact my uncle knows a guy whose cousin was on meth, gouged his eyes out, and ate his eyeballs like little hors doeuvres. Unfortunately, this story, told by an Australian member of parliament, was not able to be verified. That didn’t keep news agencies from picking up the story and running with it. Anything for the clicks. Nearly a year after the VA scandal was made public and what’s happened to the people responsible for the fraud? One person was fired, a few others were “disciplined” with paid leave and transfers. In addition, the number of patients waiting longer than 90 days to receive medical care has nearly doubled. This is the system we’re hoping to implement on a widespread basis? Here we go again with the antibiotics for appendicitis debate. According to several small studies in Europe, antibiotics can cure about 70% of patients with acute appendicitis. This article also states that most people who develop a ruptured appendix do so before they get to the hospital. And – because American sailors who were on submarines for six month stints did well when given antibiotics for appendicitis, obviously antibiotics should be a good treatment. The problem with this logic is that submarines didn’t have CT scanners to prove that patients actually had appendicitis. This just means that everyone who had a belly ache got antibiotics. We don’t know if any of the sailors actually had an inflamed appendix. In addition, even if antibiotics did cure appendicitis, who’s going to want to run to the hospital for repeat ED visits and CT scans every time they get lower abdominal pain? Remove the inflamed appendix and be done with it. Rise of the machines. iControl-RP is a machine that monitors brain wave activity, pulse ox and vital signs during surgery and adjusts the dose of anesthetic accordingly. A professor once told me that anesthesia is a boring specialty … about 95% of the time. The other 5% it is life or death. Not sure how a machine would respond in one of the 5% situations. Despite this, the machine’s co-developer is “convinced the machine can do better than human anesthesiologists.” Wonder how its intubation skills are … Pedialyte is advertising itself as a cure for hangovers. Probably because kids won’t drink it. Take a sip some day and you’ll see why. The stuff tastes horrible. The company touts the increased sodium and potassium concentrations in Pedialyte versus Gatorade as the reason it reportedly ...

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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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Letter To Doctor That Lost A Patient

By Birdstrike M.D. We all went into medicine to save lives. Deep within even the most cynical of us, is still that pre-med hopeful that believes we can and should restart each non-beating heart, make the non-breathing breathe and fill with blood those who’ve bled, filling them back with life. We expect that a patient’s condition will improve while under our care, or at least not worsen. Intellectually, we know we’ll not be successful every time. None of us became doctors to helplessly watch others die. Yet, we know there will be times, that no matter what we do, nor how perfectly we do it, that’s exactly what we’ll be forced to do, though not for lack of trying. Ultimately, regardless of what any of us says, you’ll go over the case ad nauseum to determine “What could I have done differently?” Ultimately you may conclude you could, or couldn’t have, done something different. But the crux of it, is that the answer to that medical question is irrelevant to the what is ultimately a human experience we can’t fully control. As medical as we try to be, it hurts to watch someone die. And the thing very few understand is the tremendous emotional risk we take as physicians, in having to be part of that, while at the same time charging ourselves with the responsibility of not allowing it to happen. Ultimately, we set ourselves up to fail. Some we can save. Many we can’t. Uniquely, we bear that emotional burden. The hospital CEO doesn’t feel that. The insurance adjuster who pays (or refuses to pay) the hospital claim doesn’t feel that. We share the burden with the family. I’ve seen fellow doctors, grown men, cry over patients lost. What you have to do, after you’ve done the analysis, ultimately are two things: 1-You first have to give yourself permission to be, and forgive yourself for being, human. You have to have compassion, not only for your patient and the family, but allow some for yourself. 2-You have to remind yourself, regardless of whether or not you ultimately decide you could/should have done some thing different, that by your being there, you took a large risk (an emotional one) and by doing so gave your patient a much greater chance of surviving, than if you hadn’t taken that risk. Even if the outcome wasn’t what you or the family would have hoped, you took a great emotional risk by choosing to be there if and when that patient would need you, and increased their chances much greater than if you weren’t there. Sometime their chance was never more than zero, but you did what the rest of the world didn’t have the courage, ability, or desire to do. You placed yourself there and were willing to risk taking the emotional bullet. Why? Because you’re a good human being and you care. I don’t know if that helps, but either way, I can assure you I’ve been there. I have cases that I think about years later; not all the time, but when something, or nothing at all, triggers the vivid memory. For what it’s worth, I feel your pain.   “Midnight, our sons and daughters, Were cut down and taken from us, Hear their heartbeat, We hear their heartbeat.” -U2 (Mothers of the Disappeared)

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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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I Remember You

By Birdstrike M.D.   I walk out of the patient room.  My eyes stare at the computer screen.  I’m behind, way behind.  I roll my head on my neck.  My neck feels tense, and I have a headache.  It’s been a long week.  I need a vacation.  Hurry up, click-click-click this computer, I think to myself.  Dammit, is this EMR really freezing up again? I look up.  A man walks out of a patient room across the hall.  Our eyes lock.  I quickly look away.  Ouch, my neck.   There are patients waiting. I need to get moving, or I’ll never get out of here, I think to myself.  I put my head down and turn to walk away. “Doctor.  Doctor.  Are you Doctor Bird?” he calls to me with urgency. Crap, I think to myself.  I’m never going to get caught up.  He does look familiar.  I hope he’s not mad at me.  Who is this man?  He probably wants to sue me, or maybe he’s angry I didn’t prescribe him those pills he wanted.  Man, my neck. “Yes?” I answer, hesitantly. “Did you work at —– —– Medical Center about 10 years ago?” he asks. He looks so, so familiar, but I can’t place him. “You won’t remember me, but you took care of my son,” he says, with a faint, but warming smile. Right then, it hits me, like a ton of bricks. “My son had cancer,” he says. “Brain cancer,” I answer, and right then my mind goes back 10 years at warp speed, back to room 10, during a chaotic shift at my first job out of residency.  I’m looking at a 12-yr-old boy laying in bed.  His eyes are sunken and gaunt, skin pale, hair blond. He’s dying of cancer and all treatments have failed.  I had never seen a child so sick, so ill appearing, yet still alive.  He looks like he’s in terrible pain.  There’s nothing left to do, but to try to make his last few days, hours and moments as painless as possible. He needs IV fluids, some pain and nausea medicine and needs to be made comfortable.  In a chair next to him is his father, dying inside.  My heart sinks.  “I remember you, and I remember him.  I even remember the room you were in.” “He died shortly after that.  But I still remember you.  You really took the time to ease his suffering, if only for a short time.  That meant a lot to me.  Most of all, you seemed to actually care,” he says. I felt a little dizzy.  I felt like I was having a flash-back of the PTSD sort; so vivid and real. I remember the chaos of the shift.  Walking down the far hallway, walking in the room and closing the door.  As the door closed behind me, the noisy chaos behind disappeared, and it was stark quiet.  I remember feeling the heart-wrenching sadness of this man sitting next to his dying son, so helpless.  I felt equally helpless.  I remember thinking, I don’t care how many patients are waiting.  I don’t care how long the wait is, or what chaos is swirling outside that door.  I need to pause and try to at least listen, if only for a short time.  I need to at least acknowledge what this boy, his father and family are going through.  I need to try to find some way, no matter how small, to make things a little better, or a little less painful for both of them, if I can.  At the very least, I need to ...

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